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.

Utilizing Group-Based Contingencies to Increase Hand Washing in a Large Human Service Setting.

Hand washing is the most important preventative measure for the reduction of contagious disease. Although hand washing is easy to perform, non-adherence is a ubiquitous problem. Several studies have demonstrated the effectiveness of multi-component intervention packages to improve hand washing among employees; however, interventions are limited to acute settings, are often implemented for a short period of time, and rarely, if ever, include information on long-term effectiveness. The purpose of the current study was to utilize a behavior analytic approach to determine the stimulus conditions under which hand washing should occur, and to assess and then implement a long-term monitoring system among direct care workers in a large, non-acute inpatient unit. A single-case repeated measures reversal design was used to evaluate the effectiveness of two interventions aimed at improving hand washing adherence. A lottery was found to be effective in increasing hand hygiene for 2-years with 170 staff.

Effects of specified performance criterion and performance feedback on staff behavior: a component analysis.

The present study isolated the effects of frequently used staff training intervention components to increase communication between direct care staff and clinicians working on an inpatient behavioral unit. Written "protocol review" quizzes developed by clinicians were designed to assess knowledge about a patient's behavioral protocols. Direct care staff completed these at the beginning of each day and evening shift. Clinicians were required to score and discuss these protocol reviews with direct care staff for at least 75% of shifts over a 2-week period. During baseline, only 21% of clinicians met this requirement. Completing and scoring of protocol reviews did not improve following additional in-service training (M = 15%) or following an intervention aimed at decreasing response effort combined with prompting (M = 28%). After implementing an intervention involving specified performance criterion and performance feedback, 86% of clinicians reached the established goal. Results of a component analysis suggested that the presentation of both the specified performance criterion and supporting contingencies was necessary to maintain acceptable levels of performance.

A functional analysis of crying.

Crying has yet to be examined systematically in isolation from other problem behavior, such as aggression or tantrums, during functional analyses (Hanley, Iwata, & McCord, 2003). Identification of variables that may maintain crying is especially important for populations who are susceptible to psychiatric interventions (e.g., individuals who have intellectual disabilities and communication deficits). The current study extended functional analysis methodology to crying with an adolescent boy who had been diagnosed with intellectual disabilities. Results suggested that crying was maintained by caregiver attention delivered in a sympathetic manner.

Alterations to functional analysis methodology to clarify the functions of low rate, high intensity problem behavior.

Current research provides few suggestions for modifications to functional analysis procedures to accommodate low rate, high intensity problem behavior. This study examined the results of the extended duration functional analysis procedures of Kahng, Abt, and Schonbachler (2001) with six children admitted to an inpatient hospital for the treatment of severe problem behavior. Results of initial functional analyses (Iwata, Dorsey, Slifer, Bauman, & Richman, 1982/1994) were inconclusive for all children because of low levels of responding. The altered functional analyses, which changed multiple variables including the duration of the functional analysis (i.e., 6 or 7 hrs), yielded clear behavioral functions for all six participants. These results add additional support for the utility of an altered analysis of low rate, high intensity problem behavior when standard functional analyses do not yield differentiated results.

Increasing wearing of prescription glasses in individuals with mental retardation.

This study evaluated an intervention for promoting wearing of prescription glasses in 4 individuals with mental retardation who had refused to wear their glasses previously. Distraction through noncontingent reinforcement (NCR) increased independent glasses wearing for 1 of the 4 participants. An intervention consisting of NCR, response cost, and brief response blocking (until 5 s without an attempt to remove glasses had elapsed) increased glasses wearing for the others. Partial component analyses revealed that different components of the package were sufficient or necessary to sustain glasses wearing across participants.

Assessment and treatment of problem behavior occasioned by interruption of free-operant behavior.

The current study describes the assessment and treatment of the problem behavior of 3 individuals with autism for whom initial functional analysis results were inconclusive. Subsequent analyses revealed that the interruption of free-operant behavior using "do" requests (Study 1) as well as "do" and "don't" requests (Study 2) occasioned problem behavior. Initially, treatment involved differential and noncontingent reinforcement without interruption. To make the intervention more sustainable in the natural environment (where interruptions are unavoidable), a two-component multiple-schedule arrangement was used to progressively increase the period of time in which ongoing activities would be interrupted. During generalization sessions, the intervention was applied across a variety of contexts and therapists.

Individualized sampling parameters for behavioral observations: enhancing the predictive validity of competing stimulus assessments.

Recent studies have used pretreatment analyses, termed competing stimulus assessments, to identify items that most effectively displace the aberrant behavior of individuals with developmental disabilities. In most studies, there appeared to have been no systematic basis for selecting the sampling period (ranging from 30 s to 10 min) in which items were assessed. Unfortunately, estimates based on brief samples of behavior do not always predict the extent to which items will displace aberrant behavior over longer periods. This study first examined a method for determining an accurate individualized sample length for competing stimulus assessments, based on statistical measures of correspondence with extended effects, using a small number of items. The effects of a larger number of items were then assessed using the determined sample length. Finally, the method was validated by comparing its predictions, in terms of the reduction of problem behavior over more extended periods, to predictions based on sample durations typically used in previous investigations. For two participants, predictions based on individualized determination of sample lengths were more accurate than predictions based on typical sample lengths. These results are discussed in terms of the exchange between expediency and accuracy during competing stimulus assessments.

Re-evaluation of constant versus varied punishers using empirically derived consequences.

Charlop, Burgio, Iwata, and Ivancic [J. Appl. Behav. Anal. 21 (1988) 89] demonstrated that varied punishment procedures produced greater or more consistent reductions of problem behavior than a constant punishment procedure. More recently, Fisher and colleagues [Res. Dev. Disabil. 15 (1994) 133; J. Appl. Behav. Anal. 27 (1994) 447] developed a systematic methodology for predicting the efficacy of various punishment procedures. Their procedure identified reinforcers and punishers (termed "empirically derived consequences" or EDC) that, when used in combination, reduced the destructive behavior of individuals with developmental disabilities who displayed automatically maintained destructive behavior. The current investigation combines these two lines of research by comparing the effects of constant versus varied punishers on the self-injury of two individuals with developmental disabilities. The punishing stimuli were selected via the procedures described by Fisher et al. and were predicted to be at varying levels of effectiveness. The varied presentation of punishers resulted in enhanced suppressive effects over the constant presentation of a punisher for one of two individuals, but only in comparison to a single stimulus predicted to be minimally effective. Even then, the differences were small. These results suggest that the additive effects of varied punishment are negligible if clinicians use stimuli predicted to be effective and are discussed in terms of the conditions under which stimulus variation could potentially enhance the effects of punishers.

A comparison of dense-to-lean and fixed lean schedules of alternative reinforcement and extinction.

Behavior-reduction interventions typically employ dense schedules of alternative reinforcement in conjunction with operant extinction for problem behavior. After problem behavior is reduced in the initial treatment stages, schedule thinning is routinely conducted to make the intervention more practical in natural environments. In the current investigation, two methods for thinning alternative reinforcement schedules were compared for 3 clients who exhibited severe problem behavior. In the dense-to-lean (DTL) condition, reinforcement was delivered on relatively dense schedules (using noncontingent reinforcement for 1 participant and functional communication training for 2 participants), followed by systematic schedule thinning to progressively leaner schedules. During the fixed lean (FL) condition, reinforcement was delivered on lean schedules (equivalent to the terminal schedule of the DTL condition). The FL condition produced a quicker attainment of individual treatment goals for 2 of the 3 participants. The results are discussed in terms of the potential utility of using relatively lean schedules at treatment outset.

Assessing psychopathology in individuals with developmental disabilities.

Individuals with developmental disabilities are at high risk for developing mental health problems. The prevalence of psychopathology is approximately 4 times higher than that found in the general population. Yet there is a tendency to underdiagnose psychiatric disorders in the developmentally delayed population because of diagnostic overshadowing, the lack of appropriate diagnostic criteria, and the paucity of appropriate assessment measures. Over the past decade, there has been an emergence of scales developed specifically to screen for psychopathology in individuals with developmental disabilities. In addition, advancements have been made in observation techniques, thus facilitating the ability to objectively observe behaviors often described as internal events. A description of a multimethod approach to assessing psychopathology in individuals with developmental disabilities is provided incorporating the recent advancements in the field, as well as suggestions for future research.