ABA: EVALUATION &TREATMENT OF CHALLENGING BEHAVIORS

October 11, 2013Todd Kopelman, PhD, BCBA

What are “Challenging Behaviors?”

Interfere with:

Parent-child, sibling interactions

Student’s ability to learn, socialize & participate in classroom routines.

Teacher’s ability to instruct.

Adult’s ability to obtain/maintain employment, stable housing, social relationships

Challenging Behaviors

1. Noncompliance – active (refusal), passive (off-task), or combination

2. Aggression

3. Tantrums

4. Destruction

5. Self-injurious behavior

www.statesman.com

Path to Negative Outcomes

• Reduced learning opportunities• Academic difficulties, retention, suspension, drop-out, unemployment, substance abuse (Carr et al., 1991; Wehby et al., 1993 Lipsey & Derzon, 1998, CBHC.org)

• Teacher and parent burnout (Hastings & Bham, 2003)

http://world.edu/unhappy-teacher-bad-apple-tree/

ABA: What is it?

Not ABBA!

What is ABA?

John Watson (“Little Albert”)

www.glogster.com

Burrhus Frederick Skinner (1904-1990)

Interested in understanding behavior as a function of environmental histories of

reinforcing consequences.

Applied Behavior AnalysisA systematic and experimental approach for evaluating the

effects of changes in the environment on a person’s behavior

ABA

• Behavioral principles often incorporated into other therapeutic approaches (CBT, ACT, VB, PCIT, etc)

• 1000’s peer-reviewed studies using ABA procedures published across different ages, settings, diagnoses, behaviors

ABA: An Evidence-Based Treatment

• Surgeon General Report• American Academy of Neurology• American Academy of Family Pediatrics• American Academy of Occupational Therapy

Association• American Psychological Association• American Speech-Language Hearing Association• Society for Developmental and Behavioral Pediatrics• Autism Society of America• National Institute of Child Health & Human Development• National Institute of Mental Health

Core Components of ABA • Applied (Socially significant)• Environment-behavior relationships• Technological (detailed & clear procedures)• Single subject design (Small N’s)• Observable behaviors

Do We Intervene?

www.simpsonscrazy.com

Do We Intervene?

www.ocregister.com

Do We Intervene?

Autisminnb.blogspot.com

Core Components of ABA • Applied (Socially significant)• Environment-behavior relationships• Technological (detailed & clear procedures)• Single subject design• Observable behaviors

0

20

40

60

80

100

1201/

3/13

1/4/

131/

7/13

1/8/

131/

9/13

1/10

/13

1/11

/13

1/14

/13

1/15

/13

1/18

/13

1/22

/13

1/23

/13

1/24

/13

1/25

/13

1/28

/13

1/29

/13

Hom

e2/

4/13

Met

hyop

hena

date

10m

g2/

8/13

No

Med

s2/

11/1

3Fo

calin

5m

g/cl

onid

ine

2/13

/13

Ins

to h

im2/

18/1

32/

20/1

32/

25/1

32/

28/1

33/

1/13

Faca

lin 1

0mg

3/4/

133/

6/13

3/8/

133/

11/1

33/

13/1

33/

14/1

33/

15/1

3D

ay T

reat

men

tSc

hool

1 H

r4/

15/1

34/

16/1

34/

17/1

34/

18/1

34/

19/1

34/

22/1

3

Perc

enta

ge o

f Ins

truc

tiona

l Ti

me

Dates / Changes in Interventions

Out of Instructional Control

Out of Control

Linear (Out of Control)

Function•Function: the reason why problematic behavior continues to occur.

•Social function: environmental events that maintain problematic behavior.

•Automatic function: internal events maintain problematic behavior

•Treatment is based on identified function, not on topography.

Rationale for Function-Based Treatment

Once the function of the problem behavior

is known, treatment involves:

• Disrupting the response-reinforcer relation (e.g., extinction)

• Providing a known reinforcer contingent on the desired behavior (e.g., DRA)

Maintaining Events

•Positive reinforcement: a “gain” function• Social attention, tangibles, preferred items

•Negative reinforcement: an “escape” function• Nonpreferred activities, tasks

•Automatic reinforcement: unknown or intrinsic

Functional Approach to Behavior:The Basics

http://bookwag.com/2013/03/6-actors-who-have-played-sherlock-holmes/

Functional AnalysisDirect ObservationIndirect Measures

Determining Function

Determining Function of Behavior

Indirect Measures

Behavioral Interview or Checklist• Topography of behavior• Times of day• Activities • Settings• People present• Antecedents• Consequences• Biological Variables • Medications

Determining Function of Behavior • Direct Observation: Scatter Plot Analysis

Time Mon Tues Wed Thurs Fri Activity

8:00-8:30 Hygiene Tasks

8:30-9:00 Bus

9:00-9:30 Leisure Time

9:30-10:00 M, W, F sort silverware

Functional Analysis (“Gold Standard”)

• Experimentally tests hypotheses regarding variables that maintain problem behavior

• Actively manipulate antecedents and consequences surrounding behavior

• Observations are conducted within an experimental design to demonstrate functional control.

Functional Analysis Procedures• Manipulate attention, escape, and access to preferred

items or activities.• Contrast with a control condition (free play).• Conduct 5-minute analogue conditions within an

experimental design.• Continue until a consistent pattern of behavior is

identified.

Functional Analysis Procedures

• Condition 1: Free play• Control condition• Access to preferred items and social attention• No demands• Problem behavior ignored• Appropriate behavior reinforced

Functional Analysis Procedures (continued)

• Condition 2: Escape• Task demand presented• Brief break for problem behavior

• Condition 3: Attention• Client ignored• Social attention provided for problem behavior

• Condition 4: Tangible• Removal of tangible• Access to tangible given for problem behavior

Brief Functional Analysis

We Identified the Function…Now What?

Common Treatment Components

1. Reinforcement-based procedures• Differential Reinforcement

• DRA/DRC (FCT), DRI, DRL/DRH, DRO• Noncontingent Reinforcement (NCR)

2. Extinction-based procedures

3. Punishment-based procedures

4. Antecedent-based procedures

Common Treatment Components• Uncommon to use single treatment procedure

• Individualized packages (e.g., combination of antecedent, reinforcement, extinction procedures)

• Goals of a treatment plan should be parsimony & internal consistency (treatments matched to function)

Applied Behavior Analysis

Pros Cons

Effective Effortful

Empowers parents(Can predict & control bx)

Inconsistent reimbursement

Cost effective Inconsistent Access; Geographic Lottery

ABA in Iowa: From Research to Practice

The Case for Behavioral Telehealth

Urgent Need for Behavioral Interventions

•Applied behavior analysis (ABA) is an evidence-based treatment for challenging behavior in ASD

•Access to ABA is inconsistent

Strategies for Intervention

•Use functional analysis (FA) and functional communication training (FCT), to replace problem behavior with social communication

•Train parents to use FA/FCT with their children under the direction of a behavioral consultant

•Use telehealth to reach underserved areas

In-Home ABA

Clinic Telehealth ABA

Bettendorf

Keokuk

Cedar Rapids

Centerville

Sheldon

Fairfield

Oelwein

Fertile

Armstrong

Irwin

Home Telehealth ABA

Average distance from I.C. = 122 miles

Home Telehealth Eligibility Criteria

Autism Spectrum Disorder diagnosis

Significant challenging behaviors (e.g., aggression, destruction, SIB, repetitive behaviors, severe tantrums)

Reside in IA at start of study

Referrals from CHSC or UI clinics

Children 18 to 83 months of age with:

Behavioral Procedures•Weekly 60-min telehealth sessions from UI Children’s Hospital to family home

•Parents conduct all sessions with child with telehealth coaching from behavior therapist

•All sessions recorded, scored, & graphed

•Participation lasts up to 6 months

•RCT design in home-based project

• Immediate vs wait control assignment

General Procedures (cont.)Clinic & Home-Based ABA Telehealth:Functional Analysis: Iwata et al. (1982/1994) procedures; multielement design• Assessment: Goal is to identify function of child’s target behavior(s)

Functional Communication Training: Carr & Durand, 1985.• Treatment: Goal is to replace problem behavior with appropriate communication that serves same function

Behavioral Telehealth Successes

•Reduction in problem behavior through telehealth averages over 90%, comparable to ABA provided in vivo when therapists visit the home

•High treatment acceptability

•Average weekly cost of delivering telehealth was $60 per participant, compared to $291 if consultants traveled to provide coaching on site or in home

• Increased accessibility to rural areas of state

Statewide Behavior Resources• UIHC (Outpatient & Day Treatment Programs)• Adult Psychiatry Clinic (Jodi Tate/Todd Kopelman)• ITABS (Susan Smith)• Money Follows the Person

Challenging Behavior Teams

• Each AEA has a Challenging Behavior Team (CBT)• “Top tier” experts in FBA & BIP• Local school team can request consultation• Parents can ask school if CBT is involved!

Board Certified Behavior Analysts• http://www.bacb.com/ (Can look up IA providers)• Certified to conduct behavior assessments and

interventions• BCBA’s work in school, residential, hospital, and private

practice• Certification requires Masters in behavior analysis or

closely related field & 225 graduate hrs of instruction in behavior analysis + 15oo hrs supervised experience & examination