Severe Behavior Disorders Behavior Therapy vs.

Traditional Psychotherapy -traditional therapy doesnt necessarily offer behavior mod, rather just insight Why we prefer behavior therapy in this class

Problems with quasi-medical model: May divert attention from the real problem May encourage problem Not empirically conceptualized Not empirically validated Often does not suggest a treatment Often does not suggest a prognosis BT assumes maladaptive bxrs are mostly acquired -Something becomes maladaptive when its not working for you anymore learning principles can be extremely effective specific, clearly defined treatment goals rejection of classical trait theory Implies something innate to you that creates your behavior o From your inner self so cant change Behavior Therapy vs. Traditional Psychotherapy BT adapts his/her method of treatment Remember Harry BT concentrates on the here and now BT places great value on obtaining empirical support Always have data that supports Autism Spectrum Disorder DSM-IV-TR (SEE DX CRITERIA FILE ON TED) Diagnostic manual Pervasive Developmental Disorders traditionally described by these six in early childhood development: Autistic disorder Aspergers disorder PDD-NOS persuasive developmental disorder (another type of autism) Fragile X Retts Childhood Disintegrative Disorder

Overview of ASD (Autistic, Apergers, PPD-NOS) Biologically-based neurodevelopmental disorder with multiple causes The reality is, we dont know. Maybe some environmental factors Occurs equally across cultures and SES Practitioners can detect ASD reliably by 12-18 months Typically diagnosed between 1-3 years old Important to treatment & intervention DSM-IV-TR Diagnostic Criteria Must operationalize behaviors using diagnostic criteria Three behavior categories: * Social communication, restrictive repetitive behavior or impairment in communication Qualititative impairment in social interaction o Most important o Failure to do something (difficulty making friends) o Lack of spontaneous seeking to share enjoyment, interests, or achievements with other people Qualitative impairment in communication o Echolalia, etc. o But even if language is appropriate, extended conversation is difficult o Lack of make-believe play & imagination Restricted repetitive and stereotyped patterns of behavior, interests, & activities o Vague, lots of unexplained behavior: stacking cans, etc. Engaging in behaviors that are maladaptive. I.e. mom cant move the stacked cans or the child will have a fit

Myths about ASD All individuals with ASD have special skills or abilities (Autistic Savants) Only very small portion have savant activity ASD can appear & disappear suddenly All act the same All are extremely smart All dislike physical contact and prefer to be alone Manifestation of Symptoms Speech and Language ~25-50% fail to develop speech Abnormal speech Joint Attention ability to shift attention (autistic kids cant do this) Theory of Mind whats in your mind is different from mine

ToM: false-belief task M&M test video shown where kid opened bag of M&Ms but with pencils inside instead of candy. Then asked if your dad was here, what do you think would be in the bag? Kid w/o theory of mind will say pencils. Therefore, you must specifically teach to autistic kids, rather than them learning from the environment ToM: false-belief task ToM task has no joint attention. Autistic child cannot switch to a different task Social Behavior Good babies most autistic children are not needy babies. Lack of eye contact Inappropriate affect Little sharing of experience preference for aloneness Preference for aloneness Lack of awareness of subtle social cues Lack of peer contact and interactive play Failure to attend to others Prevents learning from observation Sensory Abnormalities Desire for Sameness Stereotyped Behavior flapping bird video Associated Characteristics Physical Characteristics Coexisting medical condition (10%) Sleep disturbances and gastrointestinal symptoms - will target the sleep disturbance first Accompanying disorders and symptoms Mental Retardation Epilepsy ADHD & learning disabilities Anxieties & fears, mood problems Self-injurious behaviors Self-Injurious Behavior (SIB) 50-75% of children with autism engage in SIB old number, but it was acquired through research in behavior mod Most common forms are head-banging, self-hitting/slapping, self-biting, hair pulling. Can range from slight bruising or redness to death <how to address the behaviors with principles> Test of Operantness of SIB (Lovaas and Simmons, 1969) Is it under Sd control? yes. Rate varied in diff. stimulus situations Does it show extinction? yes. Gradually decreased when reinforcing consequences (attention) removed Does it respond to punishment? yes. Rapidly decreased when contingent punisher applied

Does it increase with positive reinforcement? Yes. Increased when contingent positive reinforcement given --Kind of a functional analysis SIB as an Operant Under Sd control?: Susceptible to extinction?: Susceptible to positive reinforcement? Functions of SIB (Edward G. Carr) Positive reinforcement Negative reinforcement Self-stimulatory (automatic reinforcement) Ed Carr also found this functional analysis. Ed Carr first person to show that +/- reinforcement works, and that SIB is internal. Functional Analysis Systematically manipulate environmental antecedents and consequences Tells us what is maintaining behavior Can use this information Functional Communication Training Assume SIB and other challenging behaviors serve communication function Teach alternative means of communication Alternative means of communication must serve same function as challenging behavior and be no more difficult to perform

Communicative Functions of Echolalia in Children with Autism: Assessment and Treatment (2002) Michelle Thibault Sullivan, Ph.D. <addressing echolalia> -She wanted to find out what the communicative function of echolalia served Research Questions Will a functional analysis identify a unique communicative function of echolalia for each child with autism? Will functional communication training replace echolalia? Functional Analysis Conditions Attention child received 30 sec attention Demand tasks were removed for 30 sec Tangible child had free access to toys, but if echolalia, gave back toys. (Wanted to see if echolalia meant child was upset) Toy Play no demands, no contingencies

-Via graph, it showed that Alan, the child subject, he used echolalia to gain attention (maintained by attention). Therefore, they gave him a redirection by teaching him to say Can you play with me? -Brad: Echolalia by teaching him to say Can you help me? -Sarah: maintained by tangible. Can I have a turn? *Was Echolalia maintained by the same thing for all kids? NO. Did they use the same intervention? Evidence-based practice (EBP) is the integration of the best available research with clinical expertise in the context of patient characteristics, culture, and preferences. What is evidence? Two controlled group design studies OR large series of single-case design studies Two investigators Treatment manual Therapist training and adherence Clinical and functional outcomes Long-term outcomes Current state of evidence-based psychosocial intervention for ASD Early intervention improves outcomes Research supports behavioral treatments and comprehensive models No one specific treatment method as the standard The cost of serving individuals with ASD in the US is over $35 million per year Types of Behavioral Treatment Structured, adult-driven, repetition (academic) DISCRETE TRIAL THERAPY (DT or DTT) -first treatment therapy that showed that autistic children can be taught to talk -after that, they switched to a more naturalistic model (generalization) Unstructured, child-driven, incidental (play) INCIDENTAL TEACHING PIVOTAL RESPONSE TRAINING (PRT) Augmentative communication system PICTURE EXCHANGE COMMUNICATION SYSTEM (PECS) Discrete Trial Training (DTT) A-B-C model all behavioral therapy talked about today uses ABC model Discrete Trial Features: Show me blue; show me colors!

Adult-directed, structured over and over; repetitive Controlled setting, usually at a table Break down tasks to simplest components Repetitive trials DTT Results of Early Behavioral Intervention Initial demonstrations involved highly structured discrete trial format Proved to be very effective in establishing a wide range of behaviors Provided basis for all behavioral treatments to follow Can lead to substantial improvement in many children with autism Limitations of DTT: Difficulties with generalization maintenance robotic responding lack of spontaneity prompt dependency waiting for you to ask; reliant on you acceptability by child/clinician use of aversives Pivotal Response Training (PRT) Koegel and Schreibman, 1988 pivotal behaviors critical for wide area of functioning (like response generaln.) Motivation find out whats interesting to that child multiple cues Play-based, natural setting, to increase generalization Components of Pivotal Response Training Motivation find out whats interesting to that child Child Attention Child Choice Reinforce Attempts - shaping Direct Reinforcement you can only reinforce what the childs asking for Intersperse Maintenance Tasks Shared Control (Turn Taking) Responsivity Stimulus overselectivity or the failure to learn via simultaneous multiple cues. Tasks require response to simultaneous multiple cues (conditional discriminations). Naturalistic Strategies Occur in naturally-occurring situations and environments Child initiated incidental teaching, pulling it out of whats already there Play based Involve natural and direct consequences Involve more loosely arranged interactions

DTT vs. PRT DTT is not natural and strictly arranged PRT is more flexible & enjoyable (less staff & parent burnout) Results of Naturalistic Teaching Strategies Greater generalization More positive affect subjects smile more & seem happier & parents will adopt More positive home interactions - flexible More enjoyable for children and for treatment provider Story-Based Intervention Package (other interventions) Written description of challenging situations Stories may be supplemented with: Prompting Reinforcement Discussion Social Stories are the most well-known story-based interventions behaviors that you want your child to do. Like a behavioral contract w/ yourself. Do things piece by piece. Youre making an operational behavior chain. Also creates discussion for child who has cognitive ability but has trouble explaining. seek to answer the who, what, when, where, and why (5 Ws) i.e. Walking in Line social skills lesson (gives child alt. behavior) Comprehensive Behavioral Treatment for Young Children (CBTYC)* -this is what you see mostly in California Combination of ABA txts delivered to young children in a variety of settings with a low student-to-teacher ratio -you want to be able to think on your feet. Legislature is influenced by what is found in research Targeting the defining symptoms of ASD (especially social) Treatment manuals High degree of intensity do it a lot in order to create pathways (like titrate meds) Measuring overall effectiveness Picture Exchange Communication System (PECS) also behavior mod/naturalistic sort of like PRT Naturalistic Use of pictures symbols to communicate instead of language Bridge to language Reduce prompt dependence Increase independence pictures are clear Does not require receptive language

Picture Exchange Communication System (PECS) cont Does not require imitation Does not require a pointing response Does not require use of abstract symbols Seems to be readily acquired by most students Can be expanded to involve more linguistically complex components Involves social interaction more than PRT b/c kids approach you Limitations of Behavioral Intervention Differential response to treatment differential=differently responding (looks the same at pre, but very different at post Variable deficits Clinical judgment based intervention (wastes precious time and resources) Evidence-based practice Values and Preferences Values of family members this is a big part. Dont just pick interventions u are trained in. Family values are ethical, and makes family accept it more Ineffective outcomes or undesirable side-effects Client rights Capacity Implemented in an existing system must fit into local system local expert nearby person or facility What has to be considered when applying an EBP? Fidelity! -Medical Model: o Condition o Patient o Drug/procedure o Dosage o How administered o Measure of efficacy o When to change -Education/Intervention o Content/behavior o Student o Teaching approach o How much time daily o Specific procedures o Data collection & examination o When to change approaches Why is data critical for EBP use? like a social story for yourself, must have a plan mapped out. The below are affected by laws and principles. Performance data tells us: What should we be teaching? Is our instruction successful? Is the student making progress?

Do we need to change the teaching plan? Is it time to introduce a new skill? Next steps in research Determining which intervention to use based on specific child characteristics. i.e. we usually start w/ PRT, but if nothing changes in six weeks we change Developing research-based ways to choose specific interventions. Early Start Denver Model (example only) Alternative Communication Decision Hierarchy Generalization Strategies there are generalization problems with DTT or PRT?? (Find out)(You want stimulus generalization). Train and hope Sequential modification Introduce to natural maintaining contingencies Train sufficient exemplars Train loosely tickling video (make up on the spot) Use indiscriminable contingencies Program common stimuli Mediate generalization Train to generalize FUNCTIONAL ASSESSMENT use when trying to determine what maintains behavior (origins). Must use experimental approach. (see less severe bx notes)