Addressing Stereotypy The Importance of a Balanced Approach to this Core Symptom of Autism

Transcription

1 Addressing Stereotypy The Importance of a Balanced Approach to this Core Symptom of Autism Gregory P. Hanley. Ph.D., BCBA-D For more information go to: THE GRODEN NETWORK'S 4th Annual Symposium Evidence-based and Emerging Trends for Parents and Practitioners of Persons with ASD April 11, 217

2 Persons diagnosed with Autism often engage in repetitive acts that appear to serve no function

3 These acts are collectively referred to as stereotypy due to the formal similarity of the acts and the periodicity with which they are emitted

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6 HFA LFA DLD NALIQ = High functioning autism =Low functioning autism = Developmental language disorder = Non-autistic low IQ

7 Stereotypy can serve different functions From Hanley, Iwata, and McCord, JABA, 23, p. 166

8 Stereotypy is usually maintained by sensory (automatic) reinforcement)

9 When is Stereotypy a Problem?.when it is exhibited with impairing frequency

10 When is Stereotypy a Problem?.when it is exhibited with impairing frequency when it interferes with attempts to teach skills or concepts

11 When is Stereotypy a Problem?.when it is exhibited with impairing frequency when it interferes with social interactions

12 When is Stereotypy a Problem?.when it is exhibited with impairing frequency when the prohibition of stereotypy results in more serious problem behavior (DeLeon et al., 211)

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14 Some applications of the model Three teenagers Jon, Patrick, & Edward Stereotypy Hand flapping, finger tapping or flicking, body rocking, mouthing, eye pressing, ear holding

15 Step 1: Functional analysis Responses per min (Stereotypy) Attention Escape Alone Control Responses per min (Stereotypy) 1 Jon Attention 15 Sessions Escape 8 Alone Control Responses per min (Stereotypy) Sessions Attention Escape Alone Control Edward Sessions Patrick Conclusion Stereotypy is probably maintained by automatic reinforcement

16 Step 2: Conduct a preference assessment See these studies for the successful treatment of stereotypy by providing free access to materials identified via preference assessment Favell, McGimsey, & Schell (1982) AIDD Piazza, Adelinis, Hanley, Goh, & Delia (2) JABA Roscoe, Iwata, & Goh (1999) JABA

17 Step 2: Preference Assessment Duration (in sec) Simple Engagement Jon Patrick Edward Response per min (Stereotypy) Beads Links Stamps Dinos Interstars Play Doh Cups Items Lite Brite Shape Sorter Interstars Legos Lite Brite Matching Items Stamps Beads Etch-a-sketch Stickers Control Beads Shape Sorter Lacing Interstar Items Stamps Links Lite Brite Legos

18 Step 2: Preference Assessment Duration (in sec) Simple Engagement Response per min (Stereotypy) Beads Links Stamps Dinos Interstars Play Doh Cups Lite Brite Items Jon Shape Sorter Interstars Legos Lite Brite Matching Stamps Beads Etch-a-sketch Stickers Items Patrick Control Beads Shape Sorter Lacing Interstar Items Stamps Links Edward Conclusion Reinforcers earned via item engagement 5 were neither substitutable for nor did they 14 effectively compete with reinforcers earned 12 1 via stereotypy Lite Brite Legos

19 Step 3: Add Prompting of Item Engagement See these studies for the successful application of prompting engagement with freely available toys to address stereotypy Britton, Carr,, Landaburu, & Romick (22) BI Horner (198) JABA Lindberg, Iwata, & Kahng (1999) JABA

20 Jon

21 Edward

22 Step 3: Add Prompting of Item Engagement Conclusion: Stereotypy persisted, so.. prompting apparently did not result in access to more or better reinforcers for item engagement

23 Step 4: Alter consequence of stereotypy-- add blocking See these studies for the successful treatment of stereotypy by blocking stereotypy Lerman, & Iwata (1996) JABA Reid, Parsons, Phillips, & Green (1993) JABA Roscoe, Iwata, & Goh (1999) JABA

24 Jon

25 Edward

26 Step 4: Alter consequence of stereotypy-- add blocking Conclusion: Stereotypy persisted or worsened Why? Interpretation of functional properties of stereotypy was incorrect Only saw early stage of extinction Are not removing all reinforcers (there were integrity breaches) Motivation to produce automatic reinforcement was high with no other way to produce similar reinforcers

27 Step 5: Add differential reinforcement to strengthen some desirable behavior See these studies for the successful treatment of stereotypy via differential reinforcement Charlop, Kurtz, & Casey (199) JABA Hanley, Iwata, Thompson, & Lindberg (2) JABA Wolery, Kirk, & Gast (1985) JADD

28 Jon

29 Edward

30 Patrick

31 The treatment activities prompting (teaching) blocking while teaching earned access to stereotypy can then be used to teach more complex play skills

32 Responses per min Treatment for Shaping Specific Forms of Functional Engagement Baseline Stereotypy Specific Functional Engagement Prompted SFE Jon # of Rs / Form Requirements / 2 cubes / I-bar on posts (1 cube) / 4 posts on I-bar / 3 posts on I-bar / 2 posts on I-bar / 1 post on I-bar Sessions

33 Responses per min Treatment for Shaping Specific Forms of Functional Engagement Baseline Stereotypy Specific Functional Engagement (SFE) Prompted SFE Edward # of Rs / Form Requirements 12 / 2nd House / 6 Legos / 1st House 5 / 5 Legos 4 / 4 Legos 3 / 3 Legos 2 2 Legos 1 / 1 Lego Sessions

34 Is this a humane treatment? Are staff willing to implement these treatments? Does the person with stereotypy like or loathe this treatment?

35 Table 2 Questions and Results of the Social Validity Questionnaire Questions 1. Do you think that the treatment that involved prompting engagement, blocking stereotypy, and differentially reinforcing engagement with 3 s access to the participant s own stereotypy was acceptable? 2. Do you think that the amount of behavior change was acceptable and sufficient? 3. I feel that the overall goals of this treatment were acceptable, appropriate and important for the individual. 4. I would recommend this treatment package to other therapists/providers that are attempting to decrease motor stereotypy and increase age-appropriate play skills. Responses Mean (range) (6-7) 6.6 (5-7) 6.8 (6-7)

36 Similar inquiry, different respondent: Which treatment did each teenager prefer?

37 % Selected Jon Orange Purple Light Blue Hot Pink Royal Blue Colors White Pink Teal

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39 Cumulative # of Selections No Differential Consequences for Selections Differential Consequences for Selections Link Colors Correlated Treatments Pink Blocking only Light Blue Activities only Royal Blue Tx Package (1) (2) (3) (4) (5) (6) (7) (8) (9) (1)(11)(12)(13)(14)(15)(16)(17)(18)(19)(2)(21)(22)(23)(24)(25)(26)(27)(28)(29)(3)(31) (Sessions) Trials No Differential Consequences for Selections Jon

40 Initial Links Terminal Links Pink Card Contingency: FR-1 Blocking Only Light Blue Card Activities Only Royal Blue Card Activities, Blocking, and Contingent Access to Stereotypy

41 Cumulative # of Selections No Differential Consequences for Selections Differential Consequences for Selections Link Colors Correlated Treatments Pink Blocking only Light Blue Activities only Royal Blue Tx Package (1) (2) (3) (4) (5) (6) (7) (8) (9) (1)(11)(12)(13)(14)(15)(16)(17)(18)(19)(2)(21)(22)(23)(24)(25)(26)(27)(28)(29)(3)(31) (Sessions) Trials No Differential Consequences for Selections Jon

42 16 No Differential Consequences for Selections Differential Consequences for Selections No Differential Consequences for Selections Cumulative # of Selections Link Colors Correlated Treatments Pink Blocking only Yellow Green Activities only Tx Package Trials Patrick (1) (2) (3) (4) (5) (6) (7) (8) (9) (1) (Sessions)

43 Cumulative # of Selections No Differential Consequences for Selections Differential Consequences for Selections Link Colors Correlated Treatments Green Blocking Only Orange Activities Only Blue Tx Package (1) (2) (3) (4) (5) (6) (7) (8) (9)(1) (11)(12) (13)(14) (15)(16) (17)(18) (19)(2) (21)(22) (23)(24) (25)(26) (27)(28) (Sessions) Trials No Differential Consequences for Selections Edward

44 Results Summary No one preferred blocking only No one avoided the treatment with all three components Two of three preferred the treatment with all three components

45 Why a preference for this treatment? Preference for contingencies?

46 Some Take-Home Points Don t assume function Test for sensitivity to social reinforcers first; see:

47 Some Take-Home Points It is important to recognize the necessity and insufficiency of blocking as a treatment for stereotypy

48 Some Take-Home Points Immediate treatment goal is not elimination of stereotypy More appropriate goal is having it occur in acceptable places and at acceptable times

49 Can we simply obtain stimulus control over stereotypy? Yes but the notion of a contingency is important here too.

50 Multiple schedule S - : stereotypy blocked S + : stereotypy allowed Chained schedule S - : stereotypy blocked S + : stereotypy allowed Changeover between S - and S + components is time-based Changeover between S - and S + components is contingent

51 Average component duration (minutes) Stereotypy per min Multiple Chained 12 S- 6 3 S FR Schedule FR Schedule S- 2 Item engagement per min Max S+ Molly Sessions

52 Okay, but did either yield stimulus control over stereotypy?

53 Sessions Chained Multiple Chained Multiple 1 1 Latency to stereotypy (% time elapsed) S- S Latency to engagement (% time elapsed) Max Molly

54 Okay, but did either yield stimulus control over stereotypy? Yes The chained schedule. The notion of a contingency is important here too.

55 Do children prefer time-based alternation (multiple schedules) or behavior-based alternation (chained schedules)?

56 Cumulative selections Multiple Chained Extinction Free choice Max Free choice Forced choice Free choice Molly Trials These children preferred behavior-based alternation (chained schedules)

57 When treating stereotypy are we missing some important opportunities? Can we address the other core deficits of autism (language and social) while addressing stereotypy? Can we allow the child more control over where and when to engage in stereotypy? Can we make the treatment more flexible so it fits into everyday life a little better? I think we can.

58 New Alternative: Skill-Based Treatment Permission/ Check-in based model in which communication, toleration, and contextually appropriate behaviors are strengthened (Hanley, Jin, Vanselow, & Hanratty, JABA, 214) 1. Teach child to request access to stereotypy (via blocking and contingent access to stereotypy) 2. Teach child to tolerate denials of mands for stereotypy (via blocking and contingent, intermittent, and unpredictable access to stereotypy) 3. Teach child to engage in contextually relevant behavior (via prompting, blocking and contingent, intermittent, and unpredictable access to stereotypy)

59 S- duration (min) # demands 1 BL FCT TRT Response Chaining 2 Motor stereotypy % of component S- S Simple FCR per min Complex FCR per min TR per min Accuracy (%) Sessions Milo 6 4 2

60 Response Chaining Sequence Level Task Longest chain of demands Total demands Field size 1 Matching pictures Matching numbers, letters (Same as above) (Same as above) (Same as above) (Same as above) (Same as above) Matching objects ADLs Receptive ID of pictures

61 S- duration (min) # demands 1 BL FCT TRT Response Chaining 2 Motor stereotypy % of component S- S Simple FCR per min Complex FCR per min TR per min Accuracy (%) Sessions Milo 6 4 2

62 Social Validity Results Question Rater 1 Rater 2 The treatment that involved teaching a request for stereotypy, teaching an appropriate response to the denial of that request, and teaching the individual to complete an increasing number of demands before earning access to stereotypy was acceptable. The amount of behavior change (i.e., the effects of treatment) was acceptable or sufficient. The overall goals of this treatment were acceptable, appropriate, and important for the individual. I would recommend this treatment package to other therapists or providers who are attempting to decrease stereotypy and increase appropriate engagement

63 1 Al. BL FCT TR RC Exten. [1] [2] [3] [4] [5] [1] [2] 1 Motor stereotypy % of component S- S S- duration (min) 4 3 FCR per min 2 1 * 2 15 TR per min 1 5 Compliance (%) Grant # demands completed Sessions ial sessions {

64 1 = Strongly disagree 7 = Strongly agree 1. The treatment that involved teaching a request for stereotypy, teaching an appropriate response to the denial of that request, and teaching the individual to complete an increasing number of demands before earning access to stereotypy was acceptable The amount of behavior change (i.e., the effects of treatment) was acceptable or sufficient The overall goals of this treatment were acceptable, appropriate, and important for the individual I would recommend this treatment package to other therapists or providers who are attempting to decrease stereotypy and increase appropriate engagement. 7

65 Next Step Evaluate generality of the skill-based treatment in different contexts and when applied under longer periods by relevant teachers and caregivers Evaluate treatment when applied to: Hand mouthing Scripting Interactive, imaginative play

66 Final Take-Home Points Treatment for interfering stereotypy. can be function-based should be comprehensive should involve a strong contingency to inhibit stereotypy and do something else contextually appropriate in order to engage in stereotypy

67 Thanks for listening. For more information go to: