A retrospective analysis of the relation between resurgence and renewal of behavior targeted for reduction.

Functional communication training (FCT) is an evidence-based treatment for behavior targeted for reduction that often combines extinction for target responses and arranges functionally equivalent reinforcement for alternative behavior. Long-term effectiveness of FCT can become compromised when transitioning from clinic to nonclinic contexts or thinning reinforcement schedules for appropriate behavior. Such increases in targeted behavior have been conceptualized as renewal and resurgence, respectively. The relation between resurgence and renewal has yet to be reported. Therefore, the present report retrospectively analyzed the relation between renewal and resurgence in data collected when implementing FCT with children diagnosed with developmental disabilities. We found no relation when evaluating all 34 individuals assessed for resurgence and renewal or a subset of individuals exhibiting both resurgence and renewal. These findings suggest that one form of relapse may not be predictive of another form of relapse.

A comparative effectiveness trial of functional behavioral assessment methods.

Clinicians report primarily using functional behavioral assessment (FBA) methods that do not include functional analyses. However, studies examining the correspondence between functional analyses and other types of FBAs have produced inconsistent results. In addition, although functional analyses are considered the gold standard, their contribution toward successful treatment compared with other FBA methods remains unclear. This comparative effectiveness study, conducted with 57 young children with autism spectrum disorder, evaluated the results of FBAs that did (n = 26) and did not (n = 31) include a functional analysis. Results of FBAs with and without functional analyses showed modest correspondence. All participants who completed functional communication training achieved successful outcomes regardless of the type of FBA conducted.

Expanding a laboratory model for evaluating relapse of caregiver nonadherence.

Caregiver adherence to treatment plans is likely maintained by negative reinforcement and can contact extinction when child responding relapses. When caregiver adherence contacts extinction, caregiver nonadherence, such as reinforcing their child's challenging behavior, relapses, threatening treatment efficacy. Previous laboratory models demonstrating the relapse of caregiver nonadherence only evaluated treatment for behavior maintained by social-positive reinforcement, not that maintained by social-negative reinforcement. These models only measured caregiver nonadherence as discrete events, which cannot capture the magnitude of each error. The present study was an evaluation of the relapse of caregiver nonadherence during simulated treatments for escape-maintained challenging behavior. First, caregivers placed demands in a home-like setting and a research confederate responded to these demands in a manner mimicking clinical clients. Next, caregivers were taught to implement treatment in a clinical setting and the confederate's behavior gradually improved. Last, caregivers returned to the home-like setting and confederate challenging behavior relapsed. Nonadherence relapsed for all caregivers, demonstrating the need for additional research on methods for mitigating caregiver relapse during treatment of children's challenging behavior and the usefulness of the proposed measurement system for future research.

The Development and Acceptability of a Comprehensive Crisis Prevention Program for Implementation in Health Care Settings.

INTRODUCTION: Behavioral crises are increasingly prevalent in health care settings. Existing programs, however, include procedures that lack adaptability, omit critical components, and deviate from clinical best-practice recommendations. Health care employees also continue to report lacking confidence for safely managing behavioral crises. AIMS: We described the development and acceptability of a comprehensive crisis prevention program and its modification for a large pediatric health care system to help remediate the limitations of existing programs. METHOD: Chi-square analyses evaluated the acceptability of the crisis prevention program pre- versus post-training and at 3- and 6-month follow-up times. For insignificant outcomes, logistical regressions identify whether responses differed between emergency-department and nonemergency-department employees. RESULTS: Chi-square analyses were significant for 10 of 15 questions suggesting that employees were more confident in managing and communicating during behavioral crises post-training, and that this confidence was maintained. Logistic regressions found that emergency-department employees differed in some responses to the acceptability questionnaire than nonemergency-department employees over time. CONCLUSION: The present crisis prevention program is adaptable to various settings and patients, and it is well received overall by employees. The safety of patients and employees is integral to the delivery of quality care and improving patient-provider relations.

Behavioral Assessment and Treatment via Telehealth for Children with Autism: From Local to Global Clinical Applications.

Functional analyses (FA) and functional communication training (FCT) are the most commonly used behavioral assessment and treatment approaches via telehealth for children with autism spectrum disorder (ASD) who display challenging behavior. The FA + FCT telehealth model has been shown to maintain treatment effectiveness (i.e., child behavioral outcomes and parent acceptability), as well as demonstrate treatment efficiency (i.e., cost savings). However, the majority of these studies have been conducted in the United States. Therefore, the purpose of this study was to evaluate the outcomes obtained with the telehealth FA + FCT model that included global applications. Descriptive statistics were used to analyze the results of the 199 participants who enrolled in the telehealth project across all project sites. The results showed that behavioral outcomes and parent acceptability maintained at similar levels to previous studies across all sites. Additionally, very few differences were found across project sites in relation to drop-out rates, visit cancellations, and technology issues. These results demonstrate the effectiveness of the FA + FCT telehealth model for addressing the challenging behavior needs of children with ASD globally and highlight areas in need of additional evaluation (e.g., drop-outs, cancellations) to determine the conditions under which telehealth could be best used.

Prevalence of relapse of automatically maintained behavior resulting from context changes.

Increases in behavior due to context changes are common and are known as instances of renewal. Clinically relevant examples from the literature highlighting renewal often include socially mediated problem behaviors. This report retrospectively analyzed data during context changes for individuals who engaged in problem behavior maintained by automatic reinforcement, to evaluate the prevalence of relapse. Problem behavior reemerged during changes both in the person implementing treatment (e.g., introducing a caregiver; 36%) and in the setting (e.g., introducing treatment in the home; 26%). Most prevalence studies report greatest relapse immediately following context changes but the highest level of relapse was observed after 5 sessions following person changes and no systematic pattern with setting changes. These patterns of relapse likely reflect differences in the function of settings and people relative to automatically reinforced behavior in the present study. Implications of relapse for treatments of problem behavior maintained by automatic reinforcement are discussed.

Parent Ratings of Generalized and Indirect Effects of Functional Communication Training for Children with Autism Spectrum Disorder.

Functional communication training (FCT) is a behavioral treatment that has been shown to reduce problem behavior and increase appropriate communication in young children with autism spectrum disorder (ASD). In this study, we assessed the effects of FCT on targeted and nontargeted problem behaviors outside of the training context, as well as parent stress, for 30 young children with ASD and their parents. Indirect measures of generalization treatment effects were administered prior to and following FCT treatment delivered via telehealth. Children demonstrated significant improvement on both targeted (measured via observation) and nontargeted (measured via checklist) problem behaviors, both within and outside of the training context, and parent stress was significantly reduced following treatment. These results suggest that the impact of FCT may extend beyond the training context for both the children being treated and the parents delivering treatment, even when generalization is not specifically programmed for during treatment.

A Feasibility Randomized Clinical Trial of a Structured Function-Based Intervention for Elopement in Children with Autism Spectrum Disorder.

Elopement is a common and dangerous concern in autism spectrum disorder (ASD). There is evidence that behavior analytic treatments can successfully treat elopement, but the research is limited due to small samples and treatment components varying across studies. The current study evaluated the feasibility of studying a manualized intervention for elopement, based on strategies from single-subject research, in a randomized clinical trial with 24 individuals with ASD. Results demonstrated that recruitment was feasible; the manual was acceptable to parents; and therapists followed the manual with high-integrity. Initial efficacy results measured by the Aberrant Behavior Checklist, Clinical Global Impression Scale, and a Home Elopement Safety Checklist suggested improvement in the treatment group that should be studied in future research.

Prevalence of resurgence during thinning of multiple schedules of reinforcement following functional communication training.

The current study examined resurgence of problem behavior during thinning of multiple schedules of reinforcement following functional communication training replicating previous research (Briggs et al., 2018). Data were analyzed at each thinning step from subjects enrolled in an intensive day treatment program over a 5-year period. Results indicated that of the 239 thinning steps analyzed, resurgence was observed in 97 of those steps (40.6%), similar to results of Briggs et al. (2018). The data were also analyzed to estimate the magnitude of resurgence when it was observed. In the first session after the thinning step, the rate of problem behavior observed was 7 times higher than the average of the 5 sessions pre-thinning step.

Factors associated with enrollment into a clinical trial of caregiver-implemented intervention for infants at risk for autism spectrum disorder.

LAY ABSTRACT: Early intervention helps to address developmental delays in young children with autism spectrum disorder. Yet, research suggests there are barriers to enrollment into research studies that test the effectiveness of these interventions for infants at risk. This study identifies family characteristics that were associated with agreement to enroll in a clinical trial of early intervention for 12-month-old infants at risk for autism spectrum disorder. As part of a large longitudinal study, infants were evaluated for early signs of autism spectrum disorder at 1 year of age. Of the fifty-seven infants who were showing signs of autism and deemed eligible for the early intervention trial, 44% declined enrollment. Results suggest that families were more likely to decline enrolling into the intervention study if the mother was working full time, the total household income was between US$60,000 and US$100,000, and they lived further from the clinic. In contrast, infant autism symptoms and parental concern at 12 months were not significantly associated with enrollment. These findings highlight the need for intervention studies that are more accessible to parents, for example, intervention that takes place in the home, in addition to more research on how parental understanding of, and willingness to act on, early social-communication delays impact intervention study enrollment. Future research can then examine how to address these barriers to enrollment in early intervention studies. Such findings will shed light on best practices for dissemination of early identification and intervention strategies.

Prevalence of renewal of problem behavior during context changes.

Renewal is defined as the reemergence of a previously eliminated behavior following a context change. Determining the prevalence of this effect in clinical practice would allow clinicians to better anticipate the reemergence of problem behavior, such as when a patient is discharged from a treatment facility to return to their home. The current consecutive, case-series analysis determined the prevalence and magnitude of renewal when implementing behavioral treatments for problem behavior. Across 182 context changes, renewal was observed 77 times (42.3%). In the first session following the context change, problem behavior rates increased by a factor of 3 and then decreased across successive sessions. These results indicated that renewal effects may be common, but are also transient and return to rates observed before context changes.

Remote Coaching of Caregivers Via Telehealth: Challenges and Potential Solutions.

The use of telehealth technologies to provide clinical services to families of children with autism and other developmental disabilities is a rapidly growing area of research. In particular, remote training of caregivers via video conferencing appears to be a promising approach for disseminating behavior-analytic interventions (Neely, Rispoli, Gerow, Hong, Hagan-Burke, 2017; Tomlinson, Gore, & McGill, 2018). Although remote training offers a number of advantages, it brings a variety of challenges that are unique to this modality. The field would benefit from information on problems that practitioners may encounter when providing these services and how to train caregivers effectively. In this paper, we report on the experiences of 18 practitioners who provided caregiver training via telehealth from four different sites across a 4-year period. We describe a variety of technical and clinical issues that arose during service delivery, suggest strategies for preventing and remediating problems, and include case descriptions and data to illustrate our experiences. This information may help prepare practitioners to deliver telehealth services and guide further research in this area.

Effects of Magnitude on the Displacement of Leisure Items by Edible Items During Preference Assessments.

Studies on preference assessments have shown that when both edible and leisure items are compared, edible items tend to displace leisure items in preference hierarchies. However, the mechanisms behind this process are currently unclear. One possibility is that displacement may be a product of the relatively brief periods of access to leisure items typically used in preference assessments. The purpose of the current investigation was to examine whether the duration of access to leisure items affects displacement. In this study, participants chose between preferred leisure items and the edible items that had previously been shown to displace those leisure items in a preference hierarchy. Duration of access to the leisure item was systematically increased across series to identify the magnitude at which leisure items became more preferred than edible items. Results indicate that as the duration of access to leisure items increases, displacement decreases.

A comparison of sources of baseline data for treatments of problem behavior following a functional analysis.

It is common practice in research on the treatment of problem behavior to compare levels of targeted behaviors during treatment to levels when treatment is not in place. Some researchers use data collected as part of a multielement functional analysis as the initial baseline, whereas others collect new baseline data following completion of the functional analysis. We evaluated whether the source of baseline data influences the reliability and efficiency of decision-making. Results suggest that similar decisions are made in regard to treatment efficacy using the different sources of baseline data, but using data from a multielement functional analysis as baseline may save time. Interrater agreement was adequate, but lower for some graphs than has been observed in past studies. Several potential explanations for this discrepancy are discussed.

A Pilot Randomized Clinical Trial of a Multidisciplinary Intervention for Encopresis in Children with Autism Spectrum Disorder.

Children with autism spectrum disorder (ASD) are often delayed in achieving bowel continence, resulting in negative outcomes. In this pilot trial, 20 children with ASD and encopresis were randomly assigned to multidisciplinary intervention for encopresis (MIE; n = 10) or a waitlist control group (n = 10). The MIE group was treated for constipation and received a 10-day behavioral intervention that utilized suppositories to produce predictable bowel movements that were reinforced. Caregivers were trained to implement the intervention. Results support the feasibility of clinical trials of MIE, with high enrolment, competition, attendance, and caregiver acceptability. Preliminary outcomes were positive, with six of 10 in the MIE group achieving continence by the end of treatment compared to 0 in the control group (p = 0.005).Registered at clinicaltrials.gov (https://clinicaltrials.gov); ID: NCT02383732.

An Evaluation of Differential Reinforcement in the Treatment of Pica.

Common approaches to pica treatment involve intensive staffing and near continuous behavioral monitoring to proactively disrupt any attempts at this potentially life threatening behavior. Including differential reinforcement of discarding pica items as a contingency in such interventions has been suggested as a more practical treatment model, but the evidence base for this approach is limited. We replicated this work by evaluating differential reinforcement for discarding pica items in conjunction with response blocking and differential reinforcement of other behavior in the treatment of pica exhibited by two children. We extended this work by evaluating sustained reductions when therapist and caregiver monitoring was reduced.

Assessment and Treatment of Problem Behavior Maintained by Termination of Interruptions.

PURPOSE: Previous research has identified termination of interruptions to repetitive behaviour as a reinforcer capable of maintaining problem behaviour. Effective treatments have included functional communication training and multiple schedules of reinforcement. METHODS: In the present study, a functional analysis determined that the aggression of an eight-year-old boy with autism spectrum disorder was maintained by termination of interruptions of repetitive behaviour. An intervention was implemented consisting of differential reinforcement of other behaviour and response cost. RESULTS: The intervention produced and maintained a reduction in aggression and increased tolerance for interruptions of systematically increasing durations. CONCLUSIONS: This case study demonstrates an alternative approach to the treatment of problem behaviours such as aggression maintained by termination of repetitive behaviour that includes teaching the individual to tolerate interruption of repetitive behavior.

Using a Functional Analysis Followed by Differential Reinforcement and Extinction to Reduce Challenging Behaviors in Children With Smith-Magenis Syndrome.

Smith-Magenis syndrome (SMS) is a genetic disorder, commonly caused by a 17p11.2 deletion, affecting the Retinoic Acid Induced 1 gene. It affects approximately 1 in 25,000 individuals, with over 90% engaging in challenging behaviors. Function-based treatments, using the principles of applied behavior analysis, have consistently been shown to decrease challenging behaviors exhibited by individuals with developmental delays. However, additional research is needed to determine the effects of these interventions with specific diagnostic subsets, including SMS. The current study identified the function of challenging behavior for 2 children with SMS and found a function-based treatment, consisting of differential reinforcement and extinction, reduced challenging behavior for both.

A consecutive case series analysis of a behavioral intervention for enuresis in children with developmental disabilities.

Children with developmental disabilities (DD) are more likely than typically developing peers to have issues with enuresis. Past research has shown the success of behavioral treatments consisting of scheduled sits and reinforcement for continent voids. However, this research has included small sample sizes, while studies with larger numbers have lacked key information (i.e., baseline rates and follow-up data to evaluate maintenance and generalization). The current study conducted a consecutive case series analysis of 44 individuals with developmental disabilities who completed a 2-week program for enuresis. Results showed significant improvement in continent voids and follow-up data suggested positive results maintained when treatment was implemented by caregivers in a home environment.

Using caregiver report on the impact of challenging behavior exhibited by children with autism spectrum disorder to guide treatment development and outcomes.

Objectives: Evaluations of treatments using applied behavior analysis (ABA) for challenging behavior have relied mostly on direct behavioral observation. While observation is crucial, qualitative information can also be beneficial. In this study, we describe methods for using qualitative information in ABA treatments for challenging behavior. Method: Three participants were undergoing treatment for challenging behavior. Information was collected through caregiver interviews at the start and end of the admission. Directed content analysis identified themes in the interviews and we compared treatment outcomes using qualitative and quantitative measures. Results: Three themes emerged: description, frequency, and impact of the behavior. Quantitative and qualitative measures both suggested successful interventions for two participants. For the third, direct observation suggested treatment was effective while caregiver report did not. Conclusion: Incorporation of qualitative information into outcomes allowed for a more comprehensive view of treatment success and guided assessment and treatment decisions. Treatments based on applied behavior analysis (ABA) are commonly studied for the treatment of challenging behavior, but these studies rely mostly on direct behavioral observation. While observation is crucial, qualitative information is also useful in ensuring meaningful results. In this study, we describe a method of collecting, analyzing, and using qualitative information collected from caregivers and compare qualitative to quantitative outcomes.