1. Bio-Behavioral Approaches to the Assessment and Treatment of Autism WAYNE W. FISHER University of Nebraska Medical Center’s Munroe-Meyer Institute

2. Center for Autism Spectrum Disorders: Assessment and Treatment Clinics Severe Behavior Program Early Intervention Program Virtual Care Program Autism Diagnostic Clinic Ph.D Program School Consultation Program

3. 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

4. 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.

5. UNMC Munroe-Meyer Institute 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.

6. UNMC Munroe-Meyer Institute 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)

7. UNMC Munroe-Meyer Institute Common Functions of SIB  Social Positive Reinforcement (Attention, Tangible items)  Social Negative Reinforcement (Escape)  Automatic Reinforcement (e.g., Sensory Stimulation)

8. UNMC Munroe-Meyer Institute Modifying Functional Analyses to Identify Idiosyncratic Social and Automatic Functions

9. UNMC Munroe-Meyer Institute Previous Models  Iwata et al. (1982/1994) 1.Multielement Analog Assessment  Mace & Lalli (1991) 1.Linking Descriptive Assessments and Experimental Analyses

10. UNMC Munroe-Meyer Institute Previous Models (cont.)  Wacker et al. (1991) 1.Brief Analog Assessments  Vollmer et al. (1993); Iwata et al. (1994) 1.Reversal and Pairwise Designs

11. UNMC Munroe-Meyer Institute 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

12. UNMC Munroe-Meyer Institute 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-

13. UNMC Munroe-Meyer Institute 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-

14. 0 1 2 3 13579111315171921232527293133353739 Aggressive Responses Per Minute Sessions DemandTangible Attention Ignore Play

16. UNMC Munroe-Meyer Institute 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-

17. UNMC Munroe-Meyer Institute Pica  Pica involves the repeated ingestion of inedible substances.

18. UNMC Munroe-Meyer Institute Pica  Pica is the Latin word for magpie, a species of bird that eats almost anything.

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21. 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 Pair- wise 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 Pair- wise Analyses If Responding Persists, Analyze Automatic Sources of SR+ or SR-

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24. 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-

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26. Descriptive Assessment Methods  Staff and Parent Interviews  Collect ABC Data 1.Sulzer-Azaroff & Mayer, 1977  Selected Naturalist Observations  Probe Sessions  Hypothesis Development

27. UNMC Munroe-Meyer Institute 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 Tasks

28. UNMC Munroe-Meyer Institute 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% SchoolworkDustPick Up Trash Make Bed Fold Clothes Set TableWash Windows Vacuum TASKS PERCENTAGE OF TRIALS CONSUMED Engagement Chosen LL M M H H Sarah

29. UNMC Munroe-Meyer Institute 0 1 2 123456789101112131415161718 SESSIONS DESTRUCTIVE RESPONSES PER MINUTE Transition From Moderate Preference Task Transition From High Preference 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 Sarah

30. UNMC Munroe-Meyer Institute 0 1 2 3 4 0 10 20 30 40 50 60 70 80 90 100 0 1 2 3 4 13579 111315171921232527293133 SESSIONS 0 10 20 30 40 50 60 70 80 90 100 DESTRUCTIVE RESPONSES PER MINUTE PERCENT DURATION COMPLIANCE BLDRA+EXT(ESC) VACUUM WINDOWS Destructive Responses Compliance Treatment Evaluation (Transitions to Low Preference) Sarah

31. UNMC Munroe-Meyer Institute 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%)

32. UNMC Munroe-Meyer Institute 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%)

33. UNMC Munroe-Meyer Institute 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

34. UNMC Munroe-Meyer Institute Pica  Pica involves the repeated ingestion of inedible substances.

35. UNMC Munroe-Meyer Institute Pica  Pica is the Latin word for magpie, a species of bird that eats almost anything.

36. UNMC Munroe-Meyer Institute 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:

37. UNMC Munroe-Meyer Institute Pica (cont’d.)  Pica is often assumed to be maintained by automatic reinforcement.

38. UNMC Munroe-Meyer Institute Pica (cont’d.)  Danford and Huber (1982) reported that 25.8% of persons with mental retardation residing in an institution engaged in pica.

39. UNMC Munroe-Meyer Institute Pica (cont’d.)  Medical risks: 1.intestinal blockages 2.parasites 3.surgery to remove objects 4.lead and other poisoning 5.death

40. UNMC Munroe-Meyer Institute 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.

42. UNMC Munroe-Meyer Institute 0 1 2 3 123456789101112131415161718 SESSIONS BUTT PICA PER MINUTE Alone Toy Play Social Attention

43. UNMC Munroe-Meyer Institute 0 1 2 3 12345678910111213141516 SESSIONS BUTT PICA PER MINUTE Herbal Tobacco

44. UNMC Munroe-Meyer Institute 0 10 20 30 40 50 60 70 80 90 100 TobaccoTobacco ButtsHerbs Herbal Butts Paper STIMULI PERCENTAGE OF TRIALS CONSUMED

45. UNMC Munroe-Meyer Institute 0.0 1.0 2.0 3.0 16 111621293437424752556065 SESSIONS BUTT PICA PER MINUTE NCFNCF v. NCF + Interrupt NCF + Interrupt BL NCF NCF + Interrupt

46. UNMC Munroe-Meyer Institute 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).

47. UNMC Munroe-Meyer Institute Similarities and Differences Between Human and Nonhuman Species  "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

48. UNMC Munroe-Meyer Institute Similarities and Differences Between Human and Nonhuman Species  "Man is rated the highest animal, at least among all animals who returned the questionnaire.” 1.Robert Brault

49. UNMC Munroe-Meyer Institute 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).

51. UNMC Munroe-Meyer Institute Experiment 1: Procedure  Choice = Child selected Sr+ on VI 30”  No-choice = Therapist selected Sr+ on yoked schedule  Control = Extinction

52. UNMC Munroe-Meyer Institute 0 20 40 60 80 100 120 140 13579 Key Presses Per Minute Sessions Higher Preference (HP) Stimuli Lower Preference (LP) Stimuli HP and LP Stimuli Control No Choice Choice Lauren

53. UNMC Munroe-Meyer Institute 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.

54. UNMC Munroe-Meyer Institute Experiment 2: Procedure  Choice = Child selects between two lower preference stimuli  No-choice = Therapist selects higher and lower preference stimuli (50% each)  Control = Extinction

55. UNMC Munroe-Meyer Institute 0 20 40 60 80 100 120 140 810121416182022 Key Presses Per Minute Sessions HP and LP Stimuli HP and LP Stimuli Choice = LP No Choice = HP & LP Lauren Choice Control No Choice

56. UNMC Munroe-Meyer Institute 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.

57. UNMC Munroe-Meyer Institute Experiment 3: Procedure 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 Control = Extinction

58. UNMC Munroe-Meyer Institute 0 10 20 30 40 50 60 70 123456789101112 Key Presses Per Minute Sessions Equal ReinforcementUnequal Reinforcement Choice No Choice Control VI 30s VI 60s VI 150s VI 300s VI 600s (VI 15s) Josh

59. UNMC Munroe-Meyer Institute 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.

60. UNMC Munroe-Meyer Institute Sleep and SIB  Increased SIB following sleep deprivation (42%)  Increased SIB following nights with increased sleep (28%)  Increased sleep following days in which high levels of SIB occurred (13%)

61. UNMC Munroe-Meyer Institute Treatment of Sleep  Faded bedtime with response cost (Piazza, Fisher, & Sherer, 1997)  Chronotherapy (Piazza, Hagopian, Hughes, & Fisher, 1997)

62. UNMC Munroe-Meyer Institute Faded Bedtime with Response Cost Protocol  Establish sleep pressure with a late initial bedtime  Same night contingency  Next night contingencies

63. UNMC Munroe-Meyer Institute Chronotherapy  The individual’s bedtime is phase delayed by 2 to 3 hours each night until the desired sleep onset time is achieved.

64. Hours of Disturbed Sleep Days BaselineFaded Bedtime + RC

65. Percentage of Intervals with Problem Behavior Days BaselineFaded Bedtime + RC

66. 0.4 0.6 0.8 1 1.2 1.4 1.6 BaselineTreatment Hours of Disturbed Sleep Bedtime Scheduling Faded Bedtime + RC Randomized Controlled Trial F = 6.7; p <.03

67. UNMC Munroe-Meyer Institute Effects of Sleep Treatment on SIB  Does effective sleep treatment result in collateral improvements in SIB?

68. UNMC Munroe-Meyer Institute 0 10 20 30 40 50 09-10-9809-13-9809-16-98 09-19-98 09-22-9809-25-98 09-28-9810-01-98 10-04-9810-07-98 10-10-98 10-13-9810-16-9810-19-9810-23-9810-26-98 10-29-98 11-01-9811-04-9811-07-98 11-10-98 11-13-9811-16-98 11-19-98 0 10 20 30 40 50 09-10-98 09-13-98 09-16-9809-19-98 09-22-9809-25-98 09-28-9810-01-98 10-04-98 10-07-9810-10-98 10-13-9810-16-98 10-19-98 10-23-98 10-26-9810-29-9811-01-98 11-04-98 11-07-9811-10-98 11-13-98 11-16-9811-19-98 Self-Injurious Behavior Per Hour Non-Sleep Related SIB Sleep Related SIB Baseline Sleep Treatment Baseline Sleep Treatment Date Illness

69. UNMC Munroe-Meyer Institute 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.

70. UNMC Munroe-Meyer Institute 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.

71. UNMC Munroe-Meyer Institute 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.

72. UNMC Munroe-Meyer Institute Diagnoses Which May Warrant Assessment for Cyclicity  Atypical Bipolar Disorder  Intermittent Explosive Disorder  Temporal lobe Epilepsy

73. UNMC Munroe-Meyer Institute Detecting Cyclical Behavior Disorders  What specific behaviors should be monitored to detect cyclical behavior patterns in individuals with profound mental retardation?

74. UNMC Munroe-Meyer Institute 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.

75. UNMC Munroe-Meyer Institute Cyclical Behaviors Reported for Nonverbal Individuals Aggression Self-Injury Inappropriate Laughter Insomnia Food Refusal Food Selectivity Vocal Agitation Motor Agitation Restlessness Noncompliance

76. UNMC Munroe-Meyer Institute Detecting Cyclical Behavior Disorders (cont.)  What types of data collection systems are most sensitive to the detection of cyclical behavior patterns?

77. UNMC Munroe-Meyer Institute 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?

78. UNMC Munroe-Meyer Institute Predicting the Next Change  What is the chance probability that behavioral data will follow a cyclical pattern such as: H L H L Where: H = is a higher data point L = is a lower data point

79. UNMC Munroe-Meyer Institute 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 2.the probability of a sequence of 7 is <.01 3.the probability of a sequence of 10 is <.001

80. UNMC Munroe-Meyer Institute Testing Hypotheses About The Cyclicity of a Behavior (cont.)  What is the chance probability that a marked increase in maladaptive behavior will consistently occur within 5 days of a predicted dated?

81. UNMC Munroe-Meyer Institute Testing Hypotheses About The Cyclicity of a Behavior (cont.)  Using the formula for a Bernoulli trial 1.3 consecutive predicted increases <.05 2.5 consecutive predicted increases <.01 3.7 consecutive predicted increases <.001

82. 0 2 4 6 8 10 12 14 Days Frequency of Destructive Behavior JED

83. 0 10 20 30 40 50 60 70 80 90 100 12345678910111213 10-day cycles Average Aggressive Responses TONY

84. UNMC Munroe-Meyer Institute 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.

85. UNMC Munroe-Meyer Institute Session Number -40 -20 0 20 40 60 80 100 0 1 2 3 4 13579111315171921232527293133 Destructive Responses Per Minute R= -.73 Destructive Behavior Affect Positive Negative

86. UNMC Munroe-Meyer Institute 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.

87. 0 200 400 600 800 102030405060708090 Days Frequency of Destructive Behavior HELEN

88. 0 100 200 300 400 123 Menstrual Cycles Mean Destructive Responses Per Day HELEN Ovulation Menses Other

89. UNMC Munroe-Meyer Institute 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.

91. UNMC Munroe-Meyer Institute 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 A BehaviorAntecedentsConsequences

92. UNMC Munroe-Meyer Institute 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

93. UNMC Munroe-Meyer Institute 10.0 20.0 30.0 40.0 50.0 60.0 70.0 80.0 90.0 100.0 102030405060708090100 Sessions Percentage of Reinforcers Earned Problem Behavior Appropriate Behavior AdderalPlacebo Adderal Add.AdderalPlacebo Placebo Plac.

94. UNMC Munroe-Meyer Institute Medication Evaluation Results  Adderal biased responding toward appropriate behavior so that almost all reinforcers were earned through this response.

95. UNMC Munroe-Meyer Institute 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.

96. 0 0.5 1 1.5 2 2.5 3 8/68/209/49/18 Date Daily Recorded Seizures 0 2 4 6 8 10 12 14 16 Disrobings per Hour KEPPRA = 3250mg NEURONTIN = 1800mg SEIZURES DISROBING Mal

97. UNMC Munroe-Meyer Institute 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.

98. UNMC Munroe-Meyer Institute  "If you are out to describe the truth, leave elegance to the tailor." Albert Einstein

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100. University of Nebraska Medical Center