The role of task preference in the effectiveness of response interruption and redirection.

Response interruption and redirection (RIRD) is a common treatment for automatically reinforced vocal stereotypy; it involves the contingent presentation of task instructions. Tasks that are included in RIRD are typically selected based on caregiver report, which may affect the efficacy of RIRD. The purpose of the current study was to evaluate the role of task preference in the efficacy of RIRD for four participants who engaged in vocal stereotypy. We conducted task-preference assessments and selected tasks of varying preferences to include in RIRD. For three out of four participants, the results showed that RIRD with higher preference tasks was not effective at reducing vocal stereotypy, whereas RIRD with lower preference tasks was effective for all participants.

A retrospective analysis of stereotypy: Applicability of the behavioral subtyping model.

Recent research on automatically reinforced self-injurious behavior (ASIB) has identified specific patterns of responding in functional analyses that correlate with intervention efficacy (Hagopian et al., 2015; Hagopian et al., 2017). Whereas research by Hagopian et al. (2015, 2017) points to an important development in the assessment and treatment of ASIB, it is unclear if the applicability extends to automatically reinforced noninjurious behaviors, including stereotypy. Therefore, the current study replicated the methods of Hagopian et al. (2017), extending this research to published cases of stereotypy and related behavior. The behavioral subtype for each case was identified, and where applicable, the subtype was compared to intervention outcome data. The categorization of data sets as either Subtype 1 or Subtype 2 did not correspond with specific treatment outcomes. Unlike the results of Hagopian et al. (2015, 2017), reinforcement-based interventions were not more likely to be effective for Subtype 1 stereotypy than for Subtype 2 stereotypy.

Rethinking Stereotypies in Autism.

Stereotyped movements ("stereotypies") are semi-voluntary repetitive movements that are a prominent clinical feature of autism spectrum disorder. They are described in first-person accounts by people with autism as relaxing and that they help focus the mind and cope in overwhelming sensory environments. Therefore, we generally recommend against techniques that aim to suppress stereotypies in individuals with autism. Further, we hypothesize that understanding the neurobiology of stereotypies could guide development of treatments to produce the benefits of stereotypies without the need to generate repetitive motor movements. Here, we link first-person reports and clinical findings with basic neuroanatomy and physiology to produce a testable model of stereotypies. We hypothesize that stereotypies improve sensory processing and attention by regulating brain rhythms, either directly from the rhythmic motor command, or via rhythmic sensory feedback generated by the movements.

Brief Report: Mobile Technology to Support Parents in Reducing Stereotypy.

Although behavioral interventions have been known to effectively reduce stereotypy in children with ASD, these types of interventions are not accessible to all families. In response to this issue, we evaluated the effects of the iSTIM, an iOS application designed to support parents in the reduction of stereotypy in their child with ASD. We used a series of AB designs to determine the effectiveness of the iSTIM on stereotypy using parents as behavior change agents. The use of iSTIM by the parents led to a reduction in stereotypy for six of seven participants. Our results suggest that the use of technology may be a cost effective and easily accessible method for parents to reduce stereotypy in their child with ASD.

Autism and Access to Care During the COVID-19 Crisis.

CASE: Brian is a 6-year-old boy who was diagnosed with autism spectrum disorder (ASD) and global developmental delay at age 2. He has no other health conditions of note. Brian lives with his parents and an older brother, who also has ASD, in a rural area 2 hours from the center where he was diagnosed. Brian has a history of intermittent self-injurious behaviors (head-banging, throwing himself onto the floor, etc.) that regularly result in bruising, intense and lengthy tantrums, and aggression toward family and teachers. Brian will occasionally indicate items that he wants, but otherwise has no functional communication skills. Over the past 18 months, Brian's challenging behaviors have waxed and waned. The regional special education program is not equipped to safely manage his behaviors, and there are no in-home or center-based agencies that provide applied behavior analysis (ABA) available. Brian's developmental pediatrician initiated guanfacine (eventually adding a small dose of aripiprazole) and referred the family to psychology for weekly telehealth behavioral parent training to address behavioral concerns using the Research Units in Behavioral Intervention curriculum.1Brian's behavioral problems decreased during the initial weeks of the COVID-19 crisis, when he no longer had to leave home or attend special education. However, as summer continued, his behaviors worsened substantially (regular bruising and tissue damage, numerous after-hours consultations with his psychologist and developmental pediatrician, and one trip to the emergency department). The intensity of Brian's behaviors (maintained primarily by access to tangible items and escape from demands) made progress with behavioral supports slow and discouraging for his parents. Other psychosocial stressors coalesced for the family as well, including employment loss, limited social support because of social distancing requirements, and illness of one of his parents. The developmental pediatrician continued to modify the medication regimen over the summer, transitioning Brian from guanfacine to clonidine and increasing his aripiprazole incrementally (with clear increased benefit); hydroxyzine was also used as needed during the episodes of highest intensity.Despite the availability of best-practice guidelines for children with Brian's presenting concerns,2 a confluence of barriers (geographic, economic, ABA work force, global pandemic, etc.) present serious questions for his family and care team related to the next steps in Brian's care. Should he attend in-person school in the fall, knowing that the available program may have limited educational benefit and increase his risk of COVID-19 exposure (not to mention self-injury)? Would the potential benefits of cross-country travel to an intensive behavioral treatment program outweigh the associated psychosocial and economic stressors? How else can the virtual care team support this family? REFERENCES: 1. Bearss K, Johnson C, Smith T, et al. Effect of parent training vs parent education on behavioral problems in children with autism spectrum disorder: a randomized clinical trial. JAMA. 2015;313: 1524-1533.2. Hyman SL, Levy SE, Myers SM, et al. Identification, evaluation, and management of children with autism spectrum disorder. Pediatrics. 2020;145:e20193447.

Evaluating a treatment without extinction for elopement maintained by access to stereotypy.

Elopement is a common and potentially dangerous form of problem behavior. Results of a functional analysis found that the elopement of a child with autism was maintained by access to stereotypy in the form of door play. We implemented functional communication training and contingency-based delays dependent on the absence of elopement and increased the amount of time the participant waited prior to engaging in stereotypy. We also conducted treatment-extension probes, with the participant waiting up to 10 min without elopement.

A comparison of differential reinforcement procedures for treating automatically reinforced behavior.

Children diagnosed with autism spectrum disorder (ASD) often exhibit stereotypy, which can be socially stigmatizing, interfere with daily living skills, and affect skill acquisition. We compared differential reinforcement of alternative behavior (DRA) and differential reinforcement of other behavior (DRO) when neither procedure included response blocking or interruption for (a) reducing stereotypy, (b) increasing task engagement, and (c) increasing task completion. DRA contingencies yielded superior outcomes across each measure when evaluated with 3 individuals with autism spectrum disorder.

To What Extent Do Practitioners Need to Treat Stereotypy During Academic Tasks?

Researchers frequently argue that a child's engagement in stereotypy may compete with his ability to acquire academic skills, engage in appropriate social interactions, or both; however, few studies have directly tested these suppositions. We used a five-phase assessment to evaluate the extent to which behavioral interventions with a progressively greater number of components were necessary to decrease stereotypy and increase correct responding during academic instructions for five children diagnosed with autism spectrum disorders. For one participant, stereotypy decreased when instructors provided standard instruction without specific intervention for stereotypy. For two participants, stereotypy decreased when instructors provided standard instruction plus antecedent intervention for stereotypy with continuous music. For another participant, stereotypy decreased when instructors provided enhanced consequences for correct responding during standard instruction without either antecedent or consequent intervention for stereotypy. For the final participant, stereotypy decreased and correct responding increased when instructors provided standard instruction and consequent intervention for stereotypy.

Comparing response blocking and response interruption/redirection on levels of motor stereotypy: Effects of data analysis procedures.

Autism spectrum disorder (ASD) is marked by deficits in social communication and the presence of restrictive and/or repetitive behaviors or interests. Motor stereotypy is a form of repetitive behavior that is common in ASD. Response Interruption and Redirection (RIRD) and response blocking (RB) are two interventions found to be efficacious in reducing motor stereotypy. However, the current literature presents with inconsistencies regarding the relative efficacy of these two procedures. Thus, we sought to replicate and extend previous literature by evaluating the efficacy of both interventions on reducing motor stereotypy among 3 individuals with ASD. We also sought to evaluate how variations in data analysis affected the interpretation of treatment outcomes. Results indicated that both interventions were equally efficacious at reducing stereotypy when analyzing data exclusive of treatment-implementation time. However, when analyzing total session time data, RB produced greater and more sustained reductions in stereotypy across all participants. These results emphasize the importance of data analysis decision-making in evaluating intervention outcomes.

Tics and stereotypies: A comparative clinical review.

Tics and stereotypies are the most common pathological repetitive complex motor behaviors occurring during the neurodevelopmental period. Although they may appear transiently during development without acquiring a pathological status, when they become chronic they may be distressing, socially impairing, or even, in the case of malignant tics, potentially physically harmful. Despite a certain similarity in their phenomenology, physicians should be able to distinguish them for their different variability over time, topographical distribution, association with sensory manifestations, and relationship with environmental triggers. The complex phenomenology of tics and stereotypies is constantly enriched by the characterization of novel variants, e.g. tics triggered by auditory stimuli in association with misophonia and stereotypies associated with intense imagery activity. Their pathophysiology remains partially elusive, but both animal model and brain imaging studies confirm the involvement of all the three major loops (sensorimotor, associative and limbic) within the cortico-basal ganglia circuitry. From a management perspective, the greatest advances witnessed in the last decade involve the diffusion of behavioral strategies (e.g. habit reversal training or response interruption and redirection), including the development of protocols for telehealth on online training in order to optimise access. In the context of severe tics, e.g. in refractory Tourette syndrome, there is increasing experience with deep brain stimulation of the intralaminar thalamic nuclei or the globus pallidus internus, although more research is needed to fine tune target choice and stimulation setting definition.

Using Mobile Technology to Reduce Engagement in Stereotypy: A Validation of Decision-Making Algorithms.

We developed an iOS app, the iSTIM, designed to support parents of children with autism spectrum disorders (ASD) in reducing common repetitive vocal and motor behavior (i.e., stereotypy). The purpose of our study was to preliminarily test the decision-making algorithms of the iSTIM using trained university students to implement the assessments and interventions. Specifically, we examined the effects of the iSTIM on stereotypy and functional engagement in 11 children with ASD within alternating treatment designs. Using the iSTIM reduced engagement in stereotypy for eight participants and increased functional engagement for four of those participants. Our results indicate that the iSTIM may decrease engagement in stereotypy but that some of the decision-making algorithms may benefit from modifications prior to testing with parents.

Home-Based, Therapist-Assisted, Therapy for Young Children With Primary Complex Motor Stereotypies.

BACKGROUND: Complex motor stereotypies (CMS) typically begin before age three years and include rhythmic, repetitive, fixed movements that last for seconds to minutes and can be interrupted with distraction. OBJECTIVE: We evaluated the effectiveness of a home-based, parent-provided therapy accompanied by scheduled telephone calls with a therapist, in five- to seven-year old children with primary CMS. METHODS: Eligible families received an instructional digital versatile disk (DVD) written instructions, and scheduled telephone contacts with a therapist at baseline (DVD receipt), one, three, and eight weeks later. At each call, parents completed outcome measures and received feedback. Outcome scales Stereotypy Severity Scale (SSS) Motor and Impairment scales and a Stereotypy Linear Analogue Scale (SLAS) were also completed via the Iinternet (REDCap)-at screening, one and two months post-baseline call. At study conclusion, participants were divided into an intent-to-treat (ITT; had at least one call) or a lost-to-follow-up (LTF) group. RESULTS: Thirty-eight children (mean =  6 years ± 11 months) were enrolled. The LTF group (n = 14) had significantly higher scores than the ITT (n = 24) group on all attention-deficit/hyperactivity disorder ratings (P < 0.01), but not stereotypy severity. Primary outcome scores, acquired by telephone and REDCap, showed a significant reduction in SSS Motor and Impairment scores between the initial and the last completed evaluation (P ≤ 0.001). Calculated change ratios were SSS Motor -0.23/-0.30 (cal/REDCap); SSS Impairment -0.31/-0.32; and SLAS -0.54 (REDCap). Clinical improvement was further supported by results from a parent improvement scale and end of study questionnaires. CONCLUSIONS: Home-based, parent-administered behavioral therapy supplemented by telephone contact with a therapist is effective in reducing complex motor stereotypies in children.

Stereotypic Movement Disorders.

This review summarizes motor stereotypies in terms of description, prevalence, pathophysiology, diagnosis and management. They are fixed and persistent movements. Stereotypies begin before 3 years of age and continue into adulthood. Primary motor stereotypies occur in children of normal intelligence, whereas secondary stereotypies ensue in the setting of an additional diagnosis such as autism spectrum disorder or other neurologic disorders. They are highly associated with comorbidities such as anxiety, obsessive-compulsive symptoms, inattention, and tics. The pathophysiology of stereotypies involves fronto-striatal overactive dopaminergic pathways, and underactive cholinergic and GABAergic inhibitory pathways. No genetic markers have been identified despite a clear genetic predisposition. Behavioral therapy is the principle treatment. Future studies will focus on identifying genetic markers, and on better understanding the functional and structural neurobiology of these movements.

Teacher-Implemented Response Interruption and Redirection: Training, Evaluation, and Descriptive Analysis of Treatment Integrity.

Response interruption and redirection (RIRD) is an effective intervention for decreasing stereotypy. During RIRD, contingent on occurrences of stereotypy, therapists interrupt the behavior and prompt the participant to complete an alternative response. Although RIRD has been implemented by teachers in classrooms, it requires continuous monitoring of participants to be implemented with fidelity and may be difficult for teachers to manage. The present study evaluated the effectiveness of RIRD when implemented in classrooms. In addition, we evaluated if novice teaching assistants could be trained to implement RIRD. Finally, a descriptive analysis of treatment integrity errors during RIRD was conducted. Three children and teaching assistants participated. Following a written instructions baseline, the teaching assistants were trained to implement RIRD using modeling, rehearsal, and feedback. The training increased the accuracy of RIRD implementation for all participants. Incorrectly initiating and terminating RIRD were the most common treatment integrity errors observed.

Choosing an Appropriate Physical Exercise to Reduce Stereotypic Behavior in Children with Autism Spectrum Disorders: A Non-randomized Crossover Study.

Considerable evidence has shown that physical exercise could be an effective treatment in reducing stereotypical autism spectrum disorder (ASD) behaviors in children. The present study seeks to examine the underlying mechanism by considering the theoretical operant nature of stereotypy. Children with ASD (n = 30) who exhibited hand-flapping and body-rocking stereotypies were asked to participate in both control (story-time) and experimental (ball-tapping-exercise intervention) conditions. The experimental condition comprised 15 min of ball tapping during which the children were asked to tap a plastic ball as many times as they could. Results indicated that hand-flapping stereotypy was significantly reduced but body-rocking stereotypy following the ball-tapping-exercise intervention was not. These results not only confirm the positive impact of exercise intervention on stereotypic behavior as shown in many previous studies, but further suggest that physical exercise should be matched with the biomechanics of stereotypy to produce a desirable behavioral benefit.

Further Analysis of the Predictive Effects of a Free-Operant Competing Stimulus Assessment on Stereotypy.

We conducted five experiments to evaluate the predictive validity of a free-operant competing stimulus assessment (FOCSA). In Experiment 1, we showed that each participant's repetitive behavior persisted without social consequences. In Experiment 2, we used the FOCSA to identify high-preference, low-stereotypy (HP-LS) items for 11 participants and high-preference, high-stereotypy (HP-HS) items for nine participants. To validate the results of the FOCSAs (Experiment 3), we used a three-component multiple schedule to evaluate the immediate and subsequent effects of an HP-LS stimulus, an HP-HS stimulus, or both (in separate test sequences) on each participant's stereotypy. Results of Experiment 3 showed that the FOCSA correctly predicted the immediate effect of the HP-LS stimulus for 10 of 11 participants; however, the FOCSA predictions were less accurate for the HP-HS stimulus. Results of Experiment 4 showed that a differential reinforcement of other behavior procedure in which participants earned access to the HP-LS for omitting vocal stereotypy increased all five participants' latency to engaging in stereotypy; however, clinically significant omission durations were only achieved for one participant. Experiment 5 showed that differential reinforcement of alternative behavior in which participants earned access to the HP-LS stimulus contingent upon correct responses during discrete-trial training reduced targeted and nontargeted stereotypy and increased correct academic responding for all four participants. The potential utility of the FOCSA is discussed.

The impact of caregiver-mediated JASPER on child restricted and repetitive behaviors and caregiver responses.

Restricted and repetitive behaviors (RRBs) are a core feature of autism spectrum disorder (ASD). Compared to the social-communication impairments, we know considerably less about why children engage in RRBs and if and how to intervene with these behaviors. As a result, early intervention has typically focused on social-communication. In this study, we were interested in understanding how child RRBs changed following an intervention targeting social-communication behaviors and if caregiver training changed how they responded to their child's RRBs. Eighty-six toddlers with ASD and their caregivers received one of two interventions: caregivers were either actively coached while playing with their child (JASPER) or attended information sessions about ASD. On three different occasions (when they entered the study, following 10 weeks of intervention and 6-months after) caregivers were filmed playing with their child. From these recordings, we coded child RRBs and caregiver responses to these behaviors. Child RRBs remained relatively stable following intervention in both groups, but increased when the children returned at 6-months. Caregivers who received one-on-one coaching (JASPER) responded to a greater number of their child's RRBs and their responses were rated as more successful. Our study showed that a short-term social-communication intervention delivered through caregivers had "spillover effects" on how they also responded to their child's RRBs. Interventions targeting social-communication behaviors should also examine how these treatments affect child RRBs and how caregiver responses to these behaviors may change following training. Autism Res 2017, 10: 983-992. © 2016 International Society for Autism Research, Wiley Periodicals, Inc.

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.

Adult-onset stereotypical motor behaviors.

Stereotypies have been defined as non-goal-directed movement patterns repeated continuously for a period of time in the same form and on multiple occasions, and which are typically distractible. Stereotypical motor behaviors are a common clinical feature of a variety of neurological conditions that affect cortical and subcortical functions, including autism, tardive dyskinesia, excessive dopaminergic treatment of Parkinson's disease and frontotemporal dementia. The main differential diagnosis of stereotypies includes tic disorders, motor mannerisms, compulsion and habit. The pathophysiology of stereotypies may involve the corticostriatal pathways, especially the orbitofrontal and anterior cingulated cortices. Because antipsychotics have long been used to manage stereotypical behaviours in mental retardation, stereotypies that present in isolation tend not to warrant pharmacological intervention, as the benefit-to-risk ratio is not great enough.

Preliminary effects of parent-implemented behavioural interventions for stereotypy.

OBJECTIVE: The purpose of our study was to replicate and extend previous research on using multicomponent behavioural interventions designed to reduce engagement in stereotypy by examining their effects when implemented by parents over several months. METHODS: We used an alternating treatment design to examine the effects of the parent-implemented interventions on engagement in stereotypy and appropriate behaviour in three children with autism and other developmental disabilities. RESULTS: The parent-implemented multicomponent treatments reduced vocal stereotypy in all three participants and increased engagement in appropriate behaviour in two participants. These effects persisted up to 24 weeks following the parent training sessions. CONCLUSIONS: Altogether, our preliminary results support (a) the involvement of parents as behaviour change agents to reduce engagement in stereotypy and (b) the scheduling of regular, but infrequent (i.e. weekly to monthly), follow-up meetings to monitor the effects of behavioural interventions in outpatient and home-based service delivery models.