A Practical Guide to Finding Treatments That Work for People with Autism

Susan M. Wilczynski

• Publisher: Academic Press
• Year: 2017
• ISBN:
  9780128097083
• Topic: Psychology
• Subtopic: Cognitive Neuroscience & Neuropsychology
• Index: Psychology

A Practical Guide to Finding Treatments That Work for People with Autism provides a logical, culturally sensitive, and values-based resource to aid practitioners in making informed decisions on the most effective treatment for any given client at any given time.

By providing multiple illustrative examples, practitioners will learn to use their professional judgment to integrate the best available evidence with client values and context. This will increase the efficacy of autism treatments, with the goal of producing meaningful gains across a range of skills.

• Presents a detailed description of the evidence-based practice of applied behavior analysis as it applies to ASD
• Offers a decision-making framework that helps clinicians integrate the best available evidence with client values and context
• Guides practitioners through the process of assessing treatment outcomes that fit with client values and contextual variables
• Provides concrete examples for various age groups

Section III

Target, Stakeholder, and Leader Client Variables, Values, and Preferences

Outline

Section III. Target, Stakeholder, and Leader Client Variables, Values, and Preferences

Chapter 3 Client Health

Chapter 4 Client Repertoire and Behavioral Cusps

Chapter 5 Client Preferences

Chapter 6 Quality of Life, Generalization, and Social Validity

Chapter 7 Treatment Acceptability and Social Validity

Chapter 8 Treatment Feasibility and Social Validity

Chapter 9 Context Matters: Getting Systems to Adopt Treatments

Section III. Target, Stakeholder, and Leader Client Variables, Values, and Preferences

The target client is the direct recipient of an intervention. In addition to client history and current data, evidence-based practitioners consider the target client’s health, the skills in their client’s repertoire, their preferences, and the social validity of the intervention when selecting treatments.

Stakeholder clients usually play a fundamental role in selecting and implementing interventions that are designed to increase appropriate behaviors/developmental skills or decrease problem behaviors for individuals with ASD. Stakeholder clients have regular, direct contact with the target client (e.g., daycare worker, teacher, direct service provider, or parents of the individual with ASD). Evidence-based practitioners should assess the social validity of treatments (e.g., acceptability, family’s quality of life, etc.) as well as the feasibility of each treatment option before selecting treatments. Feasibility involves assessing the resources required to implement interventions and the environmental supports that enhance or undermine the likelihood of treatment fidelity. Treatment fidelity is an indicator of feasibility because if a treatment cannot be accurately implemented, the treatment is probably not appropriate given the context. Evidence-based practitioners also evaluate stakeholder clients’ views as to whether or not it would be feasible to sustain the intervention.

In many schools or agencies, administrative professionals or thought leaders make systemic decisions about the appropriateness of a given treatment. For example, principals or center directors may wish to increase the school’s or agency’s capacity to serve a given population (e.g., ASD). In addition to feasibility, these leader clients consider the impact on the entire organization, including their match with cultural norms and the likelihood of producing benefit for other students or clients.

Chapter 3

Client Health

Abstract

This is the first chapter in the section on client variables, values, and preferences. Prior to recommending treatment, evidence-based practitioners consider a range of client variables. Client health plays an important role in selecting appropriate treatments. A client may lack a skill or show excessive behavior problems that interfere with their capacity to fully benefit from school, home, therapeutic, and/or community environments. These skills and behaviors may be directly or indirectly a result of client health. Medication, medical conditions, comorbidity (cooccurring conditions), biological variables, and mental health are all key features that evidence-based practitioners evaluate before identifying the “right” treatment for a given client. The influence of pain on behavior, particularly in clients who cannot communicate about their pain, must be assessed before treatments can be selected. Similarly, evidence-based practitioners identify how abuse history and seizure activity should influence treatment selection.

Keywords

Health; medication; comorbidity; biological variables; mental health; abuse; pain; seizures; restraint

According to the Professional and Ethical Compliance Code for Behavior Analysts (BACB, 2014), practitioners should recommend their clients seek “medical consultation if there is any reasonable possibility that a referred behavior is influenced by medical or biological variables.” To meet this ethical obligation, evidence-based practitioners become informed about how medications, medical and comorbid conditions, and biological variables can influence behavior. Evidence-based practitioners use this information to influence the treatment selection process.

Medication

Evidence-based practitioners become familiar with medications taken by their target clients and the potential side effects of these medications. The more common side effects of psychotropic medications include headaches, gastrointestinal discomfort/distress, changes in weight (sometimes significant), and sleep disturbances. Any of these common side effects can directly and/or indirectly impact behavior. Less common but serious side effects of psychotropic medications for children are cardiovascular irregularities, suicidal ideation, and hypersensitivity events (Garcia, Logan, & Gonzalez-Heydrich, 2012).

Physicians may prescribe more than one psychotropic treatment simultaneously and some medications are prescribed off label (i.e., in way that is not approved by regulatory bodies such as the FDA; Good & Gelled, 2016). It is important to ask about medication usage both at the onset of treatment and throughout service delivery because medication use may change over time. Physicians may alter the dosage of an existing medication, change the medication, or prescribe additional medications to the target client. When the evidence-based practitioner is unaware of medication usage or changes, problems may be incorrectly attributed to environmental factors. Several undesirable outcomes could result:

• The target behavior improves but the practitioner attributes the improvement to a time- or cost-intensive behavioral intervention. The intervention is continued and valuable resources are unnecessarily expended.

• The target behavior remains the same. The client remains on a medication with potential side effects because the physician does not receive feedback about ineffectiveness.

• The target behavior worsens and a costly functional analysis is conducted to develop a potentially inappropriate intervention (i.e., based on the incorrect function).

• The target client needlessly experiences unpleasant side effects.

By maintaining an ongoing dialog about medications, evidence-based practitioners can encourage caregivers to adhere to a medication schedule or discourage caregivers from altering medication levels independently. In addition, physicians recommend frequent monitoring of children and adolescents who are taking psychotropic medications (Garcia et al., 2012), so evidence-based practitioners can not only make referrals for medical evaluations but also work collaboratively with prescribing physicians regarding behavior change.

Medical and Comorbid Conditions

Pain

Many medical conditions should impact the treatment decisions evidence-based practitioners make. Pain is often associated with problem behavior among children with ASD and other developmental disabilities (Courtemanche, Black, & Reese, 2016). Many individuals with ASD are not able to effectively communicate about their pain, and careful observation of pain-related behaviors is necessary to understand the relationship between pain and problem behavior. The Non-Communicating Children’s Pain Checklist Revised (NCCPC-R; Breau, McGrath, Camfield, & Finley, 2002) has been used to examine the relationship between pain and self-injury, aggression, and stereotypic behaviors. Evidence-based practitioners should make every effort to assess pain, prior to conducting additional analyses (e.g., functional behavioral assessment or functional analyses), particularly among people who are unable to easily communicate about their experiences of pain. Evidence-based practitioners refer any target clients with ASD for medical evaluations if pain could be a factor related to problem behavior.

Restraint

Injuries such as bites, damage to joints, broken bones, or friction burns may result from restraint procedures. Approximately 142 deaths occurred during the 1990s as a result of physical restraint (Council for Children with Behavioral Disorders, 2009) and this is reason enough to avoid using this procedure. However, there are target clients who have medical conditions that make restraint contraindicated. For example, individuals who are obese or have a history of heart conditions are particularly at risk for serious side effects (e.g., deep vein thrombosis and resulting pulmonary embolism; Ishida et al., 2014). Evidence-based practitioners must be aware of all medical conditions that may indicate physical restraint or any other procedure should not be used.

Seizures

A large number of individuals with ASD also have epilepsy (15–30%; van Iterson, De Jong, & Zijlstra, 2015). Epilepsy can be associated with seizure-induced aggression (i.e., aggression associated with frontal lobe seizures; Gedye, 1989). If evidence-based practitioners are not aware that a significant percentage of individuals with ASD have co-occurring epilepsy and that aggressions can be seizure induced, they are likely to invest considerable resources to identify the function of behavior when the seizure is the real source of the aggression. Because petit mal seizures may not be immediately obvious to stakeholder clients (i.e., adults working directly with the client), evidence-based practitioners should be trained to identify potential symptoms of epilepsy.

Biological Variables

Biological variables can serve as motivating operations (i.e., conditions that momentarily alter the effectiveness of reinforcers). For example, hunger can impact any range of behaviors directly (e.g., difficulty paying attention to work) and indirectly (e.g., preferred activities like running around and playing are no longer valuable and do not serve as reinforcers). Similarly, sleep deprivation can influence the capacity to learn (because a target client is less able to attend to relevant details), remember newly acquired information, self-regulate under distress. Further, sleep deprivation can make task demands aversive, even if the client normally tolerates them when not sleep deprived. High rates of problem behavior can occur when a target client is sleep deprived. Many children with ASD experience significant sleep dysfunction (Kennedy & Meyer, 1996) and treatments that should be effective may not produce change. Evidence-based practitioners refer individuals with chronic sleep deprivation to sleep specialists.

Stamina (i.e., physical capacity to sustain effort) is also a biological variable that can serve as a motivating operation. Many individuals with ASD do not receive sufficient opportunities to exercise (Place, 2015) or exercise is given a lower priority than learning to speak, interact with others, and develop academic or work skills. Yet stamina can directly impact progress in each of these domains. Consider a 10-year-old girl with ASD who is not making progress across multiple program goals. Although she performs independently and accurately in the morning, all trials in the afternoon show a decrement in performance. Her capacity to physically perform activities in the afternoon is poorer as a result of a weak core (i.e., holding her body erect in her seat and then reaching for and selecting the correct item from an array is physically challenging). In addition, the value of reinforcers can be diminished if the item involves manipulation ...