Assessment and Treatment of Severe Introduction to Problem Behavior - PDF document

Assessment and Treatment of Severe Introduction to Problem Behavior in Problem Behavior Children with ASD Joanna Lomas Mevers, PhD, BCBA-D Program Manager-Severe Behavior Clinics Assistant Professor Division of Autism and Related Disorders Emory School of Medicine Autism & Pro ble m Be havio r Co re Sympto ms o f Autism Autism Spectrum • Problem behavior is not a core symptom of autism Disorder Deficits in Social Restricted and Repetitive Subtypes • What are the core symptoms of autism? Communication and Patterns of Behavior Interactions and/or Interests With Cognitive With Language Impairment Impairment Ho w ASD re late s to Pro ble m Be havio r Poor Peer Problem Behavior to Avoid Social Relations Interactions Problem Behavior: What are we talking about Difficulty Asking Problem Behavior Related to for a Break Demands Elopement ( running away or leaving Aggression (hitting, kicking, biting, etc.) supervision) . . Problem Behavior When these Repetitive Interests Self-injurious behavior Stereotypy ( hand flapping, body rocking, Interests are Interrupted Text supporting the main idea. (head hitting, biting self, hand mouthing) spinning objects) . Disruption (crying, yelling, spitting) Pica ( eating inedible objects) Stereotyped Motor Repetitive Behaviors can become . . Behaviors Self-Injurious Property Destruction (throwing materials, Rumination (regurgitating food) breaking things) . Stereotyped Verbal Can become Disruptive to Other Behaviors Students

F ac to rs So me time s Use d to De te rmine T re atme nt • Diagnosis • Example: Autism vs Down Syndrome • Topography • Hitting other vs disruptive behavior • Function • Access to attention vs escape from work Re latio nship be twe e n Diag no sis Vig ne tte : T im and T re atme nt • Tim has autism • Not the same as medicine • He doesn’t have much communication • In medicine, Diagnosis X = Treatment Y • Tim hits his parent • Example: if you have a particular type of cancer then you need a certain kind of chemotherapy • Sometimes he hits them when they make him turn off the television • Treatments for problem behavior do not entirely depend on diagnosis • Sometimes he hits them when they tell him he has to brush his teeth • Different treatments are often developed for kids with the same diagnosis

Re latio nship be twe e n T o po g raphy and T re atme nt Vig ne tte : T im • Topographically Prescribed Treatment: • Topography is less relevant than most people think – Hitting = time out • Topographically prescribed treatments: • When Tim hits his parents after his parents turn off • Problem behavior X = treatment Y the television he goes to time out “When I hit, not only do I not get to watch television, • Example: biting = time out I don’t get to do anything!” • Every time a child bites you should put him in time out • When Tim hits his parents after being told to brush his teeth he goes to time out “When I hit I don’t have to brush my teeth. YAY!!!” F ac to rs So me time s Use d to F unc tio n o f Pro ble m Be havio r De te rmine T re atme nt Function = the reinforcers that maintain a response = • Diagnosis Why problem behavior occurs Function Treatment • Topography X Y • Function Attention Ignoring Function Cycle of Problem Behavior Vig ne tte : T im Function-based Treatment: • Mom asks Tim to Mom learns that brush his Hitting maintained by access to preferred activities = time out  if she lets Tim teeth get out of things he will stop Hitting maintained by escape from demands = follow through  hitting with demand Tim stops Tim hits mom When Tim hits his parents after his parents turn off the hitting • television he goes to time out “When I hit, not only do I not get to watch television, I don’t get to do anything!” Mom stops Tim learns that When Tim hits his parents after being told to brush his • asking Tim to hitting gets him teeth they follow through and make sure he brushes his brush his teeth out of things teeth “When I hit I still have to brush my teeth”

How to Identify the Function of Problem Behavior Functional Behavior Assessment: Procedures to identify • the function of problem behavior Major categories of FBA: • Identifying Function Non Experimental (2 Types) 1. Indirect: no observation (questionnaires, interviews) – Descriptive: passive observation – Experimental Functional Analysis (Analog) 2. Direct observation controlling what happens before and after – problem behavior (antecedents and consequences) “Experimental” Functional Analysis Factors that Affect Function • “Experimental” or “Analog” Functional Analysis 1 • Antecedents (what happens before the behavior) – Experimental: environment is changed so only one • Consequences (what happens after the behavior) thing changes at a time – Analog: analog to the natural environment Behavior Behavior Behavior Consequence Antecedent • The “gold-standard” for functional behavioral What happened after What happened prior to of concern of concern of concern the behavior was the behavior of concern assessments demonstrated – Treatments based on functional analyses are more effective than those that are not 2 1 Iwata, Dorsey. Slifer, Bauman and Richman, 1984/1992 2 Heyvaert, Saene, Campbell, Maes and Onghena, 2014 Communication and Problem “Experimental” Functional Analysis Behavior 4.0 Challenging behavior can be a very effective way for • individuals to communicate Problem Behavior Per Minute 3.0 Challenging behavior usually serves a purpose for the • individual Attention Severe Behavior Toy Play 2.0 Tangible Problems Escape Ignore Social Sensory Escape Tangible 1.0 Attention Functional Analysis is an assessment to determine what • 0.0 the individual is trying to communicate with problem 0 5 10 15 20 25 30 35 40 45 behavior Sessions

Common Treatments • Functional Communication Training 1 Teaching alternative way to access the functional • reinforcer via communication (e.g., teach child to ask Treatment of Severe Problem Behavior for favorite toy) Example FCT • 1 Carr and Durrand, 1985 Common Treatments Other Common Treatments • Differential Reinforcement of Other Behavior 1 • Differential Reinforcement of Alternative Reinforcement is delivered when the target behavior • Behaviors 1 has not occurred for a specific period of time (e.g., child has to go a set amount of time without engaging Reinforcement of a more appropriate replacement • in the target behavior to receive reinforcement) behavior (e.g., compliance) • Token Economics 2 Example DRA Compliance • Earn tokens that are exchangeable for back-up • reinforcers 1 Petscher, Rey, & Bailey, 2009 1 Homer and Peterson, 1980 2 Hackenburg, 2009 Extinction Side Effects of Extinction • No longer providing reinforcement for a behavior • Extinction bursts • Extinction of responses maintained by… – Around 40% of the time there will be a temporary increase in the intensity or variability of responding – Positive reinforcement: do not allow the child to have before there is a decrease the item, food, activity, or interaction • Potential for intermittent schedules of reinforcement – Example Tangible Extinction – Reinforcing some but not all responses will result in – Negative reinforcement: do not allow the child to get higher rate behaviors that are even harder to extinguish out of doing a task or avoid something he/she doesn’t like • Problem behavior temporarily comes back Lerman, Iwata, & Wallace,1999 – Example Escape Extinction Lerman, Iwata, & Wallace,1999

Example of FCT Baseline FCT Baseline FCT 6 Problem Behavior Per Minute 4 2 Making Treatment Work 80%= 0.70 80%= 0.70 0 in the Real World 0 10 20 30 Baseline Baseline FCT FCT Baseline FCT Baseline FCT 6 MULTIPLE MULTIPLE + + FCT + FCT + Communication Per Minute 6 6 EXT BL EXT BL SCHEDULE SCHEDULE wiggles car, bubbles, playdoh, backpack wiggles car, bubbles, playdoh, backpack EXT EXT 5 5 Functional Communication Functional Communication MANDS S delta MANDS S delta 4 Responses per Minute Responses per Minute 4 4 MANDS Sd MANDS Sd 3 3 2 2 2 1 1 0 0 0 0 0 0 10 10 20 20 30 30 40 40 10 50 50 60 60 70 70 80 80 90 90 100 100 20 110 110 120 120 130 130 140 140 150 150 30 Marcus Autism Center Sessions Sessions Sessions Teaching the individual to tolerate not Next Steps getting what they want • Teaching the individual to tolerate when they can’t • Discriminative Stimuli have what they want Teach using a stimulus when reinforcement is and is • not available • Generalization to the natural environment (e.g., home and community settings) • Schedule Thinning • Caregiver Training Increasing the number of responses or the duration • before reinforcement can be accessed Increasing Social Validity Outcomes for Behavioral Treatments • Generalization: spreading the effects of reinforcement across stimulus conditions • Effect size of behavioral intervention for pica 1 : Across people • 1.8 Across settings • • Effect size of behavioral intervention for To additional problem behaviors • elopement 2 : • Expand the number/variety of alternative 2.1 behaviors: to establish access to a greater variety of reinforcers and a larger community of listeners 1 Call, Simmons, Lomas Mevers, & Alvarez, 2015 2 Call, Alvarez, & Lomas Mevers, under review