CHARGE Syndrome and Comorbid Feeding Difficulties: A Summary of Outcomes following Behavior Analytic Treatment.

CHARGE syndrome is a genetic disorder caused by mutation of the CHD7 gene. Children with CHARGE syndrome often experience vision and hearing impairments, delayed growth and development, heart abnormalities, and artesia/stenosis of the chonae. Although not part of the diagnostic criteria, many individuals with CHARGE syndrome experience feeding and gastrointestinal difficulties. Interventions most commonly recommended and utilized to address feeding difficulties for children with CHARGE syndrome include tube feedings (medical approach) and oral-motor therapy. Despite the effectiveness of a behavior analytic approach to address feeding difficulties for a variety of pediatric populations, this approach is not routinely considered as a viable treatment option to address feeding difficulties for children with CHARGE syndrome. Outcome data of four children with CHARGE syndrome who participated in an intensive behavioral-based feeding program were reviewed. Variables reviewed included percentage of admission goals achieved, treatment strategies utilized, and changes in growth status, feeding tube dependence, texture and variety of foods consumed, and occurrence of inappropriate mealtime behavior. Outcomes evaluated in this review support the effectiveness of a behavior analytic approach for addressing feeding difficulties for children with CHARGE syndrome.

Toward Better Understanding of Pediatric Feeding Disorder: A Proposed Framework for Patient Characterization.

To establish a foundation for methodologically sound research on the epidemiology, assessment, and treatment of pediatric feeding disorder (PFD), a 28-member multidisciplinary panel with equal representation from medicine, nutrition, feeding skill, and psychology from seven national feeding programs convened to develop a case report form (CRF). This process relied upon recent advances in defining PFD, a review of the extant literature, expert consensus regarding best practices, and review of current patient characterization templates at participating institutions. The resultant PFD CRF involves patient characterization in four domains (ie, medical, nutrition, feeding skill, and psychosocial) and identifies the primary features of a feeding disorder based on PFD diagnostic criteria. A corresponding protocol provides guidance for completing the assessment process across the four domains. The PFD CRF promotes a standard procedure to support patient characterization, enhance methodological rigor, and provide a useful clinical tool for providers and researchers working with these disorders.

Simultaneous Presentation to Decrease Packing in a Child With a Feeding Disorder.

Children with feeding disorders may pack food (i.e., hold food in the mouth for a prolonged period of time). Treatments to target packing exist, including reinforcement contingencies, redistribution, and chasers, but these strategies are not always effective. Simultaneous presentation has also been used to reduce packing; however, it has not been faded out. The current study expanded this literature by using a treatment package, which included simultaneous presentation, to decrease packing in a 4-year-old boy with autism and food selectivity who packed nonpreferred foods. The simultaneous presentation component was then systematically faded out until generalization occurred.

Comparing behavioral treatment of feeding difficulties and tube dependence in children with cerebral palsy and autism spectrum disorder.

BACKGROUND: Feeding disorders are multifaceted with behavioral components often contributing to the development and continuation of food refusal. In these cases, behavioral interventions are effective in treating feeding problems, even when medical or oral motor components are also involved. Although behavioral interventions for feeding problems are frequently employed with children with autism, they are less commonly discussed for children with cerebral palsy. OBJECTIVE: The purpose of this study was to compare the effectiveness of using applied behavior analytic interventions to address feeding difficulties and tube dependence in children with autism and children with cerebral palsy. METHOD: Children ages 1 to 12 years who were enrolled in an intensive feeding program between 2003 and 2013, where they received individualized behavioral treatment, participated. RESULTS: Behavioral treatment components were similar across groups, predominately consisting of escape extinction (e.g., nonremoval of the spoon) and differential reinforcement. For both groups, behavioral treatment was similarly effective in increasing gram consumption and in decreasing refusal and negative vocalizations. A high percentage of individualized goals were met by both groups as well as high caregiver satisfaction reported. CONCLUSIONS: Behavioral interventions for food refusal are effective for children with cerebral palsy with behavioral refusal, just as they are for children with autism.

Treatments for the challenging behaviours of adults with intellectual disabilities.

OBJECTIVE: To provide an overview and critical assessment of common problems and best evidence practice in treatments for the challenging behaviours (CBs) of adults with intellectual disabilities (IDs). METHOD: Commonly observed problems that present obstacles to successful treatment plans are discussed, followed by an analysis of available research on the efficacy of behavioural and pharmacological therapies. RESULTS: Behavioural and pharmacological interventions are most commonly used when addressing CBs in people with IDs. However, within each of these techniques, there are methods that have support in the literature for efficacy and those that do not. As clinicians, it is important to follow research so that we are engaging in best practices when developing treatment plans for CBs. CONCLUSIONS: One of the most consuming issues for psychiatrists and other mental health professionals who work with people who evince developmental disabilities, such as IDs, are CBs. These problems are very dangerous and are a major impediment to independent, less restrictive living. However, there is a major gap between what researchers show is effective and much of what occurs in real-world settings.

Factor structure of the Matson Evaluation of Social Skills with Youngsters-II (MESSY-II).

The importance of social skills in development is a well studied area of research, and deficits in these skills can have implications long into adulthood. Therefore, assessment tools must be able to aid clinicians in identifying areas of weaknesses to target in treatment. The purpose of the current paper was to investigate the factor structure of a well researched measure of social skills, the Matson Evaluation of Social Skills with Youngsters (MESSY), which has recently been re-normed to update its psychometric properties. As such, this measure has now been dubbed the MESSY-II. This new norm sample was utilized in the current study to determine whether the original two factor structure for the MESSY would remain for the MESSY-II. Based on factor analysis, a three factor model was found to be ideal. Implications of these findings are discussed.

DSM-IV vs DSM-5 diagnostic criteria for toddlers with autism.

PURPOSE: To evaluate prevalence rates of autism and autism symptomatology in toddlers using DSM-IV vs DSM-5 criteria. METHOD: Two thousand seven hundred and twenty-one toddlers at risk for a developmental disability participated. DSM-IV and DSM-5 criteria were applied and overall prevalence using each set of criteria was established. Groups were also compared on BISCUIT-Part 1 scores to determine if groups differed on autism symptomatology. RESULTS: DSM-5 resulted in 47.79% fewer toddlers being diagnosed with ASD compared to those on the DSM-IV. Toddlers diagnosed according to DSM-5 exhibited greater levels of autism symptomatology than those diagnosed with DSM-IV, but the latter group still exhibited significant levels of autism symptomatology. CONCLUSION: The proposed DSM-5 will result in far fewer persons being diagnosed with ASD. These results replicate findings from two previous studies, with older children/adolescents and adults. As a result of these new criteria, far fewer people will qualify for needed autism services.

The effects of developmental quotient and diagnostic criteria on challenging behaviors in toddlers with developmental disabilities.

Previous research has found that individuals with intellectual disability and/or autism spectrum disorder (ASD), and those with greater symptom severity within these diagnoses, show higher rates of aggressive/destructive behavior, stereotypic behavior, and self-injurious behavior. In this exploratory cross-sectional study, toddlers at-risk for a developmental disorder (n=1509) ranging from 17 to 36 months fell into one of three diagnostic categories: Autistic Disorder, Pervasive Developmental Disorder-Not Otherwise Specified [PDD-NOS], and atypically developing - no ASD diagnosis. Mental health professionals from EarlySteps, Louisiana's Early Intervention System, interviewed parents and guardians using the Baby and Infant Screen for Children with aUtIsm Traits (BISCUIT) -Part 3 (Matson, Boisjoli, & Wilkins, 2007) to obtain measures of challenging behaviors and the Battelle Developmental Inventory, 2nd Edition (BDI-2) (Newborg, 2005) to obtain developmental quotients (DQ). Toddlers diagnosed with Autistic Disorder or PDD-NOS showed a positive relationship between total DQ and challenging behavior; whereas, atypically developing toddlers with no ASD diagnosis showed a more adaptive, negative relationship. The DQ domains that were most influential on challenging behaviors varied by diagnosis, with communication and motor domains playing greater roles for toddlers with Autistic Disorder or PDD-NOS, and personal-social and cognitive domains playing greater roles for atypically developing toddlers with no ASD diagnosis.

The relationship between race and challenging behaviours in infants and toddlers with autistic disorder and pervasive developmental disorder-not otherwise specified.

OBJECTIVE: To examine the contributions of race and diagnostic category to endorsement rates of challenging behaviours in infants and toddlers with autism, PDD-NOS and atypical development without ASD, using the Baby and Infant Screen for Children with aUtIsm Traits, Part-3 (BISCUIT Part-3). DESIGN: Multivariate analyses of variance (MANOVAs) on each sub-scale of the BISCUIT Part-3. Follow-up univariate analyses and post-hoc tests as needed. METHODS: Scores on the BISCUIT Part-3 were compared for 453 Caucasian and 409 African-American infants and toddlers, grouped by race and diagnosis. RESULTS: Significant differences between races were found on five out of 10 aggressive behaviours, while no significant differences were found on self-injurious or stereotypic behaviours. Significant differences between diagnostic groups were found on all behaviours. CONCLUSION: Cultural factors should be taken into account when examining challenging behaviours in infants and toddlers with ASD.

The effects of hearing impairment on symptoms of autism in toddlers.

OBJECTIVE: Individuals diagnosed with certain medical conditions, such as those with hearing loss or impairment, may present with symptoms that mimic those of Autism Spectrum Disorders (ASD). Therefore, the aim of this study was to investigate how hearing-compromised toddlers would score relative to toddlers diagnosed with an ASD on a measure of autism symptomatology. METHODS: The Baby and Infant Screen for Children with aUtIsm Traits (BISCUIT) was utilized to compare toddlers diagnosed with an ASD or who had hearing problems. RESULTS: The BISCUIT was effective in differentiating between children with ASD and those with hearing problems. However, atypically developing toddlers scored significantly lower than those with compromised hearing within the communication domain. CONCLUSION: Communication impairment, albeit lower than in toddlers with ASD, is present in toddlers with compromised hearing. As such, this factor should be taken into account when assessing for ASD in toddlers with hearing loss or impairment.

The relationship among side effects associated with anti-epileptic medications in those with intellectual disability.

Seizures are fairly common in those with intellectual disabilities. In order to treat these seizures, antiepileptic drugs (AEDs) are often used and in many cases are effective. However, these medications often create a variety of associated side effects. In order to monitor these side effects, measures such as the SEIZES-B have been used. While many side effects have been found to occur with the use of AEDs, research has not explored if certain side effects are more likely to co-occur. For the current study, 281 people with intellectual disability were administered the SEIZES-B to monitor side effects associated with AEDs. Correlations between side effect subscales were then computed. Several subscales were found to be significantly correlated: hepatic disturbance with dermatological changes and cognitive disturbance; respiratory disturbance with dermatological changes, sedation, and electrolyte disturbance; and cognitive disturbance with sedation and dermatological disturbance. Possible implications of these findings are discussed.

Parents' first concerns of their child's development in toddlers with autism spectrum disorders.

OBJECTIVE: Investigations about first concerns among parents of toddlers with ASD and comparisons of the same with children diagnosed with other developmental disorders are scarce. METHOD: The current study utilized a sample of toddlers diagnosed with an ASD or other developmental delay and examined the nature of parents' first concern and the age of first concern compared to the age of first assessment. RESULTS: The majority of parents of both toddlers diagnosed with ASD and non-ASD related developmental delays indicated that the area of first concern was in communication. However, the age of first concern was significantly younger for toddlers with an ASD diagnosis. In addition, there was a significant positive correlation between the age at which concerns were first noted and the age at which assessment was sought. CONCLUSION: The implications of these findings are discussed as they relate to early assessment and intervention.

The relationship between psychopathology symptom clusters and the presence of comorbid psychopathology in individuals with severe to profound intellectual disability.

In the typically developing population, comorbid psychopathology refers to the co-occurrence of two different psychopathologies other than cognitive impairments. With respect to individuals with intellectual disability, comorbidity is often described as cognitive deficits and one additional psychopathology manifesting together. However, just as within the typically developing population, individuals with intellectual disability may also present with symptoms of two or more additional disorders. The presentation of these symptom clusters may similarly correlate. Therefore, the current study used the Diagnostic Assessment for the Severely Handicapped-II in order to examine relationships between psychopathological symptom clusters in adults with severe to profound intellectual disability. Additionally, we assessed comorbid presentation of disorders other than cognitive impairments in these same adults. Several symptom clusters were identified as being related with moderate to strong positive correlations. Furthermore, elevations on the Impulse subscale were noted to be the most prevalent in the current sample, with comorbid elevations most commonly occurring along the Mood, Mania, and Anxiety subscales. The significance of these findings is discussed.

Behaviors and corresponding functions addressed via functional assessment.

One-hundred seventy-three studies that employed functional assessment were evaluated with respect to types of challenging behaviors studied and the functions identified that maintained those behaviors. For most studies, two to three behaviors were targeted. Of the 38 different challenging behaviors identified, self-injurious behavior (SIB) and aggression were by far the most studied. Other commonly studied behaviors were tantrums, stereotypies, property destruction, bizarre/inappropriate speech/vocalizations, and disruptive behaviors. The most commonly identified functions for both SIB and aggressions were attention and escape/demands. The implications of these and other data complied on target behaviors and maintaining variables are discussed.

Person characteristics of individuals in functional assessment research.

This paper is a review of person characteristics that were present in 173 studies that were reviewed on functional assessment. The purpose was to give the reader an idea about the types of individuals for which functional assessment is appropriate and to outline persons and their characteristics which have the best research support. The majority of participants were diagnosed with intellectual disability and/or autism. Additionally more males that females were included and children were frequently studied versus adolescents and older adults. Finally, while the majority of studies employed experimental functional analysis, the number of participants per study was small. Conversely, functional analysis scales were used in far fewer studies, but with much larger sample sizes. Thus, relatively equal numbers of individuals have been studied with both methods.

Stability of symptoms of autism spectrum disorders in toddlers: an examination using the Baby and Infant Screen for Children with aUtIsm Traits-Part 1 (BISCUIT).

OBJECTIVE: The diagnostic stability of Autism Spectrum Disorders (ASD) at very young ages continues to be debated, despite empirical evidence that ASDs can be reliably diagnosed in children under the age of 3 years. This topic is of the upmost importance given that early intervention increases long-term outcomes in this population. METHODS: The goal of the current study was to examine the stability of symptoms of ASD between two assessment times for 114 toddlers. The following was compared from the first to second assessment: diagnostic classification stability, correlations between scores and the impact of time between the first and second assessment. RESULTS: Significant correlations were found for toddlers as young as 18 months of age. In addition, even with up to a year between assessment intervals, symptoms of ASD were relatively stable prior to 3 years of age. CONCLUSIONS: Implications of the current findings are discussed.

Assessment of toileting difficulties in adults with intellectual disabilities: an examination using the profile of toileting issues (POTI).

A lack of toileting skills is one of many impairments that individuals with intellectual and developmental disabilities experience. Unfortunately, little research has focused on problems in this area including assessment, function, and treatment. A newly developed checklist, the Profile of Toileting Issues (POTI), is being considered for use to screen for toileting issues in this population, and to identify potential functions to target in treatment. The purpose of the current study was to examine the reliability of the POTI. Internal consistency was sound (α = .83) and interrater reliability was significant. The implications of these findings are included.

What is the evidence for environmental causes of challenging behaviors in persons with intellectual disabilities and autism spectrum disorders?

An extensive literature on the causes of challenging behaviors has been developed, primarily in the applied behavior analysis literature. One hundred and seventy-three empirical studies were reviewed where functional assessment serves as the primary method of identifying these causes. Most of the studies were able to identify a clear function or functions. Most commonly established causes were attention, the efforts to acquire tangibles, negative reinforcement in the form of escape from tasks or environments, and sensory stimulation, also described as an alone condition. Examples are provided regarding how these conditions are investigated across studies. Biological and cognitive causes have also been demonstrated. However, to date the empirical literature is limited with the bulk of studies being correlational. Considerably more research is needed, but some causes and methods to identify them are beginning to emerge.

Replacement behaviors for identified functions of challenging behaviors.

Functional assessment has become a major feature of learning-based research. A critical element of the majority of these studies includes not only methods and procedures to identify the cause of the challenging behavior, but to establish replacement treatment methods. By far the most common intervention in the 176 studies we reviewed was reinforcement. Noncontingent reinforcement (NCR) was the most common reinforcement method, followed by differential reinforcement of other behavior (DRO). Reinforcement plus extinction was the second most commonly employed treatment followed by functional communication training with or without reinforcement. Researchers proved to be very creative. Forty different treatment methods were employed. The implications of these data are discussed.

An examination of differences in symptom endorsements of autism spectrum disorders: a comparison between mothers and fathers.

OBJECTIVE: Best assessment practices for Autism Spectrum Disorders (ASD) incorporate both multimodal and multi-informant assessments. However, differences in symptoms reports from multiple informants can lead to diagnostic decision-making problems. METHODS: Thus, the purpose of this paper was to examine differences in the reports of symptoms of ASD between parents (i.e. mothers and fathers) of children and adolescents that met research criteria for an ASD and additionally for a group of children that were typically-developing (n=39). RESULTS: There were differences in the number of symptoms endorsed between mothers and fathers. CONCLUSION: Implications of the current findings are discussed.