1. BEHAVIORAL PLANNING FOR
CHILDREN WITH PERVASIVE
DEVELOPMENTAL DISORDERS?
pallav pareek m.d.
january 11th 2013

2. Objectives
 Case discussion
 Journal Article:
 Discussion and exchange of
ideas
- Is a behavioral plan
required?
- Does a neurotypical
behavioral plan work in PDD?
- What modifications (if any)
are required?
- Resources in St. Louis Metro
Area?

3. Autism Fact Sheet
 1 in 88 children and 1 in 54 boys
 Autism is the fastest-growing
serious developmental disability in
the U.S.
 Autism costs a family $60,000 a
year on average
 Autism receives less than 5% of the
research funding of many less
prevalent childhood diseases.
 0.55% of total NIH funding.
 40% of children with autism do not
speak

4. Major areas of Target for ASD’s
Behavior
Social
Communication

5. Some Challenging Behaviors in ASD’s
• Aggression is a high-profile behavior
that garners more attention
• Is aggression a reaction to frustration
Aggression and difficulty with appropriately
communicating affect state or
identifying alternative reactions to
frustrating experiences
• SIB is similar to (?) stereotypies with
Self respect to the rhythmical and
repetitive nature of the behavior, but
Injurious in the case of SIB, tissue damage
often results
Behaviors

6. Trivia!!
 What is the average cost of ABA for a family per
annum?

7. Some things that worked…
 Body Bag, Shredder App, Lifting
Weights, Trampoline, Carrying pumpkins etc..

8. History of ABA
 Watson fed up with “hypothetico-deductivo
reasoning”→Experimental Analysis of Behavior →B. F
Skinner
 Initially known as Behavioral Mod
 Lovaas is one of the pioneers: In early years aversives
(Strikes, shouting, shocks) 10 Now mostly positive reinforcers
 Judge Rotenberg Center (formerly Behavior Research
Institute) Canton, Massachusetts
 In the initial studies by Dr. Lovaas11: There were claims of up
to 47% children→ mainstream→ indistinguishable
 Remains the most popular and most evidenced based
approach for Autism
10: Moser D, Grant A (1965-05-07). "Screams, slaps and love". Life
11:Lovaas, O. I. (1987). Behavioral treatment and normal intellectual and educational functioning in autistic children. Journal of Consulting and Clinical Psychology, 55, 3-9

9. Components of ABA
 NRC: Recommends:25 hrs/wk of structured training
 DTT is used to reduce stereotypical autistic behaviours
through extinction and the provision of socially
acceptable alternatives to self-stimulatory behaviors
 EIBI: usually 30hrs/week 2-6 years
 Typical sessions: 5-6 hours, with natural breaks with
child tiring. Positive reinforcers: verbal/food/anything
13: Baer, D.M.; Wolf, M.M.; Risley, T.R. (1968). "Some current dimensions of applied behavior analysis". J Appl Behav Anal 1 (1): 91–97.
http://www.nrc-cnrc.gc.ca/eng/index.html

10. .
 1/11/13
pallav pareek m.d.
clinical case conference
january 11th 2013

11. "In a field rife with fads, pseudoscience, and popular, yet
unproven, interventions….National Standards Project are a
welcome and much-needed counterbalance to much of the
hyperbole for both professionals and families” Peter F.
Gerhardt
 National Autism Center: National Standards
Project, to produce a set of standards for
effective, research-validated education and
behavioral intervention
http://www.nationalautismcenter.org/about/national.php

12. Introduction
 Growing evidence supports the use of intensive
behavioral intervention (IBI)
 Two decades of studies have supported the use of
typical/atypical antipsychotics in treatment of
aggression in ASD
 No studies comparing antipsychotics to other med
classes or combined with IBI

13. Introduction Contd:
 ? Phenotypic overlap BD and ASD suggests mood
stabilizers may be an option
 ADHD+Sleep prompt use of non-stimulant ADHD
meds (α agonist), not for aggression
 Aims to see effects of IBI with AP/MS/NS

14. Hypotheses
1. IBI shall substantially decrease aggressive behaviors
in youth with ASD
2. Time required to achieve behavior plan success
lower in individuals taking AP/MS/NS relative to
those not taking medication
3. Younger, verbal males w low baseline aggression &
lower stereotypy, irritability, and hyperactivity who
received DRO plan predicted succeed quicker

15. Methods
 32 children attending IBI program in Cleveland.
Mean age 11.16 (4-16) 75% male
 DSM diagnosis with Autistic disorder or PDD NOS
were eligible if they received IBI for aggression
 Consecutive youths in retrospective review of charts
between 2000-2007

16. Methods cont:
 All receiving IBI≥ 30 hrs/week. No additional
behavioral therapies.
 Aggression: Any beh that harms/attempts to harm
another/destruction of property. Also interferes with
academics/scoialization/daily living & restricts access
to community involvement
 Inclusion: ↑ 4 aggressive beh/day + 1 day with
multiple aggressive beh were included

17. Methods cont:
 Aggressive beh recorded at baseline (1 wk before
IBI) and then wk 1-3 after beh plan implementation
 Success: defined as↓ 1 agg ep/day for 5 consecutive
days & five session without mod/severe aggression
 Medications: Prescribed as usual by ped
neurologist/psychiatrist/dev pediatrician. (No specific
algorithm used) on meds >2 weeks prior

18. Medications
AP: risp12, ari5, zip1, clo1, zyp1, mol1
n=3 on 2 AP’s
MS: dival6, lithium3, lamo1
NS: clonidine11, atom1
3= all classes 6= AP+MS 4= AP+NS

19. Measures
 ABC (Community) completed by classroom teacher
30-35/wk : Hyperactivity, stereotypy and
irritability subscales used
 VABS (Teacher rating form) to evaluate functl level

20. Results
Number of sessions required to succeed
Changes in frequency of aggressive beh with agg beh plan

21. # of sessions required w/wo
medication

22. # of sessions required for success by
sex/verbal ability

23. Strengths and Limitations
LIMITATIONS STRENGTHS
 Intermingled med classes
 Retrospective
 Comorbidities
 Reason to be on one
medication class vs. other
 Medication dosages?
 Evaluating combinations
 No Randomization (for IBI
or meds)

24. Take Home
 No Extinction burst observed
 Median number of 6 hour sessions needed >30
 No difference between DRO vs. DRA
 MS & NS meds have minimal effect in augmenting
aggression beh plans.

25. Thank You!!
Autists are the ultimate square
pegs, and the problem with
pounding a square peg into a
round hole is not that the
hammering is hard work. It's that
you're destroying the peg.” Paul
Collins