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

Assessment and Treatment of Severe Problem Behavior

Joanna Lomas Mevers, PhD, BCBA-D Program Manager-Severe Behavior Clinics Assistant Professor Division of Autism and Related Disorders Emory School of Medicine

Introduction to Problem Behavior in Children with ASD

Autism & Pro ble m Be havio r

• Problem behavior is not a core symptom of autism
• What are the core symptoms of autism?

Co re Sympto ms o f Autism

Autism Spectrum Disorder

Deficits in Social Communication and Interactions Restricted and Repetitive Patterns of Behavior and/or Interests Subtypes With Cognitive Impairment With Language Impairment

Ho w ASD re late s to Pro ble m Be havio r

Poor Peer Relations Problem Behavior to Avoid Social Interactions

Difficulty Asking for a Break

Problem Behavior Related to Demands Repetitive Interests Problem Behavior When these Interests are Interrupted Stereotyped Motor Behaviors Repetitive Behaviors can become Self-Injurious Stereotyped Verbal Behaviors Can become Disruptive to Other Students

Self-injurious behavior (head hitting, biting self, hand mouthing) . Disruption (crying, yelling, spitting) . Text supporting the main idea. Pica (eating inedible objects) . Rumination (regurgitating food)

Problem Behavior: What are we talking about

Stereotypy (hand flapping, body rocking, spinning objects) Elopement (running away or leaving supervision) . Aggression (hitting, kicking, biting, etc.) . Property Destruction (throwing materials, breaking things) .

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

Vig ne tte : T im

• Tim has autism
• He doesn’t have much communication
• Tim hits his parent
• Sometimes he hits them when they make

him turn off the television

• Sometimes he hits them when they tell him

he has to brush his teeth

Re latio nship be twe e n Diag no sis and T re atme nt

• Not the same as medicine
• In medicine, Diagnosis X = Treatment Y
• Example: if you have a particular type of cancer then

you need a certain kind of chemotherapy

• Treatments for problem behavior do not entirely

depend on diagnosis

• Different treatments are often developed for kids

with the same diagnosis

Re latio nship be twe e n T

• po g raphy and T

re atme nt

• Topography is less relevant than most people think
• Topographically prescribed treatments:
• Problem behavior X = treatment Y
• Example: biting = time out
• Every time a child bites you should put him in time out

Vig ne tte : T im

• Topographically Prescribed Treatment:

– Hitting = time out

• When Tim hits his parents after his parents turn off

the television he goes to time out

• When Tim hits his parents after being told to brush

his teeth he goes to time out “When I hit, not only do I not get to watch television, I don’t get to do anything!” “When I hit I don’t have to brush my teeth. YAY!!!”

F ac to rs So me time s Use d to De te rmine T re atme nt

• Diagnosis
• Topography
• Function

F unc tio n o f Pro ble m Be havio r

Function = the reinforcers that maintain a response = Why problem behavior occurs

Function X Treatment Y Attention Function Ignoring

Vig ne tte : T im

• Function-based Treatment:
• Hitting maintained by access to preferred activities = time out
• Hitting maintained by escape from demands = follow through

with demand

• When Tim hits his parents after his parents turn off the

television he goes to time out

• When Tim hits his parents after being told to brush his

teeth they follow through and make sure he brushes his teeth

“When I hit, not only do I not get to watch television, I don’t get to do anything!” “When I hit I still have to brush my teeth”

Cycle of Problem Behavior

Tim stops hitting Mom learns that if she lets Tim get out of things he will stop hitting Tim learns that hitting gets him

• ut of things

Mom asks Tim to brush his teeth Tim hits mom Mom stops asking Tim to brush his teeth

Identifying Function

How to Identify the Function of Problem Behavior

• Functional Behavior Assessment: Procedures to identify

the function of problem behavior

• Major categories of FBA:

1.

Non Experimental (2 Types)

–

Indirect: no observation (questionnaires, interviews)

–

Descriptive: passive observation

2.

Experimental Functional Analysis (Analog)

–

Direct observation controlling what happens before and after problem behavior (antecedents and consequences)

Factors that Affect Function

• Antecedents (what happens before the behavior)
• Consequences (what happens after the behavior)

Antecedent

What happened prior to the behavior of concern

Behavior

• f concern

Behavior

• f concern

Behavior

• f concern

Consequence

What happened after the behavior was demonstrated

“Experimental” Functional Analysis

• “Experimental” or “Analog” Functional Analysis1

– Experimental: environment is changed so only one

thing changes at a time

– Analog: analog to the natural environment

• The “gold-standard” for functional behavioral

assessments

– Treatments based on functional analyses are more

effective than those that are not2

1Iwata, Dorsey. Slifer, Bauman and Richman, 1984/1992 2 Heyvaert, Saene, Campbell, Maes and Onghena, 2014

Communication and Problem Behavior

• Challenging behavior can be a very effective way for

individuals to communicate

• Challenging behavior usually serves a purpose for the

individual

• Functional Analysis is an assessment to determine what

the individual is trying to communicate with problem behavior

Social Attention Escape Tangible Sensory

Severe Behavior Problems

“Experimental” Functional Analysis

0.0 1.0 2.0 3.0 4.0 5 10 15 20 25 30 35 40 45 Attention Toy Play Tangible Escape Ignore

Problem Behavior Per Minute Sessions

Treatment of Severe Problem Behavior

Common Treatments

• Functional Communication Training1
• Teaching alternative way to access the functional

reinforcer via communication (e.g., teach child to ask for favorite toy)

• Example FCT

1Carr and Durrand, 1985

Common Treatments

• Differential Reinforcement of Alternative

Behaviors1

• Reinforcement of a more appropriate replacement

behavior (e.g., compliance)

• Example DRA Compliance

1Petscher, Rey, & Bailey, 2009

Other Common Treatments

• Differential Reinforcement of Other Behavior1
• Reinforcement is delivered when the target behavior

has not occurred for a specific period of time (e.g., child has to go a set amount of time without engaging in the target behavior to receive reinforcement)

• Token Economics2
• Earn tokens that are exchangeable for back-up

reinforcers

1Homer and Peterson, 1980 2Hackenburg, 2009

Extinction

• No longer providing reinforcement for a behavior
• Extinction of responses maintained by…

– Positive reinforcement: do not allow the child to have

the item, food, activity, or interaction

– Example Tangible Extinction – Negative reinforcement: do not allow the child to get

• ut of doing a task or avoid something he/she doesn’t

like

– Example Escape Extinction

Lerman, Iwata, & Wallace,1999

Side Effects of Extinction

• Extinction bursts

– Around 40% of the time there will be a temporary

increase in the intensity or variability of responding before there is a decrease

• Potential for intermittent schedules of

reinforcement

– Reinforcing some but not all responses will result in

higher rate behaviors that are even harder to extinguish

• Problem behavior temporarily comes back

Lerman, Iwata, & Wallace,1999

Marcus Autism Center

Example of FCT

2 4 6 10 20 30 Baseline FCT 80%= 0.70 Baseline FCT 1 2 3 4 5 6 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 Responses per Minute Functional Communication wiggles car, bubbles, playdoh, backpack Sessions MANDS S delta MANDS Sd Baseline FCT + EXT BL FCT + EXT MULTIPLE SCHEDULE 80%= 0.70 1 2 3 4 5 6 10 20 30 40 50 60 70 80 90 100 110 120 130 140 150 Responses per Minute Functional Communication wiggles car, bubbles, playdoh, backpack Sessions MANDS S delta MANDS Sd Baseline FCT + EXT BL FCT + EXT MULTIPLE SCHEDULE 2 4 6 10 20 30 Sessions Baseline FCT Baseline FCT Problem Behavior Per Minute Communication Per Minute

Making Treatment Work in the Real World

Next Steps

• Teaching the individual to tolerate when they can’t

have what they want

• Generalization to the natural environment (e.g.,

home and community settings)

• Caregiver Training

Teaching the individual to tolerate not getting what they want

• Discriminative Stimuli
• Teach using a stimulus when reinforcement is and is

not available

• Schedule Thinning
• Increasing the number of responses or the duration

before reinforcement can be accessed

Increasing Social Validity

• Generalization: spreading the effects of

reinforcement across stimulus conditions

• Across people
• Across settings
• To additional problem behaviors
• Expand the number/variety of alternative

behaviors: to establish access to a greater variety

• f reinforcers and a larger community of listeners

Outcomes for Behavioral Treatments

• Effect size of behavioral intervention for pica1:
• Effect size of behavioral intervention for

elopement2:

2.1 1.8

1Call, Simmons, Lomas Mevers, & Alvarez, 2015 2Call, Alvarez, & Lomas Mevers, under review