One in 68 Children has Autism

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Future Focus on Autism Treatment: Precision Medicine

October 31, 2016 3:00 pm Published by

dna-strain“Personalized Medicine”, “Precision Medicine”, or “Individualized Medicine” is a concept that has modern applications to treatment of malignancies, heart disease, cystic fibrosis, HIV, asthma, hepatitis C, alpha 1 antitrypsin deficiency, among many disease. Jameson and Longo (2015) define precision medicine “as treatments targeted to the needs of individual patients on the basis of genetic, biomarker, phenotypic, or psychosocial characteristics that distinguish a given patient from other patients with similar clinical presentations”. In respect to Autism, our advancements in understanding the disorder has not yet translated to our ability to provide precision medicine. We have amassed a wealth of knowledge of the disorder, but have limited therapies to treat it.

According to a report by Sahin and Sur (2015), the heritability of autism has been estimated between 0.7–0.8%, including de novo mutations and epigenetic and environmental factors configuring complex risk architecture (Frye and Rossignol, 2016). Genome analysis has shown association with autism and 15q11–13, 16p11.2, and 22q11.2 copy number variants (CNV) and single nucleotide variants which some of them are de novo (not found in either parent). In addition, several studies, using whole exome sequencing, have estimated between 400-1,000 susceptibility genes associated with autism (Kim and Leventhal, 2015).

Even though the advances in basic neuroscience and human genetics, according to Sahin and Sur (2015), patients with autism spectrum disorder have limited pharmacological options. So far, the FDA has approved only two drugs to treat irritability and not symptoms domain of autism, Risperidone (dopamine antagonist) and Aripiprazole (dopamine agonist). It is imperative to validate a set of measures, indicators or biomarkers (molecular, imaging and behavioral) to develop medications or a particular treatment which target different autistic phenotypes.

Early diagnosis of subtypes of autism would be important in testing which targeted treatment plans are most effective.



Francisco Monegro currently serves as the residential Clinical Director of adult services programs at QSAC. He is also a consultant on autism for the PSCH clinic and the Shield Institute. Dr. Monegro received his MD/PhD in clinical psychology from the University of Santo Domingo/University of Kansas. In 1988, he received a diploma from the American Board of Medical Psychotherapists, Nashville, and from the International Academy of Behavioral Medicine, Counseling and Psychotherapy, Dallas, TX.

Instructional Fading – A Path to Increased Productivity

October 3, 2016 3:00 pm Published by

At the QSAC Preschool and Day School, we apply proactive strategies to increase prosocial behavior and decrease or prevent the occurrence of problem behavior. The proactive strategies that we implement are part of a system of Positive Behavior Intervention and Supports (PBIS). PBIS is a decision making framework that improves staff and student behavior through reward systems, careful environmental manipulation, and the use of evidence based practices and ongoing data analysis to monitor staff and student progress. Our PBIS framework includes 13 proactive/preventative strategies for increasing prosocial skills and improving overall behavior. One proactive strategy that we strive to include is instructional fading. Instructional fading allows instructors to systematically increase response requirements for students, so that students can learn to complete work sessions at a level that is as easy for them, before moving on to more difficult and longer work sessions. This blog post offers a synopsis of the research in instructional fading as an antecedent strategy. It is adapted from Maffei-Almodovar & Sturmey (2013).

Instructional fading is typically used to reduce problem behavior that functions for escape from a non-preferred activity (Butler & Luiselli, 2007; Horner, et al., 1991; Pace, Iwata, Cowdery, Andree, & McIntyre, 1993; Weeks & Gaylord-Ross, 1981; Zarcone, Iwata, Smith, Mazaleski & Lermanm, 1994) including SIB maintained by task avoidance (Iwata, et al., 1990; Repp, Felce, & Barton, 1988; Steege, Wacker, Berg, Cigrand, & Cooper, 1989).

Instructional fading consists of drastically decreasing the rate or difficulty of instructions identified as antecedents to escape maintained problem behavior and then systematically increasing the rate or difficulty of instructions to a predetermined acceptable level (Horner, Day, Sprague, O’Brien, & Heathfield, 1991; Pace et al., 1993; Weeks & Gaylord-Ross, 1981; Zarcone, Iwata, Vollmer, Jagtiani, Smith, & Mazauiski, 1993). Instructional fading is one way of possibly decreasing the momentary value of escape for a student.

Four studies have utilized instructional fading to decrease dangerous problem behavior (Butler and Luiselli, 2007; Pace, et al., 1993; Zarcone et al., 1994; Zarcone et al., 1993).  These studies were published in English and in peer-reviewed journals, included participants with identified developmental or intellectual disabilities, utilized a reversal or multiple baseline design to allow for Percentage of All Non-overlapping Data calculations (PAND), and targeted a dangerous problem behavior.  Dangerous problem behavior is defined here as a behavior likely to result in injury to the individual or to others in the immediate environment such as various forms of self-injurious behavior (SIB), aggression, elopement and property destruction.

Participants in the four studies (10 total) included seven females and three males aged two to 40 years.  Nine out of ten participants were diagnosed with moderate to profound intellectual disabilities and one was diagnosed with autism.  Experimental settings included a therapy room, two state residential facilities and one private school for children with developmental disabilities.  All 10 participants engaged in escape maintained SIB and one also engaged in escape maintained aggression.  Instructional fading interventions varied across studies to include instructional fading plus extinction (Pace, et al., 1993; Zarcone et al., 1994), instructional fading plus non-contingent escape (Butler & Luiselli, 2007) and a comparison of instructional fading plus extinction with extinction alone (Zarcone et al., 1993).

There were large effect sizes across all four studies, however, since each study utilized a slightly different variation of the instructional fading intervention, effect sizes will be reported separately for each study. Pace, et al., (1993) applied Instructional fading plus extinction to significantly reduce SIB across 3 participants (PAND = 94%.)  Zarcone, et al. (1993) compared instructional fading plus extinction with extinction alone and found that both interventions significantly reduced SIB.  Zarcone et al. (1993), however, also found that extinction alone produced less reduction in SIB (PAND = 85%) than instructional fading plus extinction (PAND = 94%).  Zarcone et al. (1994) also utilized instructional fading only applying extinction (with the rate of instructions held constant) when SIB remained high across 10 sessions.  Effect sizes for Zarcone et al. (1994) were less robust (PAND =  82%) indicating that instructional fading alone may be less effective than instructional fading plus extinction.  Finally, Butler and Luiselli (2007) implemented non-contingent escape plus instructional fading and reduced problem behavior with the most robust effect size (PAND = 100%.)

Experimenters in all four studies also reported increases in appropriate responses to instructions as instructional difficulty and frequency were faded in during interventions.  In this way, studies also reported increases in participant engagement. Instructional fading shows promise as a component in a treatment package to decrease and possibly prevent dangerous problem behavior when combined with either extinction or non-contingent escape.

At the QSAC schools, instructional fading is often included as a proactive, antecedent strategy and as part of a behavior intervention plan for escape maintained problem behavior after functional behavior assessments have been completed. Instructional fading is a tool that allows us to teach ours students to tolerate increasingly difficult task requirements. The ability to complete ever increasing work requirements is a skill that all working adults ideally possess. This is an important skill for all of our students, especially those that are preparing to enter less restrictive learning environments and work sites. Instructional fading is an avenue to increased independence that can help our students to meet their goals as independent working adults.



LMaffei-Blog-BubbleLindsay Maffei-Almodovar, MS Ed, MA, BCBA, has worked in the field special education since 2001. She joined Quality Services for the Autism Community (QSAC) in 2011 and is currently the ABA Training & Development Coordinator. She is responsible for designing, evaluating and monitoring staff training initiatives at both the preschool and Day School programs. Lindsay is a certified New York State Early Childhood General & Special Education Teacher and a Licensed Behavior Analyst. Lindsay is also a doctoral student in the Behavior Analysis Training Area of the Psychology Department at Queens College and The Graduate Center City University of New York (CUNY). Her research focuses on efficient methods of training staff members in evidence based behavior analytic procedures.






Butler, L.R.  & Luiselli, J. K. ( 2007). Escape-maintained problem behavior in a child with

autism: Antecedent functional analysis and intervention evaluation of noncontingent

escape and instructional fading. Journal of Positive Behavior Interventions, 9, 195



Maffei-Almodovar, L., & Sturmey, P. (2013). Evidence-based practice and crisis intervention. In

D. D. Reed, F. D. DiGennaro Reed & J. K. Luiselli (Eds.), Handbook of Crisis

Intervention and Developmental Disabilities (pp. 46-69). New York: Springer.


Pace, G. A.,  Iwata, B. A., Cowdery, G. E.,  Andree, P.J., & McIntyre, T. (1993). Stimulus

(instructional) fading during extinction of self-injurious escape behavior. Journal of

Applied Behavior Analysis, 26, 205-212.


Zarcone, J. R., Iwata, B. A., Smith, R. G., Mazaleski, J. L., & Lerman, D. C. (1994).

Reemergence and extinction of self-injurious escape behavior during stimulus

(instructional) fading. Journal of Applied Behavior Analysis 27, 307-316.


Zarcone, J. R.,  Iwata, B. A., Vollmer, T. R., Jagtiani, S., Smith, R. G. & Mazauiski, J. L.(1993).

Extinction of self-injurious escape behavior with and without instructional fading.

Journal of Applied Behavior Analysis, 26, 353-360.


QSAC is a New York City and Long Island based nonprofit that supports children and adults with autism, together with their families, in achieving greater independence, realizing their future potential, and contributing to their communities in a meaningful way by offering person-centered services.

QSAC pursues this mission through direct services that provide a supportive and individualized setting for children and adults with autism to improve their communication, socialization, academic, and functional skills.