Applied Behavior Analysis (ABA) Integrated With Psychotropic Medications

Treatment plans for autistic individuals are uniquely tailored with the person in mind and under the premise that every autistic person is impacted differently and may benefit from individualized treatments or interventions. Nevertheless, there exists a growing consensus that among the various treatments for autism, Applied Behavior Analysis (ABA) integrated with psychotropic medications is more effective at targeting physical aggression, self-injurious behaviors and property destruction in autistic individuals, especially for those individuals with dual diagnosis such as Autism and Bipolar Disorder, Not Otherwise Specified or Impulse Control Disorder, NOS.

Applied Behavior Analysis (ABA) – which encompasses behavioral intervention – can produce comprehensive and lasting improvements in many skill areas for most people with autism. There have been no other treatments besides ABA that have shown sufficient evidence of effectiveness, especially if the treatment begins early in infancy. (Baer et al., 1968; Lovass & Smith, 1989; Schreibman, 1988; Schreibam, Charlop, & Milstein, 1993; Smith, 1993).

Applied behavior analysis (ABA) is a systematic process of studying and modifying observable behavior through a manipulation of the environment. ABA methods are used to increase and maintain desirable adaptive behaviors, reduce maladaptive behaviors or teach new skills, and generalize behaviors to new environments or situations. (Baer et al., 1987; 1968).

Functional Behavioral Analysis, which falls under the purview of Applied Behavior Analysis, is useful in identifying antecedents and consequences that are associated with increased frequency of behaviors. One of the most widely used descriptive analysis is the A-B-C procedure (Antecedent-Behavior-Consequence) (Bijou, et al., 1968). The underlying hypothesis of this procedure is that, over time, a careful recording of the "ABCs" of a target behavior will permit the identification of a specific antecedent and/or subsequent (function or cause of behaviors) to the target behavior that predict high and low frequency of the behavior.

Determining the source of control of a behavior (cause) is critical to determine the appropriate intervention. One of the challenges of behavior analysts is to identify the function or cause of a maladaptive behavior (e.g. self-injurious behavior, physical aggression outburst or property destruction) and to control a complex environmental context or contingency relationships due to the fact that some maladaptive behaviors may have been controlled by multiple variables (Smith, Iwata, Vollmer, & Zarcone, 1993).

It is extensively investigated that Applied Behavior Analysis or interventions based on the function (cause) of a behavior have proven to be very effective in changing and controlling challenging behaviors in autistic individuals. However, the problem becomes more complex when the challenging behaviors are multi-factorial and determined by learned behaviors and /or brain physiology or chemistry dysfunction. In these cases, Applied Behavior Analysis integrated with psychotropic medications has proven beneficial for many autistic individuals.

Maladaptive behaviors may be maintained by any number of variables such as a medical condition, idiosyncratic condition or lack of verbal communication in non-verbal individuals and / or neurological or psychiatric disorders. If the function is deemed, by the person's interaction with the environment, such as to escape from or avoid a noisy room or attention-seeking, it would be understandable to develop an intervention accordingly. However, if an autistic individual engages in self-injurious behavior as a result of a sinus infection, dental problem, pain or a bodily discomfort, using a behavioral intervention or psychotropic medications intervention to address the problematic behavior, would be ineffective and unethical.

In a research that took a sample of Medicaid enrolled individuals with autism, 56% used at least 1 psychotropic medication, 20% of whom were prescribed 3 medications concurrently. Neuroleptic medications were the most common psychotropic class (31%), followed by antidepressants (25%) and stimulants (22%) (Mandell, et al. 2008); 11.5% anti-epileptic drugs and 12.5% antihypertensive drugs (e.g. alpha or beta blockers) (Aman, et al. 2004).

In summary, Applied Behavior Analysis and psychotropic medications (e.g. Risperdal, Haldol) are empirically validated treatments for reducing problem behaviors in individuals with autism. Additionally, ABA research methods could be used to study drug effects (Behavioral-Pharmacology) (Weeden, 2009; Durand, 2005, Mace, et al., 2001). However, it is imperative to have in consideration several aspects before determining that a combined treatment is warranted: 1) a rigorous functional behavioral analysis; 2) consistency in the implementation of the behavioral intervention is needed. 3) a carefully selection of the psychotropic medication and dosage to target specific symptoms and / or comorbid conditions (e.g. some autistic individuals may develop drug or dose intolerance, or they may have a pre existing condition such as Fragile X, Epilepsy or Tuberous Sclerosis) and 4) the development of a comprehensive treatment plan (Efron et al., 2003). These dimensions are very important to guarantee the effectiveness of an integrated treatment plan.

Prognosis of Autism(s)

On June 16, 2009, Qsac held its annual workshop for parents and professionals at the Sheraton La Guardia Hotel. A group of experts on autism discussed the complexity of social behavior in autism, screening, diagnosis and treatment strategies, applied behavior analysis and discrete trial training. During a panel, one of the participants asked a question about the prognosis of autism. This is a very challenging question because of the heterogeneity within the autism diagnosis, which affect our ability to develop an effective treatment and prognosis. Autism is a neurodevelopmental disorder that has been defined exclusively on behaviorally based symptom domains of impairments in social interactions and communication, and repetitive or stereotypical behaviors (DSM-IV-TR, APA, 2000). The neuropsychiatric component of autism is not part of the DSM-IV-TR classification and criteria.

From a clinical point of view, the diagnosis have shown a range of variability in the core symptom domains, including a low to above normal IQ, and low to high functioning in school (Bailey et al., 1998; Spence, 2001; Silverman et al., 2002; Folstein et al., 1998; Spiker, 1999; Beglinger and Smith, 2001; Spiker et al., 2002)

In terms of the research studies, we can observe a lack of consistency and uniformity. Although autism disorder is under the “pervasive developmental disorder” (PDD) classification in the DSM-IV-TR, due to the variability in the autism phenotypes, severity, associated symptoms and causality, some researchers prefer to talk about autism spectrum disorder instead of PDD.

According to Miles and colleagues (2005), some genetic studies have focused on the correlation of genetic indicators with behavioral symptoms, cognition, and core symptom domains such as language impairment.

Miles and colleague (2003, 2005), defined autism spectrum disorder from a genetic etiological point of view into two subgroups, (1) Idiopathic, in which no cause can be identified and represents 90-95% of the cases with autism; and (2) Secondary, in which chromosome abnormality, single-gene disorder or environmental agents can be identified and represents 5-10%.

Idiopathic autism can be divided in (a) complex autism and (b) essential autism. The complex autism is characterized by the presence of a significant number of physical anomalies, lower male to female ratio and / or microcephaly in 5-15% of cases; they scored with lower IQ, experience more seizure and /or abnormal EEG's and more abnormal findings, and represent 20-30% of the autistic population. The essential autism is characterized by no evidence of abnormal structure during development [morphogenesis] and represents70% of the autistic population.

The essential and complex groups are relatively easy to identify clinically, and appear to differ in their outcomes, recurrence risks, sex ratios, and family histories (Miles et al., 2000, 2003, 2005.) For instance, the ratio of males vs. females in essential autism is greater than in individuals with complex autism (6.5:1). This classification of autism between complex and essential autism helps to clarify the etiologic heterogeneity within the autism spectrum disorders. However, until we separate the genetic indicators of the behavioral autism, it would be very difficult to understand the prognosis of autism spectrum disorder.

The prognosis will vary depending of the phenotype features of the autistic disorder [e.g. the observable physical or biochemical characteristics of an individual, as determined by both genetic makeup and environmental influences.] For instance, the prognosis of an autistic individual with idiopathic autism may be better than an individual with secondary autism; an individual with idiopathic autism-complex may have a worse prognosis than an individual with idiopathic essential-autism. This classification between idiopathic and secondary opens a debate about the heterogeneity and clinical variability of autism, which has prompted some researchers to use the term Autisms instead of autism (Pardo & Eberhart, 2007; Miles & Hillman, 2003; Herbert, 2003, 2005.)

To talk about the prognosis of autism becomes more complex since some research evidences have pointing out the genetics alone do not determine the entire Autism Spectrum Disorder, it is only a risk, and non-genetic factors are playing an important role as modifiers of processes determined by genetic susceptibility (e.g. environmental and epigenetic factors) (Pardo & Eberhart, 2007; Hebert, 2004, 2005.)

The prognosis of autism(s) would be better understood when researchers are able to determine the different variations in autism(s) and their genetic-environmental-timing influences.

Autism Genes Implicated in Early Neural Development Discovered

Two recently published studies – the results of collaborative efforts of researchers from more than a dozen institutions, and led by Hakon Hakonarson, M.D., Ph.D., director of the Center for Applied Genomics at The Children's Hospital of Philadelphia – have identified genes with important contributions to autism. One study pinpoints a gene region that may account for as many as 15 percent of autism cases, while another study identifies missing or duplicated stretches of DNA along two crucial gene pathways. In total, they analyzed DNA from 12,834 subjects. Significantly, both studies detected genes implicated in the development of brain circuitry in early childhood.

Because other autism researchers have made intriguing suggestions that autism arises from abnormal connections among brain cells during early development, it is very compelling to find evidence that mutations in genes involved in brain interconnections increase a child's risk of autism,” said study leader Hakon Hakonarson, M.D., Ph.D., director of the Center for Applied Genomics at The Children's Hospital of Philadelphia. By using highly automated genotyping tools that scan the entire genome of thousands of individuals, the researchers found that children with ASDs were more likely than healthy controls to have gene variants on a particular region of chromosome 5. Neuronal cell-adhesion molecules are important because they affect how nerve cells communicate with each other, thought to be an underlying problem in ASDs.

“Although we cannot immediately apply this research to clinical treatments, these findings increase our understanding of how autism spectrum disorders arise, and may in time foster the development of strategies for prevention and early treatment,” said developmental pediatrician Susan E. Levy, M.D., a co-author of both studies who is the medical director of the Regional Autism Center and a member of the Center for Autism Research (CAR), both at Children's Hospital.

Geri Dawson, Ph.D., chief science officer for Autism Speaks, appeared on the CBS Evening News and ABC World News on Tuesday, April 28, to discuss the studies. View the CBS story here and the ABC story here.

Inclusion Program for Students with Autism: A Controversy

Inclusion is a term coined to describe the notion that students with disabilities including individuals with autism can or should be educated in the general education classrooms (mainstream of public education) despite of the severity of disabilities.

The debate about the inclusion of students with disabilities in general education settings started 1975 when the US Congress passed the Individuals with Disabilities Education Act (IDEA – Public Law 94-142, 1975 formerly: Education of All Handicapped Children Act). This law established that all children with disabilities would receive a free appropriate public education designed to meet each student’s special needs. In 1986 the Regular Education Initiative (REI) called for placing students with disabilities into regular education classrooms. Rapidly, a division emerged among REI supporters, one group considered that REI should be for students with mild disabilities and alternative settings outside of the general education classroom should remain for individuals with severe and profound disabilities. On the other hand, another group felt that all students with disabilities should be included in general education classrooms regardless of disability type or severity level (Reynolds, et al., 1987; Lipsky and Gartner, 1989; Buell et al., 1999; Pivik at al., 2002).

The controversy has continued among both general and special educators despite the 2004 version of the Individuals with Disabilities Education Improvement Act, which has made the general education classroom the primary placement for students with disabilities including students with Autism Spectrum Disorders. In order to resolve this debate, Dr. de Boer & Simpson (2009) exhort that general and special educators should develop an integrated system of inclusion as a continuum of placement and service options that meet the needs of students with disabilities.

Dr. de Boer & Simpson (2009) commend that to design an appropriate and successful inclusion program for students with Autism Spectrum Disorders represents a challenge for the educational system.

An inclusion program is not simply to place students in the general education classrooms. For instance, students with autism are very complex in their disabilities. Some are non-verbal or with verbal delays or echolalic speech with severe cognitive or learning impairments; others function at a level of students in the general education classrooms. Students within the spectrum present deficit in adaptive behavior skills, self-care or self-help skills (e.g. toileting, sleeping, eating bathing dressing) and challenging and stressful problem behaviors (e.g. aggressive behaviors toward others, self-injurious behaviors, hyperactivity or psychomotor agitation, non-compliance behaviors with instructions, property destruction, stereotypic behaviors, inattention, obsessive-compulsive behaviors with objects, activities or routines). Moreover, individuals with Autism Spectrum Disorders have motor and physical challenges (e.g. difficulties with gross and fine motor skills) and sensory sensitivities (e.g. hyper or hyposensitivity to some stimuli: sight, sound, smell, touch, body position and movement) (Simpson, de Boer, Smith-Myles, 2003; Mesibov and Shea, 1996; de Boer & Simpson, 2009).

Educate students with Autism Spectrum Disorders requires thorough knowledge and understanding of the challenging conditions such as cognitive, social, sensory, communicative and behavioral deficits. Without an appropriate training in autism and a clear educational model by administrators, educators, school personnel and parents, the implementation of inclusive educational program for students with autism will not achieve the ultimate goal of developing their full potential (ASA, 1994).

The inclusive education programs have become more prevalent within the public school system and we have made some progress in the tri-state area [NY, NJ, and CT] preparing teachers to work with students with autism. But unfortunately, it seems that our educational system is not ready yet to implement a successful inclusion program for students with Autism Spectrum Disorders due to the lack of teachers’ training and knowledge, limited research and resources and negative attitude toward teaching students within the Autism Spectrum Disorders (Simpson, de Boer, Smith-Myles, 2003; de Boer & Simpson, 2009).

A successful inclusive education program for students with Autism Spectrum Disorders is a challenging and demanding process which should require special training and collaborative efforts for general and special educators, paraprofessionals, administrators and parents (Zager, 1999). Despite of the controversy, a full-time inclusion for all students with Autism Spectrum Disorders, which means that “students with special needs can and should be educated in the same settings as their normally developing peers with appropriate support services”, does not seem to be appropriate for all autistic children. Mesibov and Shea (2005) suggest that we do not have the enough empirical evidence for this approach. In addition, parents’ perceptions toward inclusion for their children with autism are divided (Kasari et al. 2004). It seems that a continuum model of placement and service options should be the answer (de Boer & Simpson, 2009). For more than two decades, TEACCH program has been offering appropriate educational solutions for students with Autism Spectrum Disorders in the public schools (TEACCH program).

A good resource to inform yourself of this topic is the book, Successful Inclusion for Students with Autism: Creating a Complete, Effective ASD Inclusion Program by Dr. Sonja R. de Boer & Richard L. Simpson (2009). It offers practical solutions and “a wealth of helpful forms, checklists, and handouts that will assist with implementing the inclusion program and ensure that all involved have the information necessary to make the program successful”.

Learning Websites for Children with Autism

The following websites are wonderful resources for your children, especially the ZACbrowser, the first web browser developed specifically for children with autism.
Special thanks to Suzanne Prestigiacomo, a parent who helped me put list this together.


www.zacbrowser.com - ZAC is the first web browser developed specifically for children with autism, and autism spectrum disorders such as Asperger syndrome, pervasive developmental disorders (PDD), and PDD-NOS. We have made this browser for the children - for their enjoyment, enrichment, and freedom. Children touch it, use it, play it, interact with it, and experience independence through ZAC.
www.sensoryworld.org – Interactive place learning that is fun, stimulating, relevant, appropriate and responsive.
www.videoplaylist.org - Perfect for parents and caregivers of autistic children as it allows you to create your own playlist from available youtube videos that launches from your own webpage supplied by them - adfree webpage! Then you can simply click on the link on the left and the video plays.
www.babybumblebee.com/company/freebies.cfm - Many free printables including number and alphabet posters and cards. Handwriting sheets, color flash cards, vocabulary builder flash cards, printable books.
www.do2learn.com – Games, songs, communication cards, print visuals, Make a schedule, activities and more resources.
www.avenscorner.com – Games for children with special needs, but can be enjoyed for children of all ages.
www.starfall.com – Where children have fun learing to read. ABC, picture stories, fun reading learning games.
www.treehousetv.com – Games and video.
www.funbrain.com – Games, math, reading, playground, web books, comics, videos.
www.usevisualstrategies.com/pictures - visual pictures.
www.pecsplace.com - PECS PLACE is a game, it is meant to be fun and rewarding, and yet at the same time… can be used by parents, habilitators, and therapists alike, to be another tool to help teach your child!
www.trainland.tripod.com/pecs - Beyond Autism Pecs Pictures,
www.mousetrial.com - Fun animated online exercises to help kids with autism.
www.earobics.com/gamegoo/gooeyhome - Fun educaltional games that help develop
early reading skills.
www.visualaidsforlearning.com - Visual Aids for Learning has created downloadable visuals to help people learn everyday activities. The images are ideal for children, particularly those with learning difficulties. Where appropriate, the images are gender specific.
www.pics4learning.com - Pics4Learning collection consists of thousands of images that have been donated by students, teachers, and amateur photographers.
www.elearning.autism.net/visuals - Visual images and visual boards for everyday. Demonstration videos to explain how to use the images with the boards.
www.abclearningtime.com – ABC, tell time, learning numbers and more.
www.kinderwebgames.com – Educational childrens games.
www.gamequarium.com – The site that swims with learning fun.
www.learninggamesforkids.com -These learning games and songs are fun, teach important skills for preschool and elementary school kids and they're free. Want educational games that help build skills? You've come to the right place!
Schooltimegames.com
Photobucket.com

Functional Analysis of Problem Behavior

Doug, 10, is enrolled at the QSAC Day School. He has a variety of independent skills. Doug used to engage in frequent and repetitive object-tapping (banging two items together). Due to his persistence tapping, it was difficult to return him to classroom activities and ongoing instruction. He seemed to engage in this behavior to escape or delay academic instruction. Some instructors felt the reason was to get attention because he typically laughed or struggled with them when they attempted to take the items away. Also, because tapping occurred so frequently, some felt that he engaged in this behavior because of the sensory stimulation that it provided.

It was decided to conduct a functional analysis (FA). As described in our previous newsletter, a functional analysis involves the systematic exposure of the behavior to different “tests” to see how the behavior is affected.


The results showed that tapping behavior was highest during the attention and alone conditions, demonstrating that tapping served to gain attention from others and was automatically reinforced. Additionally, the results showed that tapping did not function to escape or avoid tasks, or to gain other types of tangibles in the environment. Tapping, because of the multiple functions that it served, was considered a multiply-maintained behavior for Doug. Multiply-maintained behavior can be particularly difficult to address because an intervention would have to be effective in addressing both reasons or be comprised of different components that could address each one separately. Treatment conducted at the QSAC Day School will follow in a future newsletter.

by Ronald Lee, Ph.D., BCBA, Director of QSAC Day School

Single-Dose Measles, Mumps Rubella Vaccines May Be Discontinued by Merck

Merck & Co. has been producing monovalent (independent, single-dose) measles and rubella vaccines and was scheduled to make an individual mumps vaccine available this spring.

Last December, Merck notified the CDC that it is no longer producing or taking orders for monovalent measles, mumps and rubella vaccines. The company has not announced whether or not it will make the single-dose versions available for sale again in the future. Since there is great concern by many parents and professionals in the autism community regarding the safety of the trivalent measles, mumps and rubella (MMR) vaccine, there is much support for the availability of monovalent vaccines until there is adequate unbiased research to properly evaluate the safety and efficacy of the trivalent MMR vaccine.

Merck & Co. is the only provider of monovalent versions of these vaccines. Parents, caregivers and providers are encouraged to contact a Merck representative at (800)672-6372 to voice their opinions on this important issue.