ABA Journal Club: Clinical Decision Making
Our ABA Journal Club discussion questions for September 2019!
Problem Behavior Triggered by Specific Words
This month’s ASAT feature comes to us from Mary E. McDonald, PhD, BCBA-D, LBA. To learn more about ASAT, please visit their website atwww.asatonline.org. You can also sign up for ASAT’s free newsletter, Science in Autism Treatment, and like them on Facebook!
I have an adolescent with autism in my class who responds negatively when people say certain words. He seems to have a sensitivity to them and may respond with a behavioral outburst. Have you heard of this happening with other students with autism and do you have any thoughts on intervention?
Answered by Mary E. McDonald, PhD, BCBA-D, LBA
Hofstra University/Eden II Genesis Programs
This negative response to certain words, or “trigger words,” that you describe can be a real problem for individuals with autism and their families. Individuals with autism may react to a particular word or set of words when they are said by familiar and unfamiliar people in their environment. The way in which they react may vary and can range from verbal protesting or body tensing to an extreme behavioral outburst including aggression, self-injury or destructive behavior. This response to trigger words can have a great impact on the person’s ability to interact with others, participate in social situations, and be involved in the community or at a job site.
Some examples are:
- A student is with his class shopping at the supermarket and the cashier says, “Thank you.” The student stomps his feet in reaction to hearing “thank you” and the staff quickly escorts him from the store before the behavior escalates.
- A family is at a restaurant and someone at another table says “Wow, that’s beautiful” in conversation. The child starts to yell in response to the word “wow” and the parents attempt to distract the child from the conversation at the other table.
Assessment
As with any behavior, it is important to assess the situation to be better able to provide an appropriate intervention. The function of the problem behavior can be assessed through a functional behavior assessment (FBA) (Alter, Conroy, Mancil, & Haydon, 2008). Function of behavior can be determined through interviews, structured observations and the collection and analysis of data to identify patterns in the behavior. Data can also be recorded on possible trigger words to determine the frequency, intensity and latency of behavior in response to various words (data collection considerations will be shared later).
If you have already conducted an FBA and determined that the trigger words have frequently been the antecedent to the behavior of concern, the question then becomes why do these words serve as an antecedent to this behavior? While it is true that there may be a reason, it is not always apparent what the reason is. For example, it may be that the student had a history with denial of a reinforcer paired with a specific word such as “later,” or demands were consistently paired with words such as “Let’s go.” In these cases, the words could have become aversive to the student through frequent pairings. However, you may not be able to determine what caused the word to become a “trigger word.” While knowing the history can be helpful for preventing future trigger words from developing, it is still possible to treat the behavior without knowing the initial reason the word became an antecedent for challenging behavior.
To further assess, you may want to observe how the student responds to the trigger word in various conditions. For example, you can analyze the occurrence of behavior based on who says the word (familiar or unfamiliar person), if it is spoken directly to the student or overheard, the setting in which the student reacts to a trigger word, and the ongoing activity (preferred or non-preferred). You can also assess the student’s reaction to various forms of the word (written word, spoken word, word in a sentence) to help plan for desensitization training. One can also assess whether a cumulative effect is observed (i.e., the first instance of the trigger word does not occasion the behavior; however, multiple instances of the trigger word cause the student to react). All of these factors can be reflected as columns on your ABC data sheet.
Comorbidity.
The complexity of this behavior requires us to look at other factors that may affect its occurrence. Considerable evidence suggests that children and adolescents with autism spectrum disorders (ASD) are at increased risk of anxiety and anxiety disorders (Ghaziuddin, 2002) and this may worsen during adolescence. Children with autism may display problematic emotional reactions and behaviors when faced with social situations (Lainhart, 1999). It is important to consider the possibility that the trigger words function as stimuli that increase the student’s anxiety. Behaviors associated with anxiety can appear on your ABC data sheet.
Researchers are attempting to study co-morbidity in individuals with autism. Leyfer et al. (2006) studied various disorders associated with autism. They found that specific phobia was the most common disorder (in 44% of participants) found in individuals with ASD, and even higher prevalence rates have been reported in other studies (Muris et al., 1998). There are a number of specific phobias that relate to words, including nomotophobia (fear of names) and verbophobia (fear of words). Onomatophobia is an irrational or compulsive fear of hearing certain words. However, there is little research on this phobia and no research in relation to individuals with autism to date.
The second most frequent disorder found in the study was obsessive compulsive disorder (OCD), diagnosed in 37% of the children with autism (Leyfer et al., 2006). The most common type of compulsion was a ritual involving others. About 50% of the children diagnosed with OCD had compulsions that involved others having to do things a certain way. Examples included:
- Parents having to perform certain daily routines
- An adult having to act or respond in a certain way
- An adult having to respond to repeated questions
What was most interesting about the findings is that the two most frequent compulsions involved attempts to control the behavior of others. Given this, it is plausible that for some children with autism and OCD, the problem behavior that occurs in response to the trigger words may be attempts to control what is said by others. However, again, no research specifically addresses trigger words as an antecedent to behavior in children with OCD or autism.
Data Collection
When collecting data on behavior in reaction to trigger words, a frequency measure can be used but it may not provide you with the most accurate data. These data may be misleading as it can depend on how often the trigger word is heard by the student. Instead, it may be more accurate to record occurrence as a percent per opportunity, where an opportunity is when the trigger word is heard by the student. With this data, one can see the percentage of the time the student responds to the trigger word. It may also be helpful to note the time that the student hears each instance of the trigger word to determine if the student’s reaction occurs after the first occurrence or after a number of occurrences indicating a more cumulative effect of the words on behavior.
Treatment Considerations
Prevention. Often the first reaction to increased problem behavior in response to trigger words is to prevent the behavior from occurring by avoiding the antecedent entirely. Therefore, adults may refrain from saying trigger words or reacting negatively to trigger words when they are spoken. However, the issue in this case is that it is not so easy to simply remove the antecedent from the environment. First, it is unlikely that someone can truly remove a word from their vocabulary consistently. Second, outside of the small circle of family and therapists, there are many people the individual will come in contact with whose behavior is not easily controlled.
Predictability and preparation. Predictability and preparation may be more viable options in reducing behavior. Predictability can be used by letting the individual know that the word is going to be used, similar to how you would warn a student with autism that the fire alarm is going to ring if preparing him for the aversive stimulus. This can be done verbally or with a non-verbal signal or visual cue. This warning may be one part of an intervention package. Preparation can also be used to prepare the student for when he/she is going to be in a community location where it may be likely that the student will hear a trigger word. For example, a student may choose to wear headphones while in the community.
Generalization. We know that newly acquired responses may be controlled not only by the original stimulus but also by others resembling those stimuli (Stokes & Baer, 1977). Therefore, it is possible that the problem behavior may generalize from the original trigger word to new but similar words. As a result, assessing responses to similar words could also be important so that generalized words can also be included in treatment from the onset. Generalization can also occur from one person to another and to novel settings, which could be considered during assessment.
Interventions
Systematic desensitization/exposure. The student may be able to learn to better tolerate the trigger words through systematic desensitization (Grös & Antony, 2006). In this behavioral intervention, the student is gradually exposed to the stimulus through a hierarchy of antecedents that increase in aversiveness based on the individual’s behavioral response to the various steps. For example, desensitization may begin with the use of technology in the form of video or a virtual environment in cases where this presentation is more tolerable for the individual (Mager, Bullinger, Mueller-Spahn, Kuntze, & Stoermer, 2001). Providing reinforcement for successfully tolerating aversive stimuli is a key component of this procedure.
Sample desensitization steps for a student:
- Student hears audio recording of trigger word by unfamiliar person
- Student hears an app label the trigger word paired with a sight word presentation
- Student reads trigger word presented on a flashcard
- Student hears the trigger word stated aloud by a familiar staff person
Stimulus pairing and reconditioning. Another approach is to recondition the trigger words so that they do not evoke a negative behavioral response. One can attempt to do this by pairing the trigger words with a preferred stimulus. For example, a slideshow in which videos of someone saying trigger words are interspersed with preferred videos (music, movie clips) could be used to pair the aversive stimulus with more preferred stimuli. Alternatively, the student could be engaged in a preferred activity when the trigger word is used (e.g., student is playing on the iPad) or the trigger word can be said while presenting a preferred item to the student (e.g., “Wow, I love chocolate, too”).
Functional communication training. Functional communication training (FCT) has been a highly successful approach for replacing challenging behavior with communication in students with ASD. As an example, Rispoli, Camargo, Machalicek, Lang, and Sigafoos (2014) demonstrated the effectiveness of FCT with students with ASD for behavior that was ritualistic in nature. It may be possible to teach the student some form of communication that may help him or her to communicate rather than engage in challenging behavior when a trigger word is heard. The individual may not be able to completely avoid hearing trigger words, but may be able to ask to leave a particular area, such as a crowded area with high probability of trigger words.
Summary
When working with a student with ASD who engages in behavior related to trigger words, it will be important to acknowledge the complexity of this behavior. Consider conducting a thorough and ongoing assessment to determine the most appropriate interventions to best meet the needs of the individual, while always remembering the importance of data collection and data analysis to help guide decision making.
References
Alter, P. J., Conroy, M. A., Mancil, G. R., & Haydon, T. (2008). A comparison of functional behavior assessment methodologies with young children: Descriptive methods and functional analysis. Journal of Behavioral Education, 17(2), 200-219.
Ghaziuddin, M. (2002). Asperger syndrome: Associated psychiatric and medical conditions. Focus on Autism and Other Developmental Disabilities, 17(3), 138-144.
Grös, D. F., & Antony, M. M. (2006). The assessment and treatment of specific phobias: A review. Current psychiatry reports, 8(4), 298-303.
Lainhart, J. E. (1999). Psychiatric problems in individuals with autism, their parents and siblings. International Review of Psychiatry, 11(4), 278 -298.
Leyfer, O. T., Folstein, S. E., Bacalman, S., Davis, N. O., Dinh, E., Morgan, J., … & Lainhart, J. E. (2006). Comorbid psychiatric disorders in children with autism: interview development and rates of disorders. Journal of Autism and Developmental Disorders, 36(7), 849-861. Mager, R., Bullinger, A., H., Mueller-Spahn, F., Kuntze, M. F., & Stoermer, R. (2001). Real-time monitoring of brain activity in patients with Specific Phobia during
exposure therapy, Employing a stereoscopic virtual environment. CyberPsychology and Behavior 4(4), 465–469.
Muris, P., Steerneman, P., Merckelbach, H., Holdrinet, I., & Meesters, C. (1998). Comorbid anxiety symptoms in children with pervasive developmental disorders. Journal of Anxiety Disorders, 12(4), 387-393.
Rispoli, M., Camargo, S., Machalicek, W., Lang, R., & Sigafoos, J. (2014). Functional communication training in the treatment of problem behavior maintained by access to rituals. Journal of Applied Behavior Analysis, 47(3), 580-593.
Stokes, T. F., & Baer, D. M. (1977). An implicit technology of generalization. Journal of Applied Behavior Analysis, 10(2), 349-367.
Citation for this article:
McDonald, M. (2018). Clinical corner: Problem behavior triggered by specific words. Science in Autism Treatment, 15(1), 5-8.
About The Author
Dr. McDonald is a Professor in the Special Education Department at Hofstra University. She directs the Advanced Certificate Programs including the advanced certificate in ABA and the Advanced Certificate in Severe and Multiple Disabilities. She currently teaches courses related to autism spectrum disorders, applied behavior analysis and single subject research. Dr. McDonald serves as the Associate Executive Director of Long Island Programs for Eden II/Genesis Programs. She has over 25 years experience directing programs for students with autism from early intervention through adulthood. Dr. McDonald completed her PhD in Learning Theory at the CUNY Graduate Center and is a Board Certified Behavior Analyst – Doctoral Level and a licensed behavior analyst. Dr. McDonald serves on a number of advisory boards and presents at local, national and international conferences on the topic of autism. She has published a book on including students with ASD and book chapters on technology and evidence-based interventions. She has published both peer-reviewed and popular articles. Some areas of publication include: self-management, social reciprocity, PECS, scripts and semantic webs, creativity and including students with ASD.
Resources For Parents
This month’s ASAT feature comes to us from Peggy Halliday, MEd, BCBA. To learn more about ASAT, please visit their website at www.asatonline.org. You can also sign up for ASAT’s free newsletter, Science in Autism Treatment, and like them on Facebook!
The following websites include milestones’ checklists, booklets, and a wealth of information to help parents become savvy consumers of autism treatment. The contributors are parent groups well as professional, medical, scientific, and legal and/or advocacy organizations which are available to meet the needs of families.
American Academy of Pediatrics (AAP)
The AAP is an organization of 67,000 pediatricians committed to the well-being of infants, children, adolescents, and young adults. The AAP website contains recent information about autism prevalence, links to many external resources and training websites, information about pediatrician surveillance and screening, and early intervention guidelines. This site offers great tools and resources for both pediatricians and families.
Association for Behavior Analysis International (ABAI)
The ABAI is a nonprofit professional membership organization whose objective for education is to develop, improve, and disseminate best practices in the recruitment, training, and professional development of behavior analysts. ABAI offers membership to professionals and consumers, which entitles them to a newsletter and other benefits, including event registration discounts, and continuing education opportunities.
Association of Professional Behavior Analysts (APBA)
The APBA is a nonprofit professional membership organization that is focused on serving professional practitioners of behavior analysis by promoting and advancing the science-based practice of applied behavior analysis. Membership is open to professional behavior analysts and others who are interested in the practice of ABA, including professionals from various disciplines, consumers, and students.
Association for Science in Autism Treatment (ASAT)
The ASAT is a non-profit organization founded in 1998 “to promote safe, effective, science-based treatments for people with autism by disseminating accurate, timely, and scientifically sound information, advocating for the use of scientific methods to guide treatment, and combating unsubstantiated, inaccurate and false information about autism and its treatment.” To serve its mission ASAT provides a comprehensive website which includes Research Synopses of a vast array of autism treatments to help families and organizations make informed choices, as well as specific resources for journalists, medical providers, and parents of newly diagnosed children. ASAT also publishes a monthly online publication, Science in Autism Treatment,with over 12,000 subscribers from all 50 states and over 100 countries. ASAT has Media Watch Initiative that responds quickly to both accurate and inaccurate portrayals of autism treatment in the media, and an Externship Program which includes students, professionals, and family members.
Autism NJ is now the largest statewide network of parents and professionals dedicated to improving the lives of individuals with autism and their families. Since its establishment in 1965, Autism New Jersey’s mission has been to ensure that all individuals with autism receive appropriate services. Autism New Jersey is a nonprofit agency committed to ensuring safe and fulfilling lives for individuals with autism, their families and the professionals who support them through awareness, credible information grounded in science, education, and public policy initiatives.
The Autism Science Foundation (ASF)
As well as providing information about autism to the general public and promoting awareness of the needs of individuals and families affected by autism, the Autism Science Foundation’s mission is to support and fund scientists and organizations conducting research into Autism Spectrum Disorder.
Autism Speaks supports global research into the causes, prevention, treatments, and cure for autism and raises public awareness. The website contains information on resources by state, resources for families, advocacy news, and suggested apps for learners with autism. The Autism Speaks 100 Day Kit for Newly Diagnosed Families of Young Children was created specifically for families of children ages 4 and younger to make the best possible use of the 100 days following their child’s diagnosis of autism.
Autism Wandering Awareness Alerts Response Education (AWAARE).
This organization has developed three “Big Red Safety Toolkits” to respond to wandering incidents: one for caregivers, one for First Responders, and one for teachers. They are free and downloadable from their website.
Behavior Analyst Certification Board (BACB)
The BACB is a nonprofit corporation established as a result of credentialing needs identified by behavior analysts, state governments, and consumers of behavior analysis services. Their mission is to develop, promote and implement an international certification program for behavior analysis practitioners. The BACB website contains information for consumers (including a description of behavior analysis), conduct guidelines, requirements for becoming certified and maintaining certification, and a registry of certificants that can be searched by name or state.
Cambridge Center for Behavioral Studies
The Cambridge Center for Behavioral Studies website seeks to bring together knowledge and behavior analysis resources, a glossary of behavioral terms, online tutorials and suggestions for effective parenting. A continuing education course series is offered through collaboration with the University of West Florida and is designed to provide instruction in a variety of areas of behavior analysis. To utilize all of the features of the website, you must register.
Centers for Disease Control and Prevention (CDC)
The Act Early website from the CDC contains an interactive and easy-to-use milestones’ checklist you can use to track how your child plays, learns, speaks, acts, and moves ages 3 months through 5 years. The milestones checklist is now available as a free downloadable tracker that follows your child’s progress. There are tips on how to share your concerns with your child’s doctor and free materials that you can order, including fact sheets, resource kits, and growth charts.
Council of Parent Attorneys and Advocates, Inc. (COPAA)
The Council of Parent Attorneys and Advocates is a national American advocacy association of parents of children with disabilities, their attorneys, advocates, and others who support the educational and civil rights of children with disabilities. The website provides important information about entitlements under federal law and is divided into resources for students and families, attorneys, advocates, and related professionals, and a peer to peer connection site.
Council for Exceptional Children (CEC)
The CEC is an international professional organization dedicated to improving the educational outcomes and quality of life for individuals with exceptionalities. The focus is on helping educators obtain the resources necessary for effective professional practice. Autism is one of many disabilities discussed.
Education Resources Information Center (ERIC)
Sponsored by the Institute of Education Services (IES) of the U.S. Dept. of Education, ERIC provides ready access to education literature to support the use of educational research and information to improve practice in learning, teaching, educational decision-making, and research.
The First Signs website contains a variety of helpful resources related to identifying and recognizing the first signs of autism spectrum disorder, and the screening and referral process. A video glossary is useful in demonstrating how you can spot the early red flags for autism by viewing side-by-side video clips of children with typical behaviors in comparison with children with autism. First Signs aims to lower the age at which children are identified with developmental delays and disorders through improved screening and referral practices.
Individuals with Disabilities Act (IDEA)
IDEA is a law that ensures services to children with disabilities throughout the nation. IDEA governs how states and public agencies provide early intervention, special education, and related services to more than 6.5 million eligible infants, toddlers, children, and youth with disabilities. The IDEA website contains information on early intervention services, local and state funding, and Individualized Educational Plan (IEP) issues including evaluation, reevaluation, and procedural safeguards.
The Interagency Autism Coordinating Committee (IACC)
IACC coordinates ASD related activities across the United States Health and Human Services Department and the Office of Autism Research. The IACC publishes yearly summary advance updates from the field of autism spectrum disorder.
The NAC is a nonprofit organization dedicated to disseminating evidence-based information about the treatment of autism spectrum disorder and promoting best practices. Through the multi-year National Standards Project, the NAC established a set of standards for effective, research-validated educational and behavioral interventions. The resulting National Standards Report offers comprehensive and reliable resources for families and practitioners.
National Professional Development Center on Autism Spectrum Disorders (NPDC)
In 2014 the NPDC, using rigorous criteria, classified 27 focused interventions as evidence- practices for teaching individuals with autism. This website allows you to access online modules for many of these practices as well as an overview and general description, step-by-step instructions, and an implementation checklist for each of the practices. NPDC is currently in the process of updating the systematic review through 2017 as part of the Clearinghouse on Autism Evidence and Practice. It also has a multi-university center dedicated to the promotion of evidence-based practices for ASD. The Center operates three sites at UC Davis MIND Institute, Waisman Center, and the Franklin Porter Graham Child Development Institute at the University of North Caroline Chapel Hill. Each of these websites delivers a wealth of information including online training modules, resources, factsheets, and more.
NIH National Institutes of Health (NIH)
The NIH, a part of the U.S. Department of Health and Human Services, is the primary federal agency for conducting and supporting medical research. Helping to lead the way toward important medical discoveries that improve people’s health and save lives, NIH scientists investigate ways to prevent disease as well as researching the causes, treatments, and even cures for common and rare diseases.
The Ohio Center for Autism and Low Incidence (OCALI)
OCALI working in collaboration with the Ohio Department of Education, is a clearinghouse of information on autism research, resources, and trends. The OCALI website contains training and technical assistance including assessment resources and ASD service guidelines.
Organization for Autism Research (OAR)
OAR is a nonprofit organization dedicated to applying research to the daily challenges of those living with autism. OAR funds new research and disseminates evidence-based information in a form clearly understandable to the non-scientific consumer. The OAR website contains downloadable comprehensive guidebooks, manuals, and booklets for families, professionals, and first responders. OAR offers recommendations and worksheets for educators and service providers to assist in classroom planning, and a newsletter, “The OARacle.” In conjunction with the American Legion Child Welfare Foundation, OAR also offers Operation Autism for Military Families, a web-based resource specifically designed and created to support military families that have children with autism.
Rethink is a global health technology company which provides cloud-based treatment too for individuals with developmental disabilities and their caregivers. Their web-based platform includes a comprehensive curriculum, hundreds of dynamic instructional videos of teaching interactions, step-by-step training modules, and progress tracking features.
Virginia Commonwealth University Autism Center for Excellence
VCU-ACE is a university-based technical assistance, professional development, and educational research center for autism spectrum disorder in the state of Virginia. VCU-ACE offers a wide variety of online training opportunities for professionals, families, individuals with ASD, and the community at large. The website contains many useful resources, including a series of short how- to videos demonstrating particular evidence-based strategies, webcasts, and online courses.
Wrights Law is an organization which provides helpful information about special education law, education law, and advocacy for children with disabilities in the USA. The Wrights Law website contains an advocacy and law library including articles, cases, FAQs and success stories, and information on IDEA.
Zero to Three: National Center for Infants, Toddlers, and Families
This is a national, nonprofit organization which seeks to inform, educate, and support professionals who influence the lives of infants and toddlers. The organization supports the healthy development and well-being of infants, toddlers, and their families by supplying parents with practical resources that help them connect positively with their babies. They also share information about the Military Families Project, which supplies trainings, information, and resources for military families with young children.
Please use the following format to cite this article:
Halliday, P. (2016 revised 2019). Consumer Corner: Some resources for parents. Science in Autism Treatment, 13(2), 27-31.
Peggy Halliday, MEd, BCBA, has served as a member of the Board of Directors of ASAT since 2010. She has been a practitioner at the Virginia Institute of Autism (VIA) in Charlottesville, Virginia since 1998. She oversees trainings for parents and professionals and provides consultation to public school divisions throughout Virginia.
