David B. McAdam

Effect of Parent Training vs Parent Education on Behavioral Problems in Children With Autism Spectrum Disorder: A Randomized Clinical Trial

IMPORTANCE Disruptive behavior is common in children with autism spectrum disorder. Behavioral interventions are used to treat disruptive behavior but have not been evaluated in large-scale randomized trials. OBJECTIVE To evaluate the efficacy of parent training for children with autism spectrum disorder and disruptive behavior. DESIGN, SETTING, AND PARTICIPANTS This 24-week randomized trial compared parent training (n = 89) to parent education (n = 91) at 6 centers (Emory University, Indiana University, Ohio State University, University of Pittsburgh, University of Rochester, Yale University). We screened 267 children; 180 children (aged 3-7 years) with autism spectrum disorder and disruptive behaviors were randomly assigned (86% white, 88% male) between September 2010 and February 2014. INTERVENTIONS Parent training (11 core, 2 optional sessions; 2 telephone boosters; 2 home visits) provided specific strategies to manage disruptive behavior. Parent education (12 core sessions, 1 home visit) provided information about autism but no behavior management strategies. MAIN OUTCOMES AND MEASURES Parents rated disruptive behavior and noncompliance on co-primary outcomes: the Aberrant Behavior Checklist-Irritability subscale (range, 0-45) and the Home Situations Questionnaire-Autism Spectrum Disorder (range, 0-9). On both measures, higher scores indicate greater severity and a 25% reduction indicates clinical improvement. A clinician blind to treatment assignment rated the Improvement scale of the Clinical Global Impression (range, 1-7), a secondary outcome, with a positive response less than 3. RESULTS At week 24, the Aberrant Behavior Checklist-Irritability subscale declined 47.7% in parent training (from 23.7 to 12.4) compared with 31.8% for parent education (23.9 to 16.3) (treatment effect, -3.9; 95% CI, -6.2 to -1.7; P < .001, standardized effect size = 0.62). The Home Situations Questionnaire-Autism Spectrum Disorder declined 55% (from 4.0 to 1.8) compared with 34.2% in parent education (3.8 to 2.5) (treatment effect, -0.7; 95% CI, -1.1 to -0.3; P < .001, standardized effect size = 0.45). Neither measure met the prespecified minimal clinically important difference. The proportions with a positive response on the Clinical Global Impression-Improvement scale were 68.5% for parent training vs 39.6% for parent education (P < .001). CONCLUSIONS AND RELEVANCE For children with autism spectrum disorder, a 24-week parent training program was superior to parent education for reducing disruptive behavior on parent-reported outcomes, although the clinical significance of the improvement is unclear. The rate of positive response judged by a blinded clinician was greater for parent training vs parent education. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT01233414.

Increasing Response Diversity in Children with Autism.

Repetitive and invariant behavior is a diagnostic feature of autism. We implemented a lag reinforcement schedule to increase response diversity for 6 participants with autism aged 6 to 10 years, 4 of whom also received prompting plus additional training. These procedures appeared to increase the variety of building-block structures, demonstrating that an intervention that includes differential reinforcement can increase response diversity for children with an autism spectrum disorder.

Behavioral Interventions to Reduce the Pica of Persons with Developmental Disabilities

The consumption of nonfood items (i. e., pica) frequently occurs in persons with developmental disabilities. Pica may result in the puncture or blockage of the digestive tract, infestation by gastrointestinal parasites, and can interfere with an individual’s daily learning, occupational performance, and quality of life. Twenty-six published studies have examined the efficacy of behavioral-intervention packages (e. g., differential reinforcement of other behavior, noncontingent attention, or overcorrection) on the pica of persons with developmental disabilities. This article reviews those studies and discusses the effectiveness, generality, and acceptability of the various intervention packages used to reduce pica. Additionally, this article highlights the recent clinical advancements that have been made in the treatment of the pica of persons with developmental disabilities.

Assessment, behavioral treatment, and prevention of pica: Clinical guidelines and recommendations for practitioners

Pica is a dangerous form of self-injurious behavior that occurs in people with developmental disabilities who are institutionalized. Studies also indicate that pica has led to the death of people with developmental disabilities. While a number of published studies have demonstrated that pica behavior can be decreased substantially with behavioral treatment, few of these studies incorporated strategies for generalization and maintenance outside of brief sessions. A second limitation of current research is that some studies reduced pica substantially, but pica responses still occurred at rates that are problematic in terms of prevention of adverse consequences, which leaves practitioners with the task of further decreasing pica to protect people exhibiting pica from harm. We make recommendations for assessment, treatment, and prevention of pica for practitioners. These recommendations are based on two extensive reviews of the literature and our extensive experience as practitioners in the treatment of pica. Our hope is that administrators, professionals and practitioners will consider our guidelines and recommendations as they attempt to protect people with pica and developmental disabilities from harm by developing standards for assessment, treatment and prevention for this difficult-to-treat population. Our hope is that children with pica will receive early intervention to prevent pica from developing into life-threatening behavior.

Effects of Risperidone on Aberrant Behavior in Persons With Developmental Disabilities: II. Social Validity Measures

Consumer satisfaction and social validity were measured during a double-blind, placebo-controlled evaluation of the atypical neuroleptic risperidone in treating severe aberrant behavior of persons with developmental disabilities. First, a satisfaction survey was completed after a medication trial by each participants caregiver. Results showed that 100% of the caregivers felt that participation was a positive experience for themselves and participants. Second, 52 community members viewed videotapes of 5 participants during a clinical interview when they were taking either placebo or risperidone. Raters also indicated that when on the medication, participants displayed fewer aberrant behaviors, were less irritable, in a better mood, and were more responsive to their environment.

Drug-behavior interactions in persons with mental retardation and developmental disabilities

Treatment for aberrant behavior in persons diagnosed with developmental disabilities typically involves either behavioral interventions or medication. Often, the treatment is a combination of the two. Schroeder and coworkers (Schroeder et al. [1983] Adv Learn Behav Disabil 2:179–225) outlined criteria for the evaluation of the combination of behavioral and drug interventions in persons with developmental disabilities. A review of the research that examined the combination of drug and behavior interactions since 1983, using the Schroeder et al. criteria, is provided. An evaluation of research since 1983 that examined medication effects on multiple dependent measures and between multiple medications, using the criteria for medication research by Sprague and Werry (Sprague and Werry [1971] Int Rev Res Ment Retard vol. 5) is also provided. Additionally, the final section provides a list of recommendations and criteria for practitioners and researchers when conducting or evaluating research designed to examine medication effects on multiple variables in persons with developmental disabilities. MRDD Research Reviews 1999;5:322–334.

Assessment and Treatment of Feeding-Related Problem Behaviors of a 16-Year-Old Girl With PDD-NOS: A School-Based Case Study

This case study describes the successful implementation of a behavioral intervention for the mealtime problem behaviors of a 16-year-old girl with Pervasive Developmental Disorder Not Otherwise Specified attending a private school for students with developmental disabilities. Initially, an analogue-functional analysis using a pairwise single-case experimental design was conducted, and based on the results of this assessment, a multicomponent function-based intervention was developed. The results obtained demonstrated that interventions for problem behaviors developed in hospital-based clinics can be implemented in community-based educational settings successfully. The results also demonstrated that behavioral intervention strategies shown to be effective with young children with developmental disabilities also work for a teenager with an autism spectrum disorder, illustrating the generality of a behavioral approach to feeding difficulties. Methodological limitations of the case study, advantages of a community-based treatment approach, and recommendations for clinicians are provided.

Textual prompts as an antecedent cue self-management strategy for persons with mild disabilities

Providing learners written task analyses to be used as textual prompts was examined as a self-management strategy for persons with mild disabilities. Initially, modeling, corrective verbal feedback, and contingent descriptive praise were employed to train participants to use the written task analysis to perforn one home maintenance task. Subsequently, participants were tested on their use of different task analyses combined with general feedback to perform two novel home maintenance tasks. No training was provided on how to use these new task analyses. Either a multiple baseline or a multiple probe across settings experimental design was used to control extraneous variables. Results indicated that the written task analyses served as self-administered textual prompts and, along with general feedback, provided stimulus control for the second and third tasks. When the self-management task analyses and general feedback were withdrawn, transfer of stimulus control occurred to the natural discriminative stimuli for the majority of tasks. The research suggests that written task analyses, as presented in the present study, may have utility for the self-management of instruction by persons with mild disabilities.

The Role of Functional Assessment in Treatment Planning

Treatment planning to reduce challenging behavior (e.g., aggression and property destruction) can be complex and requires a prescriptive interprofessional team-based approach. As with other problems that interfere with an individual’s quality of life, such as health issues, the best course of treatment is one that accurately assesses the problem, leads to effective treatment for the issue of concern, and is empirically supported. This is especially important when treating individuals who display problem behavior which frequently interfere with their opportunities to learn and to live and be educated in less-restrictive settings (Matson, Mayville, & Laud, 2003). The utility of functional behavior assessments (FBAs) and functional analyses (FAs) in the identification of the specific function or purpose of challenging behavior has been embraced commonly by persons charged with supporting individuals who display challenging behavior (e.g., behavior analysts and educators). This is demonstrated by the laws requiring FBAs be conducted when individuals are struggling in educational environments (Individuals with Disabilities Education Improvement Act, 2004) and the belief that the assessments conducted should result in the development of interventions that help preserve the child’s placement in the least restrictive appropriate educational setting. The utility of these assessments has been repeatedly demonstrated in the published literature (e.g., Derby et al., 1992; Iwata, Dorsey, Slifer, Bauman, & Richman, 1994; Kennedy & Souza, 1995; Kern, Childs, Dunlap, Clarke & Falk, 1994; McCord, Thompson, & Iwata, 2001; Ellingson, Miltenberger, Stricker, Galensky, & Garlinghouse, 2000). Several excellent reviews of this extensive literature have been conducted and have independently identified functional analysis and assessment as best practice (e.g., Carr, 1994; Hanley, Iwata, & McCord, 2003).