Sleep and stereotypy in children with autism: effectiveness of function-based behavioral treatment

ObjectivesChildren with autism spectrum disorder (ASD) experience high rates of sleep problems, which exacerbate the core symptoms of ASD, including stereotypy (restricted and repetitive behaviors). Conversely, stereotypy can interfere with sleep by actively competing with sleep-facilitative behaviors (eg, lying down quietly). Behavioral interventions informed by functional behavioral assessment (FBA) significantly reduce sleep problems in children with ASD, however, their impact on sleep-interfering stereotypy is not clear. This study investigated the effectiveness of function-based behavioral treatments for sleep problems, including sleep-interfering stereotypy, in children with ASD, the maintenance of these effects, and parents’ satisfaction with the treatment process.MethodsA non-concurrent multiple baselines across participants design was used to evaluate the effectiveness of function-based, individualized treatments for sleep problems and sleep-interfering stereotypy in three children with ASD. For each participant, stereotypy was automatically maintained and interfered with the initiation and/or re-initiation of sleep. Parents implemented multi-component treatments that included a faded bedtime procedure.ResultsTreatment reduced sleep problems in 2/3 participants, and the duration of stereotypy was reduced in all participants. Treatment effects were largely maintained at follow-up, and parent-reported satisfaction was high.ConclusionThese results support prior research demonstrating the effectiveness of FBA-informed behavioral treatments for sleep problems in children with ASD. Further, this study shows that these treatments may be effective in reducing sleep-interfering stereotypy. Future research should more thoroughly investigate the bidirectional relationships between sleep and core symptoms of ASD, and address how these relationships are assessed and treated in the sleep context.     

Kata techniques training consistently decreases stereotypy in children with autism spectrum disorder

The effects of 14 weeks of Kata techniques training on stereotypic behaviors of children with autism spectrum disorders (ASD) were investigated. The study included 30 eligible (diagnosed ASD, school age) children with ages ranging from 5 to 16 years whom they assigned to an exercise (n=15) or a no-exercise control group (n=15). Participants of the exercise group received Kata techniques instruction four times per week for 14 weeks (56 sessions). Stereotypy was assessed at baseline (pre-intervention), week 14 (post-intervention), and at one month follow up in both groups. Results showed that Kata techniques training significantly reduced stereotypy in the exercise group. Following participation in Kata techniques training, stereotypy decreased from baseline levels by a M of 42.54% across participants. Interestingly, after 30 days of no practice, stereotypy in the exercise group remained significantly decreased compared to pre-intervention time. The participants of the control group did not show significant changes in the stereotypy. Teaching martial arts techniques to children with ASD for a long period of time consistently decreased their stereotypic behaviors.     

Vocal stereotypy in children with autism: Structural characteristics,variability, and effects of auditory stimulation

Two experiments were conducted to examine (a) the relationship between the structural characteristics (i.e., bout duration, inter-response time [IRT], pitch, and energy) and overall duration of vocal stereotypy, and (b) the effects of auditory stimulation on the duration and temporal structure of the behavior. In the first experiment, we measured the structural characteristics of vocal stereotypy in five children with autism during five 30-min free-operant sessions. The results suggested that the structure of vocal stereotypy varied considerably within and across participants. Furthermore, the overall duration of vocal stereotypy was positively correlated with bout duration and negatively correlated with IRT. In the second experiment, reversal designs were used to examine the effects of noncontingent access to auditory stimulation (i.e., music) on the vocal stereotypy of three participants. Music decreased engagement in vocal stereotypy for two of the participants. The reductions were mostly associated with a considerable increase in IRT. The implications of the results are discussed in terms of measuring the structural characteristics of vocal stereotypy to identify more effective matched stimuli and using music to facilitate the implementation of other interventions.     

The Use of Differential Reinforcement of Other Behaviours to Establish Inhibitory Stimulus Control for the Management of Vocal Stereotypy in Children with Autism

Objective: This study examined the efficacy of an inhibitory stimulus control procedure (ISCP) for the management of vocal stereotypy in three children with autism. Method: During discrimination training, implemented within a changing criterion design, participants were taught that there were no consequences for vocal stereotypy in the absence of an inhibitory stimulus but that differential reinforcement procedures were in effect in the presence of the stimulus. Functional control of the inhibitory stimulus was subsequently assessed within a reversal design. Results: Inhibitory stimulus control was established during discrimination training, with participants inhibiting vocal stereotypy for 30 min periods in the presence of the inhibitory stimulus. Reductions in vocal stereotypy were maintained in the presence of the inhibitory stimulus and in the absence of further programmed consequences. Discussion: This study extends current knowledge by demonstrating the efficacy of ISCPs paired with reinforcement only, and illustrating the functional control of the inhibitory stimulus.     

A systematic review and evaluation of inhibitory stimulus control procedures as a treatment for stereotyped behavior among individuals with autism

Purpose: Stereotypy is pervasive among persons with autism and may impact negatively on social inclusion and learning. The implementation of resource-intensive behavioral interventions to decrease these behaviors has been questioned. Inhibitory stimulus control procedures (ISCPs) comprise a type of antecedent-based intervention that has been proposed as an effective treatment approach for stereotypy but has received limited research attention to date. Method: The current systematic review sought to examine and synthesize the literature reporting applications of ISCPs in the treatment of stereotypy among persons with autism. Treatment outcomes were analyzed quantitatively and the status of ISCPs as evidence-based practice was evaluated in accordance with the National Autism Center’s National Standards Report guidelines. Results: A total of 11 studies were reviewed with results indicating that ISCPs constituted an emerging treatment for the stereotypy exhibited by persons with autism. Conclusions: ISCPs comprise a promising intervention for stereotyped behavior but further research is required.     

The effect of MK-801 and SCH23390 on the expression and sensitization of morphine-induced oral stereotypy

Repeated high doses of morphine sulfate, administered in a 24–36 h period, stimulates the expression of oral stereotypy in rats. Sensitization to this effect of morphine is demonstrated by the reexpression of the stereotypy by the administration of 4.0 mg/kg of morphine one week following the original exposure. To investigate the role ofN-methyl-d-aspartic acid (NMDA) and D₁ dopamine (DA) receptors in the acute expression and sensitization of morphine-induced oral stereotypy, rats were administered four injections of morphine (10.0 mg/kg) one injection every 12 h and observed for the expression of stereotyic behaviors following pretreatment with selective antagonists. Pretreatment with the NMDA antagonist, MK-801 (0.7 mg/kg), before each of the four morphine injections antagonized both the initial expression of oral stereotypy and the development of sensitization. In contrast, the DA D₁ receptor antagonist SCH23390 (40.0 μg/kg) administered during the four high-dose treatments with morphine antagonized the initial expression of oral stereotypy and not the development of sensitization. These findings implicate glutamate's action at the NMDA receptor in both the acute expression of morphine-induced oral stereotypy, and the development of sensitization of this morphine effect, whereas DA D₁ receptors may only be involved in the acute expression of the stereotypy.     

An evaluation of the effects of experimenter control of objects on individuals' engagement in object stereotypy

In two experiments, the authors evaluated the extent to which (a) individuals preferred engaging in object stereotypy versus observing an experimenter while the experimenter engaged in object stereotypy and (b) an experimenter's engagement in object stereotypy decreased the participants' engagement in object stereotypy. Results of Experiment 1 indicated that behaver-controlled (BC) object stereotypy was preferred over experimenter-controlled (EC) object stereotypy by three of four participants. Results of Experiment 2 indicated that EC object stereotypy decreased object stereotypy for only one of three participants. Implications of these findings for determining the relative importance of control over stimulation generated by stereotypy are briefly discussed.     

Analysis of demand conditions associated with stereotypy

Possible escape/avoidance functions of stereotypic behavior were investigated in a classroom setting using functional academic tasks. A 6-year-old boy's stereotypic mouthing was assessed during high vs low response activities, familiar vs novel activities and avoidance vs partial-avoidance conditions. Results showed that stereotypy occurred at higher rates during more difficult activities (i.e. those that were novel or required a greater number of responses), and when stereotypy was allowed to effect a delay in instructional demands. Treatment procedures based on these analyses were implemented by the classroom teacher and shown to be effective.     

Choosing an Appropriate Physical Exercise to Reduce Stereotypic Behavior in Children with Autism Spectrum Disorders: A Non-randomized Crossover Study

Considerable evidence has shown that physical exercise could be an effective treatment in reducing stereotypical autism spectrum disorder (ASD) behaviors in children. The present study seeks to examine the underlying mechanism by considering the theoretical operant nature of stereotypy. Children with ASD (n?=?30) who exhibited hand-flapping and body-rocking stereotypies were asked to participate in both control (story-time) and experimental (ball-tapping-exercise intervention) conditions. The experimental condition comprised 15 min of ball tapping during which the children were asked to tap a plastic ball as many times as they could. Results indicated that hand-flapping stereotypy was significantly reduced but body-rocking stereotypy following the ball-tapping-exercise intervention was not. These results not only confirm the positive impact of exercise intervention on stereotypic behavior as shown in many previous studies, but further suggest that physical exercise should be matched with the biomechanics of stereotypy to produce a desirable behavioral benefit.     

Behavioural effects of chronic treatment with apomorphine in combination with neuroleptic drugs

Groups of male Wistar rats were injected with either apomorphine alone twice daily for one week or with apomorphine in combination with chlorpromazine or thioridazine. The neuroleptics were administered once daily so that it was possible to assess their duration of effect on the apomorphine responses. Other groups were injected with saline (controls) chlorpromazine or thioridazine. The nature and time of onset and duration of the stereotyped response following apomorphine injection was determined twice daily. In addition, the behaviour of the rats on the hole board apparatus was also assessed after seven days of drug treatment. Apomorphine was found to induce either a "sniffing/burrowing" or a "fighting" stereotypy. Chlorpromazine increased the latency and reduced the duration of both types of stereotypy. In contrast thioridazine only increased the latency and reduced the duration of response the "fighting" group. On the hole board apparatus, both neuroleptics reduced the ambulation and rearing scores of the "fighting groups alone. It is suggested that the different types of stereotypy induced by chronic apomorphine administration, and their sensitivity to the two neuroleptics, are mediated by different types of dopamine receptors.     

Partial reversal of stress-induced behavioral sensitization to amphetamine following metyrapone treatment

Several studies indicate that blockade of stress-induced corticosterone secretion prevents the development of stress-induced sensitization to the behavioral effects of stimulants. The present study examined whether chronic blockade of corticosterone synthesis with metyrapone could reverse stress-induced amphetamine sensitization in rats. Restraint stress in cylindrical chambers, 2 times 30 min/day for 5 days over an 8-day schedule, was used as the stressor. Following completion of the stress protocol, animals were cannulated with microdialysis guide cannulae over the nucleus accumbens, and then treated with either metyrapone (50 mg/kg, i.p.) or vehicle (1 ml/kg) for 7 days. On the seventh day, animals were implanted with microdialysis probes in the nucleus accumbens, and on the following day, all animals were tested for their locomotor, stereotypy, and nucleus accumbens dopamine and DOPAC release responses to an injection of saline followed 60 min later by d-amphetamine (1.5 mg/kg, i.p.). Neither stress or metyrapone treatment had an effect on the behavioral or dopamine release response to saline. However, amphetamine-stimulated locomotion and stereotypy were strongly enhanced, while amphetamine-stimulated dopamine release response was slightly enhanced (significant only by drug×time interaction), in stressed animals. Metyrapone treatment reduced the stress-induced increase in the locomotor, but not stereotypy, response to amphetamine. In contrast, the dopamine release response to amphetamine was enhanced in metyrapone-treated animals, in both stressed and non-stressed groups, while DOPAC levels were unaffected by treatment group. This augmentation was particularly evident in the stressed-metyrapone-treated animals. Furthermore, non-stressed animals showed an increased locomotor and stereotypy response to amphetamine after treatment with metyrapone. These findings indicate that metyrapone treatment can reverse, or inhibit the expression of, stress-induced sensitization to the behavioral effects of amphetamine. However, the ability of metyrapone treatment to enhance the behavioral (in non-stressed animals) and dopamine release (in non-stressed and stressed animals) responses to amphetamine indicate that chronic metyrapone treatment will produce stimulant sensitization when given alone.     

Modification of apomorphine-induced behaviour following chronic swim exercise in rats.

Four week swim exercise schedule (45 min day-1, 6 days each week) in rats led to a significant adaptive change in functional responsiveness of dopamine receptors (auto-receptors) in the nigrostriatal and mesolimbic system that was evident from the modification of behavioural responses elicited by a low dose of apomorphine, a direct acting dopamine receptor agonist. Thus, a remarkable increase in yawning response, development of full blown stereotypy, as well as profound attenuation of locomotory and hypothermic response was observed in exercise-trained rats as compared with the non-exercise group (control), following intraperitoneal administration of 0.3 mg kg-1 of apomorphine.     

The use of conditional probability analysis to identify a response chain leading to the occurrence of eye poking

In contrast to the literature on shaping adaptive behavior chains, few applied studies have described procedures for identifying and treating behavior chains involving problem behavior such as self-injury. The present study expands upon past work by conducting a conditional probability analysis and within-session analysis to identify a response chain leading to the occurrence of self-injurious behavior. Based on the hypothesis that stereotypy and self-injury constituted a response chain, the effects of blocking stereotypy were examined. Reductions in both self-injury and in response effort for treatment implementation were observed.     

Identifying specific sensory modalities maintaining the stereotypy of students with multiple profound disabilities

In Experiment 1, analogue functional analyses were conducted to identify the functions of stereotypy for six students with multiple profound disabilities. Results indicated that stereotypy (a) occurred across conditions, (b) occurred primarily when alone, or (c) occurred during all sessions except in the Control condition. Experiment 2 analyzed stereotypy while masking visual, auditory, or tactile sensory consequences. Results showed that stereotypy was maintained by visual stimulation, tactile stimulation, or was undifferentiated across conditions. In Experiment 3, we showed that stereotypy could be reduced by providing competing sensory stimulation. In Experiment 4, stereotypy that was undifferentiated in Experiment 1 was analyzed using a concurrent operants procedure. Results showed that stereotypy was not multiply determined, but occurred to produce visual sensory stimulation. Our findings are discussed in terms of the sensory and social reinforcers that maintain stereotypy, assessment procedures used to identify those reinforcers, and the interpretation of assessment results.     

Development and implementation of the Dutch protocol for rehabilitative management in amyotrophic lateral sclerosis.

INTRODUCTION: In the Netherlands, rehabilitation care plays an important role in the symptomatic and palliative treatment of ALS patients. However, until 1999 there were no guidelines or practice parameters available for the management of ALS. Therefore, the Dutch protocol for rehabilitative management in ALS was developed. We describe the development process, the outcome and implementation of the protocol. METHODS: A concept management protocol was written and the Delphi method was selected to develop the protocol further. This method comprises repetitive discussion sessions from postulates, using a combination of written questionnaires and work-conferences. Between 80 and 90 persons (rehabilitation team members of different professional backgrounds and neurologists) were involved in this process. The protocol was implemented by sending it to all consultants in rehabilitation medicine in the Netherlands; they were asked to inform all the treatment team members about the final protocol and to implement it in their treatment of ALS patients. RESULTS: The protocol was developed in 1999, implemented in 2000 and evaluated in 2001. Recommendations for improvement were made during the evaluation and improvements are currently being developed by an expert group. The protocol is widely used (88.9%) by consultants in rehabilitation medicine and their treatment teams in the Netherlands. CONCLUSIONS: The Dutch protocol for rehabilitative management was developed to provide an optimal and adequate care plan for patients with ALS. It is widely used in the Netherlands.     

Functional analysis of aberrant behavior maintained by automatic reinforcement: assessments of specific sensory reinforcers

The purpose of this study was to develop a systematic functional assessment package for aberrant behaviors maintained by nonsocial (automatic) reinforcement. The assessment package included four components: (1) functional analysis, (2) antecedent assessment of specific automatic reinforcement sources, (3) stimulus preference assessment, and (4) treatment evaluation. Functional analysis data indicated automatic reinforcement functions of the stereotypy exhibited by a 10-year-old male and the self-injury (SIB) exhibited by a 30-year-old male. Antecedent assessments of sensory classes indicated that auditory stimulation and tactile stimulation were associated with stereotypy and SIB, respectively. A multiple-stimulus-without-replacement procedure was conducted with each participant to identify the most- and least-preferred stimuli within the identified sensory classes. In an attempt to validate the assessment package for each participant, a DRO procedure was implemented using a reversal design with a multielement component. DRO procedures using stimuli within the targeted sensory classes were successful in eliminating the aberrant behaviors of both participants. The results are discussed in the context of improving the methodology for assessing and treating automatically reinforced behaviors.     

The Meta-Contrast Technique--a projective test predicting suicide.

Sixty-nine inpatients who had attempted suicide were studied by means of the Meta-Contrast Technique (MCT), a projective test measuring personality factors, especially defensive strategies. The patients were divided into 3 subgroups, one of which was defined as stereotypy only, which denotes stereotypy (perceptual retardation) without any other coded defenses. At follow-up 7 of 8 completed suicides belonged to this subgroup and they matched various main diagnoses according to DSM-III-R. When the MCT findings of all patients were compared with 99 depressed inpatients from a previous study, the latter group more often had mature defensive strategies. In both investigations most completed suicides were found in the stereotypy only group. Our findings indicate that, regardless of psychiatric diagnosis, stereotypy without other defenses in MCT predicts suicide.     

Play skills taught via behavioral intervention generalize,maintain, and persist in the absence of socially mediated reinforcement in children with autism

We measured generalization, maintenance and parent reports of child happiness in the context of a behavioral intervention to teach toy-play skills to three young children with autism. Lag schedules of reinforcement were implemented for two participants whose play did not initially generalize. The play skills intervention was conducted within the participants’ early childhood classroom and the utility of teaching play as a means to reduce stereotypy within this setting was also evaluated. A multiple baseline design across participants demonstrated that play taught via behavioral intervention may be maintained after programmed reinforcement is discontinued, generalize across settings and toys (i.e., response and stimulus generalization), and occasion a decrease in stereotypy. Further, the occurrence of play in the absence of socially mediated reinforcement suggested that play taught via behavioral interventions may come to be automatically reinforced. Finally, parent responses on rating scales suggested that two of the participants were happier, in a better mood, and were more interested in appropriate toy-play following behavioral intervention.     

Stereotypy I: a review of behavioral assessment and treatment

In this paper, we review definitional issues related to stereotypy, behavioral interpretations of stereotypy, procedures for determining operant function(s) of stereotypy, and behavioral interventions for stereotypy. In general, a preponderance of the assessment literature suggests that most forms of stereotypy are maintained by automatic reinforcement. Review of the treatment literature suggests that antecedent (e.g., environmental enrichment) and consequent (e.g., differential reinforcement of alternative behavior) interventions produce at least short-term reductions in stereotypy. Suggestions for further assessment and treatment of stereotypy are provided.     

Characteristics of feeding induced by the serotonin agonist 8-hydroxy-2-(di-n-propylamino) tetralin (8-OH-DPAT)

The effects of the putative serotonin agonist 8-hydroxy-2-(di-n-propylamino) tetralin (8-OH-DPAT) on food intake in freely-feeding and food deprived rats were examined. In freely-feeding rats, low doses of 8-OH-DPAT (15-60 micrograms/kg) significantly increased food intake without affecting drinking, grooming, rearing or locomotion. Higher drug doses (125-4000 micrograms/kg) also produced feeding and caused locomotor stimulation and serotonin-related stereotyped behaviour (i.e., forepaw padding, headweaving, wet dog shakes, flat body posture). When feeding and stereotypy were observed concurrently, response competition was evident and feeding behaviour was fragmented into numerous short eating bouts. As drug-induced stereotypy declined with time, this fragmented pattern of eating was succeeded by long bouts of eating which were similar to those observed at doses of 15-60 micrograms/kg 8-OH-DPAT. In 24 hr food deprived rats, low doses of 8-OH-DPAT had no effect on food intake. However, high doses of 8-OH-DPAT (250-4000 micrograms/kg) decreased feeding in food deprived animals, an effect which was probably secondary to the induction of stereotypy. It is proposed that the behavioural effects of 8-OH-DPAT may be explained by a dual effect on brain serotonergic mechanisms, which is dose dependent. Thus, low doses of the drug may preferentially activate inhibitory presynaptic serotonin receptors (autoreceptors), decrease serotonin metabolism and thereby increase feeding. In contrast, high doses of 8-OH-DPAT appear to stimulate postsynaptic serotonin receptors and thus produce stereotypy. Alternatively, it is possible that 8-OH-DPAT may elicit feeding by postsynaptic serotonin receptor blockade.