Training Parents in ABA Using E-Learning

We reviewed this study in our July 2019 Journal Club meeting. The full citation is: Jang, J., Dixon, D. R., Tarbox, J., Granpeesheh, D., Kornack, J., & de Nocker, Y. (2012). Randomized trial of an eLearning program for training family members of children with autism in the principles and procedures of applied behavior analysis. Research in Autism Spectrum Disorders, 6, 852-856.

For some background info…. staff at CARD in the R&D department as well as some of the staff in the Training Department (now known as the Institute for Behavioral Training) conducted this study on E-Learning. In full disclosure, I worked at CARD when staff conducted these studies.

We know that training parents to implement ABA is possible. (See some of Dr. Hancock (now Blackmon) and Dr. Kaiser’s vast work in the area of training parents to implement EMT and other language interventions).

I love this excerpt from the National Research Council’s book on educating children with autism (National Research Council 2001. Educating Children with Autism. Washington, DC: The National Academies Press. https://doi.org/10.17226/10017.)

The committee recommends that families’ participation should be
supported in education through consistent presentation of information
by local school systems, through ongoing consultation and individualized
problem solving, and through the opportunity to learn techniques
for teaching their children new skills and reducing behavioral problems.
Although families should not be expected to provide the majority of educational programming for their child, the parents’ concerns and perspectives should actively help shape educational planning.

The introduction section of this paper builds the case for parent training. For example, see this statement, “Thus, it has become the consensus that all treatment for children with autism spectrum disorders (ASD) should
include substantial parent and family training (Brookman-Frazee, Stahmer, Baker-Ericzen, & Tsai, 2006; Matson, Mahan, &​ ​Maton, 2009; McConachie & Diggle, 2007).​“​ And while we have little data on the amount of parent training provided to parents as part of on-going ABA programs, we do know that insurance companies reimburse ABA providers for the service of parent training and for group parent training (when fewer than 8 parents participate)​​. Additionally, we know that E-Learning is an effective tool for teaching fact based knowledge regarding ABA concepts. Thus, the purpose of the study is logical: “evaluate the effectiveness of an eLearning program for training family​ ​members of children with ASD in the principles and procedures of ABA treatment​”​

The authors recruited 28 family members (mostly moms) to participate in this study. The majority of participants held a bachelor’s degree or higher.​ All participants spoke English and had access to high speed internet. 25 of the participants reported that their children currently received ABA services. The combination of these factors would suggest that the results of the study might not be generalizable to all populations but rather to those with higher education and SES.

The authors utilized a group design study and randomly assigned participants to one of two groups: treatment and waitlist. This design removed any ethical concerns regarding a no treatment group. Thus, the participants who were assigned to the no treatment group would ultimately receive training, just at a later date. In our online meeting, we discussed the limitation regarding the wait. Participants only had to wait one week after taking the pre-test before receiving access to E-Learning. We felt that a longer waiting period may have been better because participants may have been tested too much, too close together. Specifically, participants in the waitlist group took a pre-test, waited a week, took the pre-test, then started training and took the pre-test again.

The authors reported that the E-Learning resulted in improved performance on the test with the treatment group improving, on average, from 63% to 90% correct and the control group improving from 51% to 92% but only after they received training.

I think we can all agree that E-Learning is a viable option for teaching concepts. As the authors noted, having this technology available for parents is helpful to reach parents who live in rural areas. Using E-learning also allows families to proceed at their own pace. And finally, neither clinicians or parents have to travel to provide/receive the training.

​And while of these are advantages for E-Learning, our bigger struggle is the next p​​hase of training: application of principles.

If you enjoyed this article, you may also enjoy reading this article where the authors used the same E-Learning Program to train therapists. Here is the full reference: Granpeesheh, D., Tarbox, J., Dixon, D. R., Peters, C. A., Thompson, K., & Kenzer, A. (2010). Evaluation of an eLearning tool for training behavioral therapists in academic knowledge of applied behavior analysis. Research in Autism Spectrum Disorders, 4(1), 11-17.

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Preschool Life Skills

Our FREE journal club met on Monday night. We discussed Fallagant & Pence 2017. You may access the article here or here.

The introduction to the paper consisted of a nice review of some of the work done to date in this area. The authors discussed why the Preschool Life Skills are so essential. 

The authors also discussed using a Response to Intervention (RTI) model for teaching these skills. You can learn more about RTI here or here. Essentially, in Tier 1, skills would be taught to a larger group or entire class. In Tier 2, small group instruction would be provided to the students who didn’t acquire the skills in Tier 1. Then in Tier 3, 1:1 instruction would occur for the students who didn’t learn the skills in Tier 1 or Tier 2.

The research was scientifically sound in terms of demonstrating experimental control. The authors used a multiple baseline across behaviors and then replicated that over 6 students. Like most research, a few flaws existed. For example, by using a multiple baseline across behaviors, experimenters lose a little bit of experimental control when the student demonstrates response generalization to an untrained behavior.

The participants in the study may have come from a convenience sample which was most likely a university affiliated preschool program. Each of the special education teachers in the school held master’s degrees in special education. The assistant teachers all held bachelor degrees.

The data in the study consisted of measuring the life skills being taught: responding to name, requesting/manding adult attention, requesting/manding adult assistance, delay tolerance, denial tolerance, and independent versus prompted responses. The authors indicated they also collected data on challenging behaviors but those data were not presented in the paper. The authors also reported high IOA data as well as high fidelity data (which is not always reported).

The authors provided a great description of the modifications provided to students who did not acquire the skills in Tier 1, 2, or 3. For these students, this included the use of an AAC device (i.e., proloquo).

One of our big discussion points occured around the author’s use of least to most prompting during Tier 1. We discussed if the results would have been different had they used most to least prompting and decided this should be a point of focus in a future study!

Another area of discussion for us revolved around the authors’ use of only 8 trials per session. This hardly seemed like enough practice for a preschooler, let alone a pre-k student with disabilities (the children had autism, Down syndrome, or DD).

We discussed, and the authors mentioned, the use of AAC and whether the students would have acquired the skills in Tier 1 had the AAC been available during that phase of instruction.

We also discussed the lack of preference assessments and whether the authors’ use of social reinforcement may have been potent enough to reinforce skill acquisition.

And finally, we discussed the limited generalization observed to peers. Some of the kids generalized skills to the adults who are obviously more skilled than the peers. But we also discussed the fact that with such few learning trials (N=8), that the kids may not have developed fluency in the skills thereby limiting their ability to readily generalize the skills. And of course, the authors mentioned that they did not program for generalization so this may have impacted generalization as well.

Bottom line, these seem to be some essential skills that we could easily teach in classrooms to increase the social skills of students.

I have identified a few extra resources. First because of all the tolerance discussion, we should look at some of the original tolerance studies. The following studies utilized FCT combined with Tolerance training.

1. Bird, F., Dores, A. P, Moniz, D., Robinson, J. (1989). Reducing severe aggressive and self-injurious behaviors with functional communication training. American Journal on Mental Retardation, 94, 37-48.
2. Brown, K. A., Wacker, D. P., Derby, K. M., Peck, S. M., Richman, D. M., Sasso, G. M., Knutson, C. L., & Harding, J. W. (2000). Evaluating the effects of functional communication training on brief functional analyses of aberrant behavior. Journal of Applied Behavior Analysis, 33, 53-71.
3. Carr, E. G., & Carlson, J. I. (1993). Reduction of severe behavior problems in the community using a multicomponent treatment approach. Journal of Applied Behavior Analysis, 26, 157-172. 
4. Day, M. H., Horner, R. H., O’Neil, R. E. (1994). Multiple functions of problem behaviors: Assessment and intervention. Journal of Applied Behavior Analysis, 27, 279-289.
5. Fisher, W. W., Thompson, R. H., Hagopian, L. P., Bowman, L. G., & Krug, A. (2000).  Facilitating toleraance of delayed reinforcement during functional communication training. Behavior Modification, 24(1), 3-29.
6. Hagopian, L. P., Wilson, D., & Wilder, D. (2001). Assessment and treatment of problem behavior maintained by escape from attention and access to tangibles. Journal of Applied Behavior Analysis, 34, 229-232.
7. Harding, J., Wacker, D. P., Berg, W. K., Barretto, A., & Ringdahl, J. (2005).  Evaluation of relations between specific antecedent stimuli and self-injury during functional analysis conditions.  American Journal on Mental Retardation, 110(3), 205-215.
8. McConnachie, G., & Carr, E. G. (1997). The effects of child behavior problems on the maintenance of intervention fidelity. Behavior Modification, 21, 123-158.
9. Symons, F. J., Fox, N. D., & Thompson, T. (1998). Functional communication training and naltrexone treatment of self-injurious behavior: An experimental case report. Journal of Applied Research in Intellectual Disabilities, 11, 273-292.

And here are some extra resources on Preschool Life Skills

1. Hanley et al 2007
2. Luczynksi & Hanly (2013)
3. Luczynski, Hanley, & Rodriguez (2014)
4. Beaulieu, Hanley, & Roberson 2012
5. Beaulieu, Hanley, & Roberson 2013
6. Hanley, Fahmie, & Heal 2014 (in headstart)
7. Francisco & Hanley (2012)
8. Robison, Mann, & Ingvarsson (in press)
9. Dogan et al 2017 (training parents)
10. Halfdanardottier, Sveinbjornsdottir & Ingvarsson (in process but looking at life skills in older students)
11. Ala’i-Rosales et al 2018
12. Fahmie & Luczynski 2018 (review of studies)

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Autism Recovery or Optimal Outcome?

What is Autism Recovery?

• 

If you know anything about me, you know that I am passionate about providing quality services for children with autism as early as possible to ensure that every child has the opportunity to progress as far as possible and to potentially recover from autism. I’ve written about this topic here, here, and here.

If you think I’ve already had a few too many to drink today, please check out this professional video from the University of Connecticut. The researcher in this video is a Licensed Clinical Psychologist. Her name is Deb Fein and she is really good at diagnosing children. She realized she needed to study this further when a child she had previously diagnosed returned to her several years later and did not meet the criteria for autism.

So she began researching this very topic. While recovery from autism describes what she sees, Dr. Fein has chosen to use the words Optimal Outcome to describe the children who ultimately obtained optimal outcome and no longer met the criteria for autism.

In our journal club meeting on Monday, we read and discussed the following article:

Moulton, E., Barton, M. Robins, D. L., Abrams, D. N., & Fein, D. (2016). Earlycharacteristics of children with ASD who demonstrate optimal progress between age two and four. Journal of Autism and Developmental Disorders, 46, 2160-2173. You may access a free copy of the article here: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4860351/pdf/nihms761908.pdf

We were a little disappointed in this paper in that it didn’t address treatment and optimal outcome but rather predictors of optimal outcome. 190 children participated in the study with 19 of them achieving optimal outcome.

At the beginning of the study, researchers classified all children into 4 groups: PDD-NOS; Asperger’s; ASD; and ASD Low MA (mental age less than 12 months). On average, all children were diagnosed around 26 months of age. Re-assessment occurred around 48 months.

Before we go further, it is important to note that the children in this study were Caucasian and far above the poverty line. Also, the study didn’t control for early intervention so it’s hard to really say other than the obvious:

1. Children who were originally diagnosed with PDD-NOS were more likely to lose their diagnosis at re-evaluation.
2. No children with ASD-Low MA met the criteria for optimal progress (OP) at follow up assessment. 
3. Children in the OP group showed less severe symptoms in the area of social skills, stereotypies, and sensory abnormalities
4. Children in the OP group showed fewer DSM-V symptoms at initial diagnosis
5. Children in the OP group showed stronger adaptive abilities
6. Lesser symptoms of restricted interests and  repetitive behaviors predicted OP.

​It is super important that we not think of this as mis-diagnosis but rather, the earlier the diagnosis, the earlier the intervention, the more quantity of intervention, and thus, better outcomes that result in losing the autism diagnosis.

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Asperger’s Syndrome and Comorbidity

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.

Method

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.

Results

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.

Suggestions

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?

Related articles

• People With Mental Illnesses Aren’t Actually More Prone to Violence (thinkprogress.org)
• School Shooting Raises Media Debate on Mental Health (newsy.com)

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Addressing ADHD in Classrooms

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 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.

Background

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.

Results

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.

Comments

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?

 

Related articles

• Small Group Instruction (kindergartenkiddos.com)
• 9 Ways Students Can Host Peer Tutoring Sessions Online (freetech4teachers.com)

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Pregnancy, Flu, Fever, and Autism?

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 our readers. Today’s article has actually been the topic of a lot of social media. See these headlines here and here and a reader actually wrote in about it on Monday.

Do pregnant women who get the flu or a fever actually increase the likelihood that their child will get autism? Let’s find out by actually reading the research.

The journal called Pediatrics published this study and Hjördis Ósk Atladóttir, Tine Brink Henriksen, Diana E. Schendel and Erik T. Parner authored the study. A quick search on Medline reveals that Dr. Atladóttir is chasing this topic of autism trying to find something to explain how it develops. He published a similar paper in 2010 in the Journal of Autism and Developmental Disorders. In that paper, he discussed pregnant women who had been hospitalized and later had a child with autism. He has published on cytokine levels and autism, patterns of contact with hospitals and autism, and family history of autoimmune disease and autism.

Purpose of the Study

The authors set out to “assess the association between self-reported common infections and autism in the child“. The authors clearly state that they estimated an association. Yet, when this study hit the news, reporters and scientists discussing the study omitted these little details.

Methods

The sample. The authors used an existing data base to gather their data (Danish National Birth Cohort). The authors selected 31% of the cohort for their data analysis.

The data collection. All the interview questions asked to the mothers occurred during the initial cohort recruitment completed by different researchers. These authors did not have contact with the mothers. Interestingly, the authors actually reported that “there was no specific question regarding respiratory disease and influenza”. It should make you wonder how they “estimated” the results of their highly disseminated “study”. In fact, the researchers actually asked the mothers, “did you take an antibiotic?” The authors clarified further, “The questionnaire did not include a question concerning the direct disease indication for the antibiotic use”. Wow! Yet all the media around this paper specifically said “flu”.

Data facts. Only 1% of the sample actually reported having the flu. Compare that to the percent of women with other issues: fever (24%), antibiotic use (19%), yeast infection (19%), cystitis (12%) and urinary tract infection (12%). Another interesting fact is that the researchers compared maternal responses during interviews with data from hospital records (e.g., diagnosis at discharge). The authors state, “The overall agreement between maternal reports of infection episodes and a corresponding hospital contact record was fairly good for most infections” (e.g., cystitis, pyelonephritis, and vaginal yeast infection). However, the authors also noted that “there was a very low agreement between maternal-reported infection and hospital-registered infection when the self-reported information was retrieved from open-ended questions” (e.g., flu). Thus, it seems that the likelihood the mothers really had the flu when they reported that they did, is actually quite low.

Data analysis. The authors used statistical analysis to determine if any relationships between the variables existed. What the media did not cover in reporting this study, is the important fact that the authors examined relationships between illnesses and any form of autism spectrum disorder as well as any relationship between diseases and infantile autism.

Results

The authors reported a number of results, most of which had no statistical significance. The authors noted that a statistically significant difference was found among mothers who self-report the flu (be sure to see the note above regarding the accuracy of reporting) and went on to have a child with autism. Specifically, out of the entire sample, only about 800 mothers reported having the flu. Of those, only 9 went on to be diagnosed with an autism spectrum disorder. This is hardly reason for alarm especially since we are having autism diagnosed at a rate of 1 in 86!

The authors noted that another statistically significant association was found between mothers who had a fever longer than 7 days. The number of women with a fever episode was quite high 23, 027). The number of them who went on to have a child with infantile autism was 101. Again, this hardly seems reason for alarm given the staggering rate of autism. Finally, the number of women who had a fever lasting longer than 7 days was 1361. Of those, only 14 went on to have a child diagnosed with infantile autism.

The authors found similar associations with antibiotic use. Again, the numbers are not alarming given the overwhelming rate of autism.

Discussion

The key statement in the discussion section should be highlighted: “There was little evidence that self-reported common infections during pregnancy are risk
factors for ASD in the child”

Can someone explain how the media complete twisted this in to a “flu during pregnancy increases the risk of autism” headline?

The authors did go on to talk about their previous work on this topic, ” We reported in our previous study that viral infection during the first trimester gave rise to an almost threefold increased risk of ASD“.

Side note: We all know that the flu is a virus. But isn’t the vaccine for the flu a live virus? Let’s see what the CDC has to say about it. Well, I’ll be darned, it appears that the nasal spray is a live virus. “Live, attenuated influenza vaccine (LAIV) contains live but attenuated (weakened) influenza virus. It is sprayed into the nostrils“. The CDC goes on to say that pregnant women should not take the live virus spray.

Other Thoughts

This study is full of methodological errors. Yet, Pediatrics continue to publish it and the media continue to twist the findings. Please, before you believe the “latest medical study”, you might find it more helpful to actually read the study rather than believe what someone tells you about the study.

The Elephant in the Room

So, if the researchers had access to all this data, why didn’t they ask better research questions? Why didn’t they look for associations between women who got the flu vaccine and still got the flu? Or how about this one: “does getting the flu shot increase the likelihood of your child getting autism?” There is so much more that could be asked, yet these researchers did not seem interested. Maybe it wasn’t the “politically incorrect” thing to do.

 

 

 

 

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Reading Research

Hi! and welcome to What Works Wednesdays where historically a success story from clinical files is shared. With all the buzz about the latest “research” on getting the flu while pregnant and the supposed link to autism, it seems logical to help readers better understand research so they can interpret findings themselves. If readers know how to read research, then they are better able to know if an intervention works (or if the conclusions from a study are flawed or misinterpreted).

What is Research?

• “work undertaken systematically to increase the stock of knowledge” (Wikipedia.org)
• “diligent and systematic inquiry or investigation into a subject in order to discover or revise facts, theories, applications, etc.” (dictionary.com)

Most scientists conduct research by utilizing the scientific method. The scientific method requires the development of a hypothesis (which is usually formed from observation or reading other research), conducting the experiment, gathering results, and determining if the results support the original hypothesis.

Different Types of Research

Using the scientific method, scientists design different types of studies. These study types include:

1. Experiments. In experimental studies, researchers recruit participants and assign them to treatment groups. Researchers can study one or more treatments and participants may receive some treatments or they may receive a placebo or no treatment at all. Usually, researchers measure one or more important variables before the study and they measure the variable(s) again after the study.
2. Single Subject Experimental Studies. In these studies (most often conducted by behavior analysts), researchers recruit participants who are observed and measured carefully for a period of time before receiving treatment. Researchers then implement treatment while continuing to observe and measure carefully.
3. Correlational studies. In these studies, researchers use existing data sets (e.g., collected for some other purpose) or they recruit participants. Researchers gather a wide range of information on each participant (e.g., age, SES, education, health history). Participants do not generally receive treatments or interventions of any kind.
4. Qualitative studies. In qualitative studies, researchers occasional recruit participants but at times they enroll participants with whom they are already familiar. In qualitative studies, researchers study one or more individuals or one or more groups (e.g., one class). Researchers carefully study the participant and take copious notes. Researchers may interview the participants and they may use focus groups to better understand some of the issues. If a treatment is provided, the researcher continues to carefully study the participants to document the participants’ responses to the treatment.

Conclusions Based on Study Type

Researchers must use caution when drawing conclusions about their studies. Researchers who use well-designed experimental designs can draw cause-effect conclusions. For example, a researcher can enroll a bunch of smokers in a study. Some of the smokers receive a behavioral treatment, some of the smokers receive nicotine patches, and other participants receive both. At the end of the study (if the researchers have conducted the study carefully), the researchers will be able to say that one or more methods is successful at helping smokers quit.

Similarly, in a single subject experimental study, researchers can demonstrate if a treatment changes behavior. Again, the study must be carefully designed and conducted but it is possible to draw cause-effect conclusions. For example, a researcher could study 3 smokers. The researcher would observe the smokers and collect data. One smoker could receive treatment. While she is being studied, the other smokers would still be studied. After the first smoker quits successfully, the next smoker would receive treatment. He would continue to be studied as would the non-treated smoker. Finally, when the last smoker receives treatment, researchers continue to observe him. If the researchers successfully help all 3 participants quit smoking (and the study is carefully designed and carried out), they will be able to say that the treatment caused the behavior change.

Correlational versus Causal

Correlational studies are designed to determine if any relationships exist between variables. Researchers could gather data on 1,000 people from an existing data base. They could sort the data into smokers and non-smokers. They could run a simple data analysis to see if smokers have other tendencies (e.g., like to go to race car events, like to drink socially, and so forth). Researchers may not conclude causal relationships from their studies. They are only able to conclude that a relationship exists. Of more importance is the strength of the relationship. For example, if researchers ran an analysis on the relationship between giving birth to a child and gender, they would find a very strong (almost perfect) relationship between giving birth and being a female. If a weak relationship exists between variables it is more likely due to chance.

Go Forth and Read

In these days of social media, spin rooms, and media crazed talk shows, very poorly designed studies are being presented to the public without appropriate interpretation of the study or its results. If you are interested in reading a few examples of this, check previous posts here and here.

In summary, don’t believe everything you read about the “latest scientific study” unless you read the study itself. When you read the actual study, what you find may actually surprise you.

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More Research on Social Stories

Here at Applied Behavioral Strategies, our 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 article is titled “Brief Report: Increasing Verbal Greeting Initiations for a Student with Autism Via a Social StoryTM Intervention”. Brian Reichow and Edward Sabornie authored the article and The Journal of Autism and Developmental Disorders published the article.

Study Purpose

It is a known fact that children with autism spectrum disorders have social deficits. One intervention that has been used is Social Stories. While social stories are widely used, the research on the effectiveness has been limited. Thus, the authors set out to determine if a Social Story could be used to increase appropriate verbal greeting initiations.

Study Methods

The authors enrolled an 11-year-old male with autism in the study. “George” as he was called, had an average IQ and he had above average grades on his report card. While he attended a social skills group at school, his social skills did not seem to be improving.

The authors developed a story according the guidelines recommended by Carol Gray. We discussed some of the differences between Social Stories TM and social stories or social narratives earlier this week.

The authors used a withdrawal design to demonstrate experimental control. Basically, in this design, an intervention is implemented. If the intervention is effected, it is removed to determine if the behavior would return to pre-treatment levels.

The authors merely counted the number (or frequency) of verbal greeting initiations. Waves and gestures did not count, only verbal greetings (e.g., hi, hello, good morning).

In baseline, George reported to his home room, picked up his schedule, and went about his day.

During intervention, George picked up his schedule (which included “read your Social Story”) and then read his social story before heading out to classes. The authors faded the social story and moved to a simple “cue card”.

Results

During baseline, George had zero verbal initiations. During intervention, George had an immediate increase in verbal greeting initiations. Specifically, he initiated greetings between 2 and 6 times a day; including greetings to peers! However, when the intervention was “withdrawn”, George stopped initiating greetings. When the intervention was reinstated, his initiations increased again to 2 to 4 initiations per day; including initiations to peers. When the social story was faded and the cue card was taught, the verbal initiations continued.

Conclusions

As we have discussed, this intervention is effective. Also as we have discussed, all interventions should be developed on an individualized basis. This is not a one size fits all approach. This individualization means that teachers, behavior analysts, and other practitioners will need to spend time developing the materials that will be used to teach the skill(s).

 

 

 

 

 

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Behavioral Feeding Therapy at School

Here at Applied Behavioral Strategies, our 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 article is titled, Intervention for Food Selectivity in a Specialized School Setting: Teacher Implemented Prompting, Reinforcement, and Demand Fading for an Adolescent Student with Autism (wonder if they could make that a little longer?). A journal called Education and Treatment of Children published the article and Maria Knox, Hanna C. Rue, Leah Wildenger, Kara Lamb, and James K. Luiselli authored it. (If you want to read the entire article, you will find it on www.freelibrary.com)

Background

Many children with autism engage in picky eating or what researchers call “food selectivity“. For example some children live on a white foods diet (chicken nuggets, french fries, and bread) while others remain stuck in pureed foods.

Applied Behavior Analysis (ABA) is one intervention that has been demonstrated repeatedly to be effective at addressing picky eating behavior. However, the intervention often results in challenging behaviors that make it difficult for parents and caregivers to implement on their own. In fact, most of the research to date has been implemented by highly trained therapists.

Purpose of the Study

Thus, authors set out to determine if an intervention could be implemented by school staff in the school setting.

Study Method: Participants

The authors enrolled one child in the study. “Anna” was 16 and had autism. She was verbal and she could follow simple instructions. Anna could feed herself. However, she limited her diet to  a few brand-specific crackers, dry cereal, and apple juice . During the study, Anna’s mother provided new foods including one main food (chicken nuggets, macaroni and cheese, or turkey and cheese sandwich) and two side foods (cheese cubes, vegetable chips, carrots, mandarin oranges, or apples).

The authors implemented all study procedures at the school in Anna’s lunchroom or her classroom. The teacher and the teaching assistants collected all the data for the study.

Study Method: Design

The authors used a changing criteria design which is one type of single subject design. In this design, the expectations are gradually increased across phases. Thus, the teacher required Anna to eat more and more food across the study.

In baseline, the food were presented. If Anna did not eat within 2.5 minutes, the food was removed. After 10 minutes, Anna was allowed to eat her preferred foods.

Study Method: Intervention Technique

The researchers taught the teacher how to implement the intervention prior to the beginning of intervention.

Prespecified Reinforcement (First-Then)

During intervention, the teacher presented the new food on a separate plate and told Anna when she ate the new food (small amount at first), she could have her preferred food.

Reinforcement

Additionally, Anna earned verbal praise and stickers for eating new food. Anna cashed her stickers in for small trinkets.

Prompts

The teaching staff verbally prompted Anna to eat her lunch, if, 30 seconds after swallowing she had not taken her bite.

Demand Fading (Increasing the Volume Slowly)

Gradually, the teaching staff increased the amount of food that Anna needed to eat in order to get her preferred foods.

Results

By the 23rd lunch session, Anna consumed 100% of the new food and she repeated this on the 24th and 25th lunch sessions. The authors came back to assess her eating 2 weeks, 6 weeks, and 7 months later. Anna continued to eat 100% of her new food.

Congrats to Anna and the research team on such a successful intervention. ABA works!

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My Supervisor Told Me to Do It

Here at Applied Behavioral Strategies, our 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 article is titled, “Replicating Milgrim”. The author, Jerry Burger, published the study in the journal, American Psychologist.

Study Purpose

The purpose of Dr. Burger’s study was to replicate the work of Milgram whose study series is known to many. (In case you are thinking–“who the H-E-Double Hockey Sticks” is Milgram, think back to the study where the supervisor told the participants to shock the “client” and the study participants did! Repeatedly!!). Psychologists now refer to those studies as the Obedience Studies.

Burger wondered, if after all these years of education, training, human compassion, and so forth, if, in fact, people today would engage in the same behavior. Burger took several steps to ensure the safety of participants in the study (yes, the ones who would be giving shock to the “learner”)

Study Methods

Participants included 29 men and 41 women with a mean age of 42 years. Participants were promised $50 for their time (two 45-minute sessions). Participants learned that they earned the money even if they withdrew from the study. Participants who were familiar with the experiment or who had extensive psychology training were excluded from the study. Experimenters then screened the remaining participants for any possible mental health condition or a reasons that may have resulted in a negative or harmful reaction from participating in the study. Researchers told participants they could quit at any time and that they could be videotaped at any time. Researchers assigned participants to one of two conditions.

The base condition consisted of the participant meeting the experimenter and the confederate (inside experimenter with knowledge of the study). The experimenter explained to the participant and the confederate that they would be in a study. He then paid both of them to give the impression that the study was randomized. Then he had them “draw” to determine who would be the teacher and who would be the learner. The “drawing” was rigged so that the participant always served as the teacher.

 

The experimenter then strapped the confederate in to the chair and attached the electrodes all the while explaining to the participant why he completed his step (e.g., to keep from burning him). Next, the experimenter told the confederate to learn the pairs of words. The experimenter told the confederate that the participant would be testing him and if he missed any answers, he would be administered a shock.

Next the experimenter taught the participant how to administer a shock. He provided a small one to the participant if he/she wanted one. The experimenter told the participant to administer a shock following each incorrect answer. He also instructed the participant to increase the intensity of the shock following each incorrect answer. Finally, the experimenter told the participant the importance of following study procedures .

The modeled refusal condition consisted of the participant meeting the experiment and 2 confederates. One confederate served as a teacher alongside the participant and the other confederate served as the learner. In this condition, the participant observed another “teacher” following the protocol. In this condition, the “teacher” (who happened to be the same gender as the participant) acted scared of the study after the first shock and then after the second shock decided that he/she would quit. The experimenter then allowed the participant to take over and continue as in the base condition.

In both conditions, the researchers enforced strict rules for ending the experiment and keeping the participant safe.

Results

In the base condition 12 out of 18 men and 16 out of 22 women (70% total) continued to administer shock treatments, despite the cries and yelps from the confederate. Meanwhile in the modeled refusal condition, 6 out of 11 men and 13 out of 19 women continued to administer shock treatments.

The researchers completed several personality assessments on the participants and used those results in additional analyses. Statistical analysis did not find any difference between scores on empathy. However statistical analysis revealed differences among participants with a strong desire for control in that they were more likely to stop the study.

Sadly, participants today responded very similarly to those participants in the 1960s.

Take Home Points

As behavior analysts, behavior analysts in training, teachers, and parents, use caution when you are instructed to implement a procedure that you may disagree with. As demonstrated in this study, humans are more likely to follow orders rather than stand up and refuse or question the treatment. When our children are being shocked (as those in Judge Rotenberg Center), restrained, and secluded, perhaps we should seek a 2nd opinion. Isn’t that what we do in medicine when we question a recommendation?

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