Severe behavior problems in SYNGAP1-related disorder: A summary of 11 consecutive patients in a tertiary care specialty clinic.

SYNGAP1-related disorder (SYNGAP1-RD) is a neurodevelopmental disorder that is commonly associated with epilepsy, autism spectrum disorder (ASD), and disruptive behaviors. In this study, behavior problems in 11 consecutive patients with SYNGAP1-RD are described and quantified based on a behavioral screening conducted within the context of a multi-disciplinary tertiary care specialty clinic visit. The behavioral phenotype was then compared to published samples of behavior problems in ASD and other genetic cause of epilepsy occurring in the context of neurodevelopmental disorders using results from the Aberrant Behavior Checklist-Community (ABC-C), an empirically derived outcome measure. We report common antecedent and consequent events surrounding problem behavior across individuals. Additionally, we report on the management approach of caregivers and the impact of problem behaviors on the family. Our results suggest a number of commonalities between behavioral profiles in SYNGAP1-RD with ASD and other genetic causes of developmental and epileptic encephalopathies, and also highlight severe behavior problems as a specific behavioral phenotype of SYNGAP1-RD.

A Neurobehavioral Continuum of Care for Individuals with Intellectual and Developmental Disabilities with Severe Problem Behavior.

The Neurobehavioral Programs at Kennedy Krieger Institute constitute a comprehensive continuum of care designed to serve individuals with intellectual and developmental disabilities with co-occurring problem behavior. This continuum includes inpatient, intensive outpatient, outpatient, consultation, and follow-up services. The mission of these programs is to fully integrate patient care, research, training, and advocacy to achieve the best possible outcomes with patients, and to benefit the broader community of individuals with severe behavioral dysfunction. The primary treatment approach utilized across all programs is applied behavior analysis, however the inpatient unit also provides fully integrated interdisciplinary care. Factors driving the development and expansion of these programs are described, as are the processes and systems by which the mission objectives are achieved.

Quantifying increases in problem behavior following downshifts in reinforcement: A retrospective analysis and replication.

The recurrence of a previously eliminated or reduced behavior following a downshift in alternative reinforcement is referred to as resurgence. Resurgence as Choice (RaC) is a quantitative model of behavioral persistence that posits that resurgence is governed by the same behavioral principles that underlie choice behavior. Consistent with the predictions of RaC, extant basic research with animals indicates that resurgence increases as an exponential function of the size of the downshift in alternative reinforcement. Recently, Shahan and Greer (2021) extended this finding to resurgence of problem behavior during schedule thinning following functional communication training (FCT). They found that when resurgence occurred, it increased exponentially as a function of relative decrements in reinforcer availability during schedule thinning with compound schedules of reinforcement. The purpose of the current study was to directly replicate the analytic procedures described in Shahan and Greer to examine resurgence of problem behavior during schedule thinning following FCT using two novel clinical datasets. Our results closely replicate the findings from Shahan and Greer, providing additional support for the generality of resurgence during downshifts in alternative reinforcement in clinical contexts. These results also highlight the potential applicability of RaC for modeling resurgence of problem behavior during FCT schedule thinning.

Assessment and treatment of tracheostomy tube manipulation: Effects of competing stimuli and protective equipment.

Functional analyses (FA) are widely used in the assessment and treatment of problem behavior. However, with limited exceptions, the procedures are rarely applied to potentially dangerous behaviors involving medical equipment. The current study replicated and extended procedures previously used by Kurtz and Chin (2004) to assess and treat tracheostomy tube manipulation in a 5-year-old boy diagnosed with extensive medical and developmental conditions. FA results indicated that tracheostomy tube manipulation (i.e., touching, pulling, occluding) was automatically maintained. An augmented competing stimulus assessment was conducted to identify stimuli associated with low levels of tracheostomy tube manipulation and elevated levels of item engagement. A treatment package consisting of noncontingent access to competing stimuli with prompting and continuous application of protective equipment produced significant reductions in tracheostomy tube manipulation, as well as significant increases in toy engagement.

Collateral Effects of Behavioral Treatment for Problem Behavior on Caregiver Stress.

When individuals with autism and intellectual and developmental disabilities exhibit severe problem behavior, assessment and treatment are often warranted. Parents of such individuals are at high risk for developing parenting stress. In this study, 194 parents completed the Parenting Stress Index-Short Form at their child's time of admission to and discharge from inpatient or outpatient treatment for severe problem behavior. Parent stress was examined in relation to rate and function of child problem behavior as determined via functional analysis. Repeated measures analyses of variance were conducted, and differential effects were observed when child participants exhibited an attention, automatic, or mands function for problem behavior. These findings highlight the importance of considering function of problem behavior in relation to parenting stress.

Further application of the generalized matching law to multialternative sports contexts.

Cox et al. (2017) successfully applied the multialternative version of the generalized matching law (GML) to pitch selection among a sample of Major League Baseball (MLB) pitchers. The purpose of the present study was to replicate and extend these findings by fitting the multialternative GML to pitch data among a sample of MLB pitchers with varying levels of success in the major leagues. We also examined how matching parameters changed as a function of novel antecedent game contexts such as the infield shift, game location, and number of times the pitcher faced the batters in the batting order. These results replicate the findings from Cox et al. and suggest the multialternative GML is a robust descriptor of pitch selection among MLB pitchers. Together, these findings further extend the generality of the multialternative GML to naturalistic, nonlaboratory environments.

Behavioral Approaches to Assessment and Early Intervention for Severe Problem Behavior in Intellectual and Developmental Disabilities.

This article summarizes the literature on prevalence and establishment of severe problem behavior in individuals with intellectual and developmental disabilities, empirical support for applied behavior analysis, and evidence-based behavioral assessment and treatment procedures. Early intervention and prevention approaches and the role of the pediatrician with regard to surveillance, early intervention, and coordination of care are discussed.

An Evaluation of Operant Behavioural Economics in Functional Communication Training for Severe Problem Behaviour.

Objective: This single-case experiment examined the use of behavioural economic concepts in a function-based treatment for problem behaviour. Methods: Behavioural economic analyses were used to evaluate the strength of functions of problem behaviour and this information was used to inform elements of function-based treatment for one child with a neurodevelopmental disorder. Results: Findings from this experiment indicated that the incorporation of behavioural economic measures resulted in positive treatment effects that were maintained throughout all phases of the evaluation, including those implemented by caregivers. Conclusions: These results suggest that behavioural economic concepts and procedures can be successful adjuncts to evidence-based assessments and treatments for problem behaviour.

Functional analysis and treatment of problem behavior exhibited by children with fragile X syndrome.

The efficacy of function-based interventions for the treatment of severe problem behavior exhibited by individuals with intellectual and developmental disabilities (IDD) is well established. However, few studies have reported on behavioral interventions in fragile X syndrome (FXS) specifically. The present study is a consecutive case-series analysis that reports on functional analysis and treatment of problem behavior of nine children with FXS. Assessment findings were consistent with previous research indicating that among individuals with FXS, problem behavior is more commonly maintained by escape from demands and access to tangible items, relative to the broader population of individuals with IDD. Functional analysis-based behavioral interventions resulted in a mean reduction in problem behavior of 95.2% across the nine participants. Additionally, generalization of treatment effects from controlled clinical settings to home, school, and community was demonstrated. The current findings suggest that function-based behavioral interventions shown to be effective with the broader population of individuals with IDD are also effective for individuals with FXS. Our results in combination with those of previous studies describing functional analysis outcomes provide additional evidence for a unique functional behavioral phenotype for severe problem behavior in individuals with FXS. Implications of study findings for early intervention and prevention of problem behavior in children with FXS are discussed.

Functional communication training with and without alternative reinforcement and punishment: an analysis of 58 applications.

Functional communication training (FCT) is an empirically supported treatment for problem behavior displayed by individuals with intellectual disabilities. Hagopian, Fisher, Sullivan, Acquisto, and LeBlanc (1998) analyzed 25 applications of FCT and showed that extinction was a necessary component of FCT, but sometimes punishment was needed to maintain low levels of problem behavior. The current consecutive case series summarized data from 58 applications of FCT in more recent cases. This analysis extended and updated Hagopian et al. by examining FCT when used in combination with alternative reinforcement (noncontingent and differential reinforcement) and multiple schedules during schedule thinning. Although it is difficult to make direct comparisons with the 1998 study, the results of the current case series analysis suggest that FCT can be enhanced when used in combination with alternative reinforcement and when multiple schedules are used during schedule thinning.

Caregiver- and staff-conducted functional analysis outcomes: a summary of 52 cases.

In the present study, caregivers were trained as therapists to conduct functional analyses (FAs) after staff-conducted FAs were inconclusive with 52 participants. Caregiver-conducted FAs identified at least 1 function for problem behavior when staff-conducted FAs were undifferentiated. When results of the staff-conducted FAs were questionable, subsequent caregiver-conducted FAs resulted in an exact match with staff-conducted FA in about 68% of cases but identified new functions in about 30% of cases. Function-based treatments based on caregiver-conducted FAs were effective in reducing problem behavior by an average of 96% relative to baseline. Results suggest that when staff-conducted FA outcomes yield inconclusive findings, using caregivers to conduct FAs is likely to produce differentiated results and ultimately result in the development of effective treatments.

An evaluation of the Aberrant Behavior Checklist for children under age 5.

Severe problem behaviors such as self-injury and aggression are frequently observed in young children under age 5 with intellectual and developmental disabilities (IDD). Although early identification of problem behavior is critical to effective intervention, there are few standardized measures available that identify severe problem behavior in this population. The Aberrant Behavior Checklist-Community (ABC-C; Aman & Singh, 1994) is a rating scale that measures the severity of a range of problem behaviors commonly observed in individuals with IDD. While it has been used with children under 5, investigations into the fit of the ABC-C for this population are sparse. The purpose of the present study was to report on ABC-C scores in a sample of 97 children under age 5 with problem behavior. Analyses included evaluating differences in scores between age groups, comparing sample norms to established norms for older children, and conducting a confirmatory factor analysis. Results indicated differences in mean scores based on age with younger children generally scoring higher on some subscales of the ABC-C. Furthermore, the original 5-factor structure of the ABC-C was not fully supported. In general, the ABC-C may over- or underestimate behavior problems in younger children; therefore more extensive investigation into the utility of the ABC-C for children under age 5 is warranted.

Identification of Emerging Self-Injurious Behavior in Young Children: A Preliminary Study.

Self-injurious behavior (SIB) is a chronic disorder that often begins in early childhood; however, few studies have examined the onset of SIB in young children. This preliminary study reports on the identification, assessment and observation of SIB in 32 children who had begun to engage in SIB within the previous 6 months. Participants were ages birth to 5 years and presented with or were at risk for intellectual and/or developmental disabilities. Assessment measures included parental interviews, developmental and language measures, standardized measures of problem behavior, and direct observations conducted in the home. Results indicated that for most children, SIB emerged prior to age 1 year, and multiple topographies of SIB and other problem behaviors developed in most children. Multiple measures were useful in identifying SIB and in characterizing the behavior by topography, frequency, and severity. Findings from the examination of child communication in relation to SIB were inconclusive. Results are discussed in relation to theories of SIB emergence, and previous observational studies of young children with SIB.

An analysis of functional communication training as an empirically supported treatment for problem behavior displayed by individuals with intellectual disabilities.

This paper examines the literature on the use of functional communication training (FCT) as a treatment for problem behavior displayed by individuals with intellectual disabilities (ID). Criteria for empirically supported treatments developed by Divisions 12 and 16 of the American Psychological Association (Kratochwill & Stoiber, 2002; Task Force, 1995) and adapted by Jennett and Hagopian (2008) for evaluation of single-case research studies were used to examine the support for FCT. Results indicated that FCT far exceeds criteria to be designated as a well-established treatment for problem behavior exhibited by children with ID and children with autism spectrum disorder, and can be characterized as probably efficacious with adults.

Evaluation of combined-antecedent variables on functional analysis results and treatment of problem behavior in a school setting.

Call, Wacker, Ringdahl, and Boelter (2005) conducted an analysis in which a single-antecedent condition was compared to a multiple-antecedent condition. The present study extended Call et al. by conducting a structured descriptive assessment (SDA) to identify the antecedent variables most associated with problem behavior in a student with traumatic brain injury and intellectual disabilities. Results indicated that the SDA was effective in identifying relevant antecedent variables that led to the development of an effective intervention in the classroom.

Therapist effects on functional analysis outcomes with young children.

Analog functional analyses (FAs) are commonly used to assess factors that maintain problem behavior of individuals with intellectual disabilities. These analyses are usually conducted by trained staff in clinic settings. However, recent research suggests that FAs conducted by unfamiliar individuals, such as hospital or clinic staff, may result in inaccurate or at least different outcomes. This finding, though, has not been sufficiently examined with young children (i.e., under 5 years of age), where therapist familiarity likely has more influence. The current study compared the outcomes of FAs conducted by unfamiliar staff with FAs conducted by parents for five children ages 2-5 years. Results demonstrate that FAs conducted by unfamiliar therapists may result in a number of differing outcomes, including no responding from the child, failure to identify a particular behavioral function, and decreased rates of responding.

A systematic review of challenging behaviors in children exposed prenatally to substances of abuse.

A review of the existing literature on the occurrence of challenging behavior among children with prenatal drug exposure was conducted. While a large number of studies were identified that evaluated various outcomes of prenatal drug exposure, only 37 were found that directly evaluated challenging behaviors. Of the 37 studies, 23 focused on prenatal cocaine exposure, and 14 focused on prenatal alcohol exposure; most studies relied on broadband measures such as the CBCL for the assessment of challenging behavior. Among the 37 studies, a clear role for the postnatal environment on developing challenging behaviors was evident; however, prenatal alcohol exposure showed a much clearer independent effect upon challenging behaviors than was noted in the prenatal cocaine studies. Additionally, only 3 of the 37 studies addressed interventions for challenging behaviors, each of which showed an improvement in child behavior or parent-child interactions. As researchers have continued to show the importance of the postnatal environment, it is likely that interventions addressing specific environmental risk factors will be helpful to reduce or prevent challenging behaviors among this population.

Treatment of challenging behavior exhibited by children with prenatal drug exposure.

A large body of literature exists describing the harmful effects of prenatal drug exposure on infant and child development. However, there is a paucity of research examining strategies to ameliorate sequelae such as externalizing behavior problems. In the present study, functional analysis procedures were used to assess challenging behavior exhibited by two children who were prenatally exposed to drugs of abuse. Results for both children indicated that challenging behavior was maintained by access to positive reinforcement (adult attention and tangible items). For one child, challenging behavior was also maintained by negative reinforcement (escape from activities of daily living). Function-based interventions were effective in reducing challenging behavior for both children. Implications for utilizing methods of applied behavior analysis in research with children with prenatal drug exposure are discussed.

Cognitive-behavioral treatment for specific phobias with a child demonstrating severe problem behavior and developmental delays.

Cognitive-behavioral treatments (CBTs) are widely used for anxiety disorders in typically developing children; however, there has been no previous attempt to administer CBT for specific phobia (in this case study, one-session treatment) to developmentally or intellectually disabled children. This case study integrates both cognitive-behavioral and behavior analytic assessment techniques in the CBT of water and height phobia in a 7-year-old male with developmental delays and severe behavior problems. One-session treatment [Ost, L. G. (1989). One-session treatment for specific phobias. Behaviour Research and Therapy, 27, 1-7; Ost, L. G. (1997). Rapid treatment of specific phobias. In G. C. L. Davey (Ed.), Phobias: A handbook of theory, research, and treatment (pp. 227-247). New York: Wiley] was provided for water phobia and then 2 months later for height phobia. The massed exposure therapy sessions combined graduated in vivo exposure, participant modeling, cognitive challenges, reinforcement, and other techniques. Both indirect and direct observation measures were utilized to evaluate treatment efficacy. Results suggested CBT reduced or eliminated behavioral avoidance, specific phobia symptoms, and subjective fear. Negative vocalizations were reduced during height exposure following treatment. Vocalizations following treatment for water phobia were less clear and may have been indicative of typical 7-year-old protests during bath time. Findings indicate CBT can be effective for treating clinical fears in an individual with developmental disabilities and severe behavior. Future research in this population should examine CBT as an alternative to other techniques (e.g., forced exposure) for treating fears.

Functional assessment of problem behaviors in adults with mental retardation.

Functional assessment has significantly improved the success of behavioral treatment of problem behaviors in adults with mental retardation. Functional assessment methods (i.e., techniques that yield a hypothesis of functional relationships) include direct observation, interviews, and checklists. Functional analysis consists of empirical methods that demonstrate behavioral function in controlled settings. Each method has advantages and limitations that reflect differences in both available resources and individual client characteristics. These methods and issues are reviewed, and future directions for both the research field and the adult population are suggested.