Association for Behavior Analysis International

Psychopharmacological and behavioural interventions are often used to treat challenging behaviours. Sometimes these intervention types are implemented concurrently, called combined interventions, while other times they are applied in isolation. Given that a large proportion of persons with intellectual disability and challenging behaviour are prescribed psychotropic medications, it is likely behavioural practitioners will be responsible for managing clients with at least one psychotropic medication prescription. Further, clinicians may be asked to attend psychiatric consultations to support families who are pursuing a medication trial for their loved one. To effectively manage challenging behaviour through psychotropic medication, behavioural practitioners may add value to the psychiatric process by identifying, implementing and overseeing effective, objective data collection strategies. These strategies may better inform the prescribing physician on how medications changes may be positively or negatively impacting the client. A thorough review of the behavioural literature indicated proposed guidelines have only targeted processes in applied behavioural pharmacology research. Some of these recommendations may not be relevant for behavioural practitioners operating outside of a research setting. We developed and piloted an evidence-informed checklist for behavioural practitioners operating within a clinical setting. The intent of this tool was to guide clinicians in selecting appropriate target behaviours and coinciding data collection strategies to objectively evaluate medication impact. Several specific case studies are described including the time committed required in following the checklist, as well as client outcomes.

In crisis situations, individuals with intellectual or developmental disabilities (IDD) may put themselves or others at risk; prompt and effective behaviour stabilization service is then required. In this report, we summarize available literature regarding services for individuals with IDD who experience a behavioural crisis. Various service approaches are described, including; outreach, hospitals, inpatient/outpatient services, and many more. We analyze service models in terms of the physical environment of service provision, team members involved, methods used, capacity and available resources, etc. The outcomes of the respective service models are also summarized, including the number of individuals accessing service, average number of days needed to stabilize the client, percentage of re-referrals, etc. General themes surrounding the challenges of crisis service delivery are discussed along with recommendations to resolve them. The available literature shows that stabilization services can be implemented effectively and that successful models have some common features. Most models are effective at providing rapid responses to urgent requests for services and are effective at stabilizing the behavioural presentations of individuals with IDD experiencing crises. However, gaps exist within health care systems and the services received by individuals with IDD experiencing a crisis are likely not sufficient to stabilize them long term.

Cigarettes smoked over five weeks were measured for four participants to determine if feedback only (FO), in the form of saliva cotinine levels, would be as effective a treatment for smoking cessation as contingency management (CM). During a one-week baseline, participants texted the daily amount of cigarettes smoked to researchers and met twice to have their saliva cotinine levels evaluated. In Week Two, all participants were introduced to smoking reduction via a changing-criterion design, in which the allowed daily amount of cigarettes was 25% lower than their baseline level. All participants continued to text the daily number of cigarettes to research associates and meet twice a week for evaluation of cotinine levels; however, Participant A received cash lottery draws for attending meetings and reduced cotinine levels from the previous meeting level (CM). Participants B through D simply received feedback regarding saliva cotinine levels (FO). Treatment continued for three weeks, with a 25% reduction targeted for each subsequent week. While complete cessation did not occur, all participants did reduce the daily number of cigarettes smoked from baseline levels, and results indicate that FO was as effective in producing this result as CM without the associated cost of the cash lottery.

Parent-Child Interaction Therapy (PCIT) is an empirically based parent training intervention used to treat behavior problems in children ages 2 to 7 (Eyberg & Funderburk, 2011). PCIT uses differential attention and a structured time out procedure to promote increased positive parent-child relations and child compliance (Eyberg & Funderburk, 2011). One limitation of PCIT is the lack of a functional analysis (FA) prior to the intervention. Determining the function of problem behavior is important, as function-based interventions are empirically based and more effective at decreasing problem behavior. A multielement design was used to determine the function of problem behavior. The effects of PCIT on problem behavior were evaluated using graphed Eyberg Child Behavior Inventory scores, per the PCIT manual. Using a single subject design, this study sought to investigate the treatment effects of PCIT on problem behavior maintained by the most common social functions of behavior. Based on patterns of responding, it is hypothesized that PCIT will be more effective at reducing problem behavior maintained by access to attention and tangibles and less effective at reducing problem behavior maintained by escape from demands. Interobserver agreement will be calculated using the proportional method for at least 33% of total sessions.

Applied Behavior Analysis is ideally suited for helping to develop behavior change in the child or adult diagnosed with ADD/ADHD, yet most so diagnosed never encounter true behavioral approaches that systematically utilize these powerful principles. Some clinicians never bother to ensure the patient with ADHD has a wristwatch or a daily calendar. Factors can be physiological, environmental, social, and vary in the time of most effective impact. This paper highlights a plethora of such basic infrastructural elements which can have an impact, if the clinician is mindful of them, including approaches to assess the sensitive issue of the use, or even obviate the use, of medications within the context of other aspects of an individuals situation. This paper presents the use of an Antecedent/Behavior/Consequence paradigm to highlight within each of those areas concepts and factors to address, serving as an objective platform to remind therapist, patient, and parent alike that typical ADHD treatment as implemented by most practitioners fails to consider many of these factors and potential interventions, thus preventing the dramatic behavior change made more likely by a robust, balanced palate of A, B, and C interventions, methodically derived, objectively reevaluated, and continuously revised, as applied behavior analysts are trained to do routinely, and well. The majority of the clinicians treating ADD/ADHD patients by definition do not have the applied behavioral background, and as a result simply fail to identify and address many potential factors, the adjustment of which could have major impacts in habits developed and behaviors emitted. Patients therefore rarely get the systematic evaluation which is done daily by behavior analysts for other clinical diagnoses, and thus have a treatment plan that typically is narrowly focused on one or two modalities, as opposed to one methodically identifying areas of intervention and implementing changes within multiple domains of the patient's life. As ABA claims to want to apply these powerful principals to more mainstream applications, ADD is clearly one of those areas, well suited for ABA. Applied behavior analysts can, and arguably, should, be the leaders in applying ABA to the ABCs for ADD! This paper highlights general techniques, and arguably, responsibilities, for doing so to the benefit of patients, practitioners, and the discipline of ABA itself.

Often times in dually-diagnosed adult populations medications are prescribed for psychiatric symptoms. Medication non-adherence is highly prevalent among patients on psychotropic medication, which compounds the challenge of behavior intervention implementation. Previous studies have demonstrated that inconsistent medication administration results in higher rehospitalization admissions and thus impedes on consistent implementation of behavioral interventions. The current objective was to increase medication compliance that addresses psychiatric symptoms to obtain consistency of administration to be able to evaluate the effects of behavior interventions on problematic behaviors. Over the past three months, the client has demonstrated an average of 70% medication compliance. The client has also been rehospitalized during the previous two months ranging from three-days to a week's admission. However, despite the inconsistency with medication administration, data for the targeted problematic behaviors (physical and verbal aggression, property destruction, and inappropriate sexual behavior) show a gradual decreasing trend. These results indicate that despite medication non-adherence, behavior interventions are effective in reducing the frequency of problematic behaviors that lead to hospitalizations.

Working with the dually-diagnosed adult population, clinicians are often times faced with frequent medication changes with little attention to the overall effectiveness of those serious medications. Medications such as depakote, lithium, haldol, and seroquel are often used to address behavior problems, even there is little research supporting its effectiveness. In addition, long term use of these medication may lead to unavoidable side effects such as tremors and chronic gastrointestinal issues. Little work has been demonstrated in the behavior analytic field regarding medication management and reduction in conjunction with behavior intervention. One reason for this may be the settings that behavior analysts work in limit the contact opportunities with prescribing psychiatrists. The purpose of this evaluation was to coordinate with prescribing psychiatrists to reduce psychiatric medications and side effects associated with those medications. We conducted assessments on associated psychiatric symptoms at intake while on a particular medication regimen, and again after behavior intervention had been applied. Also, medication changes were tracked over time along with side effects associated with the medication being taken. Results show an overall reduction of psychiatric medication, reduction of side effects, and reduction of symptoms associated with the mental health diagnosis.

Non-compliance and challenging behavior during routine medical and dental procedures is common among individuals with intellectual disabilities. These behaviors can result in increased risk to individuals and health-care professionals during procedures, negative general or dental health outcomes, and increases in reliance on intrusive behavior management procedures. Often, individuals displaying these behaviors receive sedation or anesthesia prior to routine procedures, increasing risks associated with those procedures. These problems may be greater for institutionalized adult populations who have exhibited resistant behaviors for long periods of time, have compromised physical and medical health status (often due to histories of intolerance of medical procedures), and whose living environments are often characterized by frequent changes in caregivers, poor caregiver training, and inconsistent contingencies. The current presentation describes a large-scale program designed to improve compliance with and tolerance of medical and dental routines at a large, residential/training facility for individuals with intellectual disabilities. Procedures for identifying individuals with such challenges, conducting preliminary screening assessments, assigning priorities, functional assessment, intervention, and staff training will be described.

Radiotherapy for a pediatric cancer patient often consists of 25 to 30 sessions lasting 5 to 6 weeks. Standard radiotherapy practice in children involves the use of general anesthesia during each session to ensure that the patient remains still during the treatment. The excessive use of sedation introduces many risks and side effects that, combined with chemotherapy, and cancer itself, can greatly reduce the overall quality of life for the children and their families. A small body of research shows that behavioral control techniques are successful in teaching children to remain still in an array of medical settings. We seek to evaluate the effects of continuous positive and negative feedback loops on compliance with the movement requirements of the radiotherapy procedures. Three pilot studies have been conducted on healthy adults with promising results. Using the feedback loops all pilots were able to control their motion to clinically relevant standards. If successful once transferred to children this procedure will have the potential to reduce the use of sedatives and increase the quality of life for pediatric cancer patients.

Research in Behavior Analysis has produced a sophisticated understanding of the organization of behavior. Beyond the increase in the precision with which we are able to measure and record behavior, there has been an increasing recognition of the operant nature of many acts previously thought to be impervious to feedback/antecedent control. These developments suggest that the domains in which behavior analysis might contribute are considerably broader than previously appreciated. One area in which Behavior Analysis might make important contributions is behaviorally-based health services. The current project, takes rehabilitation following post knee replacement surgery as the target. We ask if a technology-infused contingency management system can help improve rehabilitation outcomes by providing physical therapists with immediate and reliable measures of patient progress allowing physical therapists to make necessary program changes. Further, through the use of dynamic reinforcement systems and stimulus control principles, we ask if a contingency management system can successfully shape muscle amplitude in order to facilitate patient progress in a rehabilitation context. Our current data suggests that the answer is yes. Changes in reinforcement contingencies reliably result in changes in muscle amplitude. These findings set the stage for the automatic and remote management of contingencies related to healthy behavior.

Functional analyses (FA) are widely accepted as the best practices approach for ascertaining behavior function and designing effective behavioral interventions (Beavers, Iwata, & Lerman, 2013; Delfs & Campbell, 2010; Mace, 1994), having amassed over 35 years of empirical studies to support its efficacy (Hanley, Iwata, & McCord, 2003). The brief functional analysis (BFA) is a modification (Northup et al., 1991) often conducted in outpatient settings when time constraints are of concern. They have been established primarily with children with developmental disabilities, with support for typically developing children as well (Gardner, Spencer, Boelter, DuBard, & Jennett, 2012). However, several limitations still exist. Specifically, BFA's present risk of producing false positives and false negatives (Kahng & Iwata, 1999; Derby et al., 1992). Additionally, their internal validity can be questionable given the brief nature of the assessment (Wacker, Berg, Harding, & Cooper-Brown, 2004). In the current study, we conducted 60-minute brief functional analyses with typically developing children, in a time-limited outpatient setting, comparing their results to those obtained after conducting extended functional analyses. The results revealed inconsistencies in agreement, presenting questions surrounding the best practices approach to use in time-sensitive outpatient settings, with typically developing children—where problem behavior may be multiply maintained.

Sensory over-responsivity (SOR) is common in individuals with Autism Spectrum Disorder (ASD), in which the person has an aversive response to common stimuli such as the sound of a toilet flushing or a vacuum cleaner. Other aversive stimuli may be bright lights or the tactile sensation of clothes tags or tight shoes. Misophonia is a common (but widely unknown) condition in both typical and ASD populations, where specific low intensity stimuli elicit/evoke strong negative behavioral responses. Although the behavioral response to stimuli may be similar for misophonia and SOR, they are very different conditions. Misophonia is viewed as a discrete disorder which cannot be properly classified using the DSM-5 or ICD-10. With SOR, the response is typically a unconditioned sensitivity to stimuli which elicit/evoke the response. With misophonia, the response is a conditioned sensitivity to stimuli which elicit/evoke the response. Surveys of adults with misophonia indicate that misophonic stimuli are soft sounds (e.g. chewing, breathing) and repetitive visual stimuli (e.g. open mouth chewing, foot wiggling, hand movements). Onset of misophonia can occur at virtually any age. Discriminating between SOR and misophonia can be very important because treatment to address the behavior of these conditions is different.