behavioral interventions in children with pervasive developmental disorders
DESCRIPTION
TRANSCRIPT
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BEHAVIORAL PLANNING FOR CHILDREN WITH PERVASIVE DEVELOPMENTAL DISORDERS?
pallav pareek m.d.
january 11th 2013
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Objectives
Case discussion Journal Article: Discussion and exchange
of ideas- Is a behavioral plan
required?- Does a neurotypical
behavioral plan work in PDD?
- What modifications (if any) are required?
- Resources in St. Louis Metro Area?
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Autism Fact Sheet
1 in 88 children and 1 in 54 boys
Autism is the fastest-growing serious developmental disability in the U.S.
Autism costs a family $60,000 a year on average
Autism receives less than 5% of the research funding of many less prevalent childhood diseases.
0.55% of total NIH funding. 40% of children with autism do
not speak
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Major areas of Target for ASD’s
Behavior
Social
Communication
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Some Challenging Behaviors in ASD’s
• Aggression is a high-profile behavior that garners more attention
• Is aggression a reaction to frustration and difficulty with appropriately communicating affect state or identifying alternative reactions to frustrating experiences
Aggression
• SIB is similar to (?) stereotypies with respect to the rhythmical and repetitive nature of the behavior, but in the case of SIB, tissue damage often results
Self Injurious Behavior
s
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Trivia!!
What is the average cost of ABA for a family per annum?
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Body Bag, Shredder App, Lifting Weights, Trampoline, Carrying pumpkins etc..
Some things that worked…
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History of ABA
Watson fed up with “hypothetico-deductivo reasoning”→Experimental Analysis of Behavior →B. F Skinner
Initially known as Behavioral Mod Lovaas is one of the pioneers: In early years aversives
(Strikes, shouting, shocks) 10 Now mostly positive reinforcers
Judge Rotenberg Center (formerly Behavior Research Institute) Canton, Massachusetts
In the initial studies by Dr. Lovaas11: There were claims of up to 47% children→ mainstream→ indistinguishable
Remains the most popular and most evidenced based approach for Autism
10: Moser D, Grant A (1965-05-07). "Screams, slaps and love". Life
11:Lovaas, O. I. (1987). Behavioral treatment and normal intellectual and educational functioning in autistic children. Journal of Consulting and Clinical Psychology, 55, 3-9
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Components of ABA
NRC: Recommends:25 hrs/wk of structured training DTT is used to reduce stereotypical autistic
behaviours through extinction and the provision of socially acceptable alternatives to self-stimulatory behaviors
EIBI: usually 30hrs/week 2-6 years Typical sessions: 5-6 hours, with natural breaks with
child tiring. Positive reinforcers: verbal/food/anything
13: Baer, D.M.; Wolf, M.M.; Risley, T.R. (1968). "Some current dimensions of applied behavior analysis". J Appl Behav Anal 1 (1): 91–97.
http://www.nrc-cnrc.gc.ca/eng/index.html
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.
1/11/13
pallav pareek m.d.
clinical case conference
january 11th 2013
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"In a field rife with fads, pseudoscience, and popular, yet unproven, interventions….National Standards Project are a welcome and much-needed counterbalance to much of the hyperbole for both professionals and families” Peter F. Gerhardt
National Autism Center: National Standards Project, to produce a set of standards for effective, research-validated education and behavioral intervention
http://www.nationalautismcenter.org/about/national.php
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Introduction
Growing evidence supports the use of intensive behavioral intervention (IBI)
Two decades of studies have supported the use of typical/atypical antipsychotics in treatment of aggression in ASD
No studies comparing antipsychotics to other med classes or combined with IBI
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Introduction Contd:
? Phenotypic overlap BD and ASD suggests mood stabilizers may be an option
ADHD+Sleep prompt use of non-stimulant ADHD meds (α agonist), not for aggression
Aims to see effects of IBI with AP/MS/NS
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Hypotheses
1. IBI shall substantially decrease aggressive behaviors in youth with ASD
2. Time required to achieve behavior plan success lower in individuals taking AP/MS/NS relative to those not taking medication
3. Younger, verbal males w low baseline aggression & lower stereotypy, irritability, and hyperactivity who received DRO plan predicted succeed quicker
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Methods
32 children attending IBI program in Cleveland. Mean age 11.16 (4-16) 75% male
DSM diagnosis with Autistic disorder or PDD NOS were eligible if they received IBI for aggression
Consecutive youths in retrospective review of charts between 2000-2007
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Methods cont:
All receiving IBI≥ 30 hrs/week. No additional behavioral therapies.
Aggression: Any beh that harms/attempts to harm another/destruction of property. Also interferes with academics/scoialization/daily living & restricts access to community involvement
Inclusion: ↑ 4 aggressive beh/day + 1 day with multiple aggressive beh were included
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Methods cont:
Aggressive beh recorded at baseline (1 wk before IBI) and then wk 1-3 after beh plan implementation
Success: defined as↓ 1 agg ep/day for 5 consecutive days & five session without mod/severe aggression
Medications: Prescribed as usual by ped neurologist/psychiatrist/dev pediatrician. (No specific algorithm used) on meds >2 weeks prior
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Medications
AP: risp12, ari5, zip1, clo1, zyp1, mol1n=3 on 2 AP’s
MS: dival6, lithium3, lamo1
NS: clonidine11, atom1
3= all classes 6= AP+MS 4= AP+NS
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Measures
ABC (Community) completed by classroom teacher 30-35/wk : Hyperactivity, stereotypy and irritability subscales used
VABS (Teacher rating form) to evaluate functl level
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Results
Changes in frequency of aggressive beh
Number of sessions required to succeed with agg beh plan
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# of sessions required w/wo medication
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# of sessions required for success by sex/verbal ability
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Strengths and Limitations
LIMITATIONS
Intermingled med classes Retrospective Comorbidities Reason to be on one
medication class vs. other
Medication dosages? Evaluating combinations No Randomization (for IBI
or meds)
STRENGTHS
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Take Home
No Extinction burst observed Median number of 6 hour sessions
needed >30 No difference between DRO vs. DRA MS & NS meds have minimal effect in
augmenting aggression beh plans.
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Thank You!!
Autists are the ultimate square pegs, and the problem with pounding a square peg into a round hole is not that the hammering is hard work. It's that you're destroying the peg.” Paul Collins