Archive for December, 2012

Will you marry usEarlier this week, when a 3rd grader asked me whose mother I was, I explained that I was actually a step mom. I went on to explain that the child in question was super lucky because she had a mom AND a step mom.

The little boy was so confused. He said, “but you have to marry her dad” and I confirmed. Confused even more, he said, “but you cannot marry her dad until her mommy dies!”

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Rethink Mental Illness

Rethink Mental Illness (Photo credit: Wikipedia)

Here at Applied Behavioral Strategies, the mission is to improve the quality of life through effective intervention. One way we hope to do that is by reviewing research articles for readers. Today’s topic is in direct response to the Newtown Shootings. People have asked if Asperger’s is related and clearly it is not.

Is mental illness related to the shootings? We are still unclear on this; but we do know that mental illness has been associated with many if not all of the previous shootings. And sadly, mental illness can find its way in to anyone’s life at any time. Thus, today’s research review is on an article about mental illness and Asperger’s syndrome.

Luigi Mazzone, Liliana Ruta, and Laura Reale authored the article called “Psychiatric Comorbidities in Asperger’s Syndrome and High Functioning Autism”. The Annals of General Psychiatry published the paper in 2012.

Background Information

Individuals with Asperger’s and High Functioning Autism must exhibit several characteristics in order to be diagnosed with the condition. Specifically, individuals must:

  • show delays or differences in language skills
  • exhibit deficits in social skills
  • engage in stereotyped or ritualistic behaviors

Because of the language delays, professionals may have difficulty identifying signs of other comorbid psychiatric conditions. Additionally, the stereotyped or ritualistic behaviors may also make it difficult to determine if challenging behaviors are related to the Asperger’s and Autism spectrum or if those behaviors are signs of some comorbid condition.

Purpose of the Paper

The authors conducted a literature review. The authors stated that the purpose of their paper was to “examine the interplay between common psychiatric comorbidities and Asperger’s Syndrome and High Functioning Autism.” The authors planned to “discuss which psychiatric disorders have been more frequently reported in association with Asperger’s Syndrome and High Functioning Autism.” The authors wanted to identify the difficulties that clinicians and researchers face when making a correct diagnosis of a comorbid condition in Asperger’s Syndrome. Finally, the authors wanted to discuss the role of the environment and comorbid conditions.


The authors conducted a term search to identify all related articles. Next, the authors reviewed the reference lists in each article to find additional related articles. Once the authors located all the articles, they screened the articles for scientific quality and eliminated studies that lacked scientific rigor.


Internalizing Conditions. Internalizing conditions result in individuals having internal thoughts and sensations that are not easily identified by observers. The authors found that a number of studies reported internalizing comorbid conditions with Asperger’s syndrome and high functioning autism. These conditions included:

  • depression
  • bipolar disorder
  • anxiety
  • obsessive compulsive disorder

Externalizing Conditions. Externalizing conditions result in individuals engaging in behaviors that are observable to observers. The authors reported that a number of studies reported externalizing comorbid conditions with Asperger’s and High Functioning Autism. Due to diagnostic criteria, professionals cannot label a child with Asperger’s and ADHD. However, professionals know that many children with Autism Spectrum Disorders (including Asperger’s) also have attention issues and high levels of activity.

The authors noted that “high-functioning autism disorders are over-represented in the criminal population” but that this may be due to undiagnosed comorbid psychiatric conditions. The authors go on to point out that individuals with Asperger’s syndrome have issues with theory of mind (e.g., perspective taking, understanding the thoughts and feelings of others) and that this deficit may impair their social judgment resulting in “the risk of violating norms and laws.” The second point the authors make is that “individuals with Asperger’s Syndrome often show a strong sense of right and wrong, and once they have understood the rules they are likely to stick to them more rigidly than most people.”

Tic Disorders. The authors noted that a number of studies reported a comorbidity of Asperger’s syndrome and high functioning autism with tic disorders such as Tourette syndrome.

Difficulties in Diagnosing

The authors discussed the difficulties in appropriate diagnosing individuals with Asperger’s syndrome and high functioning autism. They noted, in particular, that several diagnostic scales are available. However, they also pointed out that those scales were not normed on individuals with Asperger’s syndrome and high functioning autism. Thus, professionals must use caution.

The authors note that additional research is needed in order to fully understand the relationship between autism spectrum disorders and risks for comorbid psychopathology.

The Role of the Environment

The authors discussed how the environment may influence the expression of psychiatric disorders. The authors identified the role of stress in the family. For many years, research has shown that stress is high for parents, and in particular, mothers.

The authors also discuss the role of the respondent during the diagnostic process. The authors noted that parents and teachers report behaviors differently. The differences may be attributed to the context of the respondent or it may be due to the fact that the individual’s behaviors are different in each context.

The authors also discussed the role of genetics in that individuals with Asperger’s syndrome tend to have relatives with other psychiatric conditions. Professionals need to complete an appropriate family history as part of the initial evaluation.

Finally, the authors discuss the role of social relationships. Given the social and behavioral difficulties experienced by individuals on the spectrum, they are much more likely to have social difficulties (e.g., making and keeping friends, engaging in social routines and activities). This may lead to depression and anxiety leading to a vicious cycle and potentially to the onset of comorbid conditions.


The authors close with implications for practice and these are important for all of us.

  1. Correct diagnosis. Teachers and parents are closest to children on the spectrum. They have a responsibility to make sure that individuals obtain additional diagnoses if they suspect comorbid conditions.
  2. Appropriate assessment tools. Researchers need to develop appropriate assessment tools so that professionals may appropriately diagnose individuals with comorbid conditions.
  3. Treatment. All individuals need appropriate intervention for the conditions in which they are diagnosed.

Readers, how many of your children/clients have been diagnosed with comorbid conditions? How long did it take to get that diagnosis? Has treatment changed as a result of the diagnosis?

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5,56 mm HS Produkt VHS-D assault rifle

5,56 mm HS Produkt VHS-D assault rifle (Photo credit: Wikipedia)


I am so tired of hearing people blame the Newtown shooting on Asperger’s.

Let us look at the real explanations for the shooting:

  • an assault rifle
  • hyper media coverage of previous mass shootings
  • lack of treatment for mental health

Bushmaster Assault Rifle

Why would any human (other than military and law enforcement personnel) want or need to own such a weapon? The fact that a mother purchased this weapon and kept it in her house is shocking to me. I once dated a man, who I later found had a gun in his night stand drawer. When I discovered this, I ended the relationship immediately. I do not want to live in the same house with a gun of any sort.

I should share an important side not here. My brother bought his wife a hand gun for her birthday and I still love both of them dearly. But a hand gun is quite different from an assault rifle. There is no need for an assault rifle. Period.

Mass Media Coverage

I am the first person to admit that I love the media. I am a media addict. I watch Nancy and relate to her as my BFF (although my other half refers to her as Nancy Dis Grace). Perhaps it is the behavior analyst in me. I want to understand the psychology and the environmental events that led humans to engage in behaviors that kill. I have the same interest in the Newtown shootings. What led a young man to kill innocent women and children?

Despite my need or desire to know, I would give it all up right now in order to prevent future mass murders. But media coverage alone did not cause the shootings. Media coverage gives people the ideas to do it bigger.

Mental Health Treatment

While we are still in the dark about the events leading up to the shooting, we do know that all the other mass murderers had histories of mental health issues. It seems that only one of those killers had been receiving treatment; but even his treatment was limited. Yet, all of the parents had previously admitted that their child had issues. Clearly, our current health care system failed each and every one of those killers.

Our current health care system does not adequately address the mental health needs of individuals. I sat and listened to hours of testimony at a recent hearing on this very topic in CT. You can listen to the hours of testimony here.

Leaders in each state and in Washington DC need to take action. We need an active plan for preventing these types of violent rampages from occurring again.

There will be a bigger shooting. It is just a matter of time.That is, unless we make changes. We need changes in our gun laws and changes in our mental health treatment. The two entities must work together because individuals with mental illness should not have access to guns of any type.

Post script: Thanks to Rena for pointing out a very important missing piece.

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Hi and welcome to Ask Missy Mondays where I respond to a question from readers. Today’s question is in response to the horrific events that took place on Friday in Newtown, Connecticut.

Words cannot express the horror that we all have about the event. As teachers, educators, behavior analysts, and parents, we are all hurting, confused, and want to know what we can do to prevent this from happening again.

A long-time reader wrote:

“Missy, what should I tell my child? How can I explain something to my child that I do not understand myself?”

If you have been reading this blog for any length of time, you know that not one answer is not appropriate for every child. Each parent needs to examine the needs of each child separately and determine what is appropriate to tell each one.

Children with ASD

If your child has ASD, it may not be necessary to tell him/her what has happened. Several parents on my case load have already made the decision not to tell their children. This will require that you shield them from the news, social media, and the internet. This is not an easy task. Norm and I chose to tell the girls but we have prevented them from viewing news and social media. However, just yesterday we were watching football and the news broke in to show a church being evacuated.

Children of All Ages with Anxiety

This group of children will be really vulnerable to this incident. They may worry if it will happen to them. They may spend inordinate amounts of time trying to find images or they may be visualizing the imagery in their heads. This group of children will need extra parental support and reassurance. These kids need to know that they are safe.

  1. Continue to give them the verbal, emotional, and physical support that they need.
  2. Limit access to television and social media as one way of preventing them from seeing things that they will “run wild with” in their minds.
  3. Be sure to answer their questions; but do not let them perseverate on the topic.
  4. If you notice that your child is quiet, sullen, or withdrawn, be sure to work through exercises designed to prevent children from worrying too much.

Young Children

If your child is under the age of 8, you may also choose to keep this horrific incident from them. Again, you will need to shield them from all media sources. As mentioned previously, you will have to make sure that their peers do not know about the incident.

We told our children not to discuss it with other children. We also asked them to tell their friends that they are going to discuss the matter with their parents only.

Children 8-14

This group of children is in a different place developmentally and psychologically. They think they are grown up. However, their cognitive level is not as advanced and that limits their ability to fully comprehend. This group of children will most likely want to discuss the events. Unfortunately, this is all the group that is more likely to believe exaggerated stories. Additionally, this group is also more likely to be connected to social media where strange images have already started to circulate (e.g., the letter written by the kindergarten student while he was in lockdown).

  1. Provide only the basic and necessary facts.
  2. Limit access to media as much as possible during the first couple of weeks.
  3. Answer questions honestly and factually.
  4. Reassure the child that he/she is safe.
  5. Be on the lookout for any behaviors that suggest the child may need additional supports.

Children 14+

This group of children are almost self-sufficient. However, despite their confidence and independence, they will need additional support from adults. Unfortunately, they will not want to admit that they need this support. Thus, adults will need to be on the lookout for signals that indicate the children need assistance.

  1. Provide information when asked.
  2. Ask the child if he/she needs any additional information or support.
  3. Teach the child how to digest television and social media sources.
  4. Review strategies for remaining safe during similar incidents (e.g., where to go if it happens in the mall; what to do if it happens at school)
  5. Be on the lookout for any behaviors that suggest the child may need additional support.

This is surely a difficult time for everyone. I ask that you all keep the families of all those affected in your thoughts and prayers.

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In light of all the discussions this week regarding ADHD and medication, Using ABA to Address ADHD, and a research study on Addressing ADHD in Classrooms, this cartoon seems relevant!

Thank you Hank Ketcham for your brilliance all these years!

Dennis and Impulsivity

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Teacher and SudentsHere at Applied Behavioral Strategies, the mission is to improve the quality of life through effective intervention. One way we hope to do that is by reviewing research articles for our readers. Today’s research review continues the discussion this week on using principles of ABA to address ADHD. See Monday’s post and Tuesday’s post for additional information.

Researchers from a variety of institutions collaborated to author “Peer Tutoring for Children with ADHD: Effects on Classroom Behavior and Academic Performance“. Authors included: George DuPaul, Ruth Ervin, Christine Hook, and Kara McGoey. The Journal of Applied Behavior Analysis (JABA) published the study. Readers may download the entire article here.


Children with ADHD need two types of intervention. First, teachers and parents must provide reinforcement for appropriate behaviors and research has shown this to be effective. However, reinforcement alone is not enough. Teachers and parents must also concurrently address academic behaviors. One method for addressing academic behaviors is peer tutoring. Peer tutoring consists of two or more students working together on an activity with one student providing assistance, instruction, and feedback to the other. Various models of peer tutoring have been studied by great educational researchers such as Charlie Greenwood and Doug and Lynn Fuchs.

ClassWide Peer Tutoring

One model of peer tutoring is Classwide Peer Tutoring (CWPT). Classwide Peer Tutoring is an evidence based instructional practice based on principles of Applied Behavior Analysis (e.g., prompting, reinforcement, modeling). In CWPT, students work together in pairs taking turns tutoring each other. Students address skills that have been previously taught by their teacher. The teacher also develops appropriate teaching materials for the students to use. This approach provides students with more opportunities for asking questions and getting answers.

Study Purpose

The purpose of the study was to examine the effects of CWPT on  the task engagement, activity level, and academic performance of children with ADHD and children without ADHD.

Study Methodology

Participants. Eighteen students with ADHD who were not taking medication participated in the study. Children ranged between 6 and 10 years of age. Additionally, 10 comparison children participated in the study. These children were matched to the other children on age, gender, and class (i.e., in the same class as one of the targeted students).

Measures. Researchers measured classroom behavior (on task, off task, and fidgety) using a 15-second partial interval recording. Researchers also measured academic performance using teacher-developed pre- and post-tests each week. Finally, researchers also measured social validity by asking teachers and students to rate the intervention at the end of the study.

Design. Researchers used an ABAB (or reversal) design to determine intervention effectiveness. In this design, researchers measure behaviors with no intervention. Then they measure behaviors during intervention. Then the intervention is terminated while researchers continue to measure behaviors. And finally, the intervention is reinstated while behaviors continue to be measured.

Study Validity. The researchers took two additional steps to measure the validity of the study. First, they monitored accuracy of implementation using fidelity checks. Second, the researchers measured inter-observer agreement to ensure that data collection was consistent and accurate.


During baseline, students with ADHD were on-task about 29% of the intervals. This increased to 80% of intervals during intervention. When the intervention stopped, this behavior decreased down to an average of 21% of intervals but when the intervention was reinstated, it increased again to 83%. Changes in fidgety behavior were observed in some but not all students. It is important to note that even without intervention, the occurrence of fidgety behaviors was low (i.e. 6% of intervals). Pre-and Post-test scores improved with intervention for almost half of the students with ADHD. Finally, the intervention received high marks of satisfaction across both teachers and students.


In the discussion section of the paper, the authors note how the results of their study compared to the results of studies on stimulant medication. Essentially, effective instructional practices work just as well as medication without all the side effects. The authors also noted that anecdotal data suggested that student engagement increased as well. Use of stimulant medication does not necessarily result in increased engagement. Interestingly, the comparison peers also showed improvements in on-task behaviors and academic performance.

Readers, do any of your children engage in CWPT? Behavior analysts, is this an intervention that you teach others to use in classrooms? Teachers, how difficult is it to implement CWPT in your class?


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Hi! and welcome to What Works Wednesdays where a success story from clinical files is shared. Sadly, today is going to be an example of what does not work.

On Cyber Monday, I took advantage of the sale and bought my bonus daughter a few items from Abercrombie Kids. They arrived, she tried them on and two items needed to be exchanged. To complete the exchange, I went to the Abercrombie website. The bonus daughter was super excited to learn how to exchange items so she watched eagerly over my shoulder. And then we both see this:

hands in pants

The bonus daughter says, “Why are her hands in his pants?”

And that folks, is how advertising does not work. Sex will not sell clothes to me or my family.

We will not buy any more clothes from this store.

And if this picture is not enough, here is another picture from the home page. Because if having her hands down his pants is not enough, let’s introduce our children to ménage à trois.

Apparently, this little advertising trick is working. The company’s stock is soaring. People are buying.

Please join me in sending Abercrombie a message that this type of advertising is not appropriate for our children. My family will not be buying clothes from this company until they change their practices.

two on one


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English: A child not paying attention in class.

After yesterday‘s post regarding the use of ABA to treat ADHD, readers expressed interest in learning more. So today, one intervention to address ADHD behaviors will be discussed.


Readers should not be surprised to hear that reinforcement is a recommended intervention. Reinforcement is a key topic in almost every single post on this blog. The important thing to remember is that reinforcement must be individually designed and administered in order to obtain maximum results. Individualization is not easy for teachers or parents. However, if appropriate reinforcers and correct schedules of reinforcement are utilized, great changes in behavior will be observed.

Differential Reinforcement

There are many types of differential reinforcement:

  • differential reinforcement of other behavior (DRO)
  • differential reinforcement of incompatible behavior (DRI)
  • differential reinforcement of alternative behavior (DRA)
  • differential reinforcement of higher rates of behavior (DRH; designed to increase desirable behaviors!)
  • differential reinforcement of lower rates of behavior (DRL)

Essentially, differential reinforcement is the use of reinforcement for one behavior and not for others. Differential reinforcement requires implementors to reinforce one behavior while withholding reinforcement for another.

Differential Reinforcement of Alternative Behavior (DRA)

In this intervention, reinforcement is provided when an alternative behavior is observed but not when inappropriate behaviors are observed. Specifically, if a child is engaging in off task and distractable behaviors, alternative behaviors would be identified. It is important to know why (e.g., to get out of work, to get teacher attention, etc). An assessment must first be conducted to know why a behavior is occurring. To read more on assessment, check here, here, and here. Once the assessment has been completed, then alternative behaviors to obtain the same reinforcers are identified.

If a child is trying to get out of work, an alternative behavior is to work faster so that play and non-work time may be accessed. If a child is trying to gain teacher attention, then the child is taught to use appropriate behaviors to get teacher attention.

The next step is to reinforce the new/alternative behavior. If the child is working quickly, she needs to be reinforced with a nice long work break or play time. If the child appropriately recruits teacher attention, the teacher needs to come over quickly to give attention.

Thin Reinforcement

As with any intervention, the goal is to get appropriate behavior then to thin or reduce reinforcement so that the child may function like the rest of children in the class or home. It is important to thin reinforcement at a pace that will prevent the ADHD-type behaviors from escalating.

I hope this helps readers better understand one way that ABA may be used to address ADHD.

Related articles

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ADHDHi and welcome to Ask Missy Mondays where I respond to a question from readers. Today’s question comes from Andrea who asks,

“I have a 4-year-old who was diagnosed with autism within the last 6 months. He is extremely hyperactive and inattentive. What medication do you find to be most helpful?”

Hi Andrea, and thanks for taking the time to write. I am sorry to hear about your child being diagnosed with autism but he is young so there is ample time to get appropriate intervention to help him.

Please know that as a behavior analyst and special educator, I am not licensed to practice medicine. So, making recommendations about medication is out of my preview.

However, as behavior analysts, we are trained to address all types of behaviors, including hyperactive and inattentive behaviors.


Before we address any behaviors, we first complete assessments to better understand why the behaviors are happening. The assessment includes record reviews, interviews, and asking those who know the child to complete rating scales. The assessments also include observations of the child to better understand when the behaviors are good versus when the behaviors are bad. Finally, we may even conduct analyses to determine which environmental conditions directly affect the behavior.


Once the assessments have been completed, the behavior analyst will help design interventions to address the behaviors of concern. Behavioral interventions can be designed to address attentive behaviors, impulsive behaviors, and skills related to following instructions.

Health Interventions

In addition to behavioral intervention, parents should also consider whole body interventions that address the overall health of the child. Children need daily physical activity and I am not talking about using their fingers to control the remote or the iPad. Children need full body physical activity every single day.

Children also need a healthy diet. If your child eats mostly processed foods full of sugars, fake color, and other artificial ingredients, then you should change the diet before considering the use of medication to treat behaviors that may very well be caused by foods.

Finally, children need far more sleep than they are getting. Children need at least 10 hours of sleep each night. Children (nor adults) can make up for lost sleep so make sure that your child goes to bed early and sleeps as late as possible.

When All Else Fails

If you have followed all of the other advice above (consistently) and your child continues to have behavioral issues, then consider seeing a behavioral pediatrician to assist you in determining if medication is the right thing for your child. Medication should not be your first stop, it should be your last.

If you have a behavioral question for me, email askmissy at applied behavioral strategies dot com.

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princess KateAll the fuss this week seems to be about Princess “Kate”, her pregnancy, and resulting hyperemesis gravidarum (or extreme morning sickness). I (Missy) can admit that I have been enamored with Princess Kate in the past. She’s beautiful, smart, fit, and independent–all the ingredients for a role model.

When I read that she was hospitalized, my first thought was “what if her child develops autism?”

Don’t get me wrong, I would never wish autism on anyone. Ever. But maybe, if autism introduces itself to celebrity, someone will finally do something about the biggest epidemic facing our world.

Sure, there have been other celebrities with children with autism (Doug Flutie, Sylvester Stallone, Holly Robinson Peete, and Dan Marino). And while some of those individuals have done things to increase autism awareness, none of those individuals have actually stressed finding the cause, cure, or prevention of autism.

Thankfully, the US Committee on Oversight and Reform is interested in finding some answers. Hopefully, they will find the answers soon. Unfortunately, it may be too late for Princess Kate whose child, if it is a boy, has a 1 in 54 chance of developing autism.

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