Bio-Behavioral Approaches to the Assessment and Treatment of Autism

WAYNE W. FISHER

University of Nebraska Medical Center’s

Munroe-Meyer Institute

Center for Autism Spectrum Disorders: Assessment and Treatment Clinics

SevereBehavior Program

Early Intervention

Program

Virtual Care Program

AutismDiagnostic

Clinic

Ph.D ProgramSchool

Consultation Program

Asking what contributes more to human behavior, nurture or nature is like asking what contributes more to the area of a rectangle, its width or length.

Ebbinghaus, circa 1885

UNMC Munroe-Meyer Institute

Structural vs. Functional Diagnosis

Structural Approach

1. How often a particular set of symptoms

or responses cluster or covary.

Functional Approach

1. Whether and which environmental

variables influence the response.

Functional Analysis

Identifies the environmental contexts in

which aberrant behavior is likely and

unlikely.

Identifies the consequences that

reinforce and maintain the behavior.

Used to prescribe effective treatments.

Direct Observation

"There are three principal means of

acquiring knowledge. . . observation of nature,

reflection, and experimentation. Observation

collects facts; reflection combines them;

experimentation verifies the result of that

combination."

1. Denis Diderot (1713-1784)

Common Functions of SIB

Social Positive Reinforcement

(Attention, Tangible items)

Social Negative Reinforcement

(Escape)

Automatic Reinforcement (e.g.,

Sensory Stimulation)

Modifying Functional Analyses to Identify Idiosyncratic Social and Automatic Functions

Previous Models

Iwata et al. (1982/1994)

1. Multielement Analog Assessment

Mace & Lalli (1991)

1. Linking Descriptive Assessments and

Experimental Analyses

Previous Models (cont.)

Wacker et al. (1991)

1. Brief Analog Assessments

Vollmer et al. (1993); Iwata et al.

(1994)

1. Reversal and Pairwise Designs

Previous Models (cont.)

Vollmer et al. (1995)

1. Model That Provided Decision Rules for Moving from Brief to Multielement, to Extended Alone, to Reversal Designs

Current Model

1. No Brief Assessment

2. DAs for Identifying Idiosyncratic Functions

3. Methods for Identifying Specific Automatic Functions

Conduct Standard

Functional Analysis

If Social Function is Clear, Proceed to Treatment

If Low or Variable Rates, Conduct Descriptive Assessment

If High Rates in Most Conditions, Conduct Extended Alone, Reversals or Pairwise Analyses

If High Rates in Alone, Analyze Automatic Sources of SR+ or SR-

Generate and Test Hypotheses About Idiosyncratic Functions

If Responding Decreases, Conduct Reversals or Pairwise Analyses

If Responding Persists, Analyze Automatic Sources of SR+ or SR-

Conduct Standard

Functional Analysis

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39

Sessions

DemandTangible

Attention

Ignore

11 22 33 44 55 66 77 88 99 1010 1111 1212 1313 1414 1515 1616 1717 1818 1919 2020 2121

KirkKirk

Session

Baseline Extinction BaselineFCT +Extinction

DestructiveBehavior

Communication

Conduct Standard

Functional Analysis

Pica involves the repeated ingestion of

inedible substances.

Pica is the Latin word for magpie, a

species of bird that eats almost anything.

Conduct Standard

Functional Analysis

If High Rates in Most Conditions, Conduct Extended Alone, Reversals or Pair-wise Analyses

If Responding Decreases, Conduct Reversals or Pair-wise Analyses

1 5 9 13 17 21 25 29 33 37 41 45 49 53 57 61 65 69

SESSIONS

Demand

Play Attention Tangible

Functional Analysis

72 74 76 78 80 82 84 86 88 90 92 94 96 98

SESSIONS

Functional Analysis (Pairwise)

Attention

Tangible

Demand

Attention vs. Play

Tangible vs. Play

Demand vs. Play

Conduct Standard

Functional Analysis

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39

SESSIONS

ESocial Attention

AloneDemand

Toy PlayTangible

Functional Analysis

Descriptive Assessment Methods

Staff and Parent Interviews

Collect ABC Data

1. Sulzer-Azaroff & Mayer, 1977

Selected Naturalist Observations

Probe Sessions

Hypothesis Development

Case Example: Idiosyncratic Social Function

Hypothesis I: Respondent Behavior Elicited

by Transitions or Changes in Routine

Hypothesis II: Escape from or Avoidance of

Transitions or Changes in Routine

Hypothesis III: Escape from Nonpreferred

Schoolwork Dust Pick Up Trash

Make Bed Fold Clothes

Set Table WashWindows

Vacuum

EngagementChosen

H Sarah

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

SESSIONS

Transition From Moderate Preference Task

Transition From HighPreference Task

Task Transition Assessment

Moderate to Low

Moderate to High

Low to Moderate

Low to High

High to Low

High to Moderate

Transition From Low Preference Task

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33

SESSIONS

0102030405060708090100

BL DRA+EXT(ESC)

VACUUM

WINDOWS

Destructive Responses

Compliance

Treatment Evaluation(Transitions to Low Preference)

Summary of 40 Cases

Clear Function Identified During

Standard Functional Analysis

Social SR+ N = 16 (55.2%)

Automatic SR+ N = 2 (6.9%)

Total N = 18 (62.1%)

Summary of 40 Cases (cont.)

Function Clarified Through Additional

Analyses

Idiosyncratic Social SR+ N = 7 (24.1%)Pervasive Automatic SR+ N = 4 (13.8%)

Total N = 11 (37.9%)

Studying Bio-Behavioral Relations Using ABA Methods

Pica with cigarettes

Is there a cross-species preference for

choice (i.e., loosely referred to as freedom)

Sleep, SIB, and Cyclical Behavior in

Individuals with Developmental Disabilities

(Piazza, Fisher, et al.)

Drug-Environment-Behavior Interactions

(Fisher, Piazza, et al.)

Forced Normalization

Pica involves the repeated ingestion of

inedible substances.

Pica is the Latin word for magpie, a

species of bird that eats almost anything.

Similarities and Differences Between Human and Nonhuman Species

"Drinking without being thirsty and

making love at any time, Madame, are the

only things that distinguish us from other

animals.”

Beaumarchis:

Pica (cont’d.)

Pica is often assumed to be

maintained by automatic reinforcement.

Pica (cont’d.)

Danford and Huber (1982) reported

that 25.8% of persons with mental

retardation residing in an institution

engaged in pica.

Pica (cont’d.)

Medical risks:

1. intestinal blockages

2. parasites

3. surgery to remove objects

4. lead and other poisoning

5. death

Pica (cont’d.)

The risk of death associated with pica

may be higher than that for other forms of

self-injurious behavior (Foxx & Livesay,

1984; McLoughlin, 1988).

Death rates associated with pica in

institutions are similar to those associated

with heart disease.

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18

SESSIONS

Toy Play

Social Attention

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16

SESSIONS

Herbal

Tobacco

Tobacco Tobacco Butts Herbs Herbal Butts Paper

STIMULI

1 6 11 16 21 29 34 37 42 47 52 55 60 65

SESSIONS

ENCF NCF v.

NCF + InterruptNCF

+ InterruptBL

NCF + Interrupt

Does Choice Function as a Reinforcement Across Species

Basic research has shown that pigeons prefer having multiple response options to having just one response option, even when the amount of reinforcement (food) and the size of the response apparatus are held constant (Catania & Sagvolden, 1980).

"If you pick up a starving dog and

make him prosperous, he will not bite

you. This is the principal difference

between a dog and a man.”

1. Mark Twain

"Man is rated the highest animal, at

least among all animals who returned

the questionnaire.” 1.Robert Brault

Experiment 1: Does Choice Function as Reinforcement?

The goal of this study was to

determine whether individuals with

disabilities preferred a choice to a no-

choice condition when each produced

the same terminal reinforcer(s).

Experiment 1: Procedure

Choice = Child selected Sr+ on

VI 30”

No-choice = Therapist selected Sr+ on

yoked schedule

Control = Extinction

1 3 5 7 9

Sessions

Higher Preference(HP) Stimuli

Lower Preference (LP)Stimuli

HP and LP Stimuli

Control

No Choice

Choice

Lauren

Experiment 2: Is Choice Preferred over Tangible Reward (i.e., Freedom)?

The goal of this study was to determine whether individuals with disabilities preferred having more response options (i.e., choice) when having fewer options produced a better tangible reward.

Choice = Child selects between two lower

preference stimuli

No-choice = Therapist selects higher and lower

preference stimuli (50% each)

8 10 12 14 16 18 20 22

Sessions

HP and LPStimuli

Choice = LPNo Choice = HP & LP

Lauren

Choice

Control

No Choice

Experiment 3: Is Choice Preferred over a Higher Rate of Reward?

The goal of this study was to determine whether individuals with disabilities preferred having more response options (i.e., choice) when having fewer options produced a higher rate of tangible reward.

Choice = Child selects between multiple, identical 1-oz. Cups of Coke

No-choice = Therapist selects identical 1-oz. Cups of

Coke with a higher Sr+ rate

1 2 3 4 5 6 7 8 9 10 11 12

Sessions

Equal Reinforcement Unequal Reinforcement

Choice

No ChoiceControl

VI 30s

VI 60s

VI 150s

VI 300s

VI 600s

(VI 15s)

(VI 15s) Josh

Sleep and SIB

Piazza et al. conducted lag correlations

between direct observations of SIB and sleep

patterns with 35 patients.

Significant correlations (p < .05) were

identified for 59.3% of participants.

Sleep and SIB

Increased SIB following sleep deprivation

Increased SIB following nights with

increased sleep (28%)

Increased sleep following days in which

high levels of SIB occurred (13%)

Treatment of Sleep

Faded bedtime with response cost (Piazza,

Fisher, & Sherer, 1997)

Chronotherapy (Piazza, Hagopian,

Hughes, & Fisher, 1997)

Faded Bedtime with Response Cost Protocol

Establish sleep pressure with a late initial

bedtime

Same night contingency

Next night contingencies

Chronotherapy

The individual’s bedtime is phase delayed

by 2 to 3 hours each night until the desired

sleep onset time is achieved.

Baseline Faded Bedtime + RC

Baseline Treatment

Bedtime Scheduling

Faded Bedtime + RC

Randomized Controlled Trial

F = 6.7; p < .03

Effects of Sleep Treatment on SIB

Does effective sleep treatment result in

collateral improvements in SIB?

Non-Sleep Related SIB

Sleep Related SIB

Baseline Sleep Treatment

Illness

Rapid Cycles and SIB

Rapid-cycling bipolar affective disorder is

defined as the occurrence of at least four

episodes of either mania or depression

within a year.

Estimated Prevalence?

Given independent disorders, the

expected prevalence of the co-occurrence of

profound retardation and bipolar disorder

would be 2 per 1,000,000.

We are seeing many more cases than this

estimate would predict, which suggests that

the disorder may not be independent.

Estimated Prevalence (cont.)

A. H. Reid (1972) Found 1 profoundly

retarded adult with mixed manic- depressive

psychosis in a study of over 500

institutionalized retarded adults.

Diagnoses Which May Warrant Assessment for Cyclicity

Atypical Bipolar Disorder

Intermittent Explosive Disorder

Temporal lobe Epilepsy

Detecting Cyclical Behavior Disorders

What specific behaviors should be

monitored to detect cyclical behavior

patterns in individuals with profound mental

retardation?

Detecting Cyclical Behavior Disorders (cont.)

We reviewed all of the cases in the

literature of cyclical behavior disorders

among nonverbal individuals and identified

ten behaviors reported to increase and

decrease in a cyclical pattern.

Cyclical Behaviors Reported for Nonverbal Individuals

Aggression Self-Injury

Inappropriate Laughter Insomnia

Food Refusal Food Selectivity

Vocal Agitation Motor Agitation

Restlessness Noncompliance

Detecting Cyclical Behavior Disorders (cont.)

What types of data collection systems are

most sensitive to the detection of cyclical

behavior patterns?

Testing Hypotheses About The Cyclicity of a Behavior

Based on a hypothesized cycle, can we

predict whether the behavior is going to

increase or decrease next?

Based on a hypothesized cycle, can we

predict when an increase in behavior is going

to occur?

Predicting the Next Change

What is the chance probability that behavioral

data will follow a cyclical pattern such as:

H L H L H L H L

Where: H = is a higher data point

L = is a lower data point

Testing Hypotheses About The Cyclicity of a Behavior (cont.)

Using the formula for the Bernoulli trial

1. the probability of a sequence of 5 is < .05

What is the chance probability that a

marked increase in maladaptive behavior will

consistently occur within 5 days of a

predicted dated?

Using the formula for a Bernoulli trial

1. 3 consecutive predicted increases < .05

1 2 3 4 5 6 7 8 9 10 11 12 13

10-day cycles

Cyclical Mood and Behavioral Changes

If cyclical destructive behavior is a form of

rapid cycling bipolar disorder, then changes

in destructive behavior should covary with

changes in affect.

Session Number

1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33

R= - .73DestructiveBehavior

Affect

Behavioral Changes Related to the Menstrual Cycle

In some cases, cyclical changes in

destructive behavior may be related to other

biological processes, such as the menstrual

cycle.

10 20 30 40 50 60 70 80 90

Menstrual Cycles

Ovulation

Menses

Effects of Environmental Enrichment on Affect and SIB

Candy was a 23-year-old woman with severe

mental retardation, major depression, mild left

hemiparesis, and autism.

Carbamazepine (5.3 mg/kg/day) and a

behavioral intervention effectively treated her

depression and SIB throughout the day except

when she was left alone.

Operant Phenotype of Response to Drug Treatment in ADHD

Drugs may influence aberrant behavior associated with a given condition through a variety of operant mechanisms.

Drug ADrug A

BehaviorAntecedents Consequences

Stimulant Effects On The Behavior Component Of The 3-Term Contingency

Concurrent Arrangement in which appropriate and problem behavior produced equal reinforcement under the same stimulus conditions.

Antecedent – Behavior – Consequence

Concurrent Operants

Problem Behavior Sr+ on FR 1

Appropriate Behavior Sr+ on FR 1

10 20 30 40 50 60 70 80 90 100

Sessions

Problem Behavior

AppropriateBehavior

Adderal Placebo

Adderal Adderal Add. AdderalPlacebo

Placebo

Medication Evaluation Results

Adderal biased responding toward

appropriate behavior so that almost all

reinforcers were earned through this

response.

Forced Normalization and Destructive Behavior in Autism

Force normalization is a term used to

describe a phenomenon in which temporary

remission of poorly controlled seizures is

associated with an emergence or worsening

of psychotic or aberrant behavior.

All or almost all reported cases of forced

normalization have been anecdotal reports.

8/6 8/20 9/4 9/18

KEPPRA = 3250mgNEURONTIN = 1800mg

SEIZURES

DISROBING

Studying Bio-Behavioral Relations Using ABA Methods

These data show how direct-observation

and other methods of applied behavior

analysis can be used to improve our

understanding of bio-behavioral relations

and our ability to treat severe destructive

behavior that is influenced by both biological

and environmental variables.

"If you are out to describe the truth,

leave elegance to the tailor."

Albert Einstein

UNMC Munroe-Meyer InstituteUniversity of Nebraska Medical CenterUniversity of Nebraska Medical Center

Bio-Behavioral Approaches to the Assessment and Treatment of Autism

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