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CASE SECTION Zoe is a 25-month-old girl who presented to developmental-behavioral pediatrics with her parents for follow-up after receiving a diagnosis of autism spectrum disorder with global developmental delay and language impairment 3 months ago. Zoe was born by spontaneous vaginal delivery at term after an uncomplicated pregnancy, labor, and delivery. She had a routine newborn course and was discharged home with her parents 2 days after her birth.At 7 months, Zoe was not able to sit independently, had poor weight gain, and had hypertonia on physical examination. Her parents described her to tense her arms and have hand tremors when she held her bottle during feedings and reported that she had resisted their attempts to introduce pureed or other age-appropriate table foods into her diet. The Bayley Scales of Infant and Toddler Development Screening Test was administered and found a cognitive composite score of 70, language composite score of 65, and motor composite score of 67. Chromosomal microarray analysis, testing for fragile X syndrome, laboratory studies for metabolic disorders, magnetic resonance imaging of the brain, and an audiologic examination were normal. Zoe was referred to and received early intervention services including physical therapy, feeding therapy, and infant stimulation services. By 16 months, Zoe was walking independently and was gaining weight well but continued to have sensory aversions to some foods.At 22 months, Zoe was evaluated by a multidisciplinary team because of ongoing developmental concerns and concerning results on standardized screening for autism spectrum disorder completed at her 18-month preventive care visit. Her parents also reported concern about the possibility of autism spectrum disorder (ASD) because they both were diagnosed with ASD as young children. Both parents completed college and were employed full-time. Zoe's mother seemed to be somewhat anxious during the visit and provided fleeting eye contact throughout the evaluation. Zoe's father was assertive, but polite, and was the primary historian regarding parental concerns during the evaluation.Zoe was noted to have occasional hand flapping and squealing vocalizations while she roamed the examination area grabbing various objects and casting them to the floor while watching the trajectory of their movements. She did not use a single-finger point to indicate her wants or needs and did not initiate or follow joint attention. She met criteria for ASD. In discussing the diagnosis with Zoe's parents, they shared that they were not surprised by the diagnosis. They expressed feeling that Zoe was social and playful, although delayed in her language. Hence, they were more concerned about her disinterest in eating. They were not keen on behavioral intervention because they did not want Zoe to be "trained to be neurotypical." Although the mother did not receive applied behavior analysis (ABA), the father had received ABA for 3 years beginning at age 5 years. He believed that ABA negatively changed his personality, and he did not want the same for Zoe.How would you assist Zoe's parents in identification of priorities for her developmental care while ensuring respect for their perspective of neurodiversity?

The paper, by translating the concept and the two models of endophenotype (EP), strengthens the hypothesis that there exists a linkage between anorexia nervosa (AN) and autism spectrum disorder (ASD). Specifically, the paper synthesizes empirical research that supported the idea that individuals with AN and individuals with ASD share similarities with respect to their neurocognitive EPs and temperament EPs. The paper then introduces an innovative structure to emphasize the subtle difference between neurocognitive EPs and temperament EPs in relation to AN and ASD. This structure constitutes the categorization of the shared neurocognitive EPs to the liability-index model of EP and the shared temperament EPs to the mediational model of EP. The paper argues that the shared neurocognitive EPs under the liability index model of EP are trait markers signaling the effects of genes on the phenotypes of AN and ASD; whereas, the shared temperament EPs under the mediational model of EP are state markers describing the symptomatic status of AN and ASD. The proposition of the paper suggests clinicians and researchers should target the atypical state markers (i.e., temperament EPs) shared between AN and ASD when tailoring environment-based treatments for individuals with AN who exhibit autistic behaviors and individuals with ASD who display disordered eating behaviors or anorexic symptoms.

This case study describes the successful implementation of a behavioral intervention for the mealtime problem behaviors of a 16-year-old girl with Pervasive Developmental Disorder Not Otherwise Specified attending a private school for students with developmental disabilities. Initially, an analogue-functional analysis using a pairwise single-case experimental design was conducted, and based on the results of this assessment, a multicomponent function-based intervention was developed. The results obtained demonstrated that interventions for problem behaviors developed in hospital-based clinics can be implemented in community-based educational settings successfully. The results also demonstrated that behavioral intervention strategies shown to be effective with young children with developmental disabilities also work for a teenager with an autism spectrum disorder, illustrating the generality of a behavioral approach to feeding difficulties. Methodological limitations of the case study, advantages of a community-based treatment approach, and recommendations for clinicians are provided.

Pica is an eating disorder characterized by the ingestion of inappropriate items. The items may range from relatively harmless materials (e.g., food from the floor, grass) to other substances (e.g., glass) with risk for serious health problems or even death. Previous studies have shown that behavioral techniques are effective for decreasing pica, but few studies have assessed this in naturalistic settings. The current paper describes a study conducted in a classroom setting in which functional communication was taught to a 6-year-old boy with autism to replace pica. Differential reinforcement of functional communication behavior was used to teach the boy to request food rather than to engage in pica. This procedure decreased the boy's frequency of pica and of attempted pica. Keywords: pica, autism; differential reinforcement; functional communication training; manding. Introduction Pica is an eating disorder often displayed by persons with developmental disabilities (Singh, 1983). It is typically defined as either the consumption of non-food items or the compulsive consumption of both food and non-food items (Albin, 1977; Paisey & Whitney, 1989). Many individuals with pica ingest items that are relatively harmless, such as food from the floor, grass, or bugs (Johnson et al., 1994; Fisher et al., 1994). However, some individuals with pica ingest items (e.g., glass) that can lead to serious digestive problems, health issues, and possibly death (Rojahn et al., 1987). Several literature reviews describe interventions for persons who present with pica (e.g., McAdam, Sherman, Sheldon, & Napolitano, 2004). In one recent review McAdam et al. (2004) summarized the various behavioral interventions that have been demonstrated to produce a clinically significant reduction in pica, including differential reinforcement, overcorrection, contingent aversive presentations, and discrimination training. However, this review also found that the majority of published studies used intervention packages that included a punishment component. Moreover, few of the studies were conducted in natural settings (e.g., public schools, community-based agencies for adults with developmental disabilities). Three published studies have demonstrated that differential reinforcement as the primary independent variable was successful in decreasing the pica of 6 persons with developmental disabilities. In one of these studies, Goh, Iwata, & Kahng, (1999), used naturalistic observations to assess the function of cigarette pica performed by three adult males and one female with developmental disabilities in a state residential facility. The function of pica for all participants was determined to be automatic reinforcement. That is, each participant's pica was maintained by non-socially mediated variables. Next, a series of preference assessments were conducted to identify the specific reinforcing aspect of the cigarette (e.g., the unsmoked filter) and to identify high preference items that could function as competing reinforcers. Initially, for three of the participants, the authors assessed the affect of satiation by providing preferred edible items every 10 seconds, for 5 minutes, prior to the start of a session. Next, the participants were taught to hand a cigarette to their therapist and all attempts to engage in pica were blocked. For the fourth participant, a punishment procedure was used in addition to non-contingent reinforcement to reduce the participant's pica. In another study, Donnelly and Olczak (1990) used differential reinforcement of an alternative behavior (DRA) to compete with the cigarette pica of two adult males. Both participants were differentially reinforced for chewing sugarless mint gum. The results demonstrated that gum chewing successfully competed with the participant's pica. Smith (1987) used verbal prompting ("don't touch") and differential reinforcement of incompatible behavior (DRI) to reduce the pica of an adult male participating in community-based supportive employment. …

This study describes an assessment of the influence of idiosyncratic antecedent variables on the problem behavior of a 9-year-old boy with pervasive developmental disorder and attention deficit hyperactivity disorder. The results of these analyses suggested that the boy displayed problem behavior during situations in which demands were provided and idiosyncratic variables were present. The efficacy of a treatment package consisting of a visual cue and differential reinforcement to treat the boy’s problem behaviors is described. Finally, the importance of assessing the influence of antecedent variables on the problem behavior of persons with developmental disabilities and limitations of the current research are discussed.

In the present investigation, a functional analysis of the disruptive behavior of a 18-year-old man who had been diagnosed with attention deficit hyperactivity disorder and moderate mental retardation was conducted, both when he was taking methylphenidate and when he was not taking the medication. The results of this functional analysis demonstrated that the participant's disruptive behaviors were reinforced by access to attention only when he was not taking methylphenidate.

Treatment for aberrant behavior in persons diagnosed with developmental disabilities typically involves either behavioral interventions or medication. Often, the treatment is a combination of the two. Schroeder and coworkers (Schroeder et al. [1983] Adv Learn Behav Disabil 2:179–225) outlined criteria for the evaluation of the combination of behavioral and drug interventions in persons with developmental disabilities. A review of the research that examined the combination of drug and behavior interactions since 1983, using the Schroeder et al. criteria, is provided. An evaluation of research since 1983 that examined medication effects on multiple dependent measures and between multiple medications, using the criteria for medication research by Sprague and Werry (Sprague and Werry [1971] Int Rev Res Ment Retard vol. 5) is also provided. Additionally, the final section provides a list of recommendations and criteria for practitioners and researchers when conducting or evaluating research designed to examine medication effects on multiple variables in persons with developmental disabilities. MRDD Research Reviews 1999;5:322–334. © 1999 Wiley-Liss, Inc.

Pica is a dangerous form of self-injurious behavior that occurs in people with developmental disabilities who are institutionalized. Studies also indicate that pica has led to the death of people with developmental disabilities. While a number of published studies have demonstrated that pica behavior can be decreased substantially with behavioral treatment, few of these studies incorporated strategies for generalization and maintenance outside of brief sessions. A second limitation of current research is that some studies reduced pica substantially, but pica responses still occurred at rates that are problematic in terms of prevention of adverse consequences, which leaves practitioners with the task of further decreasing pica to protect people exhibiting pica from harm. We make recommendations for assessment, treatment, and prevention of pica for practitioners. These recommendations are based on two extensive reviews of the literature and our extensive experience as practitioners in the treatment of pica. Our hope is that administrators, professionals and practitioners will consider our guidelines and recommendations as they attempt to protect people with pica and developmental disabilities from harm by developing standards for assessment, treatment and prevention for this difficult-to-treat population. Our hope is that children with pica will receive early intervention to prevent pica from developing into life-threatening behavior.

Treatment planning to reduce challenging behavior (e.g., aggression and property destruction) can be complex and requires a prescriptive interprofessional team-based approach. As with other problems that interfere with an individual’s quality of life, such as health issues, the best course of treatment is one that accurately assesses the problem, leads to effective treatment for the issue of concern, and is empirically supported. This is especially important when treating individuals who display problem behavior which frequently interfere with their opportunities to learn and to live and be educated in less-restrictive settings (Matson, Mayville, & Laud, 2003). The utility of functional behavior assessments (FBAs) and functional analyses (FAs) in the identification of the specific function or purpose of challenging behavior has been embraced commonly by persons charged with supporting individuals who display challenging behavior (e.g., behavior analysts and educators). This is demonstrated by the laws requiring FBAs be conducted when individuals are struggling in educational environments (Individuals with Disabilities Education Improvement Act, 2004) and the belief that the assessments conducted should result in the development of interventions that help preserve the child’s placement in the least restrictive appropriate educational setting. The utility of these assessments has been repeatedly demonstrated in the published literature (e.g., Derby et al., 1992; Iwata, Dorsey, Slifer, Bauman, & Richman, 1994; Kennedy & Souza, 1995; Kern, Childs, Dunlap, Clarke & Falk, 1994; McCord, Thompson, & Iwata, 2001; Ellingson, Miltenberger, Stricker, Galensky, & Garlinghouse, 2000). Several excellent reviews of this extensive literature have been conducted and have independently identified functional analysis and assessment as best practice (e.g., Carr, 1994; Hanley, Iwata, & McCord, 2003).

Lactate dehydrogenase (LD) levels rose consistently during MACOP-B chemotherapy for intermediate and high-grade non-Hodgkin's lymphoma (NHL). Levels peaked at week nine and fell to normal within six weeks of completion of therapy. Isoenzyme patterns, studied prospectively in seven patients, showed a parallel rise in LD1 and LD2 suggesting a source other than tumour tissue for the rise in total LD. In the absence of evidence of myocardial or renal damage, haematopoietic tissue was the most likely source. With no evidence of haemolysis, normal serum levels of vitamin B12 and folate and normal red cell folate, dyserythropoiesis was considered to be the underlying mechanism. A rising mean corpuscular volume further reinforced this suggestion. Intensive use of methotrexate along with co-trimoxazole as prophylaxis against pneumoycystis carinii is considered the most likely cause of marrow dysfunction. Failure to recognise that rising LD levels during such therapy is treatment-related, rather than of tumour origin, may lead to inappropriate change or abandonment of therapy.

Repetitive and invariant behavior is a diagnostic feature of autism. We implemented a lag reinforcement schedule to increase response diversity for 6 participants with autism aged 6 to 10 years, 4 of whom also received prompting plus additional training. These procedures appeared to increase the variety of building-block structures, demonstrating that an intervention that includes differential reinforcement can increase response diversity for children with an autism spectrum disorder.

IMPORTANCE: Disruptive behavior is common in children with autism spectrum disorder. Behavioral interventions are used to treat disruptive behavior but have not been evaluated in large-scale randomized trials. OBJECTIVE: To evaluate the efficacy of parent training for children with autism spectrum disorder and disruptive behavior. DESIGN, SETTING, AND PARTICIPANTS: This 24-week randomized trial compared parent training (n = 89) to parent education (n = 91) at 6 centers (Emory University, Indiana University, Ohio State University, University of Pittsburgh, University of Rochester, Yale University). We screened 267 children; 180 children (aged 3–7 years) with autism spectrum disorder and disruptive behaviors were randomly assigned (86% white, 88% male) between September 2010 and February 2014. INTERVENTIONS: Parent training (11 core, 2 optional sessions; 2 telephone boosters; 2 home visits) provided specific strategies to manage disruptive behavior. Parent education (12 core sessions, 1 home visit) provided information about autism but no behavior management strategies. MAIN OUTCOMES AND MEASURES: Parents rated disruptive behavior and noncompliance on co-primary outcomes: the Aberrant Behavior Checklist–Irritability subscale (range, 0–45) and the Home Situations Questionnaire–Autism Spectrum Disorder (range, 0–9). On both measures, higher scores indicate greater severity and a 25% reduction indicates clinical improvement.A clinician blind to treatment assignment rated the Improvement scale of the Clinical Global Impression (range, 1–7), a secondary outcome, with a positive response less than 3. RESULTS: At week 24, the Aberrant Behavior Checklist–Irritability subscale declined 47.7% in parent training (from 23.7 to 12.4) compared with 31.8% for parent education (23.9 to 16.3) (treatment effect, −3.9; 95% CI, −6.2 to −1.7; P < .001, standardized effect size = 0.62). The Home Situations Questionnaire–Autism Spectrum Disorder declined 55% (from 4.0 to 1.8) compared with 34.2% in parent education (3.8 to 2.5) (treatment effect, −0.7; 95% CI, −1.1 to −0.3; P < .001, standardized effect size = 0.45). Neither measure met the prespecified minimal clinically important difference. The proportions with a positive response on the Clinical Global Impression-Improvement scale were 68.5% for parent training vs 39.6% for parent education (P < .001). CONCLUSIONS AND RELEVANCE: For children with autism spectrum disorder, a 24-week parent training program was superior to parent education for reducing disruptive behavior on parent-reported outcomes, although the clinical significance of the improvement is unclear. The rate of positive response judged by a blinded clinician was greater for parent training vs parent education. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT01233414

Two variations of a vocal paired-stimulus preference assessment were evaluated to determine whether the verbal reports of preference, given by individuals with developmental disabilities when no access to the activity was given, matched their verbal reports when access to the activity was given contingent on their choice. The results indicated different outcomes between the two methods for 6 of the 7 participants. Subsequent reinforcer assessments, conducted for 2 participants, showed that activities identified in the preference assessments that provided access contingent on selection resulted in more responding than did activities identified in the preference assessment that did not include access to items following their selection.

The consumption of nonfood items (i. e., pica) frequently occurs in persons with developmental disabilities. Pica may result in the puncture or blockage of the digestive tract, infestation by gastrointestinal parasites, and can interfere with an individual’s daily learning, occupational performance, and quality of life. Twenty-six published studies have examined the efficacy of behavioral-intervention packages (e. g., differential reinforcement of other behavior, noncontingent attention, or overcorrection) on the pica of persons with developmental disabilities. This article reviews those studies and discusses the effectiveness, generality, and acceptability of the various intervention packages used to reduce pica. Additionally, this article highlights the recent clinical advancements that have been made in the treatment of the pica of persons with developmental disabilities.

Consumer satisfaction and social validity were measured during a double-blind, placebo-controlled evaluation of the atypical neuroleptic risperidone in treating severe aberrant behavior of persons with developmental disabilities. First, a satisfaction survey was completed after a medication trial by each participant's caregiver. Results showed that 100% of the caregivers felt that participation was a positive experience for themselves and participants. Second, 52 community members viewed videotapes of 5 participants during a clinical interview when they were taking either placebo or risperidone. Raters also indicated that when on the medication, participants displayed fewer aberrant behaviors, were less irritable, in a better mood, and were more responsive to their environment.