Blending Stimulus Fading Procedures with Forward Chaining to Address Treatment Resistance in an Adult with an Autism Spectrum Disorder

Abstract

The following paper details the implementation of a program to address the high-risk physical aggression and property destruction behavior of an adult male with an autism spectrum disorder (ASD) and severe aggressive behavior. A task analysis (TA) and forward chaining were combined with a stimulus fading procedure to allow the subject to be able to participate in van rides when prompted with no displays of aggressive or self-injurious behavior. A follow-up probe completed at 1-year post intervention demonstrated the maintenance of the gains that were made during treatment.Keywords Fading . Autism . Non-compliance . Task analysis . Physical aggression . Self-injurious behaviorThe teaching of complex skills that involve a number of steps is a challenge that faces those working with individuals with autism spectrum disorders (ASDs). The task is much more manageable when the complex behaviors are broken down into a series of steps that are taught individually. This forward chaining approach involves the first step in the task being taught followed by the succeeding steps (Cooper et al. 2007). An obstacle to completing the chain can be escapemaintained disruptive behavior. The use of effective chaining procedures can be combined with other behavioral techniques to facilitate learning despite significant aggression.Avoidance responses have been treated using various behavioral procedures (Jones and Friman 1999;Shabani and Fisher 2006). These approaches have employed graduated exposure protocols or hierarchies in order to expose the subject to the avoided stimulus. The intent is to induce extinction of the avoidance response through the systematic presentation of the feared stimulus. Shabani and Fisher (2006) demonstrated this intervention when applied to the needle phobia of an 18 year old with an autism spectrum disorder. The results showed that he was able to tolerate the use of the lancet and to follow the steps that were required to draw his blood at the completion of the hierarchy. Similar results were found with a 35-year-old female that displayed a fear of riding in cars.Operant techniques were used to treat the car avoidance displayed by a female subject (Mansdorf 1976). Verbal resistance and other aggressive behaviors were noted when the subject was told that she would have to ride in a car in order to go to a work program. A hierarchy was constructed consisting of a list of successive approximations that culminated in the subject taking progressively longer car rides with the experimenter.The current study used similar operant procedures to treat the significant aggression of an adult with an autism spectrum disorder. The aggression was displayed whenever he was prompted to ride in a van to the day program that he was attending. The primary difference in this study is the severity of the aggressive behavior and the significant obstacle that this posed to safe transport in a van. Several staff and family members had received injuries as a result of the aggressive behavior displayed when the subject wa...

Treatment of Aggression in Adults with Autism Spectrum Disorder: A Review

“…To date, there have been 21 case reports, 52 , 54 , 55 , 67 – 84 17 N of 1 nonrandomized trials, 56 , 57 , 85 – 99 16 prospective open trials, 41 , 46 , 47 , 58 , 100 – 111 8 retrospective reviews, 39 , 112 – 118 1 naturalistic case-control study, 119 and 7 randomized, controlled trials 48 , 120 – 125 of treatments for aggression in adults with ASD.…”

“…Table 2 summarizes the 17 N of 1 trials 56 , 57 , 85 – 99 that were reviewed regarding treatments for aggression in adults with ASD. These trials—primarily nonrandomized and crossover in nature—suggest potential usefulness of propranolol, 89 behavioral interventions (such as DRO schedules, 88 , 91 , 92 , 94 positive behavioral support programs, 56 , 57 nonexclusionary time-out procedures, 86 behavioral report cards, 87 use of “do” versus “don’t” requests to interrupt aggressive behavior, 95 provision of social comments prior to task demands, 93 task analysis/forward-chaining with prompt stimulus fading, 99 and electromyographic [EMG] response discrimination biofeedback training 85 ), multisensory environments, 96 and physical exercise. 90 …”

“…Finally, 10 of the 17 studies 56 , 57 , 85 – 88 , 90 , 91 , 93 , 98 were judged to be at serious risk of bias due to baseline or time-varying confounding (i.e., at least one known important confounding domain was not measured or controlled for), while the remaining 7 studies 89 , 92 , 94 – 97 , 99 were assessed to be at moderate risk of bias in this regard (i.e., confounding was expected, but all known important confounding domains were appropriately measured and controlled for). Overall, the nonrandomized nature of most of these studies makes it difficult to firmly conclude that the interventions studied were responsible for the effects observed and to exclude other factors that could have accounted for the outcomes.…”

“…Lower levels of evidence (e.g., nonrandomized N of 1 trials, prospective open trials, retrospective reviews) point to possible benefits, in adults with ASD and aggression, of behavioral interventions, 56 , 57 , 67 , 85 – 88 , 91 – 95 , 99 multisensory environments, 96 , 109 yokukansan, 58 , 110 clomipramine, 104 sertraline, 46 , 103 clozapine, 115 , 117 and aripiprazole. 76 , 77 , 82 , 116 Among these interventions, multisensory environments and yokukansan are slightly more supported based on risk-of-bias assessments.…”

“…Behavioral theories posit that aggression in individuals with ASD serves some function (e.g., to receive attention, escape from tasks or demands, obtain a tangible reinforcer, seek sensations/novelty) that leads to consequences that reinforce such behavior. 57 , 94 , 99 These behaviors are often triggered by some type of antecedent. For example, a young woman with ASD, in response to being instructed or reminded to take a shower by a caregiver (antecedent), may begin to scream and hit the caregiver (behavior), leading the caregiver to withdraw the shower reminder and offer an alternate, more desired activity (consequence).…”