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Check for updates Severe Behavior Problems Phoebe MacDowell, Felipe Lemos, and Joshua Jessel 1 Severe Behavior Problems result in harm to the child engaging in them, oth- ers, or their environment due to their intensity, Problem behavior can vary in presentation or frequency, and duration. The occurrence of these topography and in the intensity and frequency at behaviors may require multiple people to aid in which it occurs. For example, some children with intervention or management (Newcomb & autism spectrum disorder (ASD) may exhibit no Hagopian, 2018). The topography and presenta- problem behavior other than what is develop- tion of these behaviors vary by child and are typi- mentally appropriate for their age (e.g., tantrums cally referred to by their respective response during childhood). Other children may exhibit classes. The response classes often include mild or moderate problem behavior that causes aggression (e.g., hitting, kicking, biting, and some impediment to learning or functioning but pinching), self-jury (e.g., head hitting, head is not so pervasive that all facets of the child's life banging, and biting self), property destruction are affected or restrictive interventions are needed (e.g., throwing or ripping items, and punching or for treatment. For some children, the problem kicking walls), elopement (e.g., running or wan- behavior that they engage in is severe, pervasive, dering away from caregivers without their per- and persistent, with these children requiring mission when inappropriate to do so), and restrictive interventions, psychotropic medica- tantrums (e.g., crying and/or screaming that is tion, and at times, residential placements outside typically accompanied by a behavior present of their family homes. within another response class). We may consider Severe problem behavior (SPB) can be broadly problem behavior to be severe when a child defined as a set of behaviors that are likely to engages in it more frequently than their peers within the same settings, leading to reduced rates P. MacDowell of skill acquisition, impaired safety, and impaired Queens College and the Graduate Center, City development of peer relationships (Carr & University of New York, New York City, NY, USA e-mail: pmacdowell@gradcenter.cuny.edu Durand, 1985; McGuire et al., 2016). Statistics for the prevalence of problem behav- F. Lemos Luna ABA, Curitiba, Brazil iors among children with ASD vary. Gurney et al. e-mail: felipe@lunaead.com.br (2006) conducted surveys with parents of chil- J. Jessel (X) dren with and without ASD and reported that Queens College and the Graduate Center, City 58.9% of parents have been told that their child University of New York, New York City, NY, USA with ASD had behavioral or conduct problems Brock University, St. Catharines, Ontario, Canada compared to 5.2% of parents of children without e-mail: Joshua.Jessel@qc.cuny.edu 555 �� The Author(s), under exclusive license to Springer Nature Switzerland AG 2024 D. R. Dixon et al. (eds.), Handbook of Early Intervention for Autism Spectrum Disorders, Autism and Child Psychopathology Series,556 P. MacDowell et al. ASD. Self-injury (in its various topographies) persistent throughout treatment (Lentz & Cohen, has been identified to occur within an estimate of 1980; Podlesnik & Kelley, 2015). When children at least 28% of children with ASD (Soke et al., engage in more dangerous forms of problem 2016). In another study, Kanne and Mazurek behaviors, they are more likely to be subject to (2011) reported that 68% of children with ASD restrictive procedures and restrictive educational have engaged in aggression toward their caregiv- or residential placements. In fact, children who ers. Pereira-Smith et al. (2019) found that 68% of engage in SPB are more at risk for residential caregivers within their study reported that their placements in group homes (Newcomb & child engaged in elopement at some point in their Hagopian, 2018). In the most extreme cases, life, with children who exhibit limited communi- some children with ASD may become patients in cation skills being noted as more likely to elope general in-patient psychiatric units due to a lack than others. of specialized psychiatric units for children with Although these figures do provide helpful ASD (McGuire et al., 2015). information regarding the distribution of SPB Young children with ASD may also experi- among children with ASD, there is little known ence high rates of psychotropic medication. For regarding how SPB develops in the first place. example, Madden et al. (2017), found that nearly For example, Kennedy (2002) suggested that half of the children within their sample were on self-injury could potentially evolve from more some form of psychotropic medication, despite a benign patterns of behavior characteristic of ASD lack of evidence of their effectiveness in treating such as stereotypy. Others have suggested that core domain features of ASD and problem behav- there are common conditions that many children ior. The study also noted 20% of medicated chil- are likely to experience naturally in their child- dren with ASD were taking an antipsychotic, hood, which have the potential to motivate and with risperidone and aripiprazole being the most shape up SPB (e.g., Ala'i-Rosales et al., 2019; common within the sample. In comparison, only Carr, 1977). Ala'i-Rosales et al. refer to these as 7.7% of children without ASD were found to be the "Big Four" conditions and include situations on psychotropic medication. The use of such in which (a) wants and needs are not being met, medications comes with numerous side effects, (b) attention and affection may be withheld, (c) all of which can have some impact on quality of there are skill deficits in interactive and indepen- life. It is well documented that long-term use of dent play, and (d) adversity is introduced that antipsychotics is likely to result in tardive dyski- requires tolerance and coping mechanisms. nesia, a movement disorder in which an individ- Regardless of the environmental conditions by ual engages in involuntary body movements which SPB can develop, SPB impairs safety and (Cornett et al., 2017). Other side effects of some necessitates assessment and intervention from psychotropic medications can cause changes in qualified professionals to reduce the risk of harm appetite and weight, constipation, drowsiness, and increase a child's quality of life. SPB has the and insomnia, among a litany of others. potential to limit a child's ability to (a) develop The occurrence of SPB can impact not only meaningful relationships with others, (b) acquire the child's quality of life but can also have a sig- new skills, (c) contact new environments or rein- nificant impact on the quality of life of family forcers (i.e., meet behavioral cusps), and (d) members and their relationships. Caregivers of maintain physical safety and the safety of others children with ASD who engage in SPB have a (Holden & Gitlesen, 2006). Furthermore, SPB heightened risk of experiencing stress (Lovell & can, and is likely to, sustain long into adulthood Wetherell, 2016) and caregiver burnout. Some if left untreated. Such extensive and pervasive caregivers report safety concerns, such as elope- learning histories can be difficult to treat effec- ment while out in the community, from a family tively. Problem behavior that contacts reinforce- home, or from school. Other caregivers may ment contingencies for longer periods of time report safety concerns with regard to their child within the child's natural environment is more hurting another child or staff member, or theirSevere Behavior Problems 557 child being injured by someone while engaging event have an increased likelihood of engaging in in SPB. Financial strain may also be felt by fami- problem behavior, or "externalizing symptoms." lies who receive medical bills due to hospital or Manly et al. (2001) note that children who have urgent care visits for children who engage in self- directly experienced any of the various forms of injurious behaviors or aggression toward their maltreatment are faced with the likelihood that caregivers or other family members. Finding these experiences can have a significant detri- respite providers can be difficult if a child has mental impact on their development. The authors SPB and such providers are not always trained found that children who have experienced abuse properly on de-escalation procedures. This may or neglect are more likely to engage in various ultimately pose an additional financial burden to forms of disruption and aggression than children the family as well if not covered by insurance or who have not been exposed to any form of mal- state benefits. treatment. Conversely, children who engage in SPB have a greater risk of coming into contact with more restrictive interventions than peers 2 Severe Problem Behavior who do not engage in similar topographies of and Trauma behavior. Some behavior management proce- dures such as physical or manual restraint and Given that parents of children with ASD have seclusion (whether used in the context of a for- significantly higher stress levels than parents of mal time-out procedure or not) may be used due children without ASD, it is unfortunately no sur- to the safety risks posed by self-injury or aggres- prise that some children with ASD experience sion; however, these procedures can have physical and emotional abuse and neglect (Chan unwanted effects, including emotional respond- & Lam, 2016). Children with intellectual and ing. This can be conceptualized to be due to the developmental disabilities are 1.5-3 times more individual's loss of control and the potential of likely than typically developing peers to experi- such procedures to elicit fear. As such, the use of ence some form of maltreatment, including abuse these behavior management strategies may be and neglect (Kearns et al., 2015). In fact, a child's considered to be potentially traumatic. status as a child with a disability has been found Due to the nature of SPB, it is pertinent for by numerous studies to be a contributing factor young children exhibiting these behaviors, even for their abuse and neglect (see Algood et al., if the magnitude or intensity is relatively mild, to 2011). Both abuse and neglect may be considered receive treatment to prevent these behaviors from to be potentially traumatic. persisting into adolescence and adulthood. According to the APA (n.d.), trauma may be Extensive learning histories can cause SPB to be defined as " any disturbing experience that persistent despite treatment; early intervention results in significant fear, helplessness, dissocia- and the acquisition of skills can prevent such tion, confusion, or other disruptive feelings learning histories from being established. intense enough to have a long-lasting negative Clinicians should actively work to prevent chil- effect on a person's attitudes, behavior, and other dren in their care from coming into contact with aspects of functioning" (https://dictionary.apa. potentially traumatic events that are likely pre- org/trauma). Trauma is an individual and deeply ventable, such as restraint and seclusion, by emotional response. The occurrence of one or teaching them alternative skills that allow the more of the aforementioned events does not nec- child to have their needs met without the occur- essarily mean that someone has experienced rence of SPB. In lessening a child's exposure to trauma, rather that the individual has been potentially traumatic events, clinicians can take exposed to a potentially traumatic event. The part in combating adverse childhood experiences, individual's emotional response to the event is a sweeping public health crisis. In early what is considered to be trauma. Children who intervention, treatment should focus on prevent- have been exposed to a potentially traumatic ing the occurrence of SPB.558 P. MacDowell et al. 3 Preventive Strategies ing are all targeted within the treatment of for Severe Problem Behavior SPB. Implementation of the program may begin as a class-wide approach prior to instruction Based on the premise that behaviors are learned occurring in small groups. Prior to teaching, the and reinforced throughout a child's history, diffi- clinician or teacher assesses each child's ability culties can be minimized by teaching skills that to engage in the core skills. Teaching then begins prevent the early development of SPB (Beaulieu by identifying naturalistic opportunities occur- & Hanley, 2014; Hanley et al., 2013; Luczynski ring within the typical classroom routine and & Hanley, 2013; Reeve & Carr, 2000; Ruppel establishing an evocative situation in which to et al., 2021). The need to adopt a preventive prompt the child to engage in the targeted approach to address problem behaviors is well response (e.g., child needs to ask for help during known (Greenwood et al., 1993; Walker et al., an activity; the teacher is no longer available dur- 1996) and tends to focus on antecedent interven- ing play). tions for behaviors that are already part of a While PLS focuses largely on the develop- child's repertoire (Kennedy, 1994; Kern & ment of social skills that are necessary for navi- Clemens, 2007). For example, the Preschool Life gating life within structured environments, it is Skills (PLS) is a school-wide program developed limited in its practicality to be easily replicated in for young children in an effort to provide teachers a family home given the constraints and resources and clinicians with a tool to prevent problem required. To address this, the Balance program behavior from worsening in severity and becom- was developed (Ruppel et al., 2021). The Balance ing established within a child's repertoire (Hanley program focuses on creating balance between et al., 2007). Prior to PLS, behavioral approaches child-led and adult-led activities within natural to preventing problem behavior typically com- settings (Ruppel et al., 2021) for preschool aged prised of avoidance of evocative situations children who display emerging problem behav- through environmental design. While the latter ior. Whereas PLS is implemented in academic approach may prevent problem behavior from settings by trained staff, the Balance program occurring, it only does so for variables that can be occurs in-home through clinician-supported par- controlled. This approach only works until evoc- ent implementation. Similar to PLS, skills taught ative situations that are outside of a clinician's within the Balance program include responding control inevitably occur. In addition, skills such to name, functional communication, tolerance to as functional communication and tolerance are denials, and following instructions. Each skill not taught and therefore not acquired. By not sys- within the Balance program builds upon the last tematically increasing a child's tolerance, their to gradually create balance within the parent- environments will likely become more restrictive child relationship. in an effort to avoid establishing operations that Within the Balance program, an emphasis is typically precede SPB. placed on child-led play that is free from embed- PLS is comprised of 13 core skills that have ded teaching opportunities. Prior to training par- been identified to be crucial to a child's success ents, the clinician coaches the parent through an in early learning and their relevance to the treat- assessment to determine (a) establishing opera- ment of problem behavior. Skills are broken into tions likely to evoke emerging problem behavior four categories (i.e., instruction following, func- and (b) synthesized reinforcement contingencies tional communication, tolerance for delays, and likely to abate emerging problem behavior. From friendship skills). Instruction following, func- here, parent training begins and parents are pro- tional communication, and friendship skills are vided with choices as to what prompting strategy aligned with skills reported by kindergarten they would prefer to use to teach their child. teachers to be important to a child's success in Parents are then trained to teach each skill school (Lin et al., 2003). Functional communica- throughout the course of the program as they and tion, tolerance for delays, and instruction follow- their child progress. The process of the BalanceSevere Behavior Problems 559 program first begins with child-led play paired teaching, and reinforcing a set of school- with parents refraining from presenting establish- appropriate behaviors within the classroom (e.g., ing operations to emerging problem behavior. general classroom management) and outside of Response shaping is then initiated with respond- the classroom (Horner et al., 2009). Both inde- ing to name prior to shaping a functional com- pendent and group contingencies are used within munication response. Tolerance shaping follows this tier. For example, a teacher may utilize a with teaching a tolerance response and then pre- color chart for each individual child to indicate if senting instructions to a child after their request they are, or are not, engaging in appropriate to engage in further child-led time has been classroom behaviors at any given moment denied. Instructions are introduced during this throughout the day. Group contingencies may time with the eventual goal being generalization include the good behavior game (Barrish et al., of cooperation to typical routines and activities 1969), a group contingency in which the class is around the child's house. divided into 2 different teams. The teams of chil- dren work to achieve a specific criterion in the reduction of disruptive behaviors in order to 4 Reactive Strategies access reinforcement for their group. Here, for Severe Problem Behavior behavioral expectations are defined and taught to all of the students, with clear rewards for appro- While preventative strategies are meant to stop priate behavior and consequences for problem behavior from becoming established in a child's behavior (Horner et al., 2009). Of the three tiers repertoire, they do not necessarily provide effec- within the treatment model, classroom manage- tive treatment to children with established learn- ment strategies are the least restrictive. ing histories of SPB. Reactive strategies are often Following general classroom management necessary after SPB has developed, particularly strategies within the first tier, individualized for preschool and school-aged children. In fact, treatment strategies for a child may be imple- early intensive behavioral intervention (EIBI), mented. Within this second tier, children are which focuses on improving functional reper- identified as being at-risk for the development of toires and skills, has historically included proce- problem behaviors and receive intervention. dures for reducing problem behavior as well Typically, these intervention strategies are imple- (Lovaas, 1987). Lovaas described various meth- mented in addition to general classroom manage- ods such as planned ignoring of problem behav- ment, though some children may be placed in ior, the use of time-out, and other aversive stimuli classrooms with reduced student-to-teacher presented contingent on the occurrence of prob- ratios. Children within this tier may benefit from lem behavior. It is important to point out that the use of an individualized reinforcement sys- early iterations of EIBI tended to rely on arbitrary tem, such as a token board or point system. Other reinforcers and punishers because the applied supports may be utilized as well, including picto- behavioral technology was still somewhat in its rial activity schedules (MacDuff et al., 1993) to infancy. There were some idiosyncratic examples aid in task completion and provide more structure arranging environmental variables likely contrib- or predictability to the child's daily routine. uting to problem behavior to better inform the Finally, for those children whose problem use of function-based strategies at the time (e.g., behavior is severe and pervasive, treatment is Lovaas et al., 1965; Lovaas & Simmons, 1969); likely to encompass more intensive and individu- however, these were more often the exception to alized interventions, comprising of formal assess- the rule. ment and function-based treatment within more The school-wide positive behavior support restrictive settings (Fairbanks et al., 2007). These (SWPBS) approach is a tiered treatment model, interventions may require one-to-one support for developed from community health models the implemented treatment to have the targeted (Larson, 1994). SWPBS begins with identifying, effect. Function-based treatment cannot be560 P. MacDowell et al. implemented without first determining the func- between the interviewer and interviewee, and tion of the behavior in question. Given the vari- important contextual variables that may have ous environmental nuances that either evoke or been missed during a close-ended assessment abate SPB, assumptions cannot be made regard- may become evident, as responses are not con- ing function, and a referral to an appropriate cli- strained to a predetermined set of yes/no answers. nician should be made. In addition, we are likely to learn more about the child, their needs, wants, and interests in a less structured and friendlier format, something that 5 Functional Assessment is relevant for all clinicians when they are estab- lishing a relationship with a child and their fam- When children are first referred for the treat- ily, as this is something that close-ended ment of SPB, a functional assessment is con- assessments do not necessarily allow for. These ducted, with both indirect and direct measures pieces of information regarding the child, their used to identify the behavior, its antecedents, behaviors, and the conditions under which the and common consequences. Indirect assess- behavior occurs are individual and nuanced. We ments do not involve any observation of the can use the gathered information to child engaging in the behavior. Instead, these hunches, or hypotheses about the most likely, and assessments rely on completed questionnaires most important, maintaining variables to SPB during interviews with the individuals who (Hanley, 2012). The more accurate these hunches know the child well to support an interpretation are, the more likely our test and control condi- of the function of the behavior. In the closed- tions within a functional analysis are to be suc- ended variation of an indirect assessment, ques- cessful in capturing a baseline of the behavior in tions are scored at the end of the questionnaire question. and the functions with the highest scores aid in The use of the open-ended interview may not determining the likely function. Though these formally establish the function of the behavior in close-ended tools may be less time consuming question; however, clinicians should use this as a to implement than an open-ended interview, valuable opportunity to begin building rapport they are limited in what information is gathered with caregivers familiar with the child. As noted regarding the child and the environment. Close- by Taylor et al. (2018), establishing partnerships ended assessments do not directly test the poten- with parents or caregivers may lead to better tial contingencies maintaining problem behavior treatment outcomes for the child due to increased and therefore may not be accurate for establish- caregiver involvement. This is especially relevant ing a function-based treatment. There is evi- in the beginning stages of forming a relationship dence that close-ended measures are mostly with caregivers, as the first few interactions may unreliable, and therefore not valid, when set the tone for the partnership throughout the attempting to establish the function of a behav- course of treatment. If a parent or caregiver does ior to inform the best course of treatment (Iwata not feel as if their concerns and experiences are et al., 2013; Paclawskyj et al., 2001). valid, or that the clinician working with them This is not to say that indirect assessments are understands their perspective, how can trust be not an important aspect of a functional assess- established? It is not enough for clinicians to sim- ment. A viable alternative to the aforementioned ply explain the efficacy behind a chosen treat- close-ended measures would be an open-ended ment for a child in their care; establishing a interview. Open-ended interviews do not attempt compassionate connection with the parent to to quantify the information received from the address potential barriers and parental concerns interviewee, but rather allow the interviewee to before they arise during treatment may be the describe the individual contingencies they have first step toward a successful intervention and observed and experienced with the child. The for- increase parental follow through and mat of such a measure generates discussion implementation.Severe Behavior Problems 561 The descriptive assessment provides the clini- resort in a hierarchical model. That is to say, cian or teacher with more direct information start with the indirect assessment when assess- regarding the child's SPB. That is because the ing SPB and only move to the descriptive assess- descriptive assessment does not rely on verbal ment when the treatment informed by the reports from third-party individuals, the child and indirect assessment fails. Then when the their behavior are being directly observed during descriptive assessment fails, this is the opportu- this time. Information obtained is collected in a nity to consider conducting a functional analy- similar format to that of indirect assessments in sis. The hierarchical approach was often that descriptive assessments can be closed or necessary because functional analysis proce- open ended. Descriptive assessments using dures were plagued with practical concerns. For closed-ended observations will only allow for the example, many clinicians have reported func- collection of data within previously determined tional analyses to be difficult to conduct and categories. For example, the teacher may only be require a lot of time and expertise (Hanley, able to choose from a set list of (a) antecedents 2012). However, more practical approaches to (diverted attention, instruction provided, access the functional analysis have been developed in to item removed), (b) topographies of SPB recent years, which makes conducting the func- (aggression, property destruction, and self- tional analysis more accessible to professionals injurious behavior), and consequences (attention working with children who exhibit SPB. provided, instruction removed, item provided) The interview-informed, synthesized contin- during a behavioral episode. This limits possible gency analysis (IISCA) is a functional analysis interpretations during an observation and may be method that incorporates five core components why the descriptive assessment shares many of (Jessel, 2022). First, the IISCA includes only a the same concerns regarding assessment reliabil- single test condition to ensure that the analysis ity (e.g., Thompson & Iwata, 2007). can be completed in an efficient amount of time. The open-ended version of the descriptive Second, the procedures of the test and control assessment affords the clinician or teacher with conditions are informed by a previously con- the opportunity to collect more qualitatively rich ducted open-ended interview and brief contin- information about the contingencies and topogra- gency probe. The context being evaluated during phies of SPB observed. However, any variation the functional analysis should be representative of the descriptive assessment maintains the level of the environment in which the child has a his- of contributing to function hunches and may not tory of problem behavior. The open-ended inter- necessarily be effective in informing treatment. view and brief contingency probe allow the Jessel et al. (2020a) suggested conducting the clinician to establish individualized contingen- descriptive assessment more as a brief contin- cies that are ecologically relevant for each child. gency probe, giving the clinician the opportunity Third, the reinforcers in the test condition are to unsystematically arrange contingencies identi- presented in a synthesized contingency. That is, fied during the open-ended assessment. The brief reinforcers are presented as they naturally occur contingency probe is intended to create an explor- to capture all potential variables and abolish the atory environment for the curious clinician to value of engaging in SPB immediately after better hone in on the specific contingency to delivery. Fourth, the single test condition is com- evaluate behaviors to target during the functional pared to a matched control, whereby the same analysis. reinforcers presented contingently during the test The functional analysis is the only functional condition are simply made continuously avail- assessment method that includes systematic able in the control. Fifth, precursors to problem changes in environmental events to provide an behavior that precedes the occurrence of SPB are empirical demonstration of control over SPB reinforced in an open-contingency class. These (Hanley et al., 2003). Historically, the func- precursors are identified during the open-ended tional analysis has often been described as a last interview and brief contingency probe and562 P. MacDowell et al. attempt to create a safer environment by de- (Senkal et al., 2023). NCR is limited by the fact escalating before SPB occurs. that it does not teach any skills to replace SPB, The IISCA has been found to be a compara- may undermine the reinforcer maintaining the tively efficient functional analysis model that replacement behavior, and the child is likely to requires around 30 min to conduct (Jessel et al., continue to display difficulties in situations where 2016) and could take as little as 5 min, depending the reinforcers are not continuously freely on the procedures used (Jessel et al., 2020b). This available. leaves ample time for the clinician to conduct the One of the most basic consequence-based indirect assessment, descriptive assessment, and strategies is extinction. Extinction involves dis- functional analysis as a collection of procedures rupting the contingency between behavior and its rather than conducting each separately, waiting consequences, for example, by withholding rein- for one to fail before initiating the next. This forcers identified during the functional assess- allows clinicians to more confidently begin ment, leading to the reduction or elimination of behavioral treatment knowing the evocative SPB. Extinction does not prevent the problem events and consequences that have been empiri- behavior from occurring and only terminates the cally demonstrated to contribute to SPB. reinforcement contingency between the behavior and the consequences. Much like NCR, extinc- tion is never recommended to be conducted alone 6 Behavioral Treatment and should only be included in a larger treatment Strategies package. That is because extinction can provoke an initial escalation in unwanted behaviors and Function-based behavioral treatments for SPB emotional responses (Miltenberger, 2015). use the information obtained from the functional Another barrier to implementing extinction pro- assessments regarding the contingent relation cedures is that caregivers may have difficulty ter- between problem behavior and reinforcement to minating the contingency with particularly reduce problem behavior. Antecedent-based challenging to manage SPB. For example, a strategies alter the value of the functional rein- larger child may be able to overpower an adult to forcers to abate SPB while consequence-based gain access to their preferred activities. strategies alter when the functional reinforcers Differential reinforcement is the only behav- are presented. ioral treatment that arranges for the functional reinforcers to be delivered contingent on some alternative behavior. This helps to simultaneously 6.1 Initial Treatment Procedures promote appropriate alternative behavior while reducing SPB. Multiple variations of differential Noncontingent reinforcement (NCR) is an exam- reinforcement exist, depending on the scheduled ple of an antecedent-based strategy and involves delivery of those reinforcers and their relation to delivering reinforcers independent of respond- the target's appropriate behavior. Differential ing, whether appropriate alternative behavior or reinforcement of other behavior (DRO) involves SPB. The reinforcers are delivered based solely presenting the reinforcers in the absence of SPB, on the passage of time, thus eliminating any con- thus potentially strengthening any other appro- tingent relation between SPB and reinforcement. priate behavior that is occurring at the time of In addition, the value of the reinforcers is abol- delivery (Jessel & Ingvarsson, 2016). However, ished during dense NCR schedules, which this implies that there are technically no pro- reduces any motivation to engage in SPB. While grammed consequences for any specific appro- NCR is often considered a practical treatment priate behavior and the expectation remains only procedure because it requires little more than on the elimination of problem behavior. presenting a reinforcer after a specific interval Differential reinforcement of alternative behavior elapses, it should rarely be conducted alone (DRA) adjusts the contingency to strengthen aSevere Behavior Problems 563 target-appropriate response such as cooperation first course of action when training a functional with adult instruction. In addition, when the tar- communication response. This will likely place get appropriate response is a form of communi- the communication skills being taught lower than cation, the procedure is considered functional the child's baseline abilities. During complexity communication training (FCT; Carr & Durand, training, communication responses are broken 1985). down into easily consumable steps and gradually Although differential reinforcement has his- shaped into more developmentally and socially torically been combined with extinction, it is not appropriate forms of communication. The func- a necessity. Instead of entirely discontinuing any tional communication responses can incorporate reinforcement for SPB, dimensions of reinforce- actions such as gaining a listener's attention, ment can be manipulated to favor the appropriate establishing eye contact, receiving acknowledg- alternative behavior (Athens & Vollmer, 2010; ment from the listener, incorporating a verbal Iannaccone & Jessel, 2023). For example, SPB frame into one's speech pattern, and utilizing can continue to produce access to tangible items; polite social phrases. however, cooperation with an instruction to com- Increasing the complexity of the initial plete an academic task would produce longer response may improve the generality and social access to a higher preferred tangible item. This acceptability of the communication skills; how- form of differential reinforcement can avoid the ever, it leaves the schedules of reinforcement potential for any negative side effects of extinc- dense. Teachers and clinicians may still find it tion and create a more preferred environment for difficult to continuously reinforce every time the the child. child communicates appropriately. Another treat- ment extension addresses the density of rein- forcement and is termed reinforcement schedule 6.2 Treatment Extensions thinning (Hagopian et al., 2011). During rein- forcement schedule thinning, the delivery of rein- It is often recommended that initial treatment forcers is gradually reduced with the eventual procedures begin with simple contingencies and goal of the programmed reinforcement schedule dense schedules of reinforcement. This is to to be close to that of the natural environment. ensure that the child contacts reinforcement and The schedule of reinforcement can be thinned the treatment is successful in immediately reduc- based on the introduction of more time in between ing SPB. However, the primary goal of reducing when the reinforcers are available or increasing SPB has to be considered within the context in the response requirement. A teacher may begin which it is occurring. That is, the treatment pro- the behavioral treatment with reinforcement cedures have to be practical and feasible for available following every single communication teachers and clinicians to conduct in their respec- response (i.e., FCT). Eventually, the goal will be tive environments. For example, NCR may elimi- for the child to work until it is time for recess. nate SPB in the school, but the child is The teacher may then consider the treatment continuously contacting reinforcement and not extension slowly introducing small periods of completing any academic work. This may not time in which reinforcement is not available until necessarily be considered helpful for a teacher. the delay matches that of the entire class before Therefore, treatment extensions are used to main- reinforcement is once again available following tain the positive outcomes in problem behavior communication during the start of the recess while addressing issues of clinical concern. break. The teacher may also decide instead of One example of a treatment extension is to time-based reinforcement schedule thinning, she improve the complexity of communication abili- may want the child to complete some academic ties during FCT (Ghaemmaghami et al., 2018). It work. Thus, the treatment extension will involve is often recommended during FCT to start treat- contingencies for completing work, and intro- ment with basic and low-effort responses as the ducing more and more instructions before rein-564 P. MacDowell et al. forcement is returned. It is important to point out Though clinicians are not formal caregivers to that, while both time-based and contingency- children on their caseloads, the frequency of con- based methods of thinning reinforcement are tact with such children during service provision viable options, contingency-based methods tend makes the implementation of a trauma-informed to be more effective and focus on teaching addi- approach to care relevant for providers in pre- tional skills to fill the void when reinforcement is venting harm. Due to the nature of ASD, children not available (Muharib et al., 2021). on the spectrum already exhibit characteristics that may increase their risk of trauma, including deficits in communication, exposure to numerous 7 Incorporating a Trauma- clinicians and caregivers, and repeated medical Informed Framework procedures (Horton et al., 2021). Following the four "Rs" of TIC, there are six principles that Given that children with intellectual and develop- guide the implementation of a trauma informed mental disabilities have a higher risk of being approach: safety, trustworthiness and transpar- exposed to potentially traumatic events than typi- ency, peer support, collaboration and mutuality, cally developing children (Brendli et al., 2021), it empowerment (choice), and awareness of cul- is pertinent for early intervention clinicians not tural, historic, and gender issues (SAMSHA, only to understand trauma and trauma-informed 2014). Rajaraman et al. (2021a) constructed a care (TIC) but also to incorporate the relevant framework for trauma-informed care within principles into practice. TIC is not exclusive to applied behavior analysis, derived from the origi- those children with identified trauma histories; it nal six guiding principles. The four cornerstones can be incorporated into one's practice to prevent of this framework include: acknowledgement of trauma stemming from various interventions trauma and its potential impact, ensuring safety from occurring and to aid in effective service pro- and trust, promoting choice and shared gover- vision. TIC relies on four assumptions, as out- nance, and emphasizing skill building. lined by the Substance Abuse and Mental Health A trauma-informed approach begins with a Services Administration (SAMHSA, 2014). clinician's ability to acknowledge trauma and the First, the clinician realizes the impact of impact it may have. In other words, a clinician trauma, its impact on a learner and their behavior, must have an understanding that the children they their families, and their communities. Second, will encounter throughout their practice may clinicians recognize symptoms of trauma through have experienced trauma in any of its various assessment, report, and observation. Third, the forms. Trauma can cause an adaptation to a clinician should respond to these symptoms or child's functioning, including their behaviors, direct reports of trauma by incorporating the resulting in post-traumatic stress disorder. What principles of TIC into their practice. Finally, the may be considered to be a maladaptive behavior clinician should resist retraumatization. This should perhaps be considered to be adaptive for may entail advocating against the use of seclu- the individual when viewing it through the lens of sion and restraint, particularly in the case of a surviving traumatic events. Specifically, a child's child who has been exposed to traumatic events behaviors are the product of their environments that may share similar stimulus properties to such (Guarino et al., 2009; Rajaraman et al., 2021a). procedures (e.g., abandonment, neglect, physical It is not enough to simply recognize that, as a and sexual abuse). Not only should this resistance clinician, you will come into contact with chil- be applied to the children they are serving; this dren with trauma histories. One must actively should be applied to the clinician themselves, work to ensure that the child is safe within the others that they may supervise, and to other context of their relationship, and this should be stakeholders involved in service provision. evaluated frequently as one continues to work Trauma can have impacts beyond the single indi- with a child. Within the framework of TIC, safety vidual who may have experienced it. is referred to in both its physical and psychologi-Severe Behavior Problems 565 cal contexts. Safety may be indicated by a child activities, and routines, expanding play skills, when there is an absence of behaviors function- and strengthening social repertoires. Procedures ing as escape/avoidance within an environment such as DRO, NCR, and varying punishment pro- that is devoid of aversive stimuli. Without first cedures are not prioritized for a child's treatment, establishing an environment or relationship as but rather procedures that promote the acquisi- safe, trust cannot be obtained. Trust may be the tion of skills, such as DRA. Healing from trauma sum of cumulative interactions that are consis- occurs within relationships in which there is tently reinforcing and predictable (Rajaraman safety, trust, collaboration, and an emphasis on et al., 2021a). For any child, the implementation skill building. Though clinicians will inevitably of TIC is pertinent to their development; how- work with children who have not experienced ever, this is especially pertinent for young chil- trauma, the implementation of TIC principles dren, who experience several sensitive and provides clinicians the opportunity to prevent critical developmental periods within the first children from experiencing trauma as a result of few years of life (Knudsen, 2004; Nelson & their relationship. Gabard-Durnam, 2020). If we consider restraint, seclusion, and the utilization of some extinction procedures to be potentially traumatic, we must 7.1 Behavioral Assessment consider the role these behavior management with TIC Framework strategies play in a child's development. Further, we must consider the role we play as well. While Metras and Jessel (2021) were some of the restraint and seclusion may be used to mitigate researchers to first discuss the possibility of mod- safety concerns, for any child, but particularly ifying the functional analysis to incorporate a those with trauma histories, these procedures TIC framework. The modifications lead to the may not contribute to a robust therapeutic rela- development of a new functional analysis model tionship, of which trust is the foundation. identified as the performance-based IISCA The principle of promoting choice and shared (Jessel et al., 2023). The IISCA was used as an governance attempts to address this power imbal- initial starting point for incorporating the TIC ance inherent within the relationship. Choice and framework because it inadvertently already had shared governance are meant to level the playing some procedures that could have been considered field; by allowing the child to participate in their trauma-informed (Jessel et al., 2023). For exam- own treatment through the provision of choices ple, the IISCA is informed by an open-ended and collaboration with the adult, the dynamic in interview that attempts to understand the child's the therapeutic relationship shifts from the child experiences with adverse events, therefore being powerless to empowered. Allowing a child acknowledging trauma and its potential impact. choice and control within a safe relationship min- In addition, the IISCA has always included an imizes the risk of retraumatization. open-contingency class that reinforces any non- The fourth principle of TIC, emphasizing skill dangerous problem behavior to reduce escalation building, builds upon and incorporates the previ- to SPB. This helps to ensure the safety of the ous three linchpins. Once safety and trust have child and maintain a level of trust with the teacher been established, choice and shared governance who is not pushing the child to escalate in emo- are incorporated into the skill-building process. tional bursts of SPB. Clinicians become the facilitators, rather than the The performance-based IISCA delves further controllers, of skill building and healing (Brown into the TIC framework by eliminating the time- et al., 2012). Skills are taught to empower the based criterion for reinforcement removal and child-in the context of young children with leaves the child in complete control of their envi- ASD, this may be building up requesting skills to ronment. That is, any indications of escalation have needs and wants met, teaching the toleration will result in the reinforcers and the child will of delays and denials to access preferred items, continue to have access to those reinforcers until566 P. MacDowell et al. they are happy, relaxed, and engaged. What that process of skill-based treatment begins with ensures is that evocative events can never be pre- teaching of increasingly complex communica- sented during periods of unease during the tion responses that progressively improve in performance-based IISCA. Another modifica- developmental appropriateness. Following which tion, centered around the TIC framework, is that the child is taught how to tolerate exposure to the performance-based IISCA measures problem denials and delays to reinforcement. This includes behavior as a frequency and the entire assessment the probabilistic reinforcement of cooperation period is completed after only three to five with a range of different activities, instructions, instances of any problem behavior (precursors or and tasks. Since the seminal publication, there SPB). That way, the child is exposed to evocative have been replications across hundreds of partici- events only a minimal number of times and may pants with, when quantified in a meta-analysis, not experience any SPB at all, maintaining a level large effect sizes (Layman et al., 2023). While of safety with a low probability of retraumatiza- skill-based treatment has proven effective in tion. Finally, the performance-based IISCA reducing SPB and teaching skills, certain modifi- requires the measurement of appropriate behav- cations have been introduced to enhance its ior in addition to problem behavior. The child trauma-informed features. These changes aim to should spend most of this time during the assess- improve the intervention's efficacy and applica- ment in a calm state engaging with preferred bility for children experiencing trauma-related items with only periodic instances of precursors issues. to problem behavior without escalation. Rajaraman et al. (2021b) proposed advance- Iovino et al. (2022) were the first researchers ments to the original skill-based treatment proce- to empirically evaluate the performance-based dures. The modifications were based primarily IISCA with five children who exhibited SPB in a but not exclusively on choice within treatment, rehabilitation center in Italy, the majority of which led to the researchers identifying the new whom were under the age of 10 years old. The treatment as the enhanced choice model. Four performance-based IISCAs began with at least significant modifications were introduced, with 5 min of access to reinforcement where the par- extinction being the first adjustment. The ticipants were visibly calm and happy before enhanced choice model eliminates physical guid- introducing an establishing operation. The entire ance in escape extinction and instead utilizes process took less than 30 min for all participants vocal and gestural prompts as consequences for and three of the five participants did not exhibit SPB. Prior to each session, as part of the preses- any SPB during the entire time. Interestingly, sion procedure, the clinician discussed previous function-based treatments informed by the developments made during sessions while outlin- performance-based IISCA were found to be just ing expectations for upcoming tasks that include as effective as treatments informed by the tackling challenging establishing operations IISCA. This suggests that incorporating a TIC along predetermined response criteria resulting framework is unlikely to negatively impact a in reinforcement. As a third modification, there treatment's efficacy. are alternative choices given to children about which skills they wish to work on and where and when they feel comfortable training. And fourth, 7.2 Behavioral Treatment with TIC the child undergoing treatment has the liberty to Framework exit from the training room and spend some time in the hangout space or even depart from the The skill-based treatment was first introduced by facility whenever they choose. Hanley et al. (2014) and involves focusing on During the first application of the enhanced teaching a multitude of skills to replace choice model, the three young children (i.e., SPB. Participants included three children, rang- under the ages of 10 years old) were able to learn ing in age from 3 years old to 11 years old. The new communication skills, toleration skills, andSevere Behavior Problems 567 cooperation skills with little to no SPB being Algood, C. L., Hong, J. S., Gourdine, R. M., & Williams, A. B. (2011). Maltreatment of children with develop- observed throughout the entire process. The mental disabilities: An ecological systems analysis. treatment was conducted in the classroom set- Children and Youth Services Review, 33(7), 1142-1148. ting, and all teachers provided positive reports of their satisfaction with the treatment procedures American Psychological Association. (n.d.). APA dic- and outcomes. Staubitz et al. (2022) extended the tionary of psychology. 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