Behavioral Approaches to the Treatment of Autism and Severe Behavior Disorders

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Behavioral Approaches to the Treatment of Autism
and Severe Behavior Disorders

• Wayne W. Fisher
• University of Nebraska Medical Centers
• Munroe-Meyer Institute

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Autism and Childhood Schizophrenia

• Once thought to be a form of schizophrenia
• Differs from schizophrenia in terms of symptoms,
  age of onset, family history, etiology, and
  response to treatment

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Definition of Autism

• markedly abnormal or impaired development in
• social interaction
• Communication
• and markedly restricted repertoire of activities
  and interests.

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Definition of Autism

• Definitions are cheap, but explanations are dear,
  and we must be careful not to confuse them.
• David Palmer, 2004

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Prevalence of Autism

• Typically diagnosed within first three years
• Recent estimate indicate that the prevalence of
  ASD is between 1 in 38 and
• 1 in 88
• Four times more prevalent in boys than girls

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Recurrence Risk for Siblings

• If an older sibling has and autism spectrum
  disorder, the risk for a
• Younger brother is 1 in 4
• Younger sister is 1 in 11

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NIH Research Dollars Devoted to Autism

• When Compared with Other Serious Childhood
  Conditions, Autism is Much More Common, but Fewer
  Dollars Per Case are Spent on Autism.

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Prevalence of Autism and Other Conditions (Number
of Cases per 10,000 Children)
70
60
50
40
30
20
10
0
Autism
Juvenile Diabetes
Muscular Dystrophy
Leukemia
Cystic Fibrosis
9

NIH Research Dollars for Autism and Other
Conditions (Number of Dollars per Case)
140,000
120,000
100,000
80,000
60,000
40,000
20,000
-
Autism
Juvenile Diabetes
Muscular Dystrophy
Leukemia
Cystic Fibrosis
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Unfortunately, you have what we call no
insurance.
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Demographics of Autism

• Affects all racial, ethnic, and national groups
• Family income, lifestyle, and educational levels
  do not affect the chance of autism's occurrence
• Diagnosis of autism is growing at a rate of 10-17
  percent per year (U.S. Department of Education,
  2002)

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Assessment and Diagnosis of Autism

• No medical tests for diagnosing autism
• Accurate diagnosis is based on observation of the
  individual's communication, behavior, and
  developmental levels.
• Autism Diagnostic Interview-R (ADI-R)
• Autism Diagnostic Observation Schedule (ADOS)
• Home and/or school observation
• Video analysis of behavioral observation

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Social Behavior Generally Requires Little or No
Explicit Training
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Assessment and Acquired Autism

• Autism is most often diagnosed between 2 and 5
  years of age.
• Thus, it is natural for parents to look for
  environmental events occurring shortly before
  this time that may have caused the autism, such
  as childhood vaccines.

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MMR Vaccines and Autism

• 10 of the original 13 authors of the
  investigation that started the controversy have
  retracted the studys interpretation, as has the
  journal, The Lancet
• Prevalence rates of autism are equivalent in
  children who have and have not been vaccinated.
• Increases in the prevalence of autism did not
  abate when thimerosal was removed from vaccines.
• Regression in autism is no more likely in the
  months after the MMR vaccine than in the months
  before the vaccine.

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Identifying the Genetic Bases of Autism Spectrum
Disorders

• Etiologic Workups Identify Specific Genetic
  Causes for Autism in About 20 of Cases.
• At the Munroe Meyer Institute, Shaefer and
  Colleagues (2006) have developed a 3-Tiered
  Approach that Identifies Genetic Causes in 40 of
  Cases.

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Associated Disorders
Autism ASD

• Mental Retardation 50
  15
• Seizure Disorder
  35 10
• Self-Injury, Aggression 50
• Tourette Disorder
• Bipolar Disorder

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Associated Etiologic Diagnoses

• Fragile-X syndrome
• Tuberous Sclerosis
• Williams syndrome
• Landau-Kleffner syndrome
• Congenital Rubella
• Smith-Magenis syndrome
• Neurofibromatosis

19
Genetics and Twin Studies

• Autism runs in families
• Heritability for autism is about 90
• Monozygotic twin concordance, 60-100
• Dizygotic twin concordance, 10
• Associated with abnormalities on chromosomes 7q,
  2q, and 15q

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Applied Behavior Analysis (ABA)

• What is ABA?
• How is it different from other approaches?
• How is it Done?

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How Effective is ABA for Autism?

• About 50 of Children with Autism and no More
  than Mild Mental Retardation who Receive Early
  Intervention with ABA Attain Normal IQs and are
  Educated in Regular Classrooms with Minimal
  Assistance.

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Outcomes of ABA for Autism
35
30
25
20
Increases in IQ Scores
r .79
15
p lt .02
10
5
0
0
5
10
15
20
25
30
35
40
45
Hours per Week of Treatment
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Cost-Benefit Analysis of Early, Intensive ABA
for Autism

• Average Lifetime Cost for a Person with Autism is
  over 4 million
• Average cost of Early, Intensive ABA is 150,000
  over about 3 years
• Average Lifetime Savings from ABA Treatment is
  Between 1.6 and 2.7 million

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Cost-Benefit Analysis of ABA treatment for
Severe Behavior Disorders

• Children with Autism and Severe Destructive
  Behavior Cost 8 million over a lifetime.
• Keeping just one child out of chronic care pays
  for treatment of hundreds more.
• Our treatment approach has over an 80 success
  rate.

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Case Example (Costs since 1986)
4,050,000
4000
3500
3000
2500
2000
Dollars in Thousands
1500
1000
500
85,924
0
Inpatient and Outpatient Costs
Residential Costs Over 25 Years
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Autism and Problem Behavior

• 98 of children with autism have one or more of
  the following problems
• Feeding problems
• Sleeping problems
• Tantrums
• Self-injurious behavior
• Aggression
• Dominick et al. (2007)

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Variables Related to Problem Behavior in Autism

• Lower IQ scores were associated more problem
  behaviors
• Lower expressive language scores were associated
  with more problem behaviors
• Increased social deficits were associated with
  more problem behaviors
• Dominick et al. (2007)

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• Functional Analysis and Treatment of Aberrant
  Behavior

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Structural vs. Functional Diagnosis

• Structural Approach
• How often a particular set of symptoms or
  responses cluster or covary.
• Functional Approach
• Whether and which environmental variables
  influence the response.

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Functional Analysis

• Identifies the environmental contexts in which
  aberrant behavior is likely and unlikely.
• Identifies the consequences that reinforce and
  maintain the behavior.
• Used to prescribe effective treatments.

38
Common Functions of SIB

• Social Positive Reinforcement (Attention,
  Tangible items)
• Social Negative Reinforcement (Escape)
• Automatic Reinforcement (e.g., Sensory
  Stimulation)

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Essential Features of Functional Analysis
Conditions

• Unique discriminative stimuli that signal the
  available of a specific reinforcer
• Establishing operation (EO) that increases
  motivation for the specific reinforcer
• An EO is an environmental condition that
  momentarily increases the effectiveness of a
  reinforcer and that evokes responses that have
  produced that reinforcer in the past.
• Contingency between the target behavior and the
  specific reinforcer

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Identifying the Essential Features of Functional
Analysis Conditions

• See if you can identify the discriminative
  stimulus, the establishing operation, and the
  reinforcement contingency in each of the
  following functional analysis conditions.

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Attention Condition

• Adult is busy reading. Child is expected to play
  quietly with toys.
• Adult attention shifts to child following SIB
  (e.g., Please dont hit yourself).
• Determines whether adult attention functions as
  reinforcement for SIB.

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Essential Features of the Attention Condition

• Discriminative Stimulus Adult is seated in a
  chair reading a book.
• EO Attention is unavailable.
• Contingency SIB produces attention.

43
Tangible Condition

• Adult takes preferred toys or leisure materials
  from the child and returns them following SIB.
• Determines whether access to preferred items
  functions as reinforcement for SIB.

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Essential Features of the Tangible Condition

• Discriminative Stimulus Adult takes and holds
  the preferred tangible item at the start of the
  session.
• EO Tangible item is unavailable in the absence
  of SIB.
• Contingency SIB produces the tangible item.

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Demand Condition

• Child is prompted to complete non-preferred tasks
  by an adult.
• The task is removed and the child is given a
  short break following SIB.
• Determines whether termination of non-preferred
  activities functions as reinforcement for SIB.

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Essential Features of the Demand Condition

• Discriminative Stimulus Instructional materials
  and demands are presented.
• EO Nonpreferred demands are presented.
• Contingency SIB results in temporary removal of
  the demands.

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Alone Condition

• Child is placed in a room alone without toys or
  materials.
• Indirectly assesses whether SIB may be maintained
  by automatic reinforcement (e.g., sensory
  stimulation).

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Essential Features of the Alone Condition

• Discriminative Stimulus Absence of another
  individual or materials.
• EO Alternative sources of stimulation are
  unavailable.
• Contingency SIB produces self-stimulation.

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Toy Play Condition

• Child and adult play together with preferred toys
  or leisure items.
• Adult delivers praise about once every 30 seconds
  for the absence of SIB.
• Designed to be an analogue of an enriched
  environment, which serves as a control condition.

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Essential Features of the Toy Play Condition

• Discriminative Stimulus Adult and toys are near
  the individual.
• EO (or AO) Attention and tangible items (toys)
  are freely available and no demands are
  presented.
• Contingency SIB produces no consequence.

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3
Attention
2
Per Minute
Aggressive Responses
Ignore
1
Demand
Tangible
Play
0
1
3
5
7
9
11
13
15
17
19
21
23
25
27
29
31
33
35
37
39
Sessions
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Functional Analysis of Covert Drug Ingestion

• Three Operant Hypotheses Generated After
  Caregiver Interview and Chart Review
• Attention/Excitement From Medical Procedures
• Attention From Mother
• Escape From Work Activities

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Functional Analysis of Covert Drug Ingestion
(cont.)

• Sessions Conducted in a Classroom and an
  Adjoining Medication Room Baited With Placebos in
  a Pillbox.
• Patient was Left Unsupervised in the Classroom
  With a Schoolwork Assignment.

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Functional Analysis of Covert Drug Ingestion
(cont.)

• In the Pillbox Were Four Pill Bottles Containing
  Placebos.
• Each Pill Bottle had a Uniquely Colored Label.
• Consuming Pills From Each Pill Bottle Produced a
  Specific Consequence.

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Functional Analysis of Covert Drug Ingestion
(cont.)

• Red Medical Attention
• Orange Attention From Mother
• Blue Rest Period (Escape)
• Yellow Control (Ignore)

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20
Escape From Work
15
Parent Attention
PILLS INGESTED PER MINUTE
10
Control
5
Medical Attention
LYLE
0
1
5
10
15
SESSIONS
FUNCTIONAL ANALYSIS
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Treatment of Escape-Maintained Drug Ingestion

• Lyle Earned Preferred, Nonwork Activities for
  Completing Scheduled Activities and Turning in
  Pills.
• He was Required to Complete His Least Preferred
  Work Activity (Shoe Polishing) if He Ingested
  Pills.

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Treatment Extension of Escape-Maintained Drug
Ingestion

• Lyle was Gradually Exposed to Different Settings
  where He was Observed and Supervised Less.
• Detection Methods Were Faded From Direct
  Observation to Pill Bottles With Residue and Then
  to Weekly Tox Screens.

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Functional Communication Training (FCT)

• Functional communication training (FCT) is a
  treatment commonly prescribed when a functional
  analysis has shown that an individuals problem
  behavior is maintained by social consequences
  (e.g., Carr Durand, 1985 Fisher et al., 1993
  Horner, Day, Sprague, OBrien, Heathfield,
  1991 Lalli, Casey, Kates, 1995 Wacker et al.,
  1990).

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Functional Communication Training (FCT)

• With FCT, the individual is taught a
  communicative response that produces access to
  the reinforcer responsible for maintenance of the
  problem.
• For example, an individual whose problem behavior
  is maintained by escape from tasks might be
  taught to request a break by signing finished
  (e.g., Hagopian, Fisher, Sullivan, Acquisto,
  LeBlanc, 1998).

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Unique Features of FCT

• FCT is a DRA procedure that
• specifies its reinforcer (i.e., a mand
  specifying the reinforcer that previously
  maintained problem behavior),
• requires minimal response effort,
• is initially reinforced on a dense schedule
  (e.g., FR 1),
• can recruit reinforcement across environmental
  contexts.

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Unique Features of FCT

• Because of the ease and consistency with which
  reinforcement can be obtained during FCT, some
  authors have suggested that the client
  controls the delivery of reinforcement (e.g.,
  Carr Durand, 1985).
• In addition, Carr and Durand suggested that
  control over reinforcement, contributed to the
  effectiveness of FCT.

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Unique Features of FCT

• Two investigations found that noncontingent
  reinforcement (NCR), which does not allow the
  client to control the schedule of reinforcement,
  and FCT, which does, produced equivalent
  reductions in problem behavior (Hanley, Piazza,
  Fisher, Contrucci, Maglieri, 1997 Kahng et
  al., 1997).
• Nevertheless, we found that participants
  preferred FCT over NCR when given a choice
  (Hanley et al., 1997).

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Unique Features of FCT

• FCT may promote generalization and maintenance
  because the communication response may prompt
  both trained and untrained caregivers to deliver
  differential reinforcement appropriately (e.g.,
  Durand Carr, 1991).

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Limitations of FCT

• Teaching the FCT response may evoke problem
  behavior (particularly if it is maintained by
  escape).
• Individuals may display the FCT response at
  exceedingly high rates (e.g., requesting a break
  from every school task).
• Individuals may request reinforcement at times
  when it is impossible or inconvenient to deliver
  (e.g., caregiver tending to an infant sibling).
  

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Selecting the Functional Communication Response
(FCR)

• The FCR should be simple.
• The FCR should produce the reinforcer identified
  during the functional analysis.
• The FCR should quickly remove the establishing
  operation for problem behavior.

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Training the Communication Response

• The communication response matches the function
  of the childs problem behavior.
• Demand -gt Break please.
• Attention -gt Play with me, please.
• Tangible -gt Toy please.

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Training the Communication Response

• Children who do not speak are often taught to use
  a picture-exchange communication response.
• Attention -gt Child hands over a picture of the
  adult and child playing together.
• Demand -gt Child hands over a picture of the child
  leaving a work table.

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Function-Based Extinction

• EXT (Att) Attention no longer follows the target
  behavior
• EXT (Tang) Tangible item is longer presented
  following the target behavior
• EXT (Esc) Demands continue following the target
  behavior
• EXT (Auto) The sensory consequences of the
  target response are eliminated or the response is
  prevented.

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Stimulus Control Refinements of FCT

• Controlling the establishing operation for
  problem behavior is particularly important during
  the early stages of treatment.
• Bringing the functional communication response
  under tight discriminative control is
  particularly important for increasing the
  practicality and generality of FCT.

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Study 1 Does strict control of exposure to the
establishing operation (EO) for problem behavior
facilitate the effectiveness of FCT?

• We compared FCT using a picture exchange (or card
  touch) as the FCR with a vocal FCR.
• The picture exchange version of FCT (FCT-card)
  allows strict control of the EO, because the
  therapist can immediately guide the FCR and
  deliver the reinforcer, which removes the EO.
• The vocal version of FCT (FCT-vocal) does not
  allow strict control of the EO, because one
  cannot guide a vocal response.

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Study 1 Procedures

• Following baseline, the two FCT treatments
  (FCT-card and FCT-vocal) were both introduced
  using a progressive time-delay procedure to teach
  each FCR.
• The two treatments were compared using a
  multielement phase.
• Following a return to baseline, the more
  effective treatment was re-introduced in the
  final phase.

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t 3.0 p .01
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Study 1 Conclusions

• The FCT-card card condition allowed better
  control of the EO for problem behavior.
• The FCT-card condition produced more rapid
  reductions in problem behavior.
• The FCT-vocal condition was associated with an
  extinction burst for one participant, which was
  not observed in the FCT-card condition.

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Controlling the EO While Training the
Communication Response

• When FCT is initiated, the communication response
  should always produce the reinforcer.
• If the child cannot do the response
  independently, we help them and then immediately
  deliver the reinforcer.

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Stimulus Control Refinements of FCT

• Controlling the establishing operation for
  problem behavior is particularly important during
  the early stages of treatment.
• Bringing the functional communication response
  under tight discriminative control is
  particularly important for increasing the
  practicality and generality of FCT.

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Schedule Thinning During Functional Communication
Training

• Signaled and unsignaled delayed reinforcement
  (Vollmer et al., 1999)
• Activities or alternative reinforcers during the
  reinforcement delays (Fisher et al., 1998 2000)
• Multiple schedules with reinforcement and
  extinction components (Betz et al., 2913 Fisher
  et al., 1998 Hanley et al., 2001)

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Typical Multiple-Schedule Training During FCT

• Quasi-random alternation between and FR-1
  schedule and EXT for communication
• Each component correlated with a specific signal
• Initially, the duration of the reinforcement
  component is 3 to 4 times longer than the EXT
  component
• Gradually, the EXT component is lengthened
  relative to the SR component

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FR1
Extinction
Decreases reinforcer deliveries by about 75
FADING STEPS
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Purpose

• To identify the necessary and sufficient
  components for the reinforcement schedule
  thinning
• Study 2 Evaluated the effects of
  contingency-correlated stimuli during FCT
• Study 3 Evaluated the necessity of systematic
  and gradual fading steps during schedule thinning
  under multiple schedule components
• Study 4 Evaluated the extent to which
  contingency-correlated stimuli facilitated
  generalization across therapists and environments

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Functional Analysis and FCT Treatment Evaluations

• Prior to Studies 2, 3, and 4, we conducted
  functional analyses to show that problem behavior
  was reinforced by social positive reinforcement
  for all participants.
• We also conducted treatment evaluations using an
  ABAB design to show that FCT was an effective
  treatment.

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Study 2 Are contingency-correlated stimuli
necessary?

• Compared rates of FCR and problem behavior under
  equivalent mixed and multiple schedules using an
  ABAB design
• Mixed FR-160 s / EXT60 s
• Multiple FR-160 s / EXT60 s
• Data on problem behavior is not shown because it
  remained at near-zero levels throughout this
  study.

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Mixed vs. Multiple Assessment

• General Procedures
• Sessions 10 min
• Contingency specifying stimuli in both conditions
• FR1 60 s
• Extinction 60 s
• All sessions started with reinforcement interval
• All problem behavior was on extinction

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CASEY
FR1 60 s
EXT 60 s
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Study 3 Is schedule fading necessary?

• Compared rates of alternative and problem
  behavior when schedules were switched from rich
  to lean without schedule fading in a multiple
  baseline design
• Mult FR-160 s / EXT60 s to Mult FR-160 s /
  EXT240 s
• Mixed FR-160 s / EXT60 s to Mult FR-160 s /
  EXT240 s
• Data on problem behavior is not shown because it
  remained at near-zero levels throughout this
  study.

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Study 4 Do contingency-correlated stimuli
facilitate generalization across therapists and
settings?

• Compared rates of alternative and problem
  behavior when a multiple schedule was introduce
  across therapists or settings in a multiple
  baseline design
• Mixed FR-160 s / EXT60 s to Mult FR-160 s /
  EXT60 s
• Mult FR-160 s / EXT60 s to Mult FR-160 s /
  EXT300 s
• Data on problem behavior is not shown because it
  remained at near-zero levels throughout this
  study.

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Conclusions

• Study 2 showed that inclusion of contingency-
  correlated stimuli was a necessary component of
  FCT schedule thinning.
• Study 3 showed that inclusion of contingency-
  correlated stimuli was sufficient to maintain
  appropriate responding without gradually fading
  the schedule density during FCT schedule
  thinning.
• Study 4 showed that contingency-correlated
  stimuli also facilitated generalization of FCT
  effects across therapists and settings.

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Study 5 How effective is Mult-FCT across a large
cohort of patients with problem behavior?

• Hagopian et al. (1998) found that FCT with EXT
  (FCTE) failed in 14 of 25 cases during schedule
  thinning.
• They also found that FCT with punishment (FCTP)
  reduced destructive behavior by 90 or more in
  all cases, even following reinforcer-schedule
  thinning.
• In the current study, we summarized the results
  of 14 applications of Mult-FCT implemented with
  12 cases and compared the results with those of
  Hagopian et al.

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Amount of Reinforcer-Schedule Thinning

• The reinforcement schedule was thinned to the
  values listed below by rapidly lengthening the
  duration of the EXT component once the
  participant showed discriminated responding in
  Mult-FCT.
• 60/240 Seven applications (80 reduction in Sr)
• 60/540 Six applications (90 reduction in Sr)
• FR1/400 One application (gt 90 reduction in Sr)

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Calculating Percentage Reduction in Problem
Behavior

• Percentage reductions in problem behavior were
  calculated using the following formula (same as
  in Hagopian et al. 1998)
• Mean rate during last 5 sessions
• 1
• Mean rate during baseline

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Fading
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Future Grants and Research onConsequence
Control Refinements of FCT

• Using behavioral momentum theory (BMT) and
  accompanying equations to prevent relapse and
  resurgence of problem behavior.
• BMT makes predictions that are at odds with
  current clinical best practices.

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Limitations of FCT (cont.)

• When a parent is busy and fails to deliver
  reinforcement for the childs FCT response, the
  child is likely to revert to problem behavior, a
  phenomena called resurgence.
• Recent research has shown that resurgence of
  problem behavior is quite common, and problem
  behavior often occurs at pre-treatment levels
  when the FCT response goes unreinforced (Mace et
  al., 2010 Volkert et al., 2009).

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Mace et al., (2010)
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Volkert et al., (2009)
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Behavioral Momentum Theory

• Behavioral momentum theory is a quantitative
  theory of behavior that employs a comparative
  metaphor based on the classical mechanics of the
  momentum of physical objects.
• Behavioral momentum theory is relevant to FCT
  because it provides quantitative models and
  predictions about the persistence and resurgence
  of problem behavior when the FCT produces
  reinforcement and when it does not.

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The Momentum Metaphor

• In classical mechanics, the momentum of an object
  is a joint function of its mass and velocity.
• Momentum of a moving object
• mass x velocity
• Momentum of a response
• rate of reinforcement x response rate

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Equation 7 Predicts the Effects of Adding and
Removing Reinforcement for the FCT Response
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Common Practice Guidelines for FCT

• Decreases may occur more rapidly during
  treatment if problem behavior is reinforced on a
  CRF schedule during baseline (Fisher Bouxsein,
  2011).
• we strongly recommend that the communicative
  response be reinforced on a CRF schedule
  initially (Tiger, Hanley, Bruzek, 2008).
• Clinical guidelines on dosage levels of FCT are
  not available (i.e., How many sessions of FCT are
  needed before parent training and discharge?).

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Specific Recommendations of BMT

• The magnitude of resurgence predicted by Equation
  7 is minimized by
• maximizing the value of t conducting many FCT
  sessions before exposure to an EXT challenge
• maximizing the value of d by correlating periods
  of reinforcement and EXT of the FCR with
  discriminative stimuli

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Specific Recommendations of BMT

• The magnitude of resurgence predicted by Equation
  7 is minimized by
• minimizing the value of r by delivering the
  lowest possible rate of reinforcement for
  destructive behavior during baseline and
• minimizing the value of Ra by delivering the
  lowest possible rate of reinforcement of the FCR
  during FCT.

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Concluding Comments

• Mathematical models like behavioral momentum
  theory provide a method for developing new and
  interesting clinical research questions that have
  the potential to greatly improve treatments like
  FCT.

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