Assessing inter-rater agreement of the intellectual disability-frailty index short form: A descriptive pilot study

Frailty is a health concern for many adults with intellectual disability and should be measured to detect at-risk conditions, monitor disease, plan treatment, and gauge mortality. This descriptive pilot study evaluated measurement consistency (inter-rater agreement) of the Intellectual Disability-Frailty Index Short Form among multiple assessors with 20 adults (M age = 48.3 years) who had intellectual and multiple disabilities. Agreement percentages were computed for (a) non-frail, pre-frail, and frail categories derived from total index scores, and (b) each of 17 deficits listed on the form. Low average inter-rater agreement (<85%) was obtained on the index frail categories, several of the assessed deficits had acceptable inter-rater agreement (84.2-100%), while the majority of deficits were associated with moderate-to-low agreement percentages. Though research supports the Intellectual Disability-Frailty Index Short Form as a valid and practical frailty assessment instrument, our findings suggest that full-scale inter-rater agreement must be improved by adding more specificity to the form, clarifying instructions for assessors, and providing competency-based training in assessment implementation.

Teaching clinicians and nurses to prepare for and present at interdisciplinary meetings through behavioral skills training

Behavior analysts frequently collaborate with interdisciplinary colleagues to share information and make decisions about client services. This study evaluated the effects of behavioral skills training on preparation for and presentation during interdisciplinary review team meetings by clinicians (n = 4) and nurses (n = 4) at a residential school for students with intellectual and neurodevelopmental disabilities. The primary dependent measure was the percentage of preparation and presentation steps from task-analyzed behavior checklists that the participants implemented correctly. As evaluated by multiple-baseline designs, the participants improved their preparation and presentation skills to nearly 100% following behavioral skills training, maintained performance 1 month after the study, and rated training positively. We discuss elements of the training program, practice implications, and research directions.

Multiyear Evaluation of Maintenance Electroconvulsive Therapy in an Adult With Autism Spectrum Disorder, Catatonia, and Challenging Behavior

ABSTRACT

We report the case of a 30-year-old man diagnosed with autism spectrum disorder who received electroconvulsive therapy (ECT) over a 4-year period to treat catatonia associated with life-threatening self-injury, aggression, major depression, and associated self-care, daily living, and communication skills deficits. A systematic schedule of maintenance ECT (m-ECT) was associated with elimination of challenging behavior, catatonic and depressive symptom remission, removal of protective equipment, and reduced dosages of psychotropic medications.

Brief Report: A Pilot Investigation of Safety Concerns Among Direct Service Providers for Adults with Intellectual and Developmental Disabilities

We designed and distributed a survey that assessed safety concerns experienced by direct service providers (DSPs) (N = 59) of adults with intellectual and developmental disabilities (IDD) in community-based group homes at a single human services organization. Results indicated relatively few safety concerns among the respondents from a list of 25 survey statements. Possible influences on the findings are presented such as safety training of the DSPs, comprehensive safety guidelines in place at the group homes, and conditions occasioned by the COVID-19 pandemic. Current safety research in IDD supports the necessity of assessment to inform prevention and intervention strategies.

Public speaking disfluencies: A review of habit reversal training and research

From 2016 to 2022, the Journal of Applied Behavior Analysis published 7 studies that evaluated the effects of habit reversal training on speech disfluencies (filled pauses) during public speaking. This review summarizes the participants, dependent variables, procedures, experimental design, and outcomes from this research including practice implications and suggested areas of inquiry.

Clinical Safety and Treatment of Severe Aggression: Behavioral-Pharmacological Intervention Evaluation in a Young Adult With Autism Spectrum Disorder

This case study concerned clinical safety and behavioral-pharmacological intervention with an 18-year-old man who had autism spectrum disorder and high-frequency aggression toward care providers at a specialized school. A multicomponent behavior support plan included antecedent, differential reinforcement, environmental modification, and physical management procedures subsequently combined with psychotropic medication (aripiprazole). Clinical safety components emphasized comprehensive care provider training, continuous supervision, function-based treatment, and prevention-focused strategies. The behavioral-pharmacological intervention eliminated implementation of aggression-contingent physical restraint and was associated with increased transition compliance during the school day. Throughout the 7.5 months duration of the study, there were no injuries to the participant or other students and a single injury was sustained by one care provider. Intervention effects were long-standing, and care providers rated their training, implementation fidelity, and therapeutic outcome favorably.

Behavioral Training and Performance Management of Human Services Organization Care Providers During the COVID-19 Pandemic

Objectives

This report describes a model of training and performance management that was designed for and implemented with care providers at a residential school for children with neurodevelopmental and intellectual disabilities in response to the COVID-19 pandemic. The model focused on health and safety concerns, risk mitigation, and intervention integrity.

Methods

Procedures followed an applied behavior analysis (ABA) and organizational behavior management (OBM) framework. Action plans addressed (a) critical COVID-19 protocols, (b) behavior-specific implementation guidelines, (c) remote and in-person training formats, (d) in vivo supervision, and (e) knowledge and performance assessments.

Results

A competency evaluation (field study) revealed that participant care providers (N = 25) acquired and maintained COVID-19 protocols at near 100% proficiency immediately following and 1-month post-training. Supervisors had uniformly positive approval and acceptance ratings of school responsiveness to the COVID-19 pandemic.

Conclusions

Integrated and evidence-based care provider training and supervisory practices can promote risk mitigation and performance effectiveness during health crises such as the COVID-19 pandemic. More controlled research that includes multiple dependent measures is needed to replicate and extend our findings to similar human services settings.

Organizational Responsiveness to the COVID-19 Pandemic: a Mixed Methods Social Validity Assessment of Human Services Care Providers

OBJECTIVES

The COVID-19 pandemic posed many challenges to human services organizations serving persons with pre-existing conditions and health concerns. Study objectives were to assess organizational responsiveness to the pandemic through training, safety, and risk mitigation initiatives at community-based group homes for adults with intellectual disability (ID) and acquired brain injury (ABI).

METHOD

This was a two-phase mixed methods study with human services care providers. In phase 1, 54 focus group participants responded to standardized interviews about leadership actions in the early months of the COVID-19 pandemic and discussed implementation effectiveness. These qualitative findings informed the design and distribution of a multi-item questionnaire in phase 2 that quantified acceptance and approval of leadership actions among 498 participants.

RESULTS

Both focus group and questionnaire participants identified several consistent leadership actions that had a positive impact on risk mitigation, health promotion, and participant satisfaction. Participants also converged on priority needs and recommendations for performance improvement.

CONCLUSIONS

The study supports previous research on the effects of pandemic health crises among frontline healthcare workers and more definitively the impact on direct care providers of adults with ID and ABI during COVID-19. Care providers were able to judge organizational effectiveness and provide feedback to aide strategic planning. Mixed methods research provides an approach to large-scale program evaluation through integrated qualitative and quantitative analyses.

Parent-Mediated Home Intervention for Delayed Sleep-Onset and Night Waking in a Child With Autism Spectrum Disorder

We report the case of a 10-year-old boy with autism spectrum disorder who had difficulty initiating and maintaining sleep. Through home consultation, his parents were trained to implement a multicomponent sleep intervention that included (a) faded bedtime, (b) regimented pre-bedtime routines, and (c) elimination of positive social consequences contingent on sleep problems including unwanted co-sleeping. A critical element in the case was functional assessment of the conditions associated with poor sleeping and matching intervention to parent preferences. Compared to a baseline phase, intervention reduced night waking frequency and duration as well as the time required for the boy to fall asleep. Follow-up results one and 2 months post-intervention documented sustained improvement.

Effects of a peer-mediated performance improvement intervention on recording of child well-body checks by educational care-providers

We report the effects of peer-mediated training as a performance improvement intervention on recording of well-body checks by classroom instructors at a specialized school for children and youth. The instructors were trained as peer mediators and then assumed performance monitoring responsibilities in the classroom. Compared to baseline phases in a withdrawal design, peer-mediation increased recording of well-body checks to near-100% among the instructors. Results of the study document positive training effects on a critical health and wellness objective, support and expand the limited research base concerning the effects of peer-mediated training, suggest further application of such training in human services settings.

Behavioral assessment and faded bedtime intervention for delayed sleep-onset in an adult with autism spectrum disorder

Faded bedtime has been evaluated as a behavioral intervention for delayed sleep-onset principally with children and youth who have intellectual and developmental disabilities in hospital and home settings. The present case report describes behavioral assessment and faded bedtime intervention in a 21-year old adult man with autism spectrum disorder at a community-based group home. The study also documented the effects of family home visits on the man's sleep when he returned to the group home. Compared to a pre-intervention (baseline) phase, faded bedtime was associated with increased intervals of recorded sleep and a decrease in sleep-onset latency over several months of implementation. We discuss clinical implications of the case and generality of findings across populations and settings.

Applied behavior analysis measurement, assessment, and treatment of sleep and sleep-related problems

This discussion article considers applied behavior analysis measurement, assessment, and treatment of sleep and sleep-related problems among infants, children, and youth who are typically developing and have neurodevelopmental disabilities. Measurement has concentrated on designing practitioner-implemented methods and improving fidelity of data recording through sleep-monitoring instrumentation. The emphasis of assessment is identifying antecedent and consequence variables that promote sleep and evoke and maintain sleep-related problems. Treatment research has evaluated several effective interventions for problems such as delayed sleep-onset, night and early morning waking, bedtime resistance, and unwanted co-sleeping. Early and contemporary applied behavior analysis research is reviewed relative to function-based treatment formulation, intervention integrity, social validity, and research-to-practice translation.

Re-Establishing Solid Food Consumption in a Person With Traumatic Brain Injury and Extended Food Avoidance/Restriction Using a Multicomponent Behavioral Intervention

We describe and report the results of a multicomponent behavioral intervention for re-establishing solid food consumption in a 26-year-old woman with prolonged food avoidance and restriction which developed following a traumatic brain injury. The intervention was evaluated by direct measurement of daily meal consumption over a period of several months, including an extended follow-up, and resulted in successful resumption of oral feeding. A complicating paroxysmal movement disorder resolved during treatment as well and resolution of the presenting problem led to significant quality of life improvements. We discuss the relationship of the presenting symptoms to avoidant/restrictive food intake disorder and to food rejection behavior seen when substantial damage has occurred to the parietal lobe. The case illustrates the value of assessment-based, individualized intervention design and an integrated neurobehavioral case conceptualization.

Behavioral Training in the Acquisition of Skills for Blind, Severely Retarded Adults

The research described in this article evaluated the effectiveness of a behavioral training program for improving the prevocational work performance of three blind, severely retarded women. In two studies, in which the three women were trained separately, a program that combined response-contingent prompting and reinforcement procedures was successful in increasing the quantity of tasks that each woman completed. Data from one study also demonstrated that attentional behavior was enhanced following training and that improved performance could be sustained with low levels of prompts from the trainer.

Teaching students with autism spectrum disorder to tolerate haircutting

We describe intervention with 2 adolescent male students who had autism spectrum disorder (ASD) and resisted haircutting performed by care providers at a residential school. The students were exposed to a graduated hierarchy of steps including the presence of hair clippers, and increased duration of hair clippers against their scalp and hair. Edible reinforcement was presented contingent on completion of a step without interfering behavior. Both students learned to tolerate all of the steps in the graduated hierarchy and a full haircut with maintenance at 2-, 4-, and 6-month follow-up. The study supports previous tolerance-training research with children and youth who have intellectual and developmental disabilities and resist personal care and hygiene routines.

Consultation in the Residential Treatment of Visually Impaired Children

The purpose of behavioral consultation is to train direct caregivers to assess, implement, and evaluate treatment programs to reduce maladaptive behavior. This article describes a behavioral consultation model developed in a residential treatment program for visually impaired children. The two case studies presented illlustrate the application of behavioral modification techniques. The article concludes with suggestions for overcoming the resistance of staff members to using behavior modification.

Behavioral Treatment of Aggression and Self-Injury in Developmentally Disabled, Visually Handicapped Students

Management problems are often encountered among developmentally disabled populations. The authors describe behavior modification treatment procedures that were applied by direct-care staff in a residential school to control severe aggression and self-injury in two developmentally disabled, visually handicapped students. In one case, the aggressive and self-injurious behaviors of an 11-year-old with vision and hearing deficits were reduced by positive-practice overcorrection. In the other, a blind adolescent's self-injurious behavior was eliminated by a combination of restitutional overcorrection, verbal command, and response-immobilization techniques. The practicality of applying behavioral treatment procedures in educational settings for visually handicapped students is discussed.

Faded Bedtime Intervention for Delayed Sleep Onset in an Adolescent With Autism Spectrum Disorder

We report the case of an 18-year-old girl who had autism spectrum disorder (ASD) and demonstrated persistent delayed sleep onset after going to bed in her group home at a residential school. Intervention consisted of a faded bedtime in which her customary time to bed was extended later into the night, then gradually made earlier as she started falling asleep more rapidly over the course of many weeks. By conclusion of the study and at a 1-month follow-up, the girl was falling asleep in less than 30 min after going to bed and sleeping an average of 8.4 hr each night. Compared with previous research with children in inpatient and home environments, the study found positive effects from a faded bedtime intervention without additional procedures, targeted an adolescent with ASD, and was conducted by care providers in a novel residence setting.

Integrated Behavioral Intervention and Person-Centered Therapy Within Community-Based Treatment of an Adult With Acquired Brain Injury

We present the case of a 30-year-old woman who had acquired brain injury (ABI) and demonstrated clinically challenging behaviors (verbally abusive outbursts toward care providers and elopement) within her community-based group home. Following a baseline phase of evaluation, she collaborated with clinicians and care providers in developing a treatment plan that included personal goal setting, differential token reinforcement, communication training, graphic performance feedback, and reinforcement fading. During 10 months of intervention, clinically challenging behaviors steadily decreased from baseline levels and low-frequency occurrence was maintained at 3-, 6-, and 9-month follow-up assessments. As the result of treatment, the woman also avoided prior psychiatric hospitalizations, enjoyed more frequent access to pleasurable activities outside her residence, and enrolled in a college course. The study illustrates an effective person-centered therapy approach combined with behavioral intervention for persons who have ABI and experience community-living adjustment difficulties.

Treatment of Aggression in an Adult With Intellectual Disability and Physical Impairment Through Function-Based Ambulatory Support

We report the case of a man who had intellectual disability and physical impairment, required assistance from care-providers when ambulating, and demonstrated aggression during transitions between locations. Results of a functional analysis suggested that aggression was negatively reinforced by termination of transition-assisted guidance from care-providers. Intervention evaluation found that aggression during transitions was eliminated by providing the man with ambulatory support through a gait-trainer device that removed the need for care-provider assistance. The case study supports and extends previous research on the analysis and treatment of problem behaviors occurring during environmental transitions.

Improving Classroom Appearance and Organization Through a Supervisory Performance Improvement Intervention

This study evaluated the effects of a supervisory intervention on maintenance of appearance and organization in classrooms at a human services program for children and youths. The intervention combined performance feedback to classroom staff, public posting of performance outcomes, and eligibility for a performance-based incentive. Conducted in a multiple-baseline design, intervention was immediately and consistently effective in all classrooms. These findings support organizational behavior management applications within human services programs to improve performance that is related to environmental care.

Escape-Motivated Bathroom Visits: Effects of Activity Scheduling, Cuing, and Duration-Fading in an Adult With Intellectual Disability

We report the case of a woman who had intellectual disability, made frequent bathroom requests, and spent excessive time in the bathroom at a day-habilitation center. Functional behavioral assessment suggested that frequency and duration of bathroom requests were escape-motivated. Intervention was directed at reducing the reinforcing effects of visiting the bathroom through (a) activity scheduling, (b) cuing the woman to exit the bathroom according to a fixed time limit, and (c) gradually reducing the time limit to an acceptable duration. Compared with a baseline phase, intervention was associated with decreased bathroom requests and duration of bathroom visits that were maintained at 2-month follow-up. We discuss clinical implications of these findings and recommendations to practitioners.

Home-Based In Vivo Desensitization Treatment of Bathroom Avoidance in a Child With Autism Spectrum Disorder

We report the case of a 7-year-old boy who had autism spectrum disorder and displayed disruptive and avoidant behavior when using the bathroom at home with people present in adjoining rooms or nearby the bathroom door. Desensitization treatment was implemented by gradually exposing the boy to proximity of an in-home therapist when he was in the bathroom and positively reinforcing the absence of disruptive behavior. Treatment effectively eliminated bathroom avoidance and generalized to settings outside the home. Intervention outcome was maintained 6- and 7-months post-treatment.

Clinical Peer Review

This article describes a comprehensive model of clinical peer review that was established at a large behavioral healthcare organization serving children, adolescents, and adults with developmental disabilities. The purpose of peer review is to provide routine evaluation of practice standards that will produce the highest quality of habilitative care. The major components of peer review address (a) clinical support and administration, (b) intervention policies and procedures, (c) case consultation, (d) utilization of extraordinary procedures, (e) performance improvement projects, and (f) communication at all levels of the organization. This article discusses implementation of the model, including examples and illustrations, and factors that contribute to positive outcome. This approach to peer review represents a systems methodology that can be adopted by behavioral healthcare and human service organizations to build an in-house program of clinical quality improvement. It is a necessary first step in the large-scale implementation of behavioral services.

Effects of Verbal and Graphic Performance Feedback on Behavior Support Plan Implementation in a Public Elementary School

Previous research suggests that performance feedback improves treatment integrity. This study compared the effects of verbal performance feedback and verbal plus graphic performance feedback on implementation of a student-specific behavior support plan (BSP) by members of a second-grade teaching team at a public elementary school. A consultant to the school delivered feedback following regularly scheduled classroom observations. Results indicated that combining verbal and graphic performance feedback was more effective than verbal performance feedback alone in improving treatment integrity. Informal data collected on student performance also suggested that appropriate behavior increased with better implementation of the BSP. Clinical and research issues are discussed.

Training Instructional Skills With Paraprofessional Service Providers at a Community-Based Habilitation Setting

The present study evaluates a training program with paraprofessional service providers at a community-based habilitation setting. Four staff were taught to implement alternative and augmentative communication instruction with an adult who had autism and mental retardation through a combination of instruction, demonstration, behavior rehearsal, and performance feedback. Training was conducted under natural conditions at the adult's group home residence. Three of the four staff were able to maintain near-100% instructional accuracy following initial training. The results add to the limited research literature concerning community-based training of direct-care personnel.

Habit Reversal Treatment of Vocal and Motor Tics in a Child With Tourette's Syndrome

Habit reversal (HR) is a multicomponent treatment for tic disorders. This case study incorporated elements of HR (awareness training, self-monitoring, response competition), combined with relaxation, as an intervention for vocal and motor tics in a 10-year-old boy with Tourette's syndrome (TS). Therapy was provided on an outpatient basis at a pediatric clinic. In-home data collection by the boy's mother documented decreased tic frequency during the course of treatment. Clinical improvement was maintained at a 3-month follow-up. These results support previous research demonstrating efficacy of simplified HR in controlling multiple tics associated with TS.

Cognitive-Behavioral Treatment of Generalized Anxiety

This case report describes cognitive-behavioral treatment (CBT) with a 7-year-old girl diagnosed with generalized anxiety disorder (GAD) and specific phobia (fear of vomiting). Developmental history was significant for excessive worry, pervasive anxiety, and complaints of stomach discomfort. Her fear of vomiting had resulted in eating inhibition and weight loss. Treatment focused on teaching behavioral skills to reduce anxiety (distraction, relaxation), correcting misattributions about physiological sensations, reducing anxiety-inducing self-statements, and eliminating reinforcement of somatic symptoms in the family system. Self-report on the State-Trait Anxiety Inventory for Children (STAIC) before and following CBT documented clinically significant changes in anxiety. At termination, the client no longer met diagnostic criteria for GAD or specific phobia. Over the course of treatment, complaints of stomachaches were significantly reduced, and the client demonstrated weight gain. A 5-month posttreatment evaluation revealed that clinical improvement was maintained.

Evaluation of a Cognitive-Behavioral Treatment Protocol for Panic Disorder

The authors describe the case of a 34-year-old woman diagnosed with panic disorder and depression who was treated with a cognitive-behavioral protocol derived from clinical practice guidelines. Using a single-case (baseline-treatment) evaluation design, the effects of therapy were assessed for the frequency of panic attacks per week and selfreported ratings of anxiety, depression, and fear of panic. The 24-weekcourse of treatment included multiple procedures but emphasized physiological self-monitoring, cognitive restructuring, situational exposure, and anxiety regulation. Results were an elimination of panic attacks and clinically significant reductions in intensity ratings of panic fear and anxiety intensity. These outcomes were maintained 3 months posttreatment. Improvements were also documented on the BeckDepression Inventory and BeckAnxiety Inventory administered before and after therapy. Implications and recommendations are presented.

Efficacy of Stress Inoculation Training in a Case of Posttraumatic Stress Disorder (PTSD) Secondary to Emergency Gynecological Surgery

Stress inoculation training (SIT) was evaluated as treatment for posttraumatic stress disorder (PTSD) in a 27-year-old who experienced emergency gynecological surgery (hysterectomy) 3weeks after delivering her first child. She was seen at an outpatientmental health center with complaints of sleep disturbance, flashbacks, prolonged crying, avoidance of landmarks associated with the surgery, and chronic distress in response tomultiple environmental stimuli. SITwas instituted during eight treatment sessions in which she was taught progressive muscle relaxation, deep breathing, guided imagery, covert modeling, thought stopping, and thought replacement procedures. Evaluated in a single-case experimental design format, the effects of treatment were that the woman no longer had stressinducing experiences and her level of discomfort in the presence of identified environmental triggers essentially was eliminated. However, at a follow-up session she reported other life circumstances that had not improved contemporaneously. The case is discussed with reference to evidence-based treatments for PTSD.

Behavioral treatment of rumination: Research and clinical applications

This brief review describes research on rumination treatment that emphasizes functional analysis, recent intervention methods (supplemental feeding, fixed-time stimulus presentation, continuous access to preferred stimulation), clinical implications, and procedural recommendations.

Effects of an idiosyncratic stimulus on functional analysis of vocal stereotypy in two settings

OBJECTIVE

This study evaluated the effects of an idiosyncratic stimulus (Legos plastic blocks) on vocal stereotypy by a child with pervasive developmental disorder during functional analysis sessions conducted in analogue and natural settings.

METHODS

The presence and absence of the idiosyncratic stimulus was controlled in a multielement experimental design that incorporated four functional analysis conditions.

RESULTS

The background presence of the idiosyncratic stimulus was associated with a higher percentage of vocal stereotypy in all functional analysis sessions in both settings when compared with phases where the stimulus was absent.

CONCLUSIONS

The presence or absence of specific stimuli can alter the results of a functional analysis and produce inaccurate conclusions about the environmental conditions that occasion problem behavior.

Interpersonal Psychotherapy and Cognitive-Behavioral Therapy as an Integrated Treatment Approach for Co-Occurring Bipolar I and Social Anxiety Disorder

Social anxiety disorder (SAD) is frequently comorbid with bipolar disorder (BD), yet frontline pharmacological interventions for SAD are often contraindicated for individuals with BD. We present a case report of a 29-year-old male with Bipolar I Disorder who received cognitive-behavioral therapy (CBT) for SAD, followed by CBT and interpersonal therapy (IPT) for SAD. The patient completed standardized self-report measures of social anxiety and depressive symptoms throughout treatment and at 1-month and 3-month follow-ups. The greatest social anxiety symptom improvement occurred during the CBT phase, and the patient experienced small but additional benefit with the incorporation of IPT techniques. Although not a direct target of treatment, the patient’s depressive symptoms remained subthreshold throughout treatment. Finally, the patient reported significantly higher quality of life at 1-month and 3-month follow-ups, compared with a reference group of BD outpatients. Findings offer preliminary support for the integration of CBT and IPT in treating comorbid SAD among individuals with BD. Clinical implications and suggestions for future research are discussed.