1. Socially Validated Functional Assessment and Treatment of Severe Problem Behavior Associated with Autism
Gregory P. Hanley. Ph.D., BCBA-D
Good morning. Thanks to Dean Weeden for the Introduction. Big thanks to Tia Korologos for the opportunity to share my groups work at this well organized conference.
At my University, I teach a course on College Teaching. In that course I caution doctoral students about attempting to cover too much when teaching. I remind them that to cover actually means to obscure from view. In case I don’t follow my own advice and my attempt to cover too much material obscures my main point, let me share it with you now:
Lasting freedom from meltdowns, aggression, and self-injury for persons with Autism and their families is attainable. It is attainable for the vast majority without drugs, hospitalization, harsh punishment, and even without candies, stickers, and token boards. This freedom is attainable by first understanding why the child is engaging in the severe problem behavior and then incorporating that understanding into teaching the transferable skills of communication and toleration.
And contrary to conventional professional practice, this understanding of why problem behavior occurs can be realized quickly, safely, and reliably and is essential for helping families of children with autism avoid a lifestyle dictated by problem behavior.
Utah Neuropsychiatric Institute
Autism Intervention Program for Professionals
November, 2016

2. Fact: Autism is characterized by
Impairments in
language development
social interaction
and
Excessive repetitive behavior
The latest estimate from the CDC is that about 1 in 50 children have been identified as having an Autism spectrum disorder in the US. There is no biological determination of autism; however, the behavioral symptoms are typically apparent before 3 years of age. Autism is characterized by impairments in social interaction and communication and by restricted, repetitive, or stereotyped patterns of behavior.

3. The most difficult issue for parents and teachers of most children and young adults with autism: Usually, severe problem behavior
(pause) But it is the intractable problem behavior and it not the autism that leads to restrictive lifestyles of families of children with autism, it is not the autism that negatively affects the mental health of parents of children with autism—it is the chronic problem behavior, that affects more families of children with autism than not.

4. With Autism, there is a higher likelihood of problem behavior
Fact:
With Autism, there is a higher likelihood of problem behavior
Meltdowns
Aggression
Self-injury
References: Baghdadli, Pascal, Grisi, & Aussilloux, 2003; Horner et al., 2002; Kim et al., 2000; Murphy, Healy, & Leader, 2009; Thompson, 2009
Although a diagnosis of autism is not dependent on problem behaviors like aggression, self-injury, or meltdowns--those highly emotional outbursts and tantrums of extended duration that are clearly disproportionate to the circumstances, the probability of one or more of these problem behaviors occurring with regularity is higher in children with autism than in children with other developmental disabilities.
For instance, researchers have reported a 10 to 15% prevalence rate of these problem behaviors in persons with an intellectual disability, By contrast, it is estimated that 50% of children with autism engage in self-injurious behavior; and that 2/3rds engage in at least one of the problem behaviors with regularity.

5. Why does problem behavior occur?
Causes are complex—first consider all of them
Then consider the causes that you can do something about
For me, those are the consequences of the behavior that serve as reinforcement
Why does problem behavior occur?
Well, causes are complex—first consider all of them. That is a bit overwhelming.
Then consider the causes that you can do something about.
For me, those are the consequences of the behavior that serve as its reinforcement

6. Working assumptions
If problem behavior is occurring with regularity…..
it is being reinforced
Please understand this fundamental concept: If problem behavior is occurring with regularity, it is being reinforced.
In other words, there is some improvement for the person with autism following problem behavior.
This is a simple but powerful working assumption

7. Antecedent  Behavior  Consequence
Establishing operation  Problem Behavior  Reinforcement
Mom attends to Throwing toys Mom’s attention
Sibling
Dad instructs to SIB Dad gives a little turn off Ipad more time on Ipad
Teacher instructs to Meltdown Teacher tries to calm
come off swing to do child with reminders of some DT work good events & starts to comply with child requests
Perhaps more attention from others is the reinforcer. Perhaps it is access to preferred toys or their Ipad. Or perhaps it is termination of something aversive or annoying like onerous academics or confusing social interactions.
We used to think that these reinforcers worked independently and almost exclusively. We now know that they do not, that these reinforcers often work in concert. In other words, the question used to be is problem behavior maintained by attention, tangibles, or escape. The question now is: Is problem behavior maintained by escape to attention and tangibles or some other combination and what are the specific materials and interactions that are to combined. It is now understood that there are more qualitatively rich reinforcers influencing problem behavior than the usual suspects of attention, tangibles, and escape. Things like access to stereotypy and preferred conversations, resumption of ongoing activities, having someone follow their lead, or gaining caregiver compliance with previously uttered requests. These too may serve as reinforcers for problem behavior.

8. Working assumptions
If problem behavior is occurring with regularity…..
it is being reinforced
and
the child lacks a more efficient and appropriate way to obtain those same reinforcers
the child lacks a delay/denial tolerance repertoire
We also assume that if severe problem behavior is occurring with regularity that the child lacks the important life skills of communication and toleration.

9. behavior analysts conduct functional assessments
To understand =
to determine the personally relevant outcomes and context that influence problem behavior
To understand some of the reasons why problem behavior is occurring or more specifically, to determine the personally relevant outcomes and context that influences problem behavior, behavior analysts conduct functional assessments.
Our main job with the functional assessment is to find the relevant reinforcers and the contexts that seem to potentiate those reinforcers.
behavior analysts conduct
functional assessments

10. Functional Assessment Process
Indirect Assessment interviews
Descriptive Assessment
observations
The functional assessment process has evolved to include some combination of indirect assessment, descriptive assessment, and functional analysis. Indirect assessments are the initial interviews with caregivers or teachers. Descriptive assessment involves observation and measurement of the problem behavior and its context; by contrast, functional analysis consists of observation and measurement of the problem behavior in at least two conditions, with the variables suspected of influencing problem behavior conspicuously present in one and absent in the other.
Functional Analysis
observations with manipulation

11. Fact: Functional analysis of problem behavior is well researched
435 studies with functional analyses and
981 distinct functional analyses
have been published
Beavers, Iwata, & Lerman, 2013; Hanley, Iwata, & McCord, 2001
and integral to the power of behavioral intervention
Larger reductions in problem behavior were evident
when a functional analysis was part of
the functional assessment process
Campbell, 2002; Kahng, Iwata, and Lewin, 2003, Hayvaert et al., 2012
The Functional analysis part of the process is well researched.
And the analysis is integral to the power of behavioral intervention. Meta analyses have shown that larger reductions in problem behavior were evident when a functional analysis was part of the functional assessment process.

12. Opinion: Functional assessment (including analyses) is
humane and dignifying
But I do it because it is how I would like to be treated were I to engage in severe problem behavior and not articulate why.

13. Functional Assessment Process
Indirect Assessment open ended-interviews
Descriptive Assessment
observations
There are many helping professionals who do not conduct functional analyses, the scientific component of the process. There is a whole lot of DA going on. If that is you. I hope you will reconsider. The process that I will describe today, highlighted in red, is meant to be fast and safe. It primarily involves these two bits with these specific types
Functional Analysis
IISCAs

14. I am going to describe the assessment and treatment process that is highlighted in these two studies.

15. Case Example (Gail, 3 yo, dx: PDD-NOS) Therapist: Nicholas Vanselow
Setting: Outpatient Clinic
Interview suggested that Gail engaged in meltdowns and aggression….
Problem
Behavior
I will describe the assessment for Gail, the 3 year old girl first. Gail had long beautiful dark hair, her mother always dressed her impeccably, and Gail was quite excellent with dramatic play. The main issue was that she had 5 to 10 meltdowns per day that lasted from a few minutes to about an hour and it was difficult for her mother to ever predict which one was coming. She also was very aggressive towards siblings and parents, and highly noncompliant with adult instructions.

16. Case Example (Gail, 3 yo, dx: PDD-NOS) Therapist: Nicholas Vanselow
Setting: Clinic
Interview suggested that Gail engaged in meltdowns and aggression….
when Mom was attending to other tasks or siblings….
Problem
Behavior
Context
(suspected establishing operations)
The interview suggested that Gail engaged in meltdowns and aggression primarily when Mom was attending to Gail’s sisters or other tasks like cooking.

17. Case Example (Gail, 3 yo, dx: PDD-NOS) Therapist: Nicholas Vanselow
Setting: Clinic
Interview suggested that Gail engaged in meltdowns and aggression….
when Mom was attending to other tasks or siblings….
in order to gain Mom’s undivided attention and to have Mom play with her and her most preferred toys.
Problem
Behavior
Context
(suspected establishing operations)
Outcome
(suspected reinforcers)
And that Gail engaged in meltdowns and aggression in order to obtain preferred items (usually toys) and he mother’s attention. When Gail’s mother was asked in the interview what she does to calm Gail down when she is having a meltdown her mother described how she would try to talk her out of it and distract her with interactive toys. This is where I like to point out that extraordinary behavior is usually influenced by very ordinary events and interactions.

18. Case Example (Gail, 3 yo, dx: PDD-NOS) Therapist: Nicholas Vanselow
Setting: Clinic
Interview suggested that Gail engaged in meltdowns and aggression….
when Mom was attending to other tasks or siblings….
in order to gain Mom’s undivided attention and to have Mom play with her and her most preferred toys.
Problem
Behavior
Context
(suspected establishing operations)
Outcome
(suspected reinforcers)
Suspected reinforcing contingency
So this the reinforcing contingency we suspect was influencing Gail’s problem behavior.

19. Functional Analysis: Test Condition
Test: Mom attends to other tasks and people….
As soon as Gail engaged in any problem behavior, Mom directs her undivided attention to Gail while interacting with her and her most preferred toys.
We then move on to the analysis to determine whether the hunch from the interview was valid.
In the test condition, we are emulating the conditions Mom described as being associated with Gail’s problem behavior. This condition started with Gail having her mother’s undivided attention and access to her most preferred toys. At the start of the session, Gail’s mother would remove the toys and attend to another person or task. If Gail engaged in any instance of problem behavior or its precursors such as whining, her mother would represent her undivided attention and preferred toys.

20. Functional Analysis: Test Condition
Test: Mom attends to other tasks and people….
As soon as Gail engaged in any problem behavior, Mom directs her undivided attention to Gail while interacting with her and her most preferred toys.
These are the data from the test sessions showing rates of problem behavior occurring.

21. Functional Analysis: Control Condition
Control: Mom directs her undivided attention to Gail while interacting with her and her most preferred toys the entire time.
In the control condition, we attempt to emulate the conditions Mom described as being associated with no problem behavior while also being sure to remove the contingency suspected of reinforcing problem behavior and, importantly, making no other changes to the condition.

22. Functional Analysis: Control Condition
Control: Mom directs her undivided attention to Gail while interacting with her and her most preferred toys the entire time.
We observed no problem behavior in control sessions.

23. Case Example: Gail, 3 years old, PDD-NOS
By alternating between 5 minute periods of test and control conditions, we were able to turn on and off Gail’s problem behavior….
Giving us and her Mom confidence as to why she was engaging in the extraordinary problem behavior
….to simply gain and maintain her Mom’s undivided attention and play time
By alternating between 5 minute periods of test and control conditions, we were able to turn on and off Gail’s problem behavior….
Giving us and her Mom confidence as to why she was engaging in the extraordinary problem behavior
….to simply gain and maintain her Mom’s undivided attention and play time

24. Case Example (Dale, 11 yo, dx: Autism) Therapist: Sandy Jin Setting: Clinic
Hypothesis: Dale engages in meltdowns and aggression in order to obtain: “His way” in the form of escape from adult instructions and access to preferred (tangible) items, and adult attention.
The interview with dale’s parents told that he was very demanding, and when his requests were not honored, he would scream or become aggressive or destructive. In our test condition, we prompted Dale to complete typical homework and any problem behavior resulted in our terminating the prompts allowing him to walk away and watch a movie and we honored any of his requests during this “break” from homework. During the control condition he had access to “his way” the whole time (a permanent break with access to preferred items, and adult compliance with his mands). You can see that we were able to turn his problem behavior on and off in the analysis confirming the hunch about the function of his problem behavior from the interviews.

25. Some Important Aspects of our Approach
1. An open-ended interview is always part of the process
Primary goals:
Identify topographies of problem behavior that tend to co-occur
Identify events and interactions that appear to routinely evoke problem behavior
Identify interactions that follow problem behavior and are reported to stop it (these are suspected reinfrocers)
Interviews allow for discoveries
which can then be verified (or not) in the analysis
An open-ended interview is always part of the process
The contingency evaluated is designed from information provided by parents and teachers. In the interview we primarily try to determine:
-topographies of problem behavior that tend to co-occur
-the events and interactions that appear to routinely evoke problem behavior (these are suspected EOs)
-the interactions that follow problem behavior and are reported to stop it (these are suspected reinforcers) Yes, the likely reinforcers for problem behavior can often be discovered by asking questions about what people do to stop the behavior, because the first effect of reinforcement is that it stops behavior, the secondary effect is that it increases the likelihood of the behavior in a similar context in the future.
*The take home point here, is interviews allow you to discover variables whose importance can be verified, or not, in a subsequent analysis. The analytic step is where we claim some professional humility where we verify our hunches and where we don’t attempt to change a child’s behavior without first understanding at least some of its determinants.

26. Some Important Aspects of our Approach
2. We synthesize multiple contingencies into one test condition in a single test/control analysis
and the contingencies and the specific materials and interactions are informed by the interview
Second, we synthesize multiple contingencies into one test condition, if the interview suggests the contingencies are operating simultaneously

27. IISCAs: Interview-informed, Synthesized Contingency Analyses
From Jessel, Hanley, and Ghaemmaghami (JABA, 2016)
Here are the results of 30 IISCAs from a paper just released in JABA.
They include children and adults
With and without autism
They were conducted in our clinic, or in others classroom, vocational sites, or homes
And they were implemented by people with much or very little experience with functional analysis
Note the small number of sessions required.
Note the small amount of variability, especially in the control condition sessions.

28. Take Home Point
Prior to treating problem behavior of children with autism, take an hour or two to:
Conduct an open ended interview to discover the context and outcomes that seem relevant to problem behavior
Conduct an IISCA to demonstrate the validity of the suspected contingency
and to set up the motivating conditions to teach skills
The take home point here is that Prior to treating problem behavior of children with autism, take an hour to:
Conduct an open ended interview to discover the often funky and unique context and outcomes that seem relevant to problem behavior
Conduct an IISCA to demonstrate the validity of the suspected contingency
and to set up the motivating conditions to teach skills

29. IISCA-Based Treatment
Process has led to comprehensive treatments with large, generalized effects
Treatment relies on strengthening:
functional communication delay/denial toleration
compliance
With
Intermittent & unpredictable reinforcement

30. Problem behavior no longer yields the reinforcers (escape to child-directed play and teacher attention)
A simple response
(button press: “ My way please”)
is prompted and reinforced with
(escape to child-directed play & teacher attention)

31. A more interactional response
(shoulder tap,
wait for teacher acknowledgement,
two-button press:
May I have / My way please”)
is prompted and reinforced

32. Now, FCRs are reinforced half the time.
The other half, the teacher denies the bid (e.g., says’s no, do your work without me, please)
Responses to disappointment
are prompted and reinforced:
(Take a breath and nodding yes)
Cues of disappointment,
Delays to reinforcement, and
unpredictable outcomes
have now been introduced!

33. Now, FCRs are reinforced 1/3 of the time.
TRs are reinforced 1/3 of the time.
And compliance with progressively longer and more challenging instructions is reinforced

34. Treatment is now implemented by all his teachers, session length is extended across the school day. At the end, he is communicating, tolerating, complying and having his way about half the time. All without problem behavior.

35. Intermittent and unpredictable reinforcement of life skills:
What is the treatment????
Intermittent and unpredictable reinforcement of life skills:
Functional Communication
Delay/denial toleration
Compliance
Similar outcomes were achieved for all childen.

36. Reinforcement is: Response requirement is: Function-based Variable
Differential Unpredictable
Intermittent
Variable in duration
Complex FCR
“No”
Tolerance response Sr
Complex FCR Sr
Complex FCR
“No”
Tolerance response
Instruction
Compliance Sr
Complex FCR
“No”
Tolerance response Sr
Complex FCR
“No”
Tolerance response
Instruction
Compliance Sr
Complex FCR
Diagrammed with all its emphases, the treatment looks complicated.
Look how much practice of the skills there are each time an EO is presented!
We think it is these characteristics of the reinforcement program* that have led to the general and meaningful effects of our treatments.
Seems complicated right?
“No”
Tolerance response
Instruction C Sr
Complex FCR Sr
Complex FCR
“No”
Tolerance response
Instruction
Compliance Sr
Complex FCR
“No”
Tolerance response
Instruction
Compliance Sr
Complex FCR Sr

37. That looks complicated!
How does this treatment get implemented by relevant people in relevant contexts?
But it is easy to implement, partly because it relies on the same schedule that was probably maintaining the repertoire of problem behavior.

38. Treatment Implementation
Put these in your pocket
Pull one out while child is experiencing their reinforcers
Keep it to yourself
Require that behavior next time
*Materials not needed:
Laminate
Laminating machine
Glue guns
Vis a vis markers
Velcro
Tokens
Token boards
Timers
Stickers
Candies
Anything that was not already in
the child’s environment!
Based on the schematics I just showed, this sort of treatment may seem complicated to implement. But it isn’t. There are several strategies to ensure implementation with integrity. I prefer this low tech system. *
You write the behaviors down that will yield the reinforcers, put them in your pocket, pull one out while the child is experiencing their reinforcers, keep the information to yourself please, and simply require that amount of behavior the next time the child initiates communication.
Please appreciate that which is not required to implement this function-based treatment.

39. App called “Names in a Hat”

40. Is it socially valid?
Are consumers satisfied with the process, treatment procedures, and effects?
Be sure to tell them that freedom from problem behavior is attainable without
drugs, hospitalization, harsh punishment, or even candy
These are merely management techniques, they are not long term solutions, and I am afraid that reliance on any one of these only tamps down problem behavior and eventually leads to a lifestyle dictated by that problem behavior.

41. IISCAs have led socially-validated outcomes
To gain an understanding of the more general effects of the treatment not captured in our direct measures, we conduct social acceptability assessments with families.
The procedures, treatments, amount of behavior change, and overall consultation process were socially validated by the families of the children participating in the process.
from Hanley et al., 2014

42. We also ask open ended questions to parents
We also ask open ended questions to parents. These are two of the more legible responses to open-ended questions. Bob’s parents initially reported that he had gone nowhere with the family in the prior two years other than to the doctors or school because of his problem behavior.
Following treatment, the parents reported that they ….

43. But is it efficient and cost effective?
Be sure to tell them that freedom from problem behavior is attainable without
drugs, hospitalization, harsh punishment, or even candy
These are merely management techniques, they are not long term solutions, and I am afraid that reliance on any one of these only tamps down problem behavior and eventually leads to a lifestyle dictated by that problem behavior.

44. Time Assessment
These socially validated outcomes were produced within 23 to 27 1-hour visits.
We have replicated this process directly or via consultation over 150 times these past few years. The amount of visits required for these outcomes is not necessarily related to the severity of the problem behavior, it does appear to be moderated by the child’s ability to follow instructions or readily imitate. If these skills are non-existent or weak, it simply takes more teaching time.

45. Cost Assessment
The services were provided to these families free of charge as part of our service-research mission, but taking into account the going rates of the behavior analysts working together during this process, the projected cost for these outcomes is between 6 and 9000 US dollars.
Considering the much higher costs of inpatient psychological services (which is between 4 and $8000 per day), out-of-district educational placements (which cost between 80 and 130,000 per year), or long-term residential care, which is about 300,000 per year in my area, proper assessment and treatment of these problem behaviors while children with autism are young seems a reasonable investment.

46. A final message
With Autism, there is a higher likelihood of problem behavior
Meltdowns
Aggression
Self-injury
References: Baghdadli, Pascal, Grisi, & Aussilloux, 2003; Horner et al., 2002; Kim et al., 2000; Murphy, Healy, & Leader, 2009; Thompson, 2009
One final message:
Recall that with Autism, there is a higher likelihood of problem behavior

47. is attainable from these behaviors
freedom
from these behaviors
for persons with Autism and their families
is attainable
But, freedom from these behaviors for persons with Autism and their families is attainable. This is an important take home message to share with any parent of a child with autism, regardless of the child’s age or abilities.

48. It is attainable for most
without drugs
without hospitalization
without harsh punishment
without candies, stickers, and token boards
Be sure to tell them that freedom from problem behavior is attainable without
drugs, hospitalization, harsh punishment, or even candy
These are merely management techniques, they are not long term solutions, and I am afraid that reliance on any one of these only tamps down problem behavior and eventually leads to a lifestyle dictated by that problem behavior.

49. understanding can be realized quickly, safely, and analytically
It is attainable
by first understanding* why the child is engaging in the problem behavior
Make sure those you talk to recognize that Freedom is attainable by first understanding why the child is engaging in the problem behavior.
And my main point today was that this understanding can be realized quickly, safely, and analytically.
understanding can be realized quickly, safely, and analytically

50. *Communication and toleration
It is attainable
when children are taught skills* to help them navigate our complex social world
*Communication and toleration
It is important to acknowledge also that freedom is attainable when children are taught the skills of communication and toleration to help them navigate our complex social world.
There is a massive treatment buffet out there with options that are cold, old, and tasteless, and some options that will leave kids hungry, or make them sick.
We have the skills and tools to prepare a well seasoned healthy meal for children with autism that will make them more fit than ever. Serve it up…..no one else can like you….serve it up.

51. *Intermittent and unpredictable reinforcement
It is attainable
when the skills are maintained by the same schedule that resulted in the repertoire of problem behavior
*Intermittent and unpredictable reinforcement
It is attainable with treatments that prepare persons with autism for the inevitable ambiguities of the world.
There is a massive treatment buffet out there with options that are cold, old, and tasteless, and some options that will leave kids wanting more, and others that will make them sick.
I hope the buffet is closed down. We have the means to develop effective treatments for the problem behavior of persons with autism that provides a necessary balance between the child’s preferences and educational and habilitative goals. We need to serve it up.

52. Good luck with all that you do for all who you teach and provide care
For more information go to:
Contact info.:
Gregory P. Hanley, Ph.D., BCBA-D
Psychology Department
Western New England University
1215 Wilbraham Road
Springfield, Massachusetts 01119
Thank you very much.
For relevant materials and more information on this process, please visit this website and join me for discussions in the break out meetings today.