Severe Challenging Behaviour Research Articles

Evaluating Practical Functional Assessment and Skill-Based Treatment for Severe Challenging Behavior via Telehealth with Novice Dual Parent Implementers: A Pilot Investigation

Evaluating Practical Functional Assessment and Skill-Based Treatment for Severe Challenging Behavior via Telehealth with Novice Dual Parent Implementers: A Pilot Investigation

Kendra's journey: an intrinsic case study of a deaf autistic child.

This study used an intrinsic case study to investigate how interventions from applied behavior analysis impacted language development, academic progress, and the reduction of severe challenging behaviors for an 8-year-old child who is Deaf and autistic. 3 main themes were identified: language acquisition, behavioral change strategies, and academic performance. Additionally, 2 common threads wove in and out of each and connected all 3 themes: language access and qualified providers, including Deaf professionals. This study expands the literature about using behavioral strategies with children who are Deaf and autistic and discusses implications for clinical and educational practice.

Evaluation of resurgence following differential reinforcement of alternative behavior with and without extinction in a human operant model.

One of the most common treatments for severe challenging behavior involves placing the challenging behavior on extinction and differentially reinforcing an alternative response (DRA). However, extinction is not always feasible and may be unsafe or impractical to implement in some circumstances. Thus, implementing a DRA without extinction intervention may be necessary for some cases. Currently, the extent to which DRA without extinction produces durable treatment outcomes, particularly as it relates to the resurgence of challenging behavior, is unclear. The present study investigated resurgence following DRA with and without extinction using a three-phase resurgence evaluation in a translational human operant model with college students as participants. All participants demonstrated resurgence across both experimental groups. Although there were no statistically significant differences in the prevalence, magnitude, or persistence of resurgence between groups, levels of resurgence magnitude were relatively higher in the DRA-without-extinction group than in the DRA-with-extinction group. Clinical implications of these findings and directions for future human operant investigations of resurgence are discussed.

Program evaluation of a specialized treatment home for adults with severe challenging behavior

AbstractIndividuals with intellectual and developmental disabilities who engage in severe challenging behavior may comprise 5%–10% of the clinical population. Unfortunately, challenging behavior literature tends to underrepresent adult participants and emphasize efficacy (Does the intervention work?) more often than effectiveness (Does the intervention work in real world settings?). We conducted a systematic program evaluation to examine the effectiveness of a comprehensive behavioral treatment package using a hybrid quasi‐experimental consecutive case series design featuring eight adults who experienced the treatment package. The results depicted a substantial decrease in challenging behavior and increase in adaptive behavior across sessions for most participants. Impressive treatment integrity outcomes (M = 84%, range, 82%–90%) showcased that the intervention was implemented as intended. Social validity surveys administered to participants, caregivers, and case managers provide support for the acceptability of the treatment package. Project limitations, clinical considerations, and future directions are discussed.

Perspectives on managing patients with Down's syndrome among orthodontists in Saudi Arabia: A vignette and a COM-B analysis study.

This study aims to explore perspectives on managing patients with Down's syndrome among orthodontists in Saudi Arabia using a vignette study and COM-B model. This was a cross-sectional study for orthodontists working in Saudi Arabia. Participants were asked about their demographic data. Vignette (clinical scenarios) and COM-B model (C: capability, O: opportunity, M: motivation, and B: behavior) were used to assess orthodontists' perspectives regarding the management of patients with Down's syndrome. A model of Alpha (Cronbach) was used to study the properties of measurement scales. A Pearson's correlation coefficient was used to correlate variables represented by means. An independent t-test and one-way ANOVA, with least significant difference (LSD) as a post hoc test, were used to compare two group means and more than two groups, respectively. Most participants (n = 70, 85.4%) reported that they had no training/exposure to dealing with Down's syndrome patients during their orthodontic clinical training. Participants reported an average of 3.82 (SD = 1.1) when treating moderate Down's syndrome and 2.48 (SD = 1.4) when treating severe Down's syndrome with mild occlusion discrepancies. Participants also showed that their behavior and attitude are significantly related to their capability, opportunity, and motivation regarding the management of patients with Down's syndrome. The average reported agreement ranges from 2.46 (SD = 1) for the hypoplasia of the mandible to 4.38 (SD = 0.8) for the congenitally missing teeth. This study found that orthodontists in Saudi Arabia showed low confidence levels to manage Down's syndrome patients with moderate and severe challenging behavior. Despite this, the likelihood of increasing their confidence levels and attitude regarding the management of patients with Down's syndrome increased by increasing their capability, opportunity, motivation, and knowledge in this field.

Challenging behaviour, the application of restrictive measures and psychotropic drug prescription in people with intellectual disabilities

BackgroundPrescribing of psychotropic drugs (PDs) and applying restrictive measures are both frequently used in managing challenging behaviour of people with intellectual disabilities (ID), which is not always according to guidelines or good clinical practice. AimsThis study aimed to investigate the potential triangular relationship between challenging behaviour, the application of restrictive measures and PD prescription. Methods and proceduresIn this cross-sectional study, data on challenging behaviour, PD prescription and restrictive measures were collected. We defined and compared four mutually exclusive groups of participants. Outcomes and resultsChallenging behaviour in the group in whom one or more PD were prescribed as a restrictive measures (PDRM) was more severe than in the other three groups. More severe challenging behaviour, a higher number of antipsychotics, antidepressants and anxiolytics/hypnotics prescriptions, a lower dosage, and more application of domotics as restrictive measure was shown in the PDRM compared to the group in whom PDs were prescribed according to guidelines (PDNRM). Conclusions and implicationsWe did not find indications for a triangular relationship of challenging behaviour, the application of restrictive measures and PD prescriptions. Future longitudinal research is needed to better understand this complex relationship and should investigate the indication and the effect of treatment. What this paper adds?This study is a first exploration of the potential triangular relationship between symptoms of challenging behaviour, psychotropic drug (PD) prescription, and the application of restrictive measures. Prescribing PDs and applying restrictive measures are two interventions which are commonly used to manage challenging behaviour in people with intellectual disabilities. Both have been subject of research separately in recent years. However, it is conceivable that the PD prescription in treatments for challenging behaviour could be a substitute for another form of a restrictive measure, for example a physical or mechanical restraint. For this purpose, we defined and compared four mutually exclusive groups of participants. We found no indication for this triangular relationship. On the other hand, we found the highest severity of challenging behaviour in the group who used PDs as restrictive measure next to other restrictive measures. Our results may suggest that both prescribing PDs and applying non-pharmacological restrictive measures are used simultaneously in managing challenging behaviour, are not sufficiently implemented or effective.

Organizational characteristics of highly specialized units for people with dementia and severe challenging behavior

BackgroundPeople with dementia and severe challenging behavior in the Netherlands can be temporarily admitted to highly specialized units when their behavior is not manageable in regular dementia special care units (DSCUs). With scarce evidence available for the treatment of these patients, treatment in these units is in a pioneering phase. To gain more insight into these units, this study investigated organizational characteristics, i.e. admission and discharge characteristics, staffing, the physical environment, and the management of severe challenging behavior.MethodsThree data collection methods were used: 1) a digital questionnaire to be completed by the unit manager, 2) an interview with the physician responsible for medical care and often another practitioner, and 3) an observation of the physical environment for which the OAZIS-dementia questionnaire was used. Descriptive analysis was used for quantitative data and thematic analysis for qualitative data, after which data was interpreted together. Thirteen units participated, with their sizes ranging from 10 to 28 places.ResultsPatients were mainly admitted from regular DSCUs, home or mental health care, and discharged to regular DSCUs. A multidisciplinary team comprising at least an elderly care physician or geriatrician, psychologist, and nursing staff member and other therapists as needed provided the treatment. Nursing staff hours per patient considerably differed among units. Nursing staff played a central role in the treatment. Competences such as reflectiveness on one’s own behavior, and being able to cope with stressful situations were described as relevant for nursing staff. Investing in a stable nursing staff team was described as important. The units varied in whether their work-up was more intuitive or methodological. In the diagnostic phase, observation together with an extensive analysis of the patient’s biography was essential. The units used a broad variety of interventions, and all paid attention to sensory stimuli. In the observation of the physical environment, the safety scored well and domesticity relatively low.ConclusionHighly specialized units show strong heterogeneity in organizational characteristics and management, which can be understood in the light of the pioneering phase. Despite this, similarities were found in nursing staff roles, frequent multidisciplinary evaluation, and attention to sensory stimuli.

Factors affecting the feelings of safety among individuals with mild intellectual disabilities and severe challenging behaviour in residential care: A qualitative study of professional and service users' perspectives.

Background: This study focuses on what feeling safe means for people with mild intellectual disabilities and severe challenging behaviour, and which factors affect their sense of safety. Method: Thematic analysis was used to analyse data collected during (1) ethnographic longitudinal research and (2) interviews and focus groups among professionals and service users. Results: Feelings of safety can relate to three main themes: (1) a physical environment that reduces risks and temptations; (2) a reliable, predictable, and supportive environment; and (3) an accepting environment that enables service users to establish a normal life. An analysis of which factors affect service users' sense of safety identified 20 themes (e.g. team climate) and 34 subthemes (e.g. interactions with other service users). Conclusions: A range of interconnected factors can affect service users' feelings of safety. Future research should explore what organisations and external actors (e.g. the police) can do to promote those feelings.

Reinforcer value moderates response magnitude and persistence during extinction: A randomized trial.

Extinction bursts, or temporary increases in rates and intensities of behavior during extinction, can preclude the inclusion of extinction in intervention packages meant to suppress severe challenging behavior. To identify underlying behavioral mechanisms responsible for response persistence and bursting, 69 adults with developmental disabilities completed a low-stakes translational investigation employing a 2 × 2 factorial, crossed, and randomized matched blocks design, with batched randomization logic. In each of the four test groups, we made distinct antecedent manipulations with two value parameters commonly studied through behavioral economics (i.e., demand intensity, Pmax) and evaluated the extent to which each of these manipulations influenced target responding during extinction. Although we found statistically significant differences attributable to both parameters, variations in reinforcer consumption relative to demand intensity were most influential across all dependent variables. This outcome implicates consumption relative to demand intensity as both a mitigating and exacerbating preextinction factor that influences the prevalence of adverse collateral extinction effects (e.g., bursts).

A three-years follow-up of extra intensive support for individuals with intellectual disability and severe challenging behaviour in the Netherlands

Adults with Intellectual Disability who show severe challenging behaviour need intensive individual support. If intensive support proves to be insufficient, extra intensive support can be provided in the Netherlands, which is characterized by more time for individual care. The present study evaluates the impact of extra intensive support over time. Client characteristics of adults receiving intensive support (IS, N=70) or extra intensive support (IS+, N=35) are compared and the impact of provided support on challenging behaviour (Developmental Behaviour Checklist-Adults), adaptive behaviour (Vineland II), and Quality of Life (San Martin Scale) is evaluated over a three years period. Compared to adults receiving intensive support, those receiving extra intensive support initially showed higher intensity of challenging behaviour, higher number of mental health diagnoses and stronger focus on goals to reduce challenging behaviour. Over time, intensity of challenging behaviour decreased in adults receiving extra intensive support, although Quality of Life and adaptive functioning did not improve. Results show that the indications for receiving extra intensive support are clear and that the extra support is effective over time. It is concluded that extra individual support is serving those who need this support.

Psychotropic Medication Use and Polypharmacy Among Children and Adolescents Initiating Intensive Behavioral Therapy for Severe Challenging Behavior

To evaluate the prevalence, trends, and factors associated with psychotropic medication use and polypharmacy among children and adolescents initiating intensive behavioral therapy for severe challenging behavior over a 10-year period. In this retrospective observational study, we examined data from caregiver interviews and patient medical records on the number and types of psychotropic medications prescribed to patients initiating intensive behavioral therapy between January 1, 2013, and December 31, 2022. Trends in medication use and polypharmacy across the 10-year period were analyzed using regression analysis, while differences in demographics and clinical factors for patients with use and polypharmacy were analyzed using nonparametric statistical analysis with odds ratios presented for significant factors. Data from all 302 pediatric patients initiating intensive behavioral therapy across the 10-year period were analyzed. Among all patients and all years, 83.8% were taking at least 1 psychotropic medication and 68.2% experienced polypharmacy. There were no changes in the prevalence of use, mean number of medications taken, or polypharmacy across the 10-year period. Patients diagnosed with attention-deficit/hyperactivity disorder or anxiety disorder, as well as those exhibiting self-injurious behavior had higher use of psychotropic medication and polypharmacy and were taking more medications overall. Psychotropic medication use and polypharmacy were extremely high for children and adolescents with severe challenging behavior, but use and polypharmacy did not change over the 10-year period of data collection. Further research is needed to establish the generality of these findings to other regions of the US.

Parental Stress Related to Caring for a Child With Autism Spectrum Disorder and the Benefit of Mindfulness-Based Interventions for Parental Stress: A Systematic Review

Children with autism spectrum disorder (ASD) tend to exhibit more severe challenging behaviors than typically developing children and those with intellectual or other disabilities. This study aimed to review the stress levels of parents of individuals with ASD, and the use of mindfulness to decrease parental stress. The following variables of Autism, Stress, Parenting, Family, and Mindfulness were searched in PubMed and APA PsycNet databases. The studies between 2000 and 2023 with at least two of the mentioned keywords were included for further review. This review highlights the significance of further research on the severity of autism symptoms and how they are related to the level of parental stress, and it thoroughly examines the findings of pertinent studies on parental stress and autism. Furthermore, it aims to draw attention to the application of mindfulness-based interventions in reducing parental stress. Parents of children with ASD were found to have higher stress levels than those of typically developing children. Mindfulness-based interventions were found to be helpful in decreasing parents’ stress levels. Parenting a child with autism spectrum disorder is very challenging, which causes parents to experience higher stress levels than those of typically developing children.

Continuous Saliva Packing Resulting in Feeding Tube Dependence: In-Home Behaviour-Analytic Treatment

Saliva packing can be one of the most severe life-threatening and challenging behaviours to treat. A 9-year-old male with autism spectrum disorder and intellectual disability had 100% nasogastric (NG) feeding tube dependence and significant adaptive behaviour regression (in speaking, using the toilet and his hands, school attendance, sleep). He participated in an intensive behaviour-analytic paediatric feeding treatment programme. Saliva packing, as an automatically-maintained undifferentiated behaviour that persisted in all waking contexts despite high engagement in activities, warranted an additional outside of meal approach. He began swallowing, met 100% of his 21 goals, gained weight, and eliminated tube dependence. He reached a variety of 94 across all food groups, drinks, and supplements. Caregivers were trained and reported high social validity, and gains generalised and maintained in 1-month follow-up. This is the first case to our awareness in Australia of an in-home solely behaviour-analytic intervention to eliminate tube dependence, and it was conducted without hunger provocation, weight loss, or limited nutritional variety.

Evaluation of an Individualized Package of Care for a Young Person with Autism & An Intellectual Disability: Implications for Reducing Restrictive Practice

ABSTRACT Using a single case study design, we evaluated the progress of a young person in terms of incidents of challenging behaviours, and restrictive practice use following the introduction of a single-person package of care tailored specifically to his needs. This person had diagnoses of autism and intellectual disability as well as a history of severe challenging behaviours and was detained in a secure mental health unit. Analysis based on classical test theory for evaluating single case repeated measures data, revealed significant reductions in challenging behaviours and the use of physical restraint. Qualitative data obtained by interviewing a family member suggested improvements in emotional management and wellbeing, as well as in the service user’s confidence and independence. To our knowledge this is the first study to evaluate a single-person package of care as an approach to supporting individuals with autism and severe challenging behaviours.

The potential for medicinal cannabis to help manage challenging behaviour in people with intellectual disability: A perspective review.

Around 2% of the population have intellectual disabilities. Over one-third people with intellectual disabilities (PwID) present with 'challenging behaviour', which nosologically and diagnostically is an abstract concept. Challenging behaviour is influenced by a range of bio-psycho-social factors in a population, which is unable to suitably comprehend and/or communicate concerns. This predisposes to poor health and social outcomes. There is no evidence-based treatments for managing challenging behaviour. Cannabidiol (CBD) and tetrahydrocannabinol (THC) are being trialled for a range of disorders, which are over-represented in PwID and provoke challenging behaviours, such as severe epilepsy, spasticity, post-traumatic stress disorder, social phobia, pain, etc. This perspective review explores the different conditions, which benefit from medicinal CBD/THC preparations, by analysing recent literature from neurobiological, pre-clinical and clinical studies related to the topic. The evidence is synthesised to build an argument of the therapeutic benefits and challenges of medicinal cannabis to manage severe challenging behaviour in PwID. There is developing evidence of medicinal CBD/THC improving psychiatric and behavioural presentations in general. In particular, there is emergent proof in certain key areas of influence of medicinal CBD/THC positively supporting challenging behaviour, for example in children with neurodevelopmental disorders. However, there are significant challenges in employing such treatments in vulnerable populations such as PwID. Further clinical research for the considered use of medicinal CBD/THC for challenging behaviour management in PwID is needed. Strong co-production with experts with lived experience is needed for further testing to be done in this exciting new area.

Transferring people with dementia to severe challenging behavior specialized units, an in-depth exploration

Objectives One of the main reasons for people with dementia to move to a dementia special care unit of a nursing home is challenging behavior. This behavior is often difficult to manage, and in the Netherlands, residents are sometimes relocated to a severe challenging behavior specialized unit. However, relocation often comes with trauma and should be prevented if possible. This study aimed to investigate the patient- and context-related reasons for these relocations. Methods Qualitative multiple case study using individual (n = 15) and focus group interviews (n = 4 with n = 20 participants) were held with elderly care physicians, physician assistants, psychologists, nursing staff members, and relatives involved with people with dementia and severe challenging behavior who had been transferred to a severe challenging behavior specialized unit. Audio recordings were transcribed and analyzed with thematic analysis, including directed content analysis. Results After five cases, data-saturation occurred. The thematic analysis identified three main processes: increasing severity of challenging behavior, increasing realization that the clients’ needs cannot be met, and an increasing burden of nursing staff. The interaction between these processes, triggered mainly by a life-threatening situation, led to nursing staff reaching their limits, resulting in relocation of the client. Conclusion Our study resulted in a conceptual framework providing insight into reasons for relocation in cases of severe challenging behavior. To prevent relocation, the increasing severity of challenging behavior, increasing burden on nursing staff, and increasing realization that the clients’ needs cannot be met need attention.

Distance-Based Collaborations for Assessing and Treating Challenging Behavior.

An interview-informed synthesized contingency analysis (IISCA; Hanley et al. in J Appl Behav Anal 47:16-36, 2014) and related skill-based treatment process can result in socially valid outcomes for clients exhibiting severe challenging behavior when implemented by professionals and then transferred to parents (e.g., Santiago et al. in J Autism Dev Disord 46:797-811, 2016). However, many families do not have access to professionals trained to implement functional analyses or function-based treatments (Deochand & Fuqua Behav Anal Pract 9:243-252, 2016). Experimenters in the present study coached three parents of children with autism exhibiting severe challenging behavior through implementing an IISCA and resulting skill-based treatment process through distance-based collaborative consulting. All parents achieved differentiated functional analyses, taught their children to emit functional replacement skills, and reduced challenging behavior relative to baseline.

Application of the evolutionary theory of behavior dynamics to severe challenging behavior.

The evolutionary theory of behavior dynamics (ETBD) is a genetic algorithm that applies the Darwinian principles of evolutionary biology to model how behavior changes dynamically via selection by contingencies of reinforcement. The ETBD is a complexity theory where low-level rules of selection, reproduction, and mutation operate iteratively to animate "artificial organisms" that generate emergent outcomes. Numerous studies have demonstrated the ETBD can accurately model behavior of live animals in the laboratory, and it has been applied recently to model automatically maintained self-injury. The purpose of the current series of studies was to further extend the application of the ETBD to model additional functional classes of challenging behavior and clinical procedures. Outcomes obtained with artificial organisms generally corresponded well with outcomes observed with clinical cases sourced from consecutive controlled case series studies. Conceptual and methodological considerations on the application of the ETBD to model challenging behavior are discussed.

An Integrated Behavioral-Neuropsychiatric Treatment Plan Reduces Severe Challenging Behavior in an Adolescent With Neurobehavioral Complications of Neonatal Brain Injury

We present the case of a 15-year-old adolescent boy with a neurobehavioral disorder who experienced a brain injury during the first month of life. The forms of challenging behaviors were severe and included aggression, property destruction, volitional incontinence, and suicidal statements, and had resulted in two psychiatric hospitalizations and multiple emergency evaluations prior to intervention. The intervention was preceded by a functional behavior assessment suggesting that a differential reinforcement intervention could be designed to minimize reinforcement of challenging behaviors while maximizing reinforcement of adaptive, positive behaviors. The intervention was introduced following the baseline phase and there was an immediate decrease in the rate of challenging behaviors and in the utilization of emergency psychiatric services. Improvements continued for 6 weeks, after which a medication was added to promote sleep onset (to decrease sleep onset latency) along with behavioral guidelines, which led to further improvements for an additional 12 weeks. A follow-up phase of 3 months showed sustained results. The study illustrates the value of an integrated approach utilizing applied behavior analysis and sequenced neuropsychiatry, and a neurobehavioral formulation where components of the participant’s brain injury history are integrated with an operant formulation as circumstances that explain the problem behavior while effectively suggesting strategies for behavioral treatment. Because the intervention was implemented by support staff in a group home, it illustrates the ability of support staff to work therapeutically with severe behavior presentations using structured behavioral interventions.

Experienced support at work, team climate and collaboration in teams working with people with mild intellectual disabilities and severe challenging behaviour in residential care: a cross-sectional study.

This study explored the perceptions of staff for people with mild intellectual disabilities or borderline intellectual functioning and severe challenging behaviour in relation to the support they received at work from four groups of professionals (i.e. team leaders, managers, psychologists and other staff members). The team climate, such as the workplace having clearly defined goals for staff, was also explored. In addition, the associations between the support from each of the professionals and team climate with the well-being and job satisfaction of staff were examined. We hypothesised that staff would perceive higher levels of support from professionals around a team (i.e. team leaders, managers and psychologists) and a more positive team climate when professionals around a team experience more positive mutual collaboration. An online questionnaire about support at work, team climate, well-being and job satisfaction was completed by 201 staff members from 32 teams at 10 residential service organisations. In addition, professionals surrounding these teams rated their mutual collaboration. Both support received at work from all four groups of professionals and team climate showed significant small to moderate positive associations with job satisfaction. Well-being was associated with support from team leaders, psychologists and other staff members in the team, as well as with team climate. We did not find support for the hypotheses that staff would perceive higher levels of support or a more positive team climate when professionals around a team experience more positive mutual collaboration. This study highlights the importance of investing in staff support and creating a positive team climate for promoting staff well-being and job satisfaction. Implications for future research regarding staff support, team climate and the collaboration between professionals around a team are discussed.