BEHAVIORAL PLANNING FOR CHILDREN WITH PERVASIVE DEVELOPMENTAL DISORDERS?

pallav pareek m.d.

january 11th 2013

Objectives

Case discussion Journal Article: Discussion and exchange

of ideas- Is a behavioral plan

required?- Does a neurotypical

behavioral plan work in PDD?

- What modifications (if any) are required?

- Resources in St. Louis Metro Area?

Autism Fact Sheet

1 in 88 children and 1 in 54 boys

Autism is the fastest-growing serious developmental disability in the U.S.

Autism costs a family $60,000 a year on average

Autism receives less than 5% of the research funding of many less prevalent childhood diseases.

0.55% of total NIH funding. 40% of children with autism do

not speak

Major areas of Target for ASD’s

Behavior

Social

Communication

Some Challenging Behaviors in ASD’s

• Aggression is a high-profile behavior that garners more attention

• Is aggression a reaction to frustration and difficulty with appropriately communicating affect state or identifying alternative reactions to frustrating experiences

Aggression

• SIB is similar to (?) stereotypies with respect to the rhythmical and repetitive nature of the behavior, but in the case of SIB, tissue damage often results

Self Injurious Behavior

s

Trivia!!

What is the average cost of ABA for a family per annum?

Body Bag, Shredder App, Lifting Weights, Trampoline, Carrying pumpkins etc..

Some things that worked…

History of ABA

Watson fed up with “hypothetico-deductivo reasoning”→Experimental Analysis of Behavior →B. F Skinner

Initially known as Behavioral Mod Lovaas is one of the pioneers: In early years aversives

(Strikes, shouting, shocks) 10 Now mostly positive reinforcers

Judge Rotenberg Center (formerly Behavior Research Institute) Canton, Massachusetts

In the initial studies by Dr. Lovaas11: There were claims of up to 47% children→ mainstream→ indistinguishable

Remains the most popular and most evidenced based approach for Autism

10: Moser D, Grant A (1965-05-07). "Screams, slaps and love". Life

11:Lovaas, O. I. (1987). Behavioral treatment and normal intellectual and educational functioning in autistic children. Journal of Consulting and Clinical Psychology, 55, 3-9

Components of ABA

NRC: Recommends:25 hrs/wk of structured training DTT is used to reduce stereotypical autistic

behaviours through extinction and the provision of socially acceptable alternatives to self-stimulatory behaviors

EIBI: usually 30hrs/week 2-6 years Typical sessions: 5-6 hours, with natural breaks with

child tiring. Positive reinforcers: verbal/food/anything

13: Baer, D.M.; Wolf, M.M.; Risley, T.R. (1968). "Some current dimensions of applied behavior analysis". J Appl Behav Anal 1 (1): 91–97.

http://www.nrc-cnrc.gc.ca/eng/index.html

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1/11/13

pallav pareek m.d.

clinical case conference

january 11th 2013

"In a field rife with fads, pseudoscience, and popular, yet unproven, interventions….National Standards Project are a welcome and much-needed counterbalance to much of the hyperbole for both professionals and families” Peter F. Gerhardt

National Autism Center: National Standards Project, to produce a set of standards for effective, research-validated education and behavioral intervention

http://www.nationalautismcenter.org/about/national.php

Introduction

Growing evidence supports the use of intensive behavioral intervention (IBI)

Two decades of studies have supported the use of typical/atypical antipsychotics in treatment of aggression in ASD

No studies comparing antipsychotics to other med classes or combined with IBI

Introduction Contd:

? Phenotypic overlap BD and ASD suggests mood stabilizers may be an option

ADHD+Sleep prompt use of non-stimulant ADHD meds (α agonist), not for aggression

Aims to see effects of IBI with AP/MS/NS

Hypotheses

1. IBI shall substantially decrease aggressive behaviors in youth with ASD

2. Time required to achieve behavior plan success lower in individuals taking AP/MS/NS relative to those not taking medication

3. Younger, verbal males w low baseline aggression & lower stereotypy, irritability, and hyperactivity who received DRO plan predicted succeed quicker

Methods

32 children attending IBI program in Cleveland. Mean age 11.16 (4-16) 75% male

DSM diagnosis with Autistic disorder or PDD NOS were eligible if they received IBI for aggression

Consecutive youths in retrospective review of charts between 2000-2007

Methods cont:

All receiving IBI≥ 30 hrs/week. No additional behavioral therapies.

Aggression: Any beh that harms/attempts to harm another/destruction of property. Also interferes with academics/scoialization/daily living & restricts access to community involvement

Inclusion: ↑ 4 aggressive beh/day + 1 day with multiple aggressive beh were included

Methods cont:

Aggressive beh recorded at baseline (1 wk before IBI) and then wk 1-3 after beh plan implementation

Success: defined as↓ 1 agg ep/day for 5 consecutive days & five session without mod/severe aggression

Medications: Prescribed as usual by ped neurologist/psychiatrist/dev pediatrician. (No specific algorithm used) on meds >2 weeks prior

Medications

AP: risp12, ari5, zip1, clo1, zyp1, mol1n=3 on 2 AP’s

MS: dival6, lithium3, lamo1

NS: clonidine11, atom1

3= all classes 6= AP+MS 4= AP+NS

Measures

ABC (Community) completed by classroom teacher 30-35/wk : Hyperactivity, stereotypy and irritability subscales used

VABS (Teacher rating form) to evaluate functl level

Results

Changes in frequency of aggressive beh

Number of sessions required to succeed with agg beh plan

# of sessions required w/wo medication

# of sessions required for success by sex/verbal ability

Strengths and Limitations

LIMITATIONS

Intermingled med classes Retrospective Comorbidities Reason to be on one

medication class vs. other

Medication dosages? Evaluating combinations No Randomization (for IBI

or meds)

STRENGTHS

Take Home

No Extinction burst observed Median number of 6 hour sessions

needed >30 No difference between DRO vs. DRA MS & NS meds have minimal effect in

augmenting aggression beh plans.

Thank You!!

Autists are the ultimate square pegs, and the problem with pounding a square peg into a round hole is not that the hammering is hard work. It's that you're destroying the peg.” Paul Collins