June 29, 2015 3:00 pm Published by Nevena Savic, MA, BCBA
Ability to follow instruction is one of the essential skills for children to be successful in everyday situations. Instruction following occurs when behavior comes under stimulus control of the instructions delivered. In other words, a child learns to follow a specific instruction, every time an instruction is given.
One possible way to establish an instruction-following repertoire is to provide a reinforcer every time a child follows an instruction correctly. Many vocal instructions that are delivered to the children also include gestures (e.g., “put your toys away” might be accompanied by the parent handing a child a toy) or other visual stimuli (e.g., “open the door” always occurs when a child is in front of a closed door). These cues interfere with the acquisition of an instruction-following repertoire for some children (Sy, Donaldson, Vollmer, & Pizarro, 2014). In these examples when gestures (or task related objects) are present along with the instruction, a child may respond to the other irrelevant stimuli rather than a vocal instruction. Responding to irrelevant environmental cues is an example of stimulus over-selectivity, or the tendency to respond to only one aspect of the environment while ignoring all other aspects (Dickson, Deutsch, Wang, & Dube, 2006). This phenomenon tends to occur with individuals that are on the Autism spectrum and might contribute to the fact that these individuals often have difficulty following instructions from different people and in different settings.
Professionals and parents should consider some proactive strategies to reduce the chance that individuals will respond to extra environmental stimuli instead of intended instruction.
Research has shown that the treatment of skill deficits related to following an instruction, should include a combination of prompting, reinforcement, and multiple-exemplar training. Multiple-exemplar training for this skill includes varying the objects present when an instruction is delivered by removing relevant objects (the ones used to follow an instruction) or including irrelevant objects (the ones not required to follow an instruction) to prevent relevant objects from gaining stimulus control over instruction following. Making these manipulations can ensure that instructions will continue to be followed even when relevant objects are not present or irrelevant objects are present. Another important factor is to vary instruction in the presence of the same objects (e.g., in one instruction, child is asked to roll the ball; in another, to put the ball in the box).
In summary, it is important to vary the instructions delivered and the instructional context in order for that instruction following to come under stimulus control of the instructions. Arranging the learning environment by taking the above mentioned factors into consideration may help with efficient skill mastery and generalization in the natural environment.
Nevena Savic, M.A., LMFT, BCBA serves as QSAC’s Assistant Director of Family Education and Training. Prior to her current role, Nevena served as the Assistant Clinical Director for Adult Services at QSAC. She is a Board Certified Behavior Analyst (BCBA), a New York State Licensed Behavior Analyst, and a Licensed Marriage and Family Therapist.
June 1, 2015 3:00 pm Published by Francisco Monegro, Ph.D., M.D.
Dickson, C. A., Deutsch, C. K.,Wang, S. S.,& Dube,W. V. (2006). Matching-to-sample assessment of stimulus over-selectivity in students with intellectual disabilities. American Journal on Mental Retardation, 111, 447–453.
Sy, J. R., Donaldson, J. M., Vollmer, T. R., Pizarro, E. (2014). An evaluation of factors that influence children’s instruction following. Journal of Applied Behavior Analysis, 47, 101–112.
Autism Spectrum Disorder (ASD) is a very complex neuro-developmental disorder characterized by impaired socialization, reduced communication and restricted, repetitive or stereotypical activities and interest. Autistic individuals may be affected by co-morbid organic and psychiatric conditions such as Intellectual Disability (ID), heterogeneous groups of epilepsy syndromes, sleep disturbance, sensory problems, and severe cognitive functioning deterioration, Impulse Control Disorder, Anxiety Disorder, and Mood Dysregulation Disorder. They may also experience behavioral crises with severe challenging behaviors such as aggression, self-injurious behaviors, property destruction and psychomotor agitation (Guinchat, et al. 2015, Gabriels, et al., 2012).
Unfortunately, in some individuals these challenging behaviors may persist despite behavioral interventions or the integrated approach of behavioral and pharmacological interventions. These behaviors not only place the autistic individuals and direct support professionals (staff) at risk of injuries, but lead to disappointments when their occurrence becomes refractory to the treatment plan. Due to acute behavioral decompensation during a crisis situation, a high percentage of autistic individuals require a visit to the psychiatric related emergency department (ED) of general or psychiatric hospital for an evaluation. Commonly, individuals with autism in acute crisis are treated palliatively in the psychiatric emergency department, denied admission, and discharged in less than 24 hours due to clinical and administrative issues and political exigencies (e.g. time constraints, productivity, not familiar with autism spectrum disorder, reimbursement, etc.) (Bauman, 2015; MarcosRosa, 1986).
Thus, according to Gabriels and colleagues (2012), there is a growing need to establish and evaluate innovative specialized healthcare programs for crisis management for individuals diagnosed with autism spectrum disorder (ASD) and/or intellectual disability (ID). Guinchat and colleagues (2015) suggest a systematic integrative multidisciplinary approach which should include a systematic search for comorbid medical and psychiatric conditions (e.g. seizure disorder and /or mood dysregulation) and a particular profile of these individuals [e.g. poor language skills or no language at all, etc]. This process would lead to a functional evaluation of the autistic individual and the formulation of a hypothesis regarding the cause of the acute behavioral state. Moreover, in their study, Johnson and colleagues (2005) demonstrate that the creation of a crisis resolution team (CRT) called to act during socially dysfunctional and deteriorating situations reduced the rate of emergency room visits. Yet another study conducted by Schoenvald and colleagues (2000), suggests that home-based multisystemic therapy (MST) prevented emergency psychiatric visits for crisis stabilization. Multisystemic therapy is a home-based therapy where masters-level therapists engage home members in identifying and changing individual, home, and environmental factors thought to contribute to problem behaviors.
In a cross-sectional study reported by Kalb and colleagues (2012), individuals with autism visit the psychiatric emergency department (ED) 13% times more than individuals without autism (2%). Thus, I would like to call for a discussion of an agenda of amalgamation of interventions where we can incorporate a multidisciplinary approach (functional behavior analysis, coping and replacement behavior skills such as written schedules, high-tech augmentative and alternative communication (AAC) devices in facilitating requesting skills in individuals with autism (ASD), social stories, sensory regulation items, sensory input activities), and/or a community-based psychiatric system of care (e.g. Telehealth (videoconferencing), which has potential to reduce barriers to access to psychiatric care for individuals with autism spectrum disorder and to help divert psychiatry-related emergency department visits (Still, et al., 2014, Hepburn, et al. 2014, Drake, et al. 2012).