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 DBS is roughly synonymous with behaviour management, which is an outdated concept.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.

Labels and descriptions of dental behaviour support techniques: A scoping review of clinical practice guidelines.

INTRODUCTION: There is no agreed taxonomy of the techniques used to support patients to receive professional oral healthcare. This lack of specification leads to imprecision in describing, understanding, teaching and implementing behaviour support techniques in dentistry (DBS). METHODS: This review aims to identify the labels and associated descriptors used by practitioners to describe DBS techniques, as a first step in developing a shared terminology for DBS techniques. Following registration of a protocol, a scoping review limited to Clinical Practice Guidelines only was undertaken to identify the labels and descriptors used to refer to DBS techniques. RESULTS: From 5317 screened records, 30 were included, generating a list of 51 distinct DBS techniques. General anaesthesia was the most commonly reported DBS (n = 21). This review also explores what term is given to DBS techniques as a group (Behaviour management was most commonly used (n = 8)) and how these techniques were categorized (mainly distinguishing between pharmacological and non-pharmacological). CONCLUSIONS: This is the first attempt to generate a list of techniques that can be selected for patients and marks an initial step in future efforts at agreeing and categorizing these techniques into an accepted taxonomy, with all the benefits this brings to research, education, practice and patients.

Defining and Measuring Indices of Happiness and Unhappiness in Children Diagnosed with Autism Spectrum Disorder.

Improving quality of life (QoL) is the goal of behavior analytic services, but there can be barriers to assessing the QoL of autistic children due to characteristics inherent in the condition. Given that happiness is a fundamental element of QoL, previous research has relied on behavioral indicators of mood (e.g., smiling, crying) to evaluate the overall QoL of disabled individuals. However, the use of these traditional indices may not accurately reflect the emotional well-being of autistic individuals, who are known to engage in idiosyncratic mood indicators. The current study replicated selected procedures from Parsons et al. (2012) to identify and validate the unique mood indicators of young autistic children. The study showed that individualized indices of happiness and unhappiness could be operationally defined and reliably measured among these children. Key findings and limitations of this study are discussed, and the implications of these findings are presented. Supplementary Information: The online version contains supplementary material available at 10.1007/s40617-022-00710-y.

Brief Report: Differential Persistence of Primary Reflexes for Children with Autism Spectrum Disorder: A Systematic Replication.

Primary reflexes are highly stereotypical, automatic movements comprising much of the motor repertoire of newborns. The current study examined rates of presence of five primary reflexes (snout, visual rooting, sucking, tactile rooting, and grasp) and variables predictive of their persistence for children with ASD (n = 35), developmental disability (n = 30), and typically developing children matched to participants with ASD on chronological age (n = 30). There was a higher prevalence of snout and visual rooting reflex among children with ASD. These data suggest that the persistence of primary reflexes holds promise as a biomarker for autism spectrum disorder (ASD).

BeSiDe time to move behavior support in dentistry from an art to a science: A position paper from the BeSiDe (Behavior Support in Dentistry) Group.

AIMS: To share the need for agreement in terminology around how people are supported to receive dental care. METHOD: In this position paper, we make the case for a shift in behavior support in dentistry from an art to a science. RESULTS: We outline why we need agreement on the definition of behavior support across dentistry, agreement on underlying theory, aims and values, and why we need agreement on terms for specific techniques. CONCLUSIONS: We share how patients and dental teams can benefit through better science, education and practice of dental behaviour support.

A Randomized Controlled Trial of Headsprout on the Reading Outcomes in Children With Autism Using Parents as Facilitators.

Children with autism spectrum disorder (ASD) are considered an at-risk population for reading delays and challenges. In recent years, there has been emerging support for the computer-assisted instruction (CAI) Headsprout with respect to reading outcomes in children with ASD. CAI, often used within classrooms, is designed using automated and carefully sequenced instruction. A randomized controlled trial was used to explore the implementation of Headsprout by parents, including a treatment package (i.e., behavioral skills training, an online support group, and a consultative model) within the home environment, with their children with ASD. A between-groups design was used to evaluate the effects of Headsprout on the reading outcomes and print motivation of a sample of 26 children with ASD. Thirteen children were in the experimental (Headsprout) group, and thirteen were in the control group receiving treatment as usual. Supplementary online supports were provided to parents based on specific learning problems identified during the intervention. Results demonstrated that participants who received Headsprout showed greater gains in reading rate, word reading, non-word reading, and target sounds and words within Headsprout than the control group. The results of print motivation demonstrated that only Headsprout-specific print material resulted in an increase in assessed preference at posttests.

Parental satisfaction with early intensive behavioral intervention.

Research related to parental satisfaction with early intensive behavioral intervention (EIBI) remains limited. A 35-item questionnaire called the parental satisfaction scale-EIBI (PSS-EIBI) was developed with four subdomains (child outcomes, family outcomes, quality of the model, and relationship with the team). Study 1 assessed levels of satisfaction for 48 parents with their child's EIBI program after approximately 1 year of intervention. Study 2 examined the relationship between parental satisfaction, length of child participation in EIBI, and the relationship between parental satisfaction and actual outcomes for their child as assessed by the Verbal Behavior Milestones Assessment and Placement Program after approximately 2 years. Results indicate that parental satisfaction with EIBI was consistently high in all four domains of the PSS-EIBI in both studies. Parental satisfaction was found to be associated with gains in child functioning after 1 year of intervention.

The Use of Differential Reinforcement of Other Behaviours to Establish Inhibitory Stimulus Control for the Management of Vocal Stereotypy in Children with Autism.

OBJECTIVE: This study examined the efficacy of an inhibitory stimulus control procedure (ISCP) for the management of vocal stereotypy in three children with autism. METHOD: During discrimination training, implemented within a changing criterion design, participants were taught that there were no consequences for vocal stereotypy in the absence of an inhibitory stimulus but that differential reinforcement procedures were in effect in the presence of the stimulus. Functional control of the inhibitory stimulus was subsequently assessed within a reversal design. RESULTS: Inhibitory stimulus control was established during discrimination training, with participants inhibiting vocal stereotypy for 30 min periods in the presence of the inhibitory stimulus. Reductions in vocal stereotypy were maintained in the presence of the inhibitory stimulus and in the absence of further programmed consequences. DISCUSSION: This study extends current knowledge by demonstrating the efficacy of ISCPs paired with reinforcement only, and illustrating the functional control of the inhibitory stimulus.

An interview-informed synthesized contingency analysis to inform the treatment of challenging behavior in a young child with autism.

PURPOSE: Experimental Functional analysis (EFA) is considered the "gold standard" of behavioural assessment and its use is predictive of treatment success. However, EFA has a number of limitations including its lengthy nature, the high level of expertise required, and the reinforcement of challenging behaviour. This study aimed to further validate a novel interview-informed synthesised contingency analysis (IISCA). METHODS: An open-ended interview and brief direct observation informed an IISCA for a young boy with autism who engaged in challenging behaviour. Resulting data supported the hypothesis that the target behaviour was multiply controlled by escape from demands and access to tangible items. An intervention comprised of most-to-least prompting, escape extinction, differential reinforcement and a high-probability instruction sequence was evaluated using a reversal design. RESULTS: This intervention reduced challenging behaviour to low levels and resulted in increased compliance. CONCLUSIONS: Findings support the status of the IISCA as a valid, practical, and effective process for designing function-based interventions.

An evaluation of positive behavioural support for children with challenging behaviour in community settings.

This study employs a multiple baseline across individual design to describe the implementation of positive behavioural supports for seven children and adolescents in residential community settings over a period of 24 months. These individuals with intellectual disability are residing in one county with long-standing challenging behaviour resulting in home breakdown and serious physical injury. Four types of outcome are presented: rates of behaviour, rates of medication, psychiatric symptomatology and quality of life (QoL). Behaviours reduced to lower levels for the majority of participants following the implementation of positive behavioural supports, and improvements were largely sustained. The use of psychotropic medications reduced or stabilized for the majority of individuals over the same period. QoL Questionnaire scores improved substantially for four participants. The results are discussed in the context of a framework for supporting children with severe challenging behaviours in the community.

A systematic review and evaluation of procedures for the induction of speech among persons with developmental disabilities.

OBJECTIVE: Deficits in vocal speech are common among those with developmental disabilities. This review examines interventions for teaching speech to individuals who presented as nonspeaking, or with low levels of vocalizations at baseline, and assesses evidence-based practice in this area. METHODS: Systematic searches identified 78 studies suitable for inclusion. These studies were evaluated in terms of (a) participants, (b) intervention, (c) intervention setting, (d) intervention agent, (e) treatment efficacy, (f) generalization and maintenance of treatment effects, and (g) research rigor. RESULTS: A variety of interventions, primarily behavioral, intended to induce vocal speech were delivered to participants with developmental disabilities aged between six months and 57 years. Treatment efficacy was variable (PND M = 52.9%; range 0%-100%); however, results indicated that behavioral interventions constituted evidence-based practice. Non-behavioral strategies were shown to have received insufficient research evaluation to date. CONCLUSION: Results indicate that a number of procedures can induce speech among individuals with developmental disabilities.

Preliminary evaluation of the efficacy of an intervention incorporating precision teaching to train procedural skills among final cycle medical students.

Introduction: A lack of preparedness for practice has been observed among new medical graduates. Simulation technology may offer one means of producing competency. This paper describes the application of a simulation-based intervention incorporating precision teaching (PT), a method of defining target skills, assessing individual progress and guiding instructional decisions, which is used to monitor learning and the development of behavioural fluency in other domains, to procedural skills training. Behavioural fluency refers to accurate and rapid responding that does not deteriorate with time, is resistant to distraction and can be adapted into new, more complex responses. Method: This study used a between-groups design to evaluate the efficacy of a simulation-based intervention incorporating PT for teaching venepuncture among 11 medical students. The intervention consisted of timed learning trials during which participants carried out the skill in pairs and received corrective feedback. Two control groups of 11 untrained medical students and 11 junior doctors were also included in the study. Results: Intervention group participants required an average of five trials and 21.9 min to reach the criterion for fluency. The intervention group demonstrated significantly higher accuracy in venepuncture performance than either control group. Improvements persisted over time, did not deteriorate during distraction, generalised to performance with patients and performance of an untargeted skill also improved. Conclusions: The outcomes of this preliminary study support the application of PT within medical education. The implications of these data for clinical and procedural skills training are explored and suggestions are made for further research.

A systematic review and evaluation of inhibitory stimulus control procedures as a treatment for stereotyped behavior among individuals with autism.

PURPOSE: Stereotypy is pervasive among persons with autism and may impact negatively on social inclusion and learning. The implementation of resource-intensive behavioral interventions to decrease these behaviors has been questioned. Inhibitory stimulus control procedures (ISCPs) comprise a type of antecedent-based intervention that has been proposed as an effective treatment approach for stereotypy but has received limited research attention to date. METHOD: The current systematic review sought to examine and synthesize the literature reporting applications of ISCPs in the treatment of stereotypy among persons with autism. Treatment outcomes were analyzed quantitatively and the status of ISCPs as evidence-based practice was evaluated in accordance with the National Autism Center's National Standards Report guidelines. RESULTS: A total of 11 studies were reviewed with results indicating that ISCPs constituted an emerging treatment for the stereotypy exhibited by persons with autism. CONCLUSIONS: ISCPs comprise a promising intervention for stereotyped behavior but further research is required.

A systematic review of physiological reactivity to stimuli in autism.

OBJECTIVE: The prevalence of abnormal behavioural responses to a variety of stimuli among individuals with autism has led researchers to examine whether physiological reactivity (PR) is typical in this population. This article reviewed studies assessing PR to sensory, social and emotional, and stressor stimuli in individuals with autism. METHODS: Systematic searches of electronic databases identified 57 studies that met our inclusion criteria. Studies were analysed to determine: (a) participant characteristics; (b) physiological measures used; (c) PR to sensory, social and emotional or stressor stimuli; (d) the relation between PR and behavioural or psychological variables and (e) baseline physiological activity. A novel measure of methodological quality suitable for use with non-randomized, non-interventional, psychophysiological studies was also developed and applied. RESULTS: Individuals with autism were found to respond differently than typically developing controls in 78.6%, 66.7% and 71.4% of sensory, social and emotional, and stressor stimulus classes, respectively. However, this extant literature is characterized by variable and inconsistent findings, which do not appear to be accounted for by varying methodological quality, making it difficult to determine what specific factors differentiate individuals with autism who present with atypical PR from those who do not. CONCLUSIONS: Despite this uncertainty, individual differences in PR are clearly present in autism, suggesting additional research is needed to determine the variables relating to PR among those with ASD and to examine the possible existence of physiological subtype responders in the population.

An analysis of stress, burnout, and work commitment among disability support staff in the UK.

Previous research has suggested that challenging behaviour emitted by persons with intellectual and developmental disabilities negatively impacts upon the levels of stress and burnout of those who support and care for them. In the current study a sample of disability support workers in the UK (N=138) reported their levels of perceived stress, burnout, and commitment to their work. The relationship between the frequency and severity of aggressive/destructive behaviours to which they were exposed, and these three measures were examined. Results showed that participants scored lower on measures of burnout in the current study than has been reported by similar research studies in the UK and North America. The results revealed an association between challenging behaviours experienced and participants' perceived stress and emotional exhaustion. Perceived stress and burnout were also associated with participants' commitment to their work. Finally, a series of regression analyses identified a number of predictors of emotional exhaustion, depersonalization, and personal accomplishment among disability support workers. The results and their implications for the consideration of disability support worker wellbeing and future research in this area are discussed.

A quantitative examination of punishment research.

The current review examined 368 articles, published between 1967 and 2013, which evaluated punishment-based procedures for the treatment of challenging behavior among persons with developmental disabilities and quantitatively analyzed: (a) the amount of research that has assessed different types of punishment procedures; (b) the characteristics of the participants, behaviors, and treatments included in these studies, and (c) the relative efficacy of the various punishment procedures in general and with regard to the inclusion of reinforcement-based components, method of treatment selection and development, and function of the targeted challenging behaviors. Further, the study evaluated the included studies for the presence of important quality indicators. It was intended that such an analysis would provide a useful overview of the extant research on punishment procedures as a behavior reduction technique. Suggestions regarding research methodology and areas for further investigation are made for future research evaluating punishment-based interventions.

A systematic review and evaluation of response redirection as a treatment for challenging behavior in individuals with developmental disabilities.

Response redirection is widely used in clinical practice as a treatment for repetitive behavior or stereotypy in persons with developmental disabilities. However, to date the procedure has received comparatively little empirical evaluation. The current review sought to examine the literature describing the efficacy of response redirection alone, response interruption and redirection (RIRD), and multi-element treatment packages incorporating response redirection, as interventions for challenging behavior in individuals with developmental disabilities. Additionally, the status of response redirection, and RIRD, as evidence-based practice was evaluated in accordance with Reichow's (2011) recently developed criteria. Results indicated that interventions involving response redirection or RIRD typically led to large decreases in challenging behavior but did not result in behavioral suppression. On the basis of the current literature and in accordance with Reichow's criteria, interventions incorporating response redirection do not yet constitute evidence-based practice. The implications of these findings, for both research and practice, are discussed.

Investigating the Relationship between Self-Injurious Behavior, Social Deficits, and Cooccurring Behaviors in Children and Adolescents with Autism Spectrum Disorder.

Research suggests that self-injurious behavior (SIB) is related to social deficits and cooccurring problem behaviors in children and adolescents with autism spectrum disorder. A sample of 95 participants with ASD was assessed on presence and frequency of SIB (Behavior Problems Inventory), social deficits (the Matson Evaluation of Social Skills with Youngsters-II) and cooccurring problem behaviors (ASD-Comorbidity-Child version). A model was created and tested to explain the relationship between these variables. Results showed that the model was acceptable in presenting the relationships between these variables. This information could be used to help predict which individuals are at risk of developing further cooccurring behavioral problems and determine risk markers for the development of social deficits.

Examination of an antecedent communication intervention to reduce tangibly maintained challenging behavior: a controlled analog analysis.

We examined the influence of an antecedent communication intervention on challenging behavior for three students with developmental disorders. Students were taught to request tangible items that were identified as reinforcers for challenging behavior in a prior functional analysis. Individual participant multielement and reversal designs were used to compare the effects of the antecedent communication intervention versus a no antecedent communication intervention condition. Immediately following the antecedent manipulations students were exposed to the tangible condition of the functional analysis. Results indicate that the antecedent communication intervention reduced challenging behavior in the subsequent tangible test condition for all three students. The importance of examining antecedent interventions to treat challenging behavior from a function analytic perspective is discussed.

Investigating the relationship between challenging behavior, co-morbid psychopathology and social skills in adults with moderate to severe intellectual disabilities in Ireland.

Researchers suggest that social skill deficits and psychiatric issues may be affected by the presence of maladaptive behaviors in people with intellectual disabilities. A sample of 39 participants with intellectual disability was surveyed for the presence of psychiatric symptoms and social skills deficits. Outcomes indicated that individuals with severe challenging behaviors scored significantly higher than those without problem behaviors in terms of presence of psychiatric symptoms in ten of the thirteen subscales of the DASH-II. Results also showed that individuals with severe problem behaviors scored significantly lower on social skills measures, using the MESSIER, than those without. A significant difference was observed between participants presenting with psychiatric symptoms and those who did not in terms of social skills, with the former scoring significantly lower than the latter. Results of the study provide weight to current research supporting the relationships between problem behaviors, co-morbid psychopathology and social skill deficits. This information could be used to further develop positive supports for adults with intellectual disability and challenging behaviors in order to improve their quality of life, community inclusion and social networks.