behavioral approaches to the treatment of autism and severe behavior disorders wayne w. fisher...

Behavioral Approaches to the Treatment of Autism and Severe Behavior Disorders

Wayne W. FisherUniversity of Nebraska Medical Center’s

Munroe-Meyer Institute

UNMC Munroe-Meyer Institute

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


Definition of Autism

markedly abnormal or impaired

development in:

1. social interaction

2. Communication

and markedly restricted repertoire

of activities and interests.


Definition of Autism

Definitions are cheap, but

explanations are dear, and we must be

careful not to confuse them.» David Palmer, 2004


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


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


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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Autism Juvenile DiabetesMuscular Dystrophy Leukemia Cystic Fibrosis

Prevalence of Autism and Other Conditions

(Number of Cases per 10,000 Children)


$-

$20,000

$40,000

$60,000

$80,000

$100,000

$120,000

$140,000

Autism Juvenile Diabetes Muscular Dystrophy Leukemia Cystic Fibrosis

NIH Research Dollars for Autism and Other Conditions

(Number of Dollars per Case)


Unfortunately, you have what we call “no insurance.”


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)


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


Social Behavior Generally Requires Little or No Explicit Training


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.


MMR Vaccines and Autism

10 of the original 13 authors of the investigation that started the controversy have retracted the study’s 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.


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.


Associated Disorders

Mental Retardation 50% 15%

Seizure Disorder 35% 10%

Self-Injury, Aggression 50%

Tourette Disorder

Bipolar Disorder

Autism ASD


Associated Etiologic Diagnoses

Fragile-X syndromeTuberous SclerosisWilliams syndromeLandau-Kleffner syndromeCongenital RubellaSmith-Magenis syndromeNeurofibromatosis


Genetics and Twin Studies

Autism runs in familiesHeritability for autism is about 90%Monozygotic twin concordance, 60%-

100%Dizygotic twin concordance, 10%Associated with abnormalities on

chromosomes 7q, 2q, and 15q


Applied Behavior Analysis (ABA)

What is ABA?

How is it different from other

approaches?

How is it Done?


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.


Outcomes of ABA for Autism

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Hours per Week of Treatment

Incr

ease

s in

IQ

Sco

res

r = .79

p < .02

UNMC Munroe-Meyer InstituteCost-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


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.

Residential CostsOver 25 Years

Case Example(Costs since 1986)

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$85,924

Inpatient and Outpatient Costs

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Autism and Problem Behavior

98% of children with autism have one or more

of the following problems:

1. Feeding problems

2. Sleeping problems

3. Tantrums

4. Self-injurious behavior

5. Aggression

Dominick et al. (2007)


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)


Functional Analysis and

Treatment of Aberrant Behavior


Structural vs. Functional Diagnosis

Structural Approach

1. How often a particular set of symptoms

or responses cluster or covary.

Functional Approach

1. Whether and which environmental

variables influence the response.


Functional AnalysisIdentifies 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.


Common Functions of SIB

Social Positive Reinforcement

(Attention, Tangible items)

Social Negative Reinforcement

(Escape)

Automatic Reinforcement (e.g.,

Sensory Stimulation)


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

1. 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


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.


Attention Condition

Adult is busy reading. Child is expected

to play quietly with toys.

Adult attention shifts to child following

SIB (e.g., “Please don’t hit yourself”).

Determines whether adult attention

functions as reinforcement for SIB.


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.


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.


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.


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.


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.


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).


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.


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.

UNMC Munroe-Meyer InstituteEssential 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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KirkKirk

Session

Baseline Extinction BaselineFCT +Extinction

FCT +

DestructiveBehavior

Communication


Functional Analysis of Covert Drug Ingestion

Three Operant Hypotheses Generated

After Caregiver Interview and Chart

Review

1. Attention/Excitement From Medical

Procedures

2. Attention From Mother

3. Escape From Work Activities


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.



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.



Red = Medical Attention

Orange = Attention From Mother

Blue = Rest Period (Escape)

Yellow = Control (Ignore)

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Escape From Work

Parent Attention

SESSIONS

Control

Medical AttentionLYLE

FUNCTIONAL ANALYSIS


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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20Baseline Treatment Baseline Treatment

30 40 60 80

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LYLE

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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.


Functional Communication Training (FCT)

Functional communication training (FCT) is a

treatment commonly prescribed when a functional

analysis has shown that an individual’s problem

behavior is maintained by social consequences

(e.g., Carr & Durand, 1985; Fisher et al., 1993;

Horner, Day, Sprague, O’Brien, & Heathfield, 1991;

Lalli, Casey, & Kates, 1995; Wacker et al., 1990).


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).


Unique Features of FCT

FCT is a DRA procedure that:

1. specifies its reinforcer (i.e., a mand specifying the

reinforcer that previously maintained problem behavior),

2. requires minimal response effort,

3. is initially reinforced on a dense schedule (e.g., FR 1),

4. can recruit reinforcement across environmental

contexts.



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.



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).



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).


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).


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.


Training the Communication Response

The communication response matches

the function of the child’s problem

behavior.

1. Demand -> “Break please.”

2. Attention -> “Play with me, please.”

3. Tangible -> “Toy please.”


Training the Communication Response

Children who do not speak are often

taught to use a picture-exchange

communication response.

1. Attention -> Child hands over a picture of

the adult and child playing together.

2. Demand -> Child hands over a picture of the

child leaving a work table.


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.


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.


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.


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.

t = 3.0; p = .01


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.


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.


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.


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)


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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FA

DIN

G S

TE

PS

= FR1

= Extinction

Decreases reinforcer deliveries by about 75%


Purpose

To identify the necessary and sufficient components

for the reinforcement schedule thinning

1. Study 2: Evaluated the effects of contingency-correlated

stimuli during FCT

2. Study 3: Evaluated the necessity of systematic and gradual

fading steps during schedule thinning under multiple

schedule components

3. Study 4: Evaluated the extent to which contingency-

correlated stimuli facilitated generalization across therapists

and environments


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.


Study 2: Are contingency-correlated stimuli necessary?

Compared rates of FCR and problem behavior

under equivalent mixed and multiple schedules

using an ABAB design1.Mixed FR-1:60 s / EXT:60 s

2.Multiple FR-1:60 s / EXT:60 s

Data on problem behavior is not shown because

it remained at near-zero levels throughout this study.


Mixed vs. Multiple Assessment

General Procedures

1. Sessions = 10 min

2. Contingency specifying stimuli in both conditions

3. FR1 = 60 s

4. Extinction = 60 s

5. All sessions started with reinforcement interval

6. All problem behavior was on extinction

FR1: 60 s

EXT:60 s

CASEY


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-1:60 s / EXT:60 s to Mult FR-1:60 s / EXT:240 s

Mixed FR-1:60 s / EXT:60 s to Mult FR-1:60 s / EXT:240 s

Data on problem behavior is not shown because it

remained at near-zero levels throughout this study.


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-1:60 s / EXT:60 s to Mult FR-1:60 s / EXT:60 s

Mult FR-1:60 s / EXT:60 s to Mult FR-1:60 s / EXT:300 s

Data on problem behavior is not shown because it

remained at near-zero levels throughout this study.

University of Nebraska Medical Center


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.


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.

212


Amount of Reinforcer-Schedule Thinning


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


Pe

rce

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Pro

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eh

avi

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n = 11applications

n = 17applications

n = 14applications

FCTE +Fading

FCTP +Fading

Mult-FCT +

Hagopian et al. (1998)Current

Data Set

Fading


Future Grants and Research on:Consequence 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”.


Limitations of FCT (cont.)

When a parent is busy and fails to deliver

reinforcement for the child’s 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).


Mace et al., (2010)


Volkert et al., (2009)


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.


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


Equation 7 Predicts the Effects of Adding and Removing Reinforcement for the FCT

Response


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?).


Specific Recommendations of BMT

The magnitude of resurgence predicted by

Equation 7 is minimized by:

1. maximizing the value of t conducting many FCT

sessions before exposure to an EXT challenge;

2. maximizing the value of d by correlating periods of

reinforcement and EXT of the FCR with discriminative

stimuli;


Specific Recommendations of BMT

The magnitude of resurgence predicted by

Equation 7 is minimized by:

3. minimizing the value of r by delivering the lowest

possible rate of reinforcement for destructive

behavior during baseline; and

4. minimizing the value of Ra by delivering the lowest

possible rate of reinforcement of the FCR during FCT.


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Des

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Baseline(VI 30)

FCT Extinction Challenge

c = 1, d = .001, p = .05

(VI 20)

Long Exposure(Room 1; Therapist = Purple)

Short Exposure(Room 2; Therapist = Yellow)


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Baseline FCT Extinction Challenge

c = 1, d = .001, p = .05

(VI 36 s)

VI 20 s(Room 1; Therapist = Red)

VI 120 s*(Room 2; Therapist = Blue)

*This lean schedule will be individually determined based on a progressive-interval assessment and may be different from a VI 120 s.


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Baseline (VI 36 s) FCT Extinction Challenge

c = 1, d = .001, p = .05

VI 20 s (Room 1; Therapist = Green)

VI 180 s(Room 2; Therapist = Blue)

PI


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BaselineFCT EXT Challenge

c = 1, d = .001, p = .05Long Exposure of Alt VI 120 s*

(Room 1; Therapist = Red)

Short Exposrue ofAlt VI 20 s

(Room 2; Therapist = Blue)

VI 20 s(Room 2; Ther = Blue)

VI 120 s*(Room 1; Ther = Red)

*Lean schedules to be individually determined based on PI assessments; they may be leaner or denser than VI 120 s.


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.

UNMC Munroe-Meyer InstituteUniversity of Nebraska Medical CenterUniversity of Nebraska Medical Center

behavioral approaches to the treatment of autism and severe behavior disorders wayne w. fisher...

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