The intersection of autism, low cognitive ability, and low adaptive skills increases risk for behavioral concerns that impact safety, limit independence, and lead to decrements in quality of life for a child and their family. Despite known differences in service needs between autistic youth with moderate to profound intellectual disability (AS + mID) and those without (AS), it is not yet known whether there are differences in the effectiveness of interventions to address behavioral concerns between these groups. The present study is an exploratory analysis of whether differences exist with respect to behavioral presentation at treatment onset, behavioral procedures needed for a therapeutic reduction, and intervention outcomes. This secondary analysis of a chart review examined 40 clients (22 AS + mID, 18 AS Group) who received intensive outpatient services for severe behavioral concerns between 2020 and 2023. Although no differences in intervention outcome emerged, individuals categorized with AS + mID had a significantly higher likelihood of intrusive procedures within their final treatment package compared to the AS group. There were also nuanced differences in behavioral presentation at the outset of treatment. Specifically, several individuals categorized with AS + mID displayed alarmingly high baseline rates of targeted behavior to a degree not observed in the AS group. These findings suggest that although behavioral intervention may achieve comparable outcomes between groups, additional research is needed in this subpopulation to decrease the need for intrusive procedures.

Extinction may be difficult to implement when targeting automatically maintained behavior because the putative maintaining reinforcer cannot be directly observed. The exact behavioral mechanism of procedures used to decrease automatically maintained behavior (e.g., sensory attenuation, response blocking, and response interruption and redirection) remains unclear. Comparing response patterns under these three putative extinction contingencies could help clarify the underlying mechanisms of these procedures. In a retrospective chart review of 28 cases, we evaluated response patterns of automatically maintained behavior during these procedures with the aims of: (a) identifying the prevalence of response bursting, and (b) comparing response patterns across different procedures, topographies of behavior, and subtypes of automatically maintained behavior. Response bursts occurred in 3.8

De-escalation strategies, or procedures that result in rapid cessation of dangerous behavior, may be needed when the behavior presents an immediate risk of harm to the individual or others. Most de-escalation recommendations are general and not individualized on the basis of the individual or circumstances. This study evaluates an assessment comparing five de-escalation strategies for an individual who engaged in dangerous behavior. Two strategies resulted in shorter durations of behavior episodes relative to other strategies, suggesting a promising avenue for additional study focused on individualizing de-escalation recommendations.

Elopement is a common and dangerous behavior among autistic children. Behavioral treatments can reduce elopement, but most evidence comes from small-N evaluations in specialized settings with strategies varying across studies. The current study compared the efficacy of the caregiver-mediated function-based elopement treatment to parent education program (PEP) in a 16-week randomized clinical trial of 76 autistic children (age = 4-12 years). Function-based elopement treatment involves 12 weekly appointments aimed at improving safety, identifying the function of elopement, and implementing subsequent function-based treatment strategies. No group differences were observed on the Aberrant Behavior Checklist-Hyperactivity (primary outcome). Significant improvement from baseline to endpoint in function-based elopement treatment compared to parent education program participants was observed for secondary outcomes, including caregiver ratings of safety measures (p < 0.01), severity of elopement based on the Elopement Questionnaire (p < 0.01), and caregiver-collected data on elopement (p < 0.01). The Clinical Global Impression-Improvement Scale (CGI-I) rated by a treatment-blind evaluator found 31.6% of function-based elopement treatment participants improved compared to 2.6% in parent education program (p = 0.001). Improvements were maintained at a 28-week follow-up. Attrition was 5.26%, and no significant adverse events were deemed related to treatment. Function-based elopement treatment was superior to parent education program on elopement-specific outcomes and appears safe and acceptable.Lay AbstractMany autistic children exhibit wandering or running away from supervision (i.e. elopement), which can include leaving the house in the middle of the night or getting lost from a parent in a crowded location. Elopement can result in injury when the child is not supervised and is incredibly stressful for parents. Research suggests that behavioral intervention can help with elopement. However, most studies include only a few children. In addition, treatment strategies differ across studies, making it difficult to compare outcomes. The function-based elopement treatment has compiled strategies across different studies to build a 12-session treatment manual that can be followed by clinicians. The manual guides the therapist on the delivery of parent-training strategies to improve the child's safety and reduce elopement. We compared function-based elopement treatment to a control condition where parents met weekly with a clinician for more general parent training. Children whose parents received function-based elopement treatment showed greater improvement in elopement than children whose parents received more general parent education. This result suggests that the treatment works. Further study is needed to move function-based elopement treatment into clinical practice.

Missed appointments are detrimental to the healthcare system and to the clients themselves. Autistic youth may be particularly impacted due to unique service needs and limited services available within the system. To date, there is limited literature specific to treatment attendance in autistic populations receiving behavioral services. This study examines prevalence, predictors of, and reasons for missed appointments in an outpatient clinic specializing in addressing behavioral concerns. This retrospective case review examines missed appointments in a sample of 306 autistic youths from an outpatient clinic from 2019 to 2022. An average of 5.2 appointments were cancelled and 9.0 were completed, resulting in an average individual cancellation rate of 38%. Statistically significant predictors of no shows and patient cancellations were younger age and a post-COVID appointment. The most common reasons for missed appointments was sickness, scheduling conflict, insurance authorization issues, and family emergency. Missed appointments may be common in outpatient behavioral settings for autistic youth. Resolving issues related to cancellations (e.g., sleep concerns), identifying families in need of targeted support strategies (e.g., assistance and flexibility with scheduling, transportation support), and advocating for systemic change may help meet the multifaceted needs of this population.

BACKGROUND:Behavioural concerns, such as aggression and self-injury, are common among youth with intellectual and developmental disabilities. Additional research is needed to further explore the specific ways in which these types of behaviour impact individuals and their families. METHODS:Caregivers seeking treatment for their child's behavioural concerns completed an interview regarding the negative impact of their child's behaviour related to (a) physical harm to self or others, (b) property damage, (c) structural modifications, (d) situational avoidance and (e) reactive measures. We reviewed outcomes of these interviews to report on the prevalence of various negative impacts in this clinical sample. RESULTS:Most caregivers reported at least some physical harm (72.99%), property damage (63.99%) and preventative measures such as avoiding removing preferred items or activities (72.35%). Some caregivers endorsed severe negative impacts, such as the need for emergency services (10.61%) or residential placements (5.14%). CONCLUSIONS:Caregivers in this clinical sample consistently endorsed negative impacts resulting from behavioural concerns. This information is crucial in advocating for additional services for this high-need population, and the interview used to gather this information may be a helpful tool to guide future research and clinical work.

The present evaluation aimed to begin development of a survey tool for measuring workplace stressors specific to behavioral health providers in clinical settings for autism and related developmental disabilities: the Burnout Assessment for Developmental Disability Settings (BADDS). BADDS development was guided by Patient-Reported Outcomes Measurement Information System (PROMIS®; Cella et al., (Journal of Clinical Epidemiology, 63(11), 1179–1194, 2010) procedures. We used a qualitative analysis to define the target conceptual model (Phase 1). Using the analysis and reported lived experiences, we generated individual items for the BADDS. We then piloted these items in an online survey study to examine correlations with established measures of burnout (Phase 2). Finally, we used a modified Delphi approach to refine items with an expert panel, resulting in a preliminary item pool for the BADDS (Phase 3). Qualitative interviews produced a framework of four themes and nine sub-themes for analysis. Initial items were written across each theme and sub-theme. Findings from preliminary psychometric evaluation in Phase 2 demonstrated promising internal consistency, score stability, and positive associations with validated measures of burnout level. Finally in Phase 3, an expert panel edited items for relevance and clarity across three iterations of feedback. Though further analysis is needed, the BADDS tool has the potential to provide a conceptual analysis of burnout by identifying workplace stressors impacting behavioral health providers in autism service settings. This is in contrast to existing measures that solely inquire burnout level, but do not identify causes of job stress. Organizations may develop more effective strategies for mitigating burnout within their specific setting by incorporating assessments such as the BADDS into burnout interventions for providers.

Pica includes the persistent ingestion of nonnutritive, nonfood items at a level that is inappropriate given the individual's developmental level and cultural or religious practices. Behavioral treatments involve a variety of components to target the motivating operations that evoke pica, disrupt its occurrence, and reinforce adaptive alternatives; they have been characterized as well established and empirically supported. However, the literature consists of mostly small-n studies, limiting analysis of the general and comparative efficacy of different treatment components. The current study describes outcomes from two different sites for 33 consecutively encountered cases for whom a behavioral treatment for pica was evaluated. The final treatment reduced pica by at least 90% for 30 participants. Positive outcomes were maintained when treatment was extended to novel implementers, settings, and discard apparatuses for 26 of 29 participants. We examine the comparative efficacy of treatment components and discuss tactics used to safely assess and treat pica.

Differential reinforcement of alternative behavior (DRA) is a common strategy for escape-maintained behaviors targeted for reduction (i.e., targeted behavior) exhibited by youth with intellectual and developmental disabilities. DRA often involves various methods of prompting to ensure the instruction or task remains in place until contingencies for the DRA are met. Currently, there is little research on client preference for these different prompting strategies in the context of DRA treatments. The current study includes four participants diagnosed with autism spectrum disorder (ASD) who exhibited targeted behavior maintained by escape from instructional tasks. We evaluated efficacy and preference for three prompting strategies (three-step least-to-most, repeated vocal prompt, or a single initial prompt) embedded in a DRA treatment aimed at reducing targeted behavior (e.g., aggression) and improving task completion. For all participants, more than one prompting strategy was effective when positive was combined with negative reinforcement in the DRA. We then implemented a concurrent-chains assessment to determine client preference, a rank-order task for caregiver preference, and an acceptability questionnaire for therapists. Two participants demonstrated a clear preference, and preference was obtained from a total of two caregivers and seven therapists. The initial and repeated verbal prompts were most preferred. Results are discussed in the context of client autonomy and incorporating choice in treatment planning.

Procedural extinction is sometimes associated with a temporary increase in responding known as an extinction burst. Extinction bursts present unique challenges in the context of treating behavior targeted for reduction. The present study updates the prevalence of extinction bursts using a clinical sample (N = 108) receiving treatment for targeted behavior. The prevalence of extinction bursts in our sample (24%) was consistent with that in prior literature. The extinction-burst magnitude decreased across sessions after extinction was contacted during treatment, but this sample did not demonstrate decreased persistence or magnitude of extinction bursts across successive transitions from baseline to treatment. We also examined the prevalence and magnitude of extinction bursts based on the function and topography of targeted behavior and treatment components and found no consistent relation among these variables. These findings should lead clinicians to prepare for transient extinction bursts when implementing extinction-based treatment for challenging behavior.

Past research has identified that some individuals with intellectual and developmental disabilities who engage in target behavior (e.g., aggression, self-injury) maintained by negative reinforcement engage in the behavior to escape or avoid social interaction specifically (i.e., social avoidance). However, assessment and treatment strategies for this function are understudied when compared to target behavior maintained by other forms of negative reinforcement. The current study builds on this limited research and demonstrates (a) a replication of functional analysis conditions and a negative reinforcement latency assessment to identify the specific types of social interaction that evoke target behavior, and (b) an intervention that includes stimulus fading, social conditioning, and differential reinforcement for five participants with autism spectrum disorder. Participant target behavior decreased within the intervention phase for four out of five participants. The implications of strategies to guide the use of antecedent-based treatment strategies are discussed for target behavior maintained by social avoidance.

Individuals with intellectual and developmental disabilities are at a heightened risk of engaging in self-injurious behavior (SIB) that can result in significant harm to their physical health. This is especially true for automatically maintained SIB that is not sensitive to social reinforcement. This chapter discusses considerations for addressing SIB, particularly when automatically maintained. Treating clinicians should engage a multidisciplinary team and define appropriate safeguards for assessment and treatment to reduce the occurrence and likelihood of injuries due to SIB. A thorough assessment is needed to inform essential components of treatment to produce long-lasting and therapeutic reductions in SIB. It is similarly critical to monitor safeguards to ensure SIB or mitigation strategies (e.g., protective equipment) do not cause additional harm. To avoid possible side effects, clinicians should begin with reinforcement-based procedures before considering more restrictive procedures in collaboration with the larger treatment team.

Past research suggests behavioral treatments are effective for challenging behavior in children and young adults with neurodevelopmental disorders, such as autism spectrum disorder (ASD). However, access to these services can be limited and require substantial resources. To address this issue, the current study provides a programmatic description of an individualized parent-mediated service model targeting moderate challenging behavior. In the program, therapists coached parents to implement functional analyses and individualized function-based treatment packages. Forty-one families of children and young adults with neurodevelopmental disorders participated. Most clients (75.6%) met all admission treatment goals and parents reported significant decreases in frequency and severity of challenging behaviors at discharge. Parents also reported less stress at discharge. Outcomes of the study suggest this parent-mediated treatment model is a viable option to treating moderate challenging behavior in children and young adults with intellectual and developmental disorders.

Introduction: Autistic individuals often have comorbid medical conditions, which can increase the likelihood of being severely affected by COVID-19. The best prevention for this is vaccination. However, some autistic individuals engage in behaviors that might create a barrier to successful vaccination. Aims: We describe the development and acceptability of a clinic specializing in the administration of COVID-19 vaccines for individuals diagnosed with autism spectrum disorder (ASD) who exhibit challenging behavior. Method: The clinic utilized behavioral antecedent strategies and contingencies to increase compliance with the vaccine and decrease distress associated with the procedure. Results: We achieved a 100% success rate with vaccine administration and caregivers reported high satisfaction with the clinic. Conclusions: The present vaccine clinic is adaptable to various settings and patients and was well-received overall by caregivers. Replication in different geographic regions may be beneficial when resources allow for this type of clinic.

Early studies evaluating the relative preference for leisure compared with edible items suggested that, for most participants (>80%), edible items are more preferred than leisure items. Recent studies suggest more variability in the percentage of participants with this preference. The rationale for this variability could be sampling, setting, availability of items outside of the study, or the items included. As a systematic replication, we conducted preference assessments of leisure, edible, and leisure/edible items combined of 13 children with developmental disabilities. As an inclusion criterion, all participants had an electronic item as the top-preferred leisure item. An edible item ranked first in the combined assessment for 46.2% of participants. This replicates recent findings while accounting for access to edibles outside of the study. These outcomes are important to guide use of preference assessments across reinforcer classes in clinical and school settings.

Background: Most research on aggression, self-injury, and disruption in autism spectrum disorder (ASD) has relied on caregiver report or direct observation, both of which have limitations. Past studies demonstrate preliminary evidence for direct detection of these behaviors using acceler-ometers, but additional research is needed to determine the feasibility during actual clinical as-sessments and times when a therapist cannot be present for direct observation, as measurement during these periods has the most applied significance.Aims: This study addressed these gaps by evaluating the feasibility of accelerometer use with children with ASD and severe aggression, self-injury, and disruption in clinical and home contexts. Methods and Procedures: We evaluated the feasibility of individuals with ASD wearing acceler-ometers during behavioral assessments following structured habituation procedures. We also evaluated the feasibility of caregivers applying sensors to individuals with ASD in the home setting.Outcomes and Results: Most participants passed habituation and tolerated sensors during behav-ioral assessments (e.g., functional analyses). Caregivers applied sensors in the home with variable fidelity with wear time duration and data-collection.Conclusions and Implications: The feasibility of using accelerometers with this population is promising and should be explored further in future research.

Bainbridge-Ropers syndrome (BRPS) is a rare and understudied developmental disorder associated with medical (e.g., sleep disruption) and behavioral (e.g., self-injury) challenges. There are no published treatments for BRPS. We targeted self-injury in a child with BRPS using a functional analysis and differential reinforcement, with several extensions to common procedures. Results present the first example of behavioral reduction for self-injury in BRPS. • ABA strategies can reduce self-injury in BRPS • Evaluating multiply maintained self-injury following identification of an automatic function is important. • Sleep deficits may complicate assessment.

When targeted behaviors are hypothesized to be automatically maintained, an extended assessment is often necessary to evaluate the impact of social contingencies and guide intervention selection. Elements that may be related to determining assessment outcome include observed characteristics of the behavior, type of sessions conducted, and the topography of targeted behavior. The present retrospective chart review analyzed these variables in 51 clients with developmental disabilities who were exposed to extended alone or ignore evaluations as part of a clinical admission. Findings indicate clinicians may conduct more sessions during extended assessments than previously reported. Level of behavior and pica as the presenting topography primarily drove determination of an automatic function. Session type and other topographies were not statistical predictors of assessment outcome. We discuss these findings with respect to balancing internal and social validity. We also present exploratory and statistically derived cut offs to consider when assessment length is constrained.

Prior researchers have validated the use of a latency assessment to create a hierarchy of demand aversiveness. Demand latency assessments help to identify high-aversive demands for use in functional analyses and/or treatment. The current study used the same approach to evaluate aversiveness of social interaction among four individuals who engaged in target behavior maintained by social avoidance. We obtained clear hierarchies in social interaction aversiveness across all participants. For one participant, we also used the social avoidance latency assessment to demonstrate an intervention approach using gradual fading of less- to more-aversive forms of social interactions. These results indicate latency assessments may be applicable to generate hierarchies of aversive situations that may evoke target behavior maintained by social negative reinforcement other than escape from demands, leading to several clinical implications, and future research directions.

Two subjects diagnosed with autism spectrum disorder and related disabilities who engaged in hand-clapping maintained by automatic reinforcement participated in this study. We conducted a sensory analysis to evaluate matched stimuli that functioned as an abolishing operation or extinction for different sources of sensory reinforcement. Finally, we implemented noncontingent reinforcement (NCR) using the stimuli found to compete in the assessment to reduce the target behavior, and we thinned item availability. Results showed a decrease in hand-clapping, and hand-clapping remained low when we thinned the schedule of reinforcement. This research further elucidates how NCR can treat problem behavior maintained by automatic reinforcement.