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

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: www.practicalfunctionalassessment.com THE GRODEN NETWORK'S 4th Annual Symposium Evidence-based and Emerging Trends for Parents and Practitioners of Persons with ASD April 11, 217

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

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, 23, p. 166

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

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., 211)

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

Step 1: Functional analysis Responses per min (Stereotypy) 14 12 1 8 6 4 2 Attention Escape Alone Control Responses per min (Stereotypy) 1 Jon 3 6 9 12 Attention 15 Sessions Escape 8 Alone Control 6 4 2 Responses per min (Stereotypy) Sessions 1 8 6 4 2 Attention Escape Alone Control 3 6 9 12 2 4 6 8 1 12 Edward Sessions Patrick Conclusion Stereotypy is probably maintained by automatic reinforcement

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

Step 2: Preference Assessment Duration (in sec) Simple Engagement 3 25 2 15 1 5 Jon Patrick Edward 14 12 Response per min (Stereotypy) 1 8 6 4 2 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

Step 2: Preference Assessment Duration (in sec) Simple Engagement Response per min (Stereotypy) 3 25 2 15 1 8 6 4 2 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

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

Jon

Edward

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

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

Jon

Edward

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

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

Jon

Edward

Patrick

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

Responses per min 2 15 1 5 2 15 1 5 Treatment for Shaping Specific Forms of Functional Engagement Baseline Stereotypy Specific Functional Engagement Prompted SFE Jon # of Rs / Form Requirements 1 9 8 7 6 5 4 3 2 1 / 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 1 2 3 4 5 6 7 8 9 1 11 12 Sessions

Responses per min 15 12 9 6 3 15 12 9 Treatment for Shaping Specific Forms of Functional Engagement Baseline Stereotypy Specific Functional Engagement (SFE) Prompted SFE Edward # of Rs / Form Requirements 12 / 2nd House 11 1 9 8 7 6 / 6 Legos / 1st House 5 / 5 Legos 4 / 4 Legos 3 / 3 Legos 2 2 Legos 1 / 1 Lego 6 3 1 2 3 4 5 6 7 8 9 Sessions

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

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) 7. 6.6 (6-7) 6.6 (5-7) 6.8 (6-7)

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

1 9 8 7 % Selected 6 5 4 Jon 3 2 1 Orange Purple Light Blue Hot Pink Royal Blue Colors White Pink Teal

Cumulative # of Selections 44 4 36 32 28 24 2 16 12 8 4 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) 12 24 36 48 6 72 84 96 18 12 132 144 156 168 18 (Sessions) Trials No Differential Consequences for Selections Jon

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

16 No Differential Consequences for Selections Differential Consequences for Selections No Differential Consequences for Selections Cumulative # of Selections 14 12 1 8 6 4 Link Colors Correlated Treatments Pink Blocking only Yellow Green Activities only Tx Package 2 6 12 18 24 3 36 42 48 54 6 Trials Patrick (1) (2) (3) (4) (5) (6) (7) (8) (9) (1) (Sessions)

Cumulative # of Selections 44 4 36 32 28 24 2 16 12 8 4 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) 12 24 36 48 6 72 84 96 18 12 132 144 156 168 (Sessions) Trials No Differential Consequences for Selections Edward

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

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

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.

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

Average component duration (minutes) Stereotypy per min 4 1 5 4 2 Multiple Chained 12 S- 6 3 S+ 15 1 FR Schedule 9 2 3 4 2 1 FR Schedule 123 5 7 1 2 S- 2 Item engagement per min 5 1 5 Max 1 5 1 5 1 S+ Molly 1 2 3 4 Sessions 1 2 3 4 5

Okay, but did either yield stimulus control over stereotypy?

Sessions Chained Multiple Chained Multiple 1 1 Latency to stereotypy (% time elapsed) 5 1 5 S- S+ 5 1 5 1 1 Latency to engagement (% time elapsed) 5 1 5 Max 5 1 5 Molly 1 2 3 4 1 2 3 4 5

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)?

Cumulative selections 1 8 6 4 2 Multiple Chained Extinction Free choice Max 3 6 9 12 6 4 2 Free choice Forced choice Free choice 3 6 9 12 15 Molly Trials 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, 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)

S- duration (min) # demands 1 BL FCT TRT Response Chaining 2 Motor stereotypy % of component 75 5 25 S- S+ 15 1 5 2 Simple FCR per min 15 1 5 15 Complex FCR per min 6 4 2 6 TR per min 4 2 1 1 2 3 4 7 4 5 6 7 8 9 1 8 Accuracy (%) 75 5 25 2 4 6 8 1 Sessions Milo 6 4 2

Response Chaining Sequence Level Task Longest chain of demands Total demands Field size 1 Matching pictures 3 12 3 2 + Matching numbers, letters 3 12 3 3 (Same as above) 6 18 3 4 (Same as above) 1 27 3 5 (Same as above) 1 27 4 6 (Same as above) 1 27 5 7 (Same as above) 1 27 6 8 + Matching objects 1 27 6 9 + ADLs 1 27 6 1 + Receptive ID of pictures 1 27 6

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. 7 7 7 7 7 7 7 7

1 Al. BL FCT TR RC Exten. [1] [2] [3] [4] [5] [1] [2] 1 Motor stereotypy % of component 8 6 4 2 S- S+ 8 6 4 2 S- duration (min) 4 3 FCR per min 2 1 * 2 15 TR per min 1 5 Compliance (%) 1 8 6 4 Grant 1 8 6 4 # demands completed 2 2 2 4 6 Sessions ial sessions {

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. 7 2. The amount of behavior change (i.e., the effects of treatment) was acceptable or sufficient. 6 3. The overall goals of this treatment were acceptable, appropriate, and important for the individual. 7 4. I would recommend this treatment package to other therapists or providers who are attempting to decrease stereotypy and increase appropriate engagement. 7

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

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

Thanks for listening. For more information go to: www.practicalfunctionalassessment.com