A Behavioral Model for Clinical Intervention in Autism Spectrum Disorder (ASD)
- Identifying Information and Presenting Problems
- Relevant Antecedents and Anamnesis
- Developmental history
- Socialization patterns with family and peers
- Familial composition, interaction, and history
- Medical history
- Academic history
- History of medical/mental health problems in the family
- Previous therapeutic interventions
- Reports from other stakeholders
- Establishment of ASD Diagnosis
- Examination of reports and data from previous diagnostic work, if any
- Observation during the interview, with emphasis on communication, interaction, range of interests, repetitive movements, feeding habits, and maladaptive behaviors (aggression towards self or others, tantrums, crying, etc.), observing and recording situational factors surrounding a problem behavior (e.g., antecedent and consequent events).
- Psychometric evaluation of assets and deficits, using psychometric instruments such as:
- Autism Diagnostic Interview-Revised (ADI-R), a semi structured parent interview
- Autism Diagnostic Observation Schedule (ADOS), uses observation and interaction with the child
- Childhood Autism Rating Scale (CARS), used to assess severity of autism based on observation of children
- DSM-IV-TR criteria: exhibiting at least six symptoms total, including at least two symptoms of qualitative impairment in social interaction, at least one symptom of qualitative impairment in communication, and at least one symptom of restricted and repetitive behavior. Onset must be prior to age three years, with delays or abnormal functioning in either social interaction, language as used in social communication, or symbolic or imaginative play. The disturbance must not be better accounted for by Rett Syndrome or Childhood Disintegrative Disorder. ICD-10 uses essentially the same definition.
- Functional analysis of behavior, to identify the contextual factors that contribute to behavior (including certain affective and cognitive behaviors which may be the trigger, or antecedent for the behavior, as well as an analysis of typical consequences to the behavior)
- Operational definition of behaviors to be modified, in concrete and observable terms.
- Functional analysis of targeted behaviors, with topographic descriptions, based on baseline observation of assets and deficits derived from observation processes and psychometric testing (with special emphasis on Onset, Location, Duration, Character [sharp, dull, etc.], Precipitating factors, Alleviating/Aggravating factors, Radiation, Temporal pattern [every morning, all day, etc], Symptoms or behaviors associated, Severity, Progression, Cessation, Periodicity), that is, using a variety of techniques and strategies to diagnose the causes and to identify likely interventions intended to address problem behaviors. In other words, functional behavioral assessment looks beyond the overt topography of the behavior, and focuses, instead, upon identifying biological, social, affective, and environmental factors that initiate, sustain, or end the behavior in question.
- Determine whether or not there are any patterns associated with the behavior. If patterns cannot be determined, review and revise (as necessary) the functional behavioral assessment plan to identify other methods for assessing behavior.
- Establish a hypothesis regarding the function of the behaviors in question. This hypothesis predicts the general conditions under which the behavior is most and least likely to occur (antecedents), as well as the probable reinforcers (consequences) that serve to maintain it. In other words, formulate a plausible explanation (hypothesis) for the behavior. It is then desirable to manipulate various conditions to verify the assumptions made regarding the function of the behavior.
- Development of a behavior intervention plan to address behavioral assets and deficits, based on the functional analysis of behavior, with the following primary goals, objectives, activities, and tasks:
- Control and reduction of aggressive behaviors towards self or others, if required, by use of:
- Harm-limiting devices such as helmets, gloves, face masks, etc.
- Differential reinforcement of other (adaptive) behaviors as opposed to reinforcement by providing attention to maladaptive behaviors
- If required by circumstances and harmfulness of behavioral aggression towards self or others, provide the following consequences to maladaptive behavior (with prior approval in writing of Ethics Committee, of which at least one member must be external to the institution, and all registered professionals qualified in this area of intervention):
- Restriction of movement
- Aversive stimulants, such as a few drops of lime juice by mouth
- Faradic aversive counter conditioning with the introduction of escape behaviors which are positive or adaptive
- Instauration and/or habilitation of adaptive behaviors, with emphasis on communication, interaction, range of interests, repetitive movements, and feeding habits, as per the functional analysis of behaviors, to:
- Initiate adaptive behaviors not in repertoire
- Strengthen adaptive or appropriate behaviors already present
- Generalization of learned responses to other persons, situations and environments
- Options for positive behavioral interventions may include:
- Replacing problem behaviors with appropriate behaviors that serve the same (or similar) function as inappropriate ones
- Increasing rates of existing appropriate behaviors
- Making changes to the environment that eliminate the possibility of engaging in inappropriate behavior
- Providing the supports necessary for the child to use the appropriate behaviors
- Use of behavior modification techniques as follows:
- Positive reinforcement with edible (e.g., M&M’s, non-sugar candy tidbits, popcorn, and raisins), tangible (e.g., paper stars, rubber stamps such as smiley face, tokens for exchange of privileges or goods, activities, toys, and free time), or social (e.g., smile, positive phrase, and pat on the back) consequences for adaptive, proactive or prosocial behaviors
- Shaping by systematic reinforcement of successive approximations
- Modeling procedures by role playing and vicarious learning procedures
- Behavioral contracting with daily, graded consequences depending on performance
- Time out from reinforcement as consequence to maladaptive behaviors (one minute per year of age with a maximum of five minutes in secluded area without external stimuli or social reinforcement)
- Manipulation of the antecedents and/or consequences of the behavior
- Teaching of more acceptable replacement behaviors that serve the same function as the inappropriate behavior
- Implementation of changes in curriculum and instructional strategies
- Modification of the physical environment
- Care should be given to select a behavior that likely will be elicited by and reinforced in the natural environment
- Program of academic instruction, as per the recommendations of specialist
- Program of speech habilitation/rehabilitation, as per the recommendations of specialist
- Provide support from parents and caretakers, peers, and other professionals as required
- Periodic evaluation of behavior intervention plan by:
- Systematic gathering of data via direct observations and permanent products (e.g., audio and video recordings, produced documents, records of interventions)
- Daily charting of frequency of use of procedures and of the production of targeted behaviors
- Reports from primary worker and specialists
- Meeting of stakeholders as required
- Meeting with parents, tutors, teachers, and social agency representatives, if involved
- The point is to predicate all evaluation on the person’s success. Thus, periodic revision of behavior intervention plan until goals are attained, upon:
- Reaching behavioral goals and objectives, and new goals and objectives need to be established
- The “situation” has changed and the behavioral interventions no longer address the current needs of the student
- When a change in placement is made
- When it is clear that the original behavior intervention plan is not bringing about positive changes in the person’s behavior.
 © 2010 Angel Enrique Pacheco, Ph.D., C.Psych. All Rights Reserved.
[i] The author wishes to gratefully acknowledge the reproduction, with permission, of excerpts from: Center for Effective Collaboration and Practice (16 January 1998). Addressing Student Problem Behavior. Washington, D.C.: Author.
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