6/11/2017. Addressing Stereotypy The Importance of a Balanced Approach to this Core Symptom of Autism. stereotypy. Gregory P. Hanley Ph.D.

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1 /11/17 Addressing Stereotypy The Importance of a Balanced Approach to this Core Symptom of Autism Gregory P. Hanley Ph.D., BCBA D For more information and materials, go to: Persons diagnosed with Autism often engage in repetitive acts that appear to serve no function These acts are collectively referred to as stereotypy due to the formal similarity of the acts and the periodicity with which they are emitted 1

2 /11/17 HFA LFA DLD NALIQ = High functioning autism =Low functioning autism = Developmental language disorder = Non autistic low IQ Stereotypy can serve different functions From Hanley, Iwata, and McCord, JABA, 3, p. 1

3 /11/17 Stereotypy is usually maintained by sensory (automatic) reinforcement) When is Stereotypy a Problem?.when it is exhibited with impairing frequency When is Stereotypy a Problem?.when it is exhibited with impairing frequency when it interferes with attempts to teach skills or concepts 3

4 /11/17 When is Stereotypy a Problem?.when it is exhibited with impairing frequency when it interferes with social interactions 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., 11)

5 /11/17 Some applications of the model Three teenagers Jon, Patrick, & Edward Stereotypy Hand flapping, finger tapping or flicking, body rocking, mouthing, eye pressing, ear holding Jon Jon

6 /11/17 Edward Alter consequence of stereotypy via 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 Critical Step: 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 () JABA Wolery, Kirk, & Gast (198) JADD

7 /11/17 Jon Edward Patrick 7

8 /11/17 The treatment activities prompting (teaching) blocking while teaching earned access to stereotypy can then be used to teach more complex play skills Some questions Is this a humane treatment? Are staff willing to implement these treatments? Does the person with stereotypy like or loathe this treatment? Table 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?. 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.. 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) 7.. ( - 7). ( - 7).8 ( - 7) 8

9 /11/17 Similar inquiry, different respondent: Which treatment did each teenager prefer? % Selected Jon 3 1 Orange Purple Light Blue Hot Pink Royal Blue Colors White Pink Teal 9

10 /11/17 Cumulative # of Selections No Differential Differential No Differential Consequences Consequences Consequences for Selections for Selections for Selections Link Colors Correlated Treatments Pink Blocking only 3 Light Blue Activities only Royal Blue Tx Package Jon (1) () (3) () () () (7) (8) (9) (1)(11)(1)(13)(1)(1)(1)(17)(18)(19)()(1)()(3)()()()(7)(8)(9)(3)(31) () Trials 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 Cumulative # of Selections No Differential Differential No Differential Consequences Consequences Consequences for Selections for Selections for Selections Link Colors Correlated Treatments Pink Blocking only 3 Light Blue Activities only Royal Blue Tx Package Jon (1) () (3) () () () (7) (8) (9) (1)(11)(1)(13)(1)(1)(1)(17)(18)(19)()(1)()(3)()()()(7)(8)(9)(3)(31) () Trials 1

11 /11/17 1 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 Activities only Green Tx Package Patrick (1) (1) () () (3) () () (7) (8) (9) () Trials Cumulative # of Selections No Differential Differential No Differential Consequences Consequences Consequences for Selections for Selections for Selections Link Colors Correlated Treatments Green Blocking Only 3 Orange Activities Only Blue Tx Package Edward (1) () (3) () () () (7) (8) (9)(1) (11)(1) (13)(1) (1)(1) (17)(18) (19)() (1)() (3)() ()() (7)(8) () Trials 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 11

12 /11/17 Why a preference for this treatment? Preference for contingencies? Some Take Home Points Don t assume function Test for sensitivity to social reinforcers first; see: Some Take Home Points It is important to recognize the necessity and insufficiency of blocking as a treatment for stereotypy 1

13 /11/17 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 Can we simply obtain stimulus control over stereotypy? Yes but the notion of a contingency is important here too. 13

14 /11/17 Obtaining stimulus control of stereotypy Stereotypy is blocked Stereotypy is allowed 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 on performance Stereotypy 1 Multiple Chained Item engagement 1 1 FR Schedule Max FR Schedule Molly Average component duration (minutes)

15 /11/17 Stereotypy 1 Multiple Chained Item engagement 1 1 FR Schedule Max FR Schedule Molly Average component duration (minutes) Stereotypy 1 Multiple Chained Item engagement 1 1 FR Schedule Max FR Schedule Molly Average component duration (minutes) Stereotypy 1 Multiple Chained Item engagement 1 1 FR Schedule Max FR Schedule Molly Average component duration (minutes)

16 /11/17 Okay, but did either yield stimulus control over stereotypy? Latency to stereotypy (% time elapsed) Chained Multiple 1 1 Latency to engagement (% time elapsed) 1 Max 1 Molly Chained Multiple Latency to stereotypy (% time elapsed) 1 1 Chained Multiple 1 1 Latency to engagement (% time elapsed) 1 Max 1 Molly Chained Multiple

17 /11/ Latency to stereotypy (% time elapsed) 1 1 Chained Multiple 1 1 Latency to engagement (% time elapsed) 1 Max 1 Molly Chained Multiple Okay, but did either yield stimulus control over stereotypy? Yes The chained schedule. The notion of a contingency is important here too. Do children prefer time based alternation (multiple schedules) or behavior based alternation (chained schedules)? 17

18 /11/17 Cumulative selections 1 8 Multiple Chained Extinction Free choice Max Trials Free choice Forced choice Free choice Molly These children preferred behavior based alternation (chained schedules) 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. 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, 1) 1. Teach child to request access to stereotypy (via blocking and contingent access to stereotypy). 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) 18

19 /11/17 Slaton & Hanley (1) Contingent vs. noncontingent access contingent: performance occurs Stereotypy is blocked noncontingent: time elapses Stereotypy is allowed Slaton & Hanley (1) What about permission based access? mand for stereotypy no yes Stereotypy is blocked Stereotypy is allowed Hanley, Jin, Vanselow, & Hanratty (1) Skill based treatment for socially mediated PB Reinforcement Functional communication request (FCR) Denied Tolerance response (TR) Variable amount of work/play Compliance 19

20 /11/17 Hanley, Jin, Vanselow, & Hanratty (1) Skill based treatment for socially mediated PB Granted Reinforcement Functional communication request (FCR) Denied Tolerance response (TR) Variable amount of work/play Compliance Hanley, Jin, Vanselow, & Hanratty (1) Skill based treatment for socially mediated PB Granted Reinforcement Functional communication request (FCR) Denied % Tolerance response (TR) Variable amount of work Compliance Hanley, Jin, Vanselow, & Hanratty (1) Skill based treatment for socially mediated PB Granted Reinforcement Functional communication request (FCR) Denied % Tolerance response (TR) % Variable amount of work/play Compliance

21 /11/17 The current study Combination of both treatment packages Mand for stereotypy % Denied Tolerance response % Stereotypy blocked Variable work/play Comp. % Stereotypy is allowed 1 seconds Participants Name Age Diagnosis Communication Work tasks Grant 7 Autism 1 word phrases Numbers, letters, sight words, pictures, matching Milo 1 Autism 1 3 word phrases Match and identify objects, pictures, numbers, letters; short ADL tasks Marco 1 Autism 1 3 word phrases Leisure and time management on ipad Participants: stereotypy topographies Grant Milo Marco Hand flapping Finger wiggling Object flapping Clapping Holding objects to eyes and rotating Hand flapping Tapping on teeth Rubbing or poking face Finger play Shaking objects Tapping work materials Pacing or galloping Jumping Tapping body, furniture Hair twirling Knuckle cracking 1

22 /11/17 Baseline Alone Confirm that stereotypy persists in the absence of social consequences Instructional BL Emulate the final treatment context nominated by the team No consequences for stereotypy For Milo: 1 work trials (S ) followed by 1 3 s access to stereotypy () Repeat for min Motor stereotypy % of component 1 7 BL FCT TRT Response Chaining 1 1 duration (min) Simple FCR 1 1 Complex FCR 1 Instructional Baseline Tasks TR Accuracy (%) Milo # demands Match pictures in an array of Match letters in an array of Match numbers in an array of Identify (touch) pictures in an array of Sort objects in an array of 3 Unpack backpack Put on shirt (over his current shirt) Motor stereotypy % of component 1 7 BL FCT TRT Response Chaining 1 1 duration (min) Simple FCR 1 1 Complex FCR 1 FCT TR Accuracy (%) Milo # demands 1 trial sessions Simple FCR: play please Complex FCR: Can I play please? Immediate vocal model, faded within session All FCRs were immediately granted Criteria: 3 consecutive sessions with optimal FCRs and stereotypy at % or less during S

23 /11/17 Motor stereotypy % of component 1 7 BL FCT TRT Response Chaining 1 1 duration (min) Simple FCR 1 1 Complex FCR 1 Tolerance Response Training TR Accuracy (%) Milo # demands 1 trial sessions FCR granted on trials, denied on trials Tolerance response following denial: Okay Immediate vocal model, faded within session Criteria: 3 consecutive sessions with optimal FCRs and TRs, and stereotypy at % or less during S Motor stereotypy % of component 1 7 BL FCT TRT Response Chaining 1 1 duration (min) Simple FCR 1 1 Complex FCR 1 Response Chaining TR Accuracy (%) Milo # demands 1 trial sessions trials: FCR produced the trials: TR produced the trials: compliance with work produced the Criteria: 3 consecutive sessions with 8% accuracy (or 1% for ), optimal FCRs and TRs, and stereotypy at % or less during S Motor stereotypy % of component Simple FCR Complex FCR BL FCT TRT Response Chaining 1 1 duration (min) Level Task Demand range Total demands Field size 1 Match pictures Letters, numbers (Same) (Same) (Same) (Same) TR 7 (Same) Sort objects Accuracy (%) 7 Milo 8 1 # demands 9 +ADLs Identify pictures

24 /11/17 Motor stereotypy % of component 1 7 BL FCT TRT Response Chaining 1 1 duration (min) Simple FCR Complex FCR TR Accuracy (%) 7 Milo 8 1 # demands 1 1 Motor stereotypy % of component duration (min) FCR 3 1 * TR Accuracy (%) 7 Grant 1 1 Marco # demands Discrimination index Proportion of stereotypy that occurred during Expressed as a decimal.7 1. = discriminated responding. = indiscriminate responding

25 /11/ Motor stereotypy discrimination index Grant Milo Marco 1 duration (minutes) Discrimination index (avg) Grant Milo Marco Baseline Treatment Vocal stereotypy discrimination index Grant Milo Marco 1 duration (minutes). 8 1 Social Validity 1 = highly disagree 7 = highly agree Question Grant Milo Marco 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

26 /11/17 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 vocal stereotypy and other there s a better time and place for that behaviors Hand mouthing Scripting Masterbation Interactive, imaginative play Final Take Home Points Treatment for stereotypy can (should?) be. function based comprehensive involve a strong, intermittent, and unpredictable contingency to inhibit stereotypy and do something else contextually appropriate in order to engage in stereotypy Good luck with all that you do for all who you teach and provide care For more information go to: Contact info.: Gregory P. Hanley, Ph.D., BCBA D Psychology Department Western New England University 11 Wilbraham Road Springfield, Massachusetts 1119 ghanley@wne.edu