Long-term follow-up of telehealth-enabled behavioral treatment for challenging behaviors in boys with fragile X syndrome.

BACKGROUND: A significant proportion of boys with fragile X syndrome (FXS), the most common known genetic cause of intellectual disability, exhibit challenging behaviors such as aggression and self-injury that can cause significant distress to families. Recent evidence suggests that coaching caregivers to implement functional communication training (FCT) with their child via telehealth can help to ameliorate these behaviors in FXS. In the present study, we followed families who had participated in our previous randomized controlled trial of FCT to evaluate the longer-term effects of FCT on challenging behaviors in this population. METHODS: In study 1, follow-up emails, phone calls, text messages, and letters were sent to caregivers of 48 boys with FXS who had completed our previous study conducted between 2016 and 2019. The main outcome measures administered at follow-up were the Aberrant Behavior Checklist-Community (ABC-C) and the Parenting Stress Index, 4th Edition (PSI-4). In study 2, families who had received FCT treatment but whose child exhibited challenging behaviors daily at follow-up received a 1-h parent training booster session to determine whether the intervention effect could be recovered. RESULTS: Sixteen (66.7%) of 24 families who had received FCT treatment and 18 (75.0%) of 24 families who had received treatment as usual were traced and consented between March and August 2021. The mean follow-up time was 3.1 years (range, 1.4 to 4.2 years). Longitudinal mixed effects analyses indicated that boys who had received FCT were more likely to show improvements on the irritability and lethargy/social withdrawal subscales of the ABC-C over the follow-up interval compared to boys who had continued with treatment as usual. Four of the six boys who had received the booster parent training session via telehealth were reported to exhibit fewer forms of challenging behavior at a 4-week follow-up. CONCLUSIONS: Empowering parents to implement behavior analytic treatments with their child in their own home can have durable effects on maintaining low levels of challenging behaviors in boys with FXS. These data further support the need to implement parent-mediated interventions for challenging behaviors in this population at an early age. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03510156 . Registered 27 April 2018.

Conducting In-Home Functional Analyses of Aggression and Self-Injury Exhibited by Boys with Fragile X Syndrome.

OBJECTIVE: Boys with fragile X syndrome (FXS) are at increased risk for exhibiting aggression and self-injury that can be extremely disruptive to families. Few studies, however, have examined the extent to which social-environmental factors can influence these behaviors, particularly in home settings. METHODS: Caregivers of 32 boys with FXS, aged 3 to 10 years, were coached by a board-certified behavior analyst to implement a functional analysis (FA) with their child in their home over 2 days. The functions identified in the FAs were validated by behavioral interventions conducted through telehealth over 12 weeks. RESULTS: Social functions for aggression and self-injury were identified in 29 (90.6%) cases, with the most common functions identified being escape from demands/transitions and/or tangible reinforcement. Subsequent function-based behavioral interventions (i.e., functional communication training) implemented for 22 cases by telehealth resulted in decreased rates of aggression and self-injury by 74% to 100%. CONCLUSION: These data underscore the significant impact that social-environmental factors can have on the development and maintenance of aggression and self-injury in FXS. Conducting early home-based behavioral interventions designed to increase functional communication skills may therefore be an effective solution for the treatment of aggression and self-injury in FXS in the long term.

The effects of transition to technician-delivered telehealth ABA treatment during the COVID-19 crisis: A preliminary analysis.

Telehealth delivery of applied behavior analysis treatment has focused on supervision or staff and parent training, rather than the direct delivery of treatment to clients. The novel coronavirus (COVID-19) crisis had the potential to significantly disrupt access to direct treatment for individuals with autism. We report a sample of 17 cases that transitioned from in-person to telehealth delivery of treatment when shelter-in-place orders were issued. Of these cases, 76% of participants transitioned to technician-delivered telehealth services whereas the rest transitioned to a caregiver-implemented telehealth model. Participants continued to access a similar dosage of treatment hours per week in spite of the treatment model transition (in-person M = 12; telehealth M = 11) and maintained or improved correct independent responding across all targets from in-person treatment (M = 75%) to telehealth treatment (M = 80%). These findings provide initial evidence that some clients with autism benefit from technician-delivered telehealth services.

Interpreting functional analysis outcomes using automated nonparametric statistical analysis.

Current methods employed to interpret functional analysis data include visual analysis and post-hoc visual inspection (PHVI). However, these methods may be biased by dataset complexity, hand calculations, and rater experience. We examined whether an automated approach using nonparametric rank-based statistics could increase the accuracy and efficiency of functional analysis data interpretation. We applied Automated Nonparametric Statistical Analysis (ANSA) to a sample of 65 published functional analyses for which additional experimental evidence was available to verify behavior function. Results showed that exact behavior function agreement between ANSA and the publications authors was 83.1%, exact agreement between ANSA and PHVI was 75.4%, and exact agreement across all 3 methods was 64.6%. These preliminary findings suggest that ANSA has the potential to support the data interpretation process. A web application that incorporates the calculations and rules utilized by ANSA is accessible at https://ansa.shinyapps.io/ansa/.

The Role of Compassion and Ethics in Decision Making Regarding Access to Applied Behavior Analysis Services During the COVID-19 Crisis: A Response to Cox, Plavnick, and Brodhead.

Cox, Plavnick, and Brodhead (2020, "A Proposed Process for Risk Mitigation During the COVID-19 Pandemic") published a position statement in the emergency section of Behavior Analysis in Practice in response to the COVID-19 crisis. They argued against a blanket interpretation that in-person applied behavior analysis services for all patients should continue during the pandemic. They strongly argued that the risks of continued services are almost always prohibitive and that only in rare cases would the continuation of in-person services be warranted. Colombo, Wallace, and Taylor (2020, "An Essential Service Decisions Model for Applied Behavior Analytic Providers During Crisis") soon thereafter published a response to the article pointing out the potential dangers associated with the position of the article by Cox et al. They included a detailed decision model to assist providers in making nuanced and informed data-based decisions that provide the opportunity to honor the ethical responsibility for not abandoning patients. We echo the importance of the Colombo et al. response and add points of response centered on balanced ethical decision making informed by compassionate family-centered care.

Telehealth-enabled behavioral treatment for problem behaviors in boys with fragile X syndrome: a randomized controlled trial.

BACKGROUND: Children with fragile X syndrome (FXS) are at increased risk for exhibiting problem behaviors such as aggression and self-injury. However, many children with FXS have limited access to behavioral treatments that have known efficacy due to the low availability of treatment providers and the wide geographical dispersion of families with FXS across the country. Telehealth may offer a cost-effective and practical solution to overcome these significant barriers. We examined the effect of administering an established behavior analytic intervention called functional communication training (FCT) via telehealth on levels of problem behaviors exhibited by boys with FXS. We also examined treatment acceptability, as well as the effect of the treatment on levels of parenting stress. METHODS: Boys with FXS, aged 3 to 10 years, who displayed problem behaviors daily, were randomized to receive FCT via telehealth (n = 30) or treatment as usual (n = 27) over 12 weeks. Outcome measures included in-session observations of problem behavior, the Aberrant Behavior Checklist-Community (ABC-C), the Treatment Acceptability Rating Form-Revised (TARF-R), and the Parenting Stress Index, 4th edition (PSI-4). RESULTS: Intention-to-treat analyses indicated that scores on the irritability subscale of the ABC-C, our primary outcome measure, decreased significantly for boys who received FCT via telehealth compared to boys who received treatment as usual (p < .001, Cohen's d = 0.65). In-session observations conducted for those who received treatment showed that levels of problem behavior decreased by 91% from baseline. Levels of parenting stress related to child behavioral problems were also lower following FCT treatment, and caregivers reported that the intervention was acceptable. CONCLUSIONS: These findings support telehealth-enabled FCT as a framework for expanding access to behavioral treatments for problem behaviors in children with FXS. Expanded delivery of behavior analytic treatment via telehealth also has the potential to lower healthcare costs, improve child and family quality of life, and lead to advances in the treatment of problem behavior in the broader population of individuals with neurodevelopmental disorders. TRIAL REGISTRATION: ClinicalTrials.gov, NCT03510156 . Registered 27 April 2018.

Telehealth Delivery of Function-Based Behavioral Treatment for Problem Behaviors Exhibited by Boys with Fragile X Syndrome.

Telehealth is increasingly being employed to extend the reach of behavior analytic interventions to families of children with developmental disorders who exhibit problem behaviors. In this preliminary study, we examined whether function-based behavior analytic interventions could be delivered via telehealth over 12 weeks to decrease problem behaviors exhibited by ten boys with fragile X syndrome (FXS), aged 3- to 10-years. Results showed that for eight children who completed treatment, rates of problem behavior decreased from baseline by 78.8-95.3%. Parent procedural integrity and acceptability ratings remained high throughout the treatment. These data indicate that implementing function-based behavioral treatment via telehealth can be a feasible, acceptable and potentially cost-effective approach for decreasing problem behaviors exhibited by boys with FXS.

Sibling-Implemented Script Fading to Promote Play-Based Statements of Children with Autism.

We trained three typically developing children to implement a script-fading procedure with their younger siblings with autism. The number of contextually appropriate statements made by the children with autism increased once treatment was initiated. Participants continued to emit higher levels of contextually appropriate statements after the scripts were completely faded and at a 4- or 11-week follow-up. The typically developing siblings were able to implement the script-fading procedure with high levels of fidelity.

An evaluation of photographic activity schedules to increase independent playground skills in young children with autism.

We used photographic activity schedules to increase the number of play activities completed by children with autism during unstructured time on the playground. All 3 participants engaged in more playground activities during and after training, and they continued to complete activities when novel photographs were introduced.

Interactive computer training to teach discrete-trial instruction to undergraduates and special educators in Brazil: A replication and extension.

Discrete-trial instruction (DTI) is a behavioral method of teaching young children with autism spectrum disorders (ASD) that has received a significant amount of research support. Because of a lack of qualified trainers in many areas of the world, researchers have recently begun to investigate alternative methods of training professionals to implement behavioral teaching procedures. One promising training method is interactive computer training, in which slides with recorded narration, video modeling, and embedded evaluation of content knowledge are used to teach a skill. In the present study, the effectiveness of interactive computer training developed by Pollard, Higbee, Akers, and Brodhead (2014), translated into Brazilian Portuguese, was evaluated with 4 university students (Study 1) and 4 special education teachers (Study 2). We evaluated the effectiveness of training on DTI skills during role-plays with research assistants (Study 1) and during DTI sessions with young children with ASD (Studies 1 and 2) using a multiple baseline design. All participants acquired DTI skills after interactive computer training, although 5 of 8 participants required some form of feedback to reach proficiency. Responding generalized to untaught teaching programs for all participants. We evaluated maintenance with the teachers in Study 2, and DTI skills were maintained with 3 of 4 participants.

The use of linked activity schedules to teach children with autism to play hide-and-seek.

Linked activity schedules were used to establish appropriate game play in children with autism during a game of hide-and-seek. All 6 participants demonstrated acquisition of appropriate play skills in the presence of the activity schedules and maintained responding during subsequent phases. When the schedules were removed, responding decreased to baseline levels, demonstrating that the schedules controlled responding. Implications for future research on the use of activity schedules to teach social behavior are discussed.

An evaluation of interactive computer training to teach instructors to implement discrete trials with children with autism.

Discrete-trial instruction (DTI) is a teaching strategy that is often incorporated into early intensive behavioral interventions for children with autism. Researchers have investigated time- and cost-effective methods to train staff to implement DTI, including self-instruction manuals, video modeling, and interactive computer training (ICT). ICT combines the best components of self-instruction manuals and video models, and have the same benefits; however, there is limited research on this training method. Therefore, the purpose of this study was to investigate ICT to teach university students to implement DTI with children with autism. All participants' teaching fidelity increased during both role-plays with an adult and instructional sessions with a child with autism. In addition, participants demonstrated an increase in teaching fidelity with untrained instructional programs. All participants were able to complete training in an average of 2 hr, and social validity ratings were high.

Script fading to promote unscripted bids for joint attention in children with autism.

We used a script-fading procedure to teach 3 children with autism to initiate bids for joint attention. We examined the effects of (a) scripts, (b) varied adult scripted responses, and (c) multiple-exemplar script training on promoting unscripted language during bids for joint attention. All 3 participants learned to initiate bids for joint attention, and the response generalized to untrained stimuli, conversation partners, and the classroom environment.

Increasing response variability of mand frames with script training and extinction.

We examined the effects of script training and extinction on response variability of mand frames used by children with autism. Results demonstrated that extinction following script training was effective for increasing variability for 2 of the 3 participants.