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Alenezi S, Temsah MH, Alyahya AS, Almadani AH, Almarshedi A, Algazlan MS, Alnemary F, Bashiri FA, Alkhawashki SH, Altuwariqi MH, Alsedrani R, Alkhiri A, Alarabi M. Mental health impact of COVID-19 on Saudi families and children with special educational needs and disabilities in Saudi Arabia: A national perspective. Front Public Health 2022; 10:992658. [PMID: 36238239 PMCID: PMC9551570 DOI: 10.3389/fpubh.2022.992658] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 08/23/2022] [Indexed: 01/26/2023] Open
Abstract
Introduction The COVID-19 pandemic revealed a multidimensional impact on mental health due to health concerns, social distancing and lockdowns, job loss, and limits in institutional support. Accordingly, COVID-19 may disproportionally impact families with special educational needs and disabilities (SEND) due to the already high prevalence of mental health conditions in children with SEND and their parents. Hence, it is essential to determine the short-term impact of the pandemic on the mental health of families with SEND to identify their ongoing health, including psychological wellbeing and support needs. The current study examines the anxiety level and concerns of children with SEND and their parents living in Saudi Arabia. Methodology A cross-sectional national study design was utilized as a part of an international consortium using an online Arabic survey. Data were collected from the Ministry of Human Resources and Social Development beneficiaries from May to July 2020. The sample consisted of 1,848 parents of children with SEND aged between 1 and 18 years (mean = 9.66; SD = 4.31). A descriptive and bivariant analysis is reported. Results Parental worries on all those concerns when the pandemic started were significantly higher than before the pandemic, p < 0.050. Parental-perceived general anxiety had risen significantly across time, p < 0.001, and their perceived anxiety when the pandemic started exceeded their anxiety before the pandemic, p < 0.001. The general anxiety of children with SEND had risen significantly across time (from before the pandemic to when it had started to during the pandemic), p < 0.001. The children's general worries at the start of the pandemic had correlated significantly and positively with their anxiety, adaptive, maladaptive, and coping efficacies, and parental anxiety scores, p < 0.010 each. Conclusion Anxiety levels were high in SEND and their caregivers before and during COVID-19. At the start of the pandemic, the anxiety, adaptive, maladaptive, coping efficacies, and parental anxiety scores of children with SEND were significantly and favorably correlated. These findings support the notion of SEND-specific anxiety and patterns of coping in SEND and their caregivers. The notion also attests to the institutional support required for this specifically vulnerable population during epidemics.
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Affiliation(s)
- Shuliweeh Alenezi
- Department of Psychiatry, College of Medicine, King Saud University, Riyadh, Saudi Arabia,Department of Psychiatry, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia,SABIC Psychological Health Research and Applications Chair, Department of Psychiatry, College of Medicine, King Saud University, Riyadh, Saudi Arabia,*Correspondence: Shuliweeh Alenezi
| | - Mohamad-Hani Temsah
- Pediatric Department, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | - Ahmed S. Alyahya
- Department of Psychiatry, Eradah Complex for Mental Health, Riyadh, Saudi Arabia
| | - Ahmad H. Almadani
- Department of Psychiatry, College of Medicine, King Saud University, Riyadh, Saudi Arabia,Department of Psychiatry, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia,SABIC Psychological Health Research and Applications Chair, Department of Psychiatry, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Afnan Almarshedi
- Psychiatry Department, Prince Sultan Military Medical City, Riyadh, Saudi Arabia
| | - Maha S. Algazlan
- Department of Psychiatry, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia
| | | | - Fahad A. Bashiri
- Pediatric Neurology Division, Department of Pediatrics, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Samah Hazem Alkhawashki
- Department of Psychiatry, College of Medicine, King Saud University, Riyadh, Saudi Arabia,Department of Psychiatry, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia,SABIC Psychological Health Research and Applications Chair, Department of Psychiatry, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | - Maram Hani Altuwariqi
- Department of Psychiatry, College of Medicine, King Saud University, Riyadh, Saudi Arabia,Department of Psychiatry, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia,SABIC Psychological Health Research and Applications Chair, Department of Psychiatry, College of Medicine, King Saud University, Riyadh, Saudi Arabia
| | | | - Aqeel Alkhiri
- Department of Mental Health, Al Qunfudah General Hospital, Al Qunfudah, Saudi Arabia
| | - Mohammed Alarabi
- Department of Psychiatry, College of Medicine, King Saud University, Riyadh, Saudi Arabia,Department of Psychiatry, King Saud University Medical City, King Saud University, Riyadh, Saudi Arabia,SABIC Psychological Health Research and Applications Chair, Department of Psychiatry, College of Medicine, King Saud University, Riyadh, Saudi Arabia
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Alenezi S, Alyahya AS, AlKhalifah SM, Bakhsh HR, Alismail EH, Aldhalaan H, Alwazna T, Alzrayer N, AlSuwailem SS, Alnemary F, AlAnsari AMS, Alqulaq EI, Alyamani A, Amer YS, Albawardi IM, Albalawi WM, Alhassan MA, Algazlan MS, Alramady M, Ad-Dab’bagh Y. Saudi Expert Consensus-Based Autism Spectrum Disorder Statement: From Screening to Management. Children 2022; 9:children9091269. [PMID: 36138578 PMCID: PMC9496905 DOI: 10.3390/children9091269] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 08/04/2022] [Accepted: 08/17/2022] [Indexed: 11/25/2022]
Abstract
Background: There is a large gap between the needs of individuals diagnosed with autism spectrum disorder (ASD) and the currently available services in Saudi Arabia. Services are often difficult to access, inconsistent in quality, incomplete, unsatisfactory, and costly. As such, there is a national need for expert consensus on the appropriate standards for the assessment and management of children on the autism spectrum. Methodology: A guideline development group (GDC) was formed by professionals representing all related specialties and institutions involved in the management of individuals on the autism spectrum in Saudi Arabia. They met on a regular basis over 21 months. The guideline development process consisted of five steps starting from reviewing existing guidelines and ending with discussing and writing this manuscript. A formal voting process was utilized and recommendations were discussed until a consensus was reached. Results: There was consensus on the following: A specialized diagnostic assessment needs to be carried out by an experienced multidisciplinary team for children referred to assess for ASD. They should be assessed for medical etiology, their behavioral history carefully reviewed, and symptoms directly observed. Longitudinal assessments are encouraged to reflect the effects of symptoms on the individual’s ability to function while with their family, among peers, and in school settings. An additional formal assessment of language, cognitive, and adaptive abilities as well as sensory status is essential to complete the diagnostic process. Interventions should be individualized, developmentally appropriate, and intensive, with performance data relevant to intervention goals to evaluate and adjust interventions. Target symptoms must be identified to address and develop monitoring systems to track change. Conclusion: ASD is a complex condition with widely varying clinical manifestations, thus requiring evaluation and intervention by a range of professionals working in coordination. Behavioral and environmental interventions are the key to optimal outcomes, in conjunction with medications when indicated for specific symptoms. Parental involvement in interventions is vital to sustaining therapeutic gains.
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Affiliation(s)
- Shuliweeh Alenezi
- Department of Psychiatry, College of Medicine, King Saud University, Riyadh 11451, Saudi Arabia
| | - Ahmad S. Alyahya
- Department of Psychiatry, Eradah Complex for Mental Health, Riyadh 12571, Saudi Arabia
- Correspondence:
| | - Shahad M. AlKhalifah
- Center for Autism Research, King Faisal Specialist Hospital & Research Center, Riyadh 11564, Saudi Arabia
| | - Hadeel R. Bakhsh
- Department of Rehabilitation, College of Health and Rehabilitation Sciences, Princess Nourah Bint Abdulrahman University, Riyadh 11564, Saudi Arabia
| | - Eiman H. Alismail
- Center for Autism Research, King Faisal Specialist Hospital & Research Center, Riyadh 11564, Saudi Arabia
| | - Hesham Aldhalaan
- Department of Neuroscience, King Faisal Specialist Hospital & Research Center, Riyadh 11564, Saudi Arabia
| | - Talat Alwazna
- Department of Neurology, King Saud Medical City, Riyadh 12746, Saudi Arabia
| | - Nouf Alzrayer
- Department of Special Education, College of Education, King Saud University, Riyadh 11451, Saudi Arabia
| | | | | | - Ahmed M. S. AlAnsari
- Department of Psychiatry, College of Medecine and Medical Sciences, Arabian Gulf University, Manama 293, Bahrain
| | - Enas I. Alqulaq
- Prince Mohammed Bin Salman Center for Autism and Neurodevelopment, Riyadh 12426, Saudi Arabia
- Health Services of Ministry of Defense, Riyadh 12426, Saudi Arabia
| | - Amal Alyamani
- Prince Mohammed Bin Salman Center for Autism and Neurodevelopment, Riyadh 12426, Saudi Arabia
- Department of Psychiatry, King Fahad Armed Forces Hospital, Jeddah 23311, Saudi Arabia
| | - Yasser S. Amer
- Pediatrics Department, King Khalid University Hospital, Riyadh 12372, Saudi Arabia
- Quality Management Department, King Saud University Medical City, Riyadh 12746, Saudi Arabia
- Evidence-Based Health Care and Knowledge Translation, King Saud University, Riyadh 11451, Saudi Arabia
- Alexandria Center for Evidence-Based Clinical Practice Guidelines, Alexandria University, Alexandria 5424041, Egypt
- Adaptation Working Group, Guidelines International Network (GIN), Perth PH16 5BU, UK
| | - Ibrahim M. Albawardi
- Department of Psychiatry, College of Medicine, Imam Abdulrahman bin Faisal University, Dammam 34212, Saudi Arabia
| | | | - Mohammed A. Alhassan
- Department of Psychiatry, College of Medicine, King Saud University, Riyadh 11451, Saudi Arabia
| | - Maha S. Algazlan
- Department of Psychiatry, College of Medicine, King Saud University, Riyadh 11451, Saudi Arabia
| | | | - Yasser Ad-Dab’bagh
- Mental Health Department, Neuroscience Center, King Fahad Specialist Hospital-Dammam (KFSH-D), Dammam 32253, Saudi Arabia
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Amer YS, Alenezi S, Bashiri FA, Alawami AH, Alhazmi AS, Aladamawi SA, Alnemary F, Alqahtani Y, Buraik MW, AlSuwailem SS, Akhalifah SM, Augusta de Souza Pinhel M, Penner M, Elmalky AM. AGREEing on Clinical Practice Guidelines for Autism Spectrum Disorders in Children: A Systematic Review and Quality Assessment. Children 2022; 9:children9071050. [PMID: 35884034 PMCID: PMC9323940 DOI: 10.3390/children9071050] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/06/2022] [Revised: 06/30/2022] [Accepted: 07/02/2022] [Indexed: 11/17/2022]
Abstract
Background: Autism spectrum disorder (ASD) is a multifaceted neurodevelopmental disorder requiring multimodal intervention and an army of multidisciplinary teams for a proper rehabilitation plan. Accordingly, multiple practice guidelines have been published for different disciplines. However, systematic evidence to detect and intervene must be updated regularly. Our main objective is to compare and summarize the recommendations made in the clinical practice guidelines (CPGs) for ASD in children released from November 2015 to March 2022. Methods: CPGs were subjected to a systematic review. We developed the inclusion and exclusion criteria and health-related questions, then searched and screened for CPGs utilizing bibliographic and CPG databases. Each of the CPGs used in the study were critically evaluated using the Appraisal of Guidelines for REsearch and Evaluation II (AGREE II) instrument. In a realistic comparison table, we summarized the recommendations. Results: Four eligible CPGs were appraised: Australian Autism CRC (ACRC); Ministry of Health New Zealand (NZ); National Institute for Health and Care Excellence (NICE); and Scottish Intercollegiate Guidelines Network, Healthcare Improvement Scotland (SIGN-HIS). The overall assessments of all four CPGs scored greater than 80%; these findings were consistent with the high scores in the six domains of AGREE II, including: (1) scope and purpose, (2) stakeholder involvement, (3) rigor of development, (4) clarity of presentation, (5) applicability, and (6) editorial independence domains. Domain (3) scored 84%, 93%, 86%, and 85%; domain (5) 92%, 89%, 54%, and 85%; and domain (6) 92%, 96%, 88%, and 92% for ACRC, NICE, NZ, and SIGN-HIS, respectively. Overall, there were no serious conflicts between the clinical recommendations of the four CPGs, but some were more comprehensive and elaborative than others. Conclusions: All four assessed evidence-based CPGs demonstrated high methodological quality and relevance for use in practice.
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Affiliation(s)
- Yasser S. Amer
- Pediatrics Department, King Khalid University Hospital, King Saud University Medical City, Riyadh 11451, Saudi Arabia
- Clinical Practice Guidelines and Quality Research Unit, Quality Management Department, King Saud University Medical City, Riyadh 11451, Saudi Arabia
- Research Chair for Evidence-Based Health Care and Knowledge Translation, Deanship of Scientific Research, King Saud University, Riyadh 11451, Saudi Arabia
- Alexandria Center for Evidence-Based Clinical Practice Guidelines, Alexandria University, Alexandria 5424041, Egypt
- Guidelines International Network, Perth PH16 5BU, Scotland, UK
- Correspondence: (Y.S.A.); (S.A.); Tel.: +966-508577246 (Y.S.A.); +966-504848864 (S.A.)
| | - Shuliweeh Alenezi
- Department of Psychiatry, College of Medicine, King Saud University, Riyadh 11451, Saudi Arabia
- Correspondence: (Y.S.A.); (S.A.); Tel.: +966-508577246 (Y.S.A.); +966-504848864 (S.A.)
| | - Fahad A. Bashiri
- Pediatric Neurology Division, Pediatrics Department, College of Medicine, King Saud University, Riyadh 11451, Saudi Arabia;
| | - Amel Hussain Alawami
- Johns Hopkins Aramco Healthcare, Dhahran 34465, Saudi Arabia; (A.H.A.); (M.W.B.)
| | - Ayman Shawqi Alhazmi
- Developmental Pediatric Department, Children’s Hospital, King Saud Medical City, Ministry of Health, Riyadh 12746, Saudi Arabia;
| | - Somayyah A. Aladamawi
- King Abdullah bin Abdulaziz University Hospital, Riyadh 11564, Saudi Arabia;
- College of Medicine, Princess Nourah Bint Abdulrahman University, Riyadh 11564, Saudi Arabia
| | - Faisal Alnemary
- Autism Center of Excellence, Riyadh 11564, Saudi Arabia; (F.A.); (S.S.A.); (S.M.A.)
| | | | - Maysaa W. Buraik
- Johns Hopkins Aramco Healthcare, Dhahran 34465, Saudi Arabia; (A.H.A.); (M.W.B.)
| | - Saleh S. AlSuwailem
- Autism Center of Excellence, Riyadh 11564, Saudi Arabia; (F.A.); (S.S.A.); (S.M.A.)
| | - Shahad M. Akhalifah
- Autism Center of Excellence, Riyadh 11564, Saudi Arabia; (F.A.); (S.S.A.); (S.M.A.)
| | - Marcela Augusta de Souza Pinhel
- Department of Health Science, Ribeirao Preto Medical School, University of São Paulo, Ribeirao Preto 14049-900, Brazil;
- Department of Molecular Biology, São José do Rio Preto Medical School, São José do Rio Preto 15090-000, Brazil
| | - Melanie Penner
- Holland Bloorview Kids Rehabilitation Hospital, Toronto, ON M4G 1R8, Canada;
- Department of Pediatrics, University of Toronto, Toronto, ON M5G 1X8, Canada
| | - Ahmed M. Elmalky
- Morbidity and Mortality Unit, King Saud University Medical City, King Saud University, Riyadh 11451, Saudi Arabia;
- Public Health and Community Medicine Department, Theodor Bilharz Research Institute (TBRI), Academy of Scientific Research, Cairo 3863130, Egypt
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Alenezi S, Alnemary F, Alamri A, Albakr D, Abualkhair L, Alnemary F. Psychotropic Medications Use among Children with Autism in Saudi Arabia. Children (Basel) 2022; 9:children9070966. [PMID: 35883950 PMCID: PMC9322379 DOI: 10.3390/children9070966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Revised: 06/19/2022] [Accepted: 06/22/2022] [Indexed: 11/16/2022]
Abstract
Psychotropic medication use is rising among children with autism spectrum disorders (ASD) in Saudi Arabia. Two hundred ninety-three parents of children diagnosed with ASD completed a parental concerns questionnaire (PCQ) online to examine children’s family socio-demographics, health conditions and comorbidities, and past and current exposure to psychotropic medication as prescribed by their primary doctor. Findings revealed that more than one-third of the parents (39.08%) reported that their children were using medications at the time of the survey; risperidone (53%), methylphenidate (30%), and valproic acid (9%) were the most commonly used. A smaller number of parents stated that their children had previously used medications (16.09%). The most often prescribed drugs among this group were risperidone (45%), followed by methylphenidate (32%) and valproic acid (17%). The variables that showed a statistically significant association with the current use of psychotropic drugs were the child’s age (OR = 1.25, 95% CI: 1.12, 1.40, p < 0.001), presence of comorbidities (OR = 7.75, 95% CI: 3.48, 17.24, p < 0.001), communication difficulties (OR = 1.79, 95% CI: 1.09, 2.95, p < 0.021), and anxiety symptoms (OR = 1.70, 95% CI: 1.00, 2.87, p < 0.049). Similarly, the child’s age (OR = 1.23, 95% CI: 1.08, 1.40, p < 0.002) and presence of comorbidities (OR = 2.83, 95% CI: 1.16, 6.29, p < 0.022) showed statistically significant associations with previous use.
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Affiliation(s)
- Shuliweeh Alenezi
- Department of Psychiatry, College of Medicine, King Saud University, Riyadh 11451, Saudi Arabia;
- Correspondence:
| | - Fahad Alnemary
- Department of Special Education, College of Education, Taif University, Taif 21944, Saudi Arabia;
| | - Asma Alamri
- Department of Child Psychiatry, King Abdullah Specialist Children Hospital, Riyadh 14611, Saudi Arabia;
| | - Dalal Albakr
- Department of Psychiatry, Imam Abdulrahman Bin Faisal University, Dammam 34212, Saudi Arabia;
| | - Lamees Abualkhair
- Department of Psychiatry, College of Medicine, King Saud University, Riyadh 11451, Saudi Arabia;
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Al Zaben F, Sehlo M, Alghamdi W, Tayeb H, Khalifa D, Altowaireb A, Nughays R, Jawa H, Bashrahil K, Alnemary F, Koenig H. Risk factors for ADHD and comorbid psychiatric, academic and behavior problems among primary school students in Jeddah, Saudi Arabia. Int J Psychiatry Med 2021; 56:422-432. [PMID: 33327842 DOI: 10.1177/0091217420982266] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Risk factors for attention deficit hyperactivity disorder (ADHD), psychiatric, and classroom academic/behavioral problems were examined in 929 students grades 1-6 in Jeddah, Saudi Arabia. Teachers identified ADHD by completing the Vanderbilt ADHD scale. Compared to controls without ADHD, students with ADHD were more likely to have early parental loss, head trauma, motor/language delay, family psychiatric problems, and high family stress. Among those with ADHD, risk factors for psychiatric comorbidity were older age, family psychiatric history, and motor/language delay. Risk factors for impaired academic/behavioral performance were high family stress, family psychiatric problems, and chronic illness. Identifying risk factors for ADHD and common comorbidities associated with this disorder may help parents, teachers and clinicians detect this condition, increasing effective management.
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Affiliation(s)
- F Al Zaben
- Division of Psychiatry, Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - M Sehlo
- Division of Psychiatry, Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.,Department of Psychiatry, Zagazig University, Shaibet an Nakareyah, Markaz El-Zakazik, Egypt
| | - W Alghamdi
- Division of Psychiatry, Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - H Tayeb
- Division of Neurology, Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - D Khalifa
- Division of Psychiatry, Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.,Department of Psychiatry, Ain Shams University, El-Abaseya, Egypt
| | - A Altowaireb
- Division of Psychiatry, Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - R Nughays
- Division of Psychiatry, Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - H Jawa
- Division of Psychiatry, Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - K Bashrahil
- Division of Psychiatry, Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia
| | - F Alnemary
- Division of Psychiatry, Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.,Department of Special Education, Ta'if University, Taif, Saudi Arabia
| | - H Koenig
- Division of Psychiatry, Department of Medicine, King Abdulaziz University, Jeddah, Saudi Arabia.,Department of Psychiatry and Behavioral Sciences, Duke University Medical Center, Durham, NC, USA
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Alnemary F, Wallace M, Alnemary F, Gharapetian L, Yassine J. Application of a Pyramidal Training Model on the Implementation of Trial-Based Functional Analysis: a Partial Replication. Behav Anal Pract 2016; 10:301-306. [PMID: 29021943 DOI: 10.1007/s40617-016-0159-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022] Open
Abstract
We employed a pyramidal training model (PTM) to teach staff to correctly implement and collect data for trial-based functional analysis (TBFA) in simulated situations. First, we trained four behavioral consultants (BCs) in a group format, who each trained one behavior technician (BT) in an individual format. We utilized a non-concurrent multiple baseline design to evaluate the effect of the training. During generalization probes, participants implemented TBFA with a novel problem behavior. This study will contribute to the literature on teaching staff how to conduct TBFA. This study demonstrates the application of a two-level PTM. This study illustrates how agencies can utilize the Task Analysis Training Protocol within a PTM to train staff on implementation of TBFA.
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Affiliation(s)
- Faisal Alnemary
- University of California Los Angeles, Los Angeles, CA 90095 USA.,California State University, Los Angeles, USA.,Taif University, Taif, Saudi Arabia
| | | | - Fahad Alnemary
- University of California Los Angeles, Los Angeles, CA 90095 USA.,California State University, Los Angeles, USA.,Taif University, Taif, Saudi Arabia
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