Behavioral Momentum Theory: a Tutorial on Response Persistence.

Behavioral momentum theory (BMT) provides an integrative framework for evaluating the strength of a response when it contacts a disruptor, such as the discontinuation of reinforcement (i.e., extinction). Grounded in Newtonian physics, BMT distinguishes response rate (behavioral velocity) from response strength or persistence (behavioral mass). Behavioral velocity is affected by response-reinforcer contingencies, whereas behavioral mass is affected by stimulus-reinforcer contingencies (Nevin and Wacker 2013). We describe the determiners of behavioral mass, as well as common sources of disruption that are used to measure behavioral mass. Learning activities are embedded throughout this discussion to help readers better understand BMT and its implications for practice across a range of contexts.

Preliminary evaluation of behavior technician burnout when working with boarded and traditional psychiatric inpatients diagnosed with developmental disabilities.

PROBLEM: The COVID-19 pandemic has led to a youth mental health crisis, with research demonstrating an increased prevalence of depression, anxiety, and disruptive behavior in youth compared to pre-pandemic years. Consequently, the insurgence of emergency psychiatric evaluations has increased the demands for extended inpatient stay (or patient boarding) at various licensed treatment facilities. Questions remain about the extent of burnout being experienced by behavior technicians who are caring for these patients. METHODS: The Shirom-Melamed Burnout Measure was used to evaluate symptoms of burnout of behavior technicians practicing at a specialized psychiatric inpatient unit. Comparisons were made for instances of caring for boarded (meeting criteria for discharge but unable to be discharged due to disposition) and traditional patients (short-term treatment). FINDINGS: Behavior technicians caring for boarded patients reported significantly higher scores in overall stress, physical exhaustion, cognitive fatigue, and emotional exhaustion than those managing patients getting traditional care. CONCLUSIONS: Extensive burnout can have adverse impacts at both the personal level (staff well-being, individual staff-patient interactions) and clinic level (daily operations and service, general quality of care). Efforts need to be made to address this issue to prevent staff turnover.

Evaluating Adolescent Patient Outcomes and Staff Member Injuries at a General Psychiatric Inpatient Unit.

Short-term pediatric psychiatric hospitalization is used to manage acute-crisis behaviors. Few studies have detailed their clinical model and key metrics such as patient behavioral health outcomes and staff experience. This study describes a model which emphasizes group therapy based on dialectical behavior therapy during brief inpatient stays (average length of stay of 8 days). The study variables assessed included patient symptoms of depression, anxiety, and anger at discharge, patient satisfaction, and staff safety. The program produced significant improvements in adolescent depression, anxiety, and anger, and patients reported high satisfaction with the services received. However, there was a high rate of staff injuries, correlated with staffing ratios and the time of day. The key findings from this study demonstrate the effectiveness of brief inpatient programs and highlight variables that may impact staff experiences on these units, which could serve as further discussion points to improve clinical care.

Cannabidiol for treatment of Irritability and Aggressive Behavior in Children and Adolescents with ASD: Background and Methods of the CAnnabidiol Study in Children with Autism Spectrum DisordEr (CASCADE) Study.

Introduction: Autism spectrum disorder (ASD) is a neurodevelopmental disorder commonly associated with behavioral challenges. There are few evidence based pharmacological interventions available for the treatment of behavioral symptoms associated with ASD. Cannabidiol (CBD), the non-psychoactive component of cannabis, has potential neuroprotective, antiepileptic, anxiolytic, and antipsychotic effects and may be useful in treating the behavioral symptoms of ASD. Methods: We describe the research methods of a 27-week double-blind placebo-controlled cross-over trial of cannabidiol for the treatment of irritability and aggression associated with ASD, utilizing the irritability subscale of the Aberrant Behavior Checklist-2nd edition (ABC-2) as the primary outcome measure. Adverse effects and safety monitoring protocols are included. Several secondary and exploratory outcomes measures also include anxiety, communication, repetitive behaviors, attention, hyperactivity, autism family experience, and telehealth functional behavior assessment. Conclusion: There is a significant need for clinical research exploring alternative medications for the treatment of behavioral symptoms of ASD. Cannabidiol (CBD) is being studied for the management of irritability, aggression, and other problem behaviors associated with ASD.

Training direct-care staff to implement sensory integration strategies on a psychiatric inpatient unit.

PROBLEM: Despite the importance of sensory integration therapy on psychiatric inpatient units, there continues to be a paucity of trained providers that can delivery this service to patients. METHOD: This study evaluated components of a training program to teach nurses and direct-care staff appropriate use of sensory integration strategies. Using the research team as confederates, we collected data on how three direct-care staff used sensory integration strategies across two conditions and with a patient admitted to the unit. Next, we implemented the didactic-only training, which provided education for when to use different aspects of the sensory room. Finally, we transitioned to a condition in which feedback supplemented the didactic training. FINDINGS: Before training and following the Didactic Only Training condition, accuracy was low for all participants. All three participants' accuracy with using sensory integration strategies improved and maintained when they implemented the strategies with a patient after completing the combined intervention. We were able to use the combined intervention to improve two additional direct-care staff's accuracy. CONCLUSIONS: Staff training incorporating didactic training plus feedback was most effective for training appropriate use of sensory integration strategies. We also discuss the importance of having performance-based measures to track occurrence of important skills.

Use of the Performance Diagnostic Checklist-Human Services to Assess Hand Hygiene Compliance in a Hospital.

Poor hand hygiene in hospital settings leads to the spread of communicable disease to a population of individuals already medically compromised. The current study used the Performance Diagnostic Checklist-Human Services to develop an intervention targeting hand hygiene compliance for nine participants employed by an inpatient unit. The use of performance feedback and goal setting improved hand hygiene compliance when compared to baseline for eight of nine participants. Results are discussed in terms of strategies for using performance analysis to identify effective interventions to address performance deficits.

Relations between patient and staff member characteristics and staff member injury on a psychiatric inpatient unit for children with intellectual or developmental disabilities.

PROBLEM: Staff member injuries are a pervasive and long-standing problem for psychiatric inpatient units. METHOD: The current study analyzed the prevalence of staff member injury and characteristics of patients that injured staff on a specialized psychiatric unit for children with intellectual or developmental disabilities. We evaluated staffing patterns as well as characteristics of patients (e.g., diagnoses, body mass index) between 2016 and 2018. This time period was selected because it represented an approximately equal period before and after the introduction of a new clinical model that incorporated applied behavior analysis (ABA) and other safety-related practices (e.g., personal protective equipment). FINDINGS: During this study period, there were 110 cases of staff injuries caused by 42 patients. Injuries were most likely to occur during physical management of a patient engaging in aggressive behavior, but less so when strategies requiring less physical contact were implemented. The frequency of staff injury was also significantly related to patients' diagnoses, particularly those exhibiting aggressive behavior and diagnosed with moderate-to-severe intellectual disability and/or autism spectrum disorder. CONCLUSIONS: Robust staff training incorporating the principles of ABA and the provision of other safety-related resources can be integrated to clinical guidelines to promote the safety of staff practicing in psychiatric inpatient units.

A Randomized Controlled Trial of Functional Communication Training via Telehealth for Young Children with Autism Spectrum Disorder.

Many children with autism spectrum disorder (ASD) have problem behaviors that interfere with learning and social interaction. This randomized controlled trial compared treatment with functional communication training (FCT) to "treatment as usual" for young children with ASD (n = 38, ages 21-84 months). FCT was conducted by parents with training and real-time coaching provided by behavioral consultants using telehealth. FCT treatment via telehealth achieved a mean reduction in problem behavior of 98% compared to limited behavioral improvement in children receiving "treatment as usual" during a 12-week period. Social communication and task completion also improved. For children with ASD and moderate to severe behavior problems, parent-implemented FCT using telehealth significantly reduced problem behavior while ongoing interventions typically did not.

Management of Self-injurious Behaviors in Children with Neurodevelopmental Disorders: A Pharmacotherapy Overview.

Neurodevelopmental disorders (NDDs), a group of disorders affecting ~1-2% of the general population, are caused by changes in brain development that result in behavioral and cognitive alterations, sensory and motor changes, and speech and language deficits. Neurodevelopmental disorders encompass a heterogeneous group of disorders including, but not limited to, Smith-Magenis syndrome, Lesch-Nyhan disease, cri du chat syndrome, Prader-Willi syndrome, pervasive developmental disorders, fragile X syndrome, Rett syndrome, Cornelia de Lange syndrome, and Down syndrome. Self-injurious behaviors (SIBs) are common in children with NDDs; depending on the specific NDD, the incidence of SIBs is nearly 100%. The management of SIBs in this population is complex, and little high-quality data exist to guide a consistent approach to therapy. However, managing SIBs is of the utmost importance for the child as well as the family and caregivers. Behavior therapies must be implemented as first-line therapy. If behavioral interventions alone fail, pharmacotherapy becomes an essential part of management plans. The limited available evidence for the use of common pharmacologic agents, such as second-generation antipsychotics, and less common agents, such as clonidine, n-acetylcysteine, riluzole, naltrexone, and topical anesthetics, is reviewed. Additional data from well-designed studies in children with NDDs are needed to gain a better understanding of this common and troublesome problem including efficacy and safety implications associated with pharmacotherapy. Until then, clinicians must rely on the limited available data, clinical expertise, and ongoing systematic monitoring when managing SIBs in children with NDDs.

Improving Accuracy of Data Collection on a Psychiatric Unit for Children Diagnosed With Intellectual and Developmental Disabilities.

Data collection is a hallmark of effective behavior-analytic therapy. Collecting accurate data permits a behavior analyst to evaluate the effectiveness of behavioral treatment. The current study evaluated the use of a clicker, simplified observation, and a timer to improve accuracy of data collection on a psychiatric unit for children diagnosed with intellectual and developmental disabilities. Experiment 1, conducted within a combined multiple-baseline across-participants and reversal design, was an evaluation to identify an intervention package for four participants employed by the psychiatric unit. Interventions yielding the highest interobserver agreement (IOA) were highly individualized. Thus, we selected the most comprehensive intervention and exposed four additional participants to this intervention during Experiment 2. Results showed that this intervention improved IOA for these additional participants as evaluated within a multiple-baseline across-participants design. Results of the current study will be discussed to assist other behavior analysts in improving data-collection practices in hospital or school settings.

Remote treatment of sleep-related trichotillomania and trichophagia.

We used a biobehavioral treatment consisting of melatonin and a standardized bed and wake time to decrease one girl's head and mouth touches associated with sleep-related trichotillomania and trichophagia. We remotely coached the girl's caregiver to implement all procedures and monitored response to treatment using a DropCam Pro video camera equipped with night-vision capabilities. Head and mouth touches decreased, and her sleep pattern improved with the combination of treatment strategies. We discuss our use of a novel mode of service delivery to treat sleep-related problem behavior.

Further evaluation of differential exposure to establishing operations during functional communication training.

Recent research findings (DeRosa, Fisher, & Steege, ) suggest that minimizing exposure to the establishing operation (EO) for destructive behavior when differential reinforcement interventions like functional communication training (FCT) are introduced may produce more immediate reductions in destructive behavior and prevent or mitigate extinction bursts. We directly tested this hypothesis by introducing FCT with extinction in two conditions, one with limited exposure to the EO (limited EO) and one with more extended exposure to the EO (extended EO) using a combined reversal and multielement design. Results showed that the limited-EO condition rapidly reduced destructive behavior to low levels during every application, whereas the extended-EO condition produced an extinction burst in five of six applications. We discuss these findings in relation to the effects of EO exposure on the beneficial and untoward effects of differential reinforcement interventions.

Ethical Considerations When Delivering Behavior Analytic Services for Problem Behavior via Telehealth.

Delivery of healthcare services via telehealth has been growing in popularity, and work completed by behavior analytic researchers and practitioners have supported this trend. Behavior analysts at the University of Iowa Children's Hospital (UICH) developed a telehealth model of service delivery to build upon their already established in-clinic and in-home services. Results from their telehealth studies showed positive effects. Social functions were identified for most children, and problem behavior decreased by an average of 94.14%. Additionally, parent satisfaction was quite high, suggesting this mode of service delivery was acceptable to caregivers. Given the increasing empirical support for providing behavior analytic services via telehealth, careful consideration needs to be given to the numerous ethical issues involved in telehealth service delivery. The current article describes the telehealth service delivery model developed at UICH as well as the ethical issues considered at different points when delivering these telehealth services. Following these ethical considerations, implications for future research and clinical practice are discussed.

Comparisons of synthesized and individual reinforcement contingencies during functional analysis.

Researchers typically modify individual functional analysis (FA) conditions after results are inconclusive (Hanley, Iwata, & McCord, 2003). Hanley, Jin, Vanselow, and Hanratty (2014) introduced a marked departure from this practice, using an interview-informed synthesized contingency analysis (IISCA). In the test condition, they delivered multiple contingencies simultaneously (e.g., attention and escape) after each occurrence of problem behavior; in the control condition, they delivered those same reinforcers noncontingently and continuously. In the current investigation, we compared the results of the IISCA with a more traditional FA in which we evaluated each putative reinforcer individually. Four of 5 participants displayed destructive behavior that was sensitive to the individual contingencies evaluated in the traditional FA. By contrast, none of the participants showed a response pattern consistent with the assumption of the IISCA. We discuss the implications of these findings on the development of accurate and efficient functional analyses.

Telehealth and Autism: Treating Challenging Behavior at Lower Cost.

OBJECTIVE: To determine whether challenging behavior in young children with autism and other developmental disabilities can be treated successfully at lower cost by using telehealth to train parents to implement applied behavior analysis (ABA). METHODS: We compared data on the outcomes and costs for implementing evidence-based ABA procedures to reduce problem behavior by using 3 service delivery models: in-home therapy, clinic-based telehealth, and home-based telehealth. Participants were 107 young children diagnosed with autism or other neurodevelopmental disorders, and data analysis focused on the 94 children who completed treatment. RESULTS: All 3 service delivery models demonstrated successful reduction of problem behavior by training parents to conduct functional analysis and functional communication training. The mean percentage reduction in problem behavior was >90% in all 3 groups after treatment, and treatment acceptability based on parent ratings was high for all groups. Total costs for implementing treatment were lowest for home telehealth, but both telehealth models were significantly less costly than in-home therapy. CONCLUSIONS: This research demonstrated that parents can use ABA procedures to successfully treat behavior problems associated with autism spectrum disorders regardless of whether treatment is directed by behavior consultants in person or via remote video coaching. Because ABA telehealth can achieve similar outcomes at lower cost compared with in-home therapy, geographic barriers to providing access to ABA for treating problem behavior can be minimized. These findings support the potential for using telehealth to provide research-based behavioral treatment to any family that has access to the Internet.

Relations between rate of negative reinforcement and the persistence of task completion.

Research has shown that differential reinforcement of alternative behavior (DRA) can be an effective intervention to address problem behavior maintained by negative reinforcement emitted by young children. However, few studies have evaluated the variables that are related to long-term maintenance (i.e., persistence) of treatment effects. Research on behavioral persistence predicts that the rate of reinforcement provided for a target behavior is correlated with its persistence when challenged. There were 2 purposes of the current investigation. First, we evaluated the effects of the rate of negative reinforcement on the persistence of task completion. Second, we applied the findings regarding rate of reinforcement to a treatment context for 3 participants who engaged in destructive behavior that was reinforced by escape from demands. Results were evaluated within a multielement design and indicated that the rate of negative reinforcement had a moderate influence on the persistence of task completion. These results contribute to the existing literature by extending analyses of persistence to treatment contexts.

Assessment and treatment of pica and destruction of holiday decorations.

Problem behavior exhibited by individuals with autism can be disruptive to family traditions, such as decorating for the holidays. We present data for a 6-year-old girl who engaged in automatically reinforced pica and destruction of holiday decorations. Treatment was evaluated within an ABCDCD reversal design. During baseline (Phases A and B), we observed elevated rates of problem behavior. We implemented differential reinforcement of alternative behavior in Phase C to teach a response to compete with problem behavior. Little change in toy play or problem behavior occurred. In Phase D, we added a facial screen to the differential reinforcement procedures, which resulted in increases in toy play and decreases in problem behavior. Findings are discussed in terms of how interventions for problem behavior can promote alternative behavior while they facilitate household activities and traditions.

RESURGENCE OF MANDS FOLLOWING FUNCTIONAL COMMUNICATION TRAINING.

Experimental conditions similar to those described by Lieving and Lattal (2003) were used within two experiments to evaluate the resurgence of mands with humans. Two mands from the same operant class were trained with three participants with developmental disabilities during Experiment 1 and with two participants with developmental disabilities and a history of problem behavior during Experiment 2. The two mands were then placed on extinction. Both persisted, but showed different response strength during extinction. The mand with the weaker response strength was targeted for additional functional communication training and the alternative mand was placed on extinction. Following steady levels of occurrence of the targeted mand and no occurrences of the alternative mand, both mands were placed on extinction again. At least one instance of resurgence of the alternative mand occurred with every participant and resurgence of problem behavior occurred for both participants during Experiment 2.