Preventing School Failure, 56(1), 8–18, 2012 C Taylor & Francis Group, LLC Copyright ISSN: 1045-988X print DOI: 10.1080/1045988X.2011.548418
Reducing the Threatening and Aggressive Behavior of a Middle School Student With Asperger’s Syndrome FRANK J. SANSOSTI Kent State University, Kent, OH, USA
The purpose of this case study was to demonstrate the success of a multicomponent intervention to reduce the threatening and aggressive behaviors of a middle school student with Asperger’s syndrome. The author provides information pertaining to the student and details the procedures for developing a packaged intervention. Results of this approach, although not considered to be rigorous research, demonstrate that an intervention that is based on evidence-based practices can be effective at remediating even the most severe behavioral problems demonstrated by an individual with Asperger’s syndrome. In particular, data indicated that a combined intervention approach significantly increased the student’s overall level of functioning and improved the perception of the student’s behavior by teachers and administrators. The author offers implications for practice and future research. Keywords: aggression, Asperger’s syndrome, autism spectrum disorder, middle school, positive behavior support
Asperger’s syndrome is currently understood as a developmental disorder characterized by individuals who (a) have significant difficulties in social interactions and relationships; (b) display a lack of empathy that is usually milder than that seen in classic autism; and (c) engage in unusual patterns of narrow, all-absorbing interests, often to the exclusion of other activities (American Psychiatric Association, 2000; Thede & Coolidge, 2007). Despite these areas of difficulty, children and adolescents with Asperger’s syndrome in general display average to above-average intelligence, excellent rote memory, and good structural language skills (the ability to speak in syntactically and grammatically correct sentences). These relative strengths often afford individuals with Asperger’s syndrome opportunities to achieve academic proficiency. Most individuals with Asperger’s syndrome are educated in general education classrooms (Myles, 2005), requiring, at times, only minimal supports during elementary grade levels (Sansosti & Powell-Smith, 2006). However, as individuals with Asperger’s syndrome begin to matriculate into middle and high school environments, educators often report increased behavioral problems, such as tantrums, noncompliance, and, at times, aggressive behaviors (Myles, 2005). Often, educational teams are confronted with escalating behavior problems of students with Asperger’s syndrome and are subsequently faced with increased challenges for providing
Address correspondence to Frank J. Sansosti, Kent State University, College of Education, 405 White Hall, Kent, OH 44242, USA. E-mail:
[email protected]
supports to promote student success (Buschbacher & Fox, 2003; Summers, Houlding, & Reitzel, 2004). Middle school environments often are replete with change and environmental stressors that make it difficult for individuals with Asperger’s syndrome to remain calm and transition successfully from one activity to another. For example, moving to a different classroom between periods may be perceived as threatening because of the highly variable nature of behaviors that occur in school hallways. Assemblies and other nonscheduled activities may cause misunderstanding for the student and lead to excessive questioning and/or behavioral meltdowns. Moreover, activities that the student perceives as “nonpreferred” or “too difficult” may cause excessive uneasiness and increased inappropriate behavioral displays. Across a variety of schoolbased examples, students with Asperger’s syndrome, who often demonstrate difficulties understanding even the most basic of social situations, often will perceive such changes as nebulous, unpredictable, and even threatening. When faced with this randomness, many individuals with Asperger’s syndrome become easily stressed and emotionally uncontrollable (Aspy & Grossman, 2007). When this occurs, these individuals are at an increased risk for tantrums and aggressive outbursts (Myles & Southwick, 2005). It is unfortunate that these behaviors may be misperceived by educators as willful or defiant as opposed to resultant from challenges of limited social understanding and emotional regulation. When behaviors are determined to be of malicious intent, students with Asperger’s syndrome, who have the full capability of functioning appropriately in general education classrooms, are at risk for placement in a more restrictive
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Reducing Aggressive Behavior setting (e.g., special education classroom for students with emotional disturbance). Myles and Southwick (2005) described the cycle of tantrums, rage, and meltdowns typical in individuals with Asperger’s syndrome. In particular, the authors provided rationale and support for common behaviors of students with Asperger’s syndrome along a continuum of three stages: (a) rumbling, (b) rage, and (c) recovery. During the rumbling stage, individuals with Asperger’s syndrome engage in minor behaviors that may not appear to educators as related to tantrums or aggression. Such behaviors include fidgeting, name-calling others, refusing to comply, physically withdrawing from an activity, and/or challenging the authority of the teacher (Myles, 2005; Myles & Southwick, 2005). These behaviors, although perceived as a nuisance in a classroom setting, may not signal to educators a need for prompting or intervention. However, such behaviors, if left to escalate, quickly can turn into rage. During the rage stage, an individual with Asperger’s syndrome may appear impulsive and explosive, engaging in behaviors such as threatening, hitting, kicking, destroying property, and biting. However, behaviors displayed during rage should not be regarded as purposeful (Myles, 2005). Rather, threatening and/or aggressive behaviors are resultant of combined misunderstanding of the social world and absence of emotional regulation skills that lend to increased stress and uncontrollable anxiety (Aspy & Grossman, 2007; Laurent, & Rubin, 2004; Myles & Southwick, 2005). After an outburst, individuals with Asperger’s syndrome enter the recovery stage. During this final stage of the cycle, a student with Asperger’s syndrome may apologize for his or her inappropriate behavior; become sullen; deny that any inappropriate behaviors occurred; or, in some cases, sleep for several hours (Myles, 2005; Myles & Southwick, 2005). It is necessary for educators to understand the cycle of tantrums, rage, and meltdowns as a means for preventing and decreasing the severity of problem behaviors. In particular, educators must engage in a process of creating an environment that assists the individual with Asperger’s syndrome in preventing this cycle from recurring and building strategies to teach proactive skills that cause inappropriate behavior to be reduced and/or eliminated, a process that aligns well with positive behavior support (PBS). PBS is a value-based intervention approach that uses evidence-based strategies to enhance an individual’s quality of life and prevent or reduce problem behaviors in students (Carr et al., 2002; Dunlap & Carr, 2007). Under PBS, functional behavior assessment strategies allow practitioners to gain specific knowledge of those events that occasion or maintain problem behavior(s). Such information is used to describe and predict an individual’s behavior before developing multiple support strategies (Horner, 2000). Subsequent support strategies then focus on preventing problem behaviors from occurring, as well as teaching replacement behaviors (e.g., teaching a student emotional regulation skills instead of turning over desks in the classroom). The
educative approach of PBS encourages positive interactions of the individual within a community rather than decreasing or eliminating problem behaviors. School systems face the challenge of effectively and efficiently addressing the behavioral needs of students with Asperger’s syndrome and providing a safe environment conducive to learning (Summers et al., 2004). Moreover, the Individuals With Disabilities Education Improvement Act (PL 108-446) mandates that educational teams use functional behavior assessment strategies and subsequently consider positive interventions to address the impeding behaviors of students with disabilities. As such, the use of PBS within schools is considered essential to the process of assisting students with Asperger’s syndrome, especially those who demonstrate significant behavioral limitations. Teams should comprise individuals most likely to be responsible for educating the student with Asperger’s syndrome (e.g., teachers, support specialists) and then work collaboratively to develop and implement data-based support plans (Bambara, Nonemacher, & Kern, 2009). When performed effectively, school-based teams not only can reduce the need for more restrictive placements (e.g., self-contained classrooms for students identified as having emotional disturbance; alternative settings) of students with Asperger’s syndrome, but also teach these students how to control excessive behavioral outbursts. The purpose of this case study was to demonstrate the success of an intervention developed collaboratively with a school-based educational team to reduce the threatening and aggressive behaviors of a middle student with Asperger’s syndrome. In particular, this case study examined the utility of a multicomponent PBS approach to prevent threatening and aggressive behaviors from escalating and to teach the student effective ways to regulate emotions. Results of this case analysis demonstrate the following: (a) an applied individual PBS approach for a student with Asperger’s syndrome who demonstrated excessive behavioral concerns, (b) the ability of a school district and a schoolbuilding team to work collaboratively on improving the behavior of a student rather than recommend more restrictive special education placement, and (c) increased capacity of school personnel to advocate for and use an effective behavioral change strategy.
Method Participant and setting Participant. Arturo was 12 years 7 months and attended the seventh grade in a general education classroom located in West Central Florida. An extensive review of his records revealed that Arturo had a history of language, social, and behavioral difficulties from an early age. At the age of 2 years, a team of educational professionals in New York determined that Arturo demonstrated significant
10 language delays, low adaptive behavior skills, and characteristics of autism. Arturo subsequently received prekindergarten/early intervention services. On turning 3 years of age, Arturo’s developmental progress was determined to be inadequate and he was referred for a private evaluation by a neurologist. As a result of this examination, Arturo was diagnosed with pervasive developmental disorder as a result of continued language delays, poor socialization skills, aggression, temper tantrums, and an aversion to being touched. Despite these areas of impairment, Arturo demonstrated average intellectual abilities. For the next 3 years, Arturo received special education services through a full-day public preschool program for students with autism. Upon his reevaluation at age 6 years, Arturo was considered to be academically and socially prepared for regular kindergarten (although speech and language delays remained). As a result, he was placed in a regular kindergarten classroom and received part-time speech and language services. At the age of 11 years, Arturo moved with his parents to West Central Florida, where he was evaluated privately by a psychiatrist and received a diagnosis of anxiety disorder and pervasive developmental disorder (by history) and placed on medication (medications that he continued to take during this case study). Five months later, he was reevaluated by another private psychiatrist at the request of his parents and diagnosed with Asperger’s syndrome and attention-deficit hyperactivity disorder. A review of Arturo’s academic records since moving to Florida indicated high achievement, earning consistent As and Bs across all academic content. Moreover, Arturo demonstrated superior performance on Florida’s state-based proficiency test, scoring at the 95th and 97th percentile in reading and mathematics, respectively. Despite positive academic competency, Arturo continued to demonstrate difficulty functioning in regular education settings. His teachers and parents expressed ongoing concerns relating to his social skills and, in particular, his lack of emotional regulation. As a result of these difficulties another school-based evaluation was initiated to determine if a more restrictive placement was warranted (i.e., full-time placement in a classroom for students with severe emotional disturbance). Results of the most recent reevaluation indicated that Arturo possessed above-average intellectual and academic abilities. On the Wechsler Intelligence Scale for Children—Fourth Edition (Wechsler, 2003), Arturo obtained a full-scale IQ score of 129 (placing him in the 97th percentile for his age group). Similarly, Arturo’s performance on the Woodcock-Johnson Tests of Achievement—Third Edition (Woodcock, McGrew, & Mather, 2001) was within normal limits, scoring 119, 118, and 98 on broad reading, broad math, and broad written language composites, respectively. In addition to assessing his intellectual and academic abilities, Arturo completed the self-report measure of the Behavioral Assessment System for Children—Second Edition (Reynolds & Kamphaus, 2004). His overall emotional adjustment was con-
Sansosti sidered average. However, his self-report indicated specific problem areas with regards to anxiety, temper tantrums, feelings of being overwhelmed, inflexibility, and restricted interests. Rather than recommend a more restrictive placement for Arturo on the basis of limited findings, the evaluation team determined that more specific, targeted interventions aimed at remediating his emotional regulation and social-skills difficulties were necessary. As a result of this decision, I was brought in on a consultant basis to work with the educational team to build a system of positive intervention supports to assist Arturo in improving his overall level of social and behavioral functioning. The goal of this process was to keep Arturo in a regular education classroom, reduce the frequency of his behaviors, and increase the amount of academic engaged time. A period of 1 month was selected to demonstrate changes in Arturo’s behavior. If his behaviors did not change significantly during that time, it was recommended that Arturo receive his education in an alternative school for children with severe behavioral disorders. Setting. All assessment, intervention development, and intervention implementation sessions were conducted in Arturo’s school. In particular, interviews were conducted in an empty (guidance counselor’s) office located in the administrative wing of the school. Direct observations of Arturo’s behavior for assessment and intervention periods were conducted in general education classrooms that consisted of one teacher and 20 to 25 students. In addition to these settings, two offices within the school were selected for specific purposes. First, a guidance counselor’s office was selected as a home-base location for Arturo. This location served not only as a stress-free environment, but also was a location for Arturo to report and record his behavioral progress and exchange earned points for backup reinforcers. This office was located in the main administration portion of the school. The guidance counselor was at the school every day and agreed to have Arturo check in with her on a daily basis. Second, the behavioral specialist’s office was selected as a place for Arturo to go to when he felt overly stressed or was required to remain if he lost control of his emotions. That is, this location served as a crisis response command post. This office was located in the middle of the school and permitted easy access to all of the classrooms. The behavioral specialist was at the school every day and agreed to serve as the contact person when Arturo could or would not deescalate his inappropriate behaviors. Materials and measures Stress cards. Standard store-bought business cards (Avery 5881 color laser business cards) were used as a medium for creating a portable visual support for Arturo to use during stressful situations. Each card was 3.5 in. × 2 in. and contained three short statements and small pictures to prompt and guide Arturo’s behavior (see Figure 1). The
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Reducing Aggressive Behavior Target behavior
Threatening and aggression. Threatening behaviors were defined as any moment when Arturo verbally threatened the life of himself, his teacher, or other students. Examples of threatening behavior include: • “I’m going to kill myself!” • “Why can’t you understand me; I just want to kill you!” • “I can make you stop harassing me if I kill you!” Fig. 1. Stress card used by the participant during the intervention. (Color figure available online.) (Color figure available online).
Nonexamples of threatening behavior included statements include: • “This is so stupid and I don’t want to do it!” • “Just leave me alone!”
statements on the stress card provided a visual reminder for Arturo of what to do when he felt overly stressed and provided direction for engaging in appropriate behavior that would earn the respect of his teacher, as well as earn him points. Token economy/point store. A specific point system was devised as a motivational and reward tool for Arturo. In particular, points were provided to Arturo for nonthreatening and nonaggressive behaviors by using the stress card appropriately (see the Procedures section for full description). Points were accumulated and recorded in the guidance counselor’s office (home-base). In addition, a point store (a small bookshelf located in the guidance counselor’s office) was created for Arturo to exchange his points for backup reinforcers. Before purchasing the backup reinforcers, Arturo completed a reinforcer checklist. This checklist allowed the school staff to identify and purchase only those items that would be highly rewarding for Arturo. Examples of reinforcers included, but were not limited to, Harry Potter trading cards, Nintendo Power magazine, access to computer time during study hall, free homework passes, and lunch dates with the guidance counselor.
Observational data forms. Each classroom teacher was asked to complete two brief observational data forms during baseline and intervention phases. First, AntecedentBehavior-Consequence (ABC) Cards were used to assist in determining the function of Arturo’s inappropriate behaviors. The ABC Cards (see Figure 2) were provided to teachers and completed immediately after Arturo displayed some form of inappropriate behavior. Second, a Behavior Data Form (see Figure 3) was created for teachers to record the amount of time that Arturo was engaged within the classroom, provide a frequency count of his threatening and/or aggressive behavior throughout the period, and total points earned (during the intervention stage). At the end of the class period, the teacher completed this form, signed it, and gave it back to Arturo to include in his binder.
Aggression was defined as those instances when Arturo was physically throwing an object; hitting, slapping, or punching an object or person; or kicking an object or person. Examples of aggression included Arturo throwing his knapsack at his teacher or classmates, punching the wall, or kicking a desk as he left the classroom. Nonexamples of aggression included yelling or screaming or walking out of the classroom without any physical exchange. Academic engaged time. Because threatening and aggression were considered to be behaviors of high intensity but with low frequency, a different standard of measurement was selected to demonstrate the effect of the intervention components. For this reason, academic engaged time was used as an overall dependent variable and was defined as any time Arturo was engaged, either actively or passively, in class. Examples included periods of time when Arturo was engaged actively in assigned work such as reading, writing, or talking to a teacher or classmate about the assigned materials, as well as those times when Arturo was engaged passively by listening to a lecture, looking at an assignment, or looking at the teacher during instruction. Academic engaged time did not include any sort of threatening or aggressive act such as cursing, shouting, pushing, name-calling, hitting, or making forceful bodily contact with another person or object. Overall, academic engaged time included those times when Arturo remained in the classroom during each class period and demonstrated some level of work. This dependent variable was an overall measure of progress since attending academically was viewed to be incompatible with threatening and/or aggressive behavior. Design A basic, nonexperimental AB single-subject design was used to evaluate the overall utility of the intervention. Although this design was determined to be adequate for demonstrating overall student improvement, it did not assess a direct functional relationship between the dependent and independent variables (Kazdin, 1982). However, within the context of the school setting, this type of design
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Sansosti Student:
Teacher:
Date:
Time of Incident:
Structured Activity Behavior:
Activity/Setting Large Group Instruction Other (specify):______________
Unstructured Activity
What Happened Before? Demand / Request Denial Difficult Task Introduced Nonpreferred Task Introduced Consequences Imposed Denied Access to Activity / Object Provoked by Another Student Interruption of Routine / Activity Transition Work Incomplete Attention Given to Others No Direct Adult Attention Presence of Specific Adult, Peer, or Sensory Events (e.g., lights, noise) Other:_______________________ ______________________________
Small Group Instruction _____________________________ Additional Comments What Happened After? Related Issues: Illnesses, conflict, fight, fatigue, eating routine, Behavior Ignored weather, things obtained or avoided… Reprimand / Warning Verbal Redirection Physical Redirection Loss of Privileges Removal of Activity / Materials Peer Attention / Laughter Adult Attention / Assistance Time Out in Class Time Out in Another Class Removal / Office Referral Suspension: ISS OSS Physical Restraint Home Note / Parent Conference Other (specify):______________ _____________________________
Fig. 2. Antecedent-Behavior-Consequence (A-B-C) data collection card used to assist in determining the function of the participant’s behaviors. Adapted from High-functioning autism/Asperger syndrome in schools: Assessment and intervention, by F. J. Sansosti, K. A. Powell-Smith, and R. J. Cowan, 2010, p. 228. Copyright 2010 by Guilford Press.
Arturo
Student: Observer: Setting:
Date: Time Started: Time Ended:
Target Behavior:
Academic Engaged Time (AET)
Behavior Definition:
Periods of time when Arturo is engaged actively in assigned work such as, reading, writing, or talking to a teacher or classmate about the assigned materials. Instances of AET also include those times when Arturo is engaged passively as demonstrated by behaviors such as, listening to a lecture, looking at an assignment, or looking at the teacher during instruction.
Episode
Behavior Started
Behavior Ended
Duration
Total Duration of Target Behavior Percent of Time Target Behavior Displayed (Duration/Total Time) Inappropriate Bxs Number of Times Arturo Threatened Others: Number of Times Arturo Acted Aggressively:
#: #:
Points Earned During Period
#:
Points Earned
Teacher Signature:____________________________________________ Student Signature:____________________________________________
Fig. 3. Behavior recording form completed by teachers to record the participant’s amount of academic engaged time, number of threatening or aggressive behavior, and total points earned. Adapted from High-functioning autism/Asperger syndrome in schools: Assessment and intervention, by F. J. Sansosti, K. A. Powell-Smith, and R. J. Cowan, 2010, p. 223. Copyright 2010 by Guilford Press.
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Reducing Aggressive Behavior frequently is accepted by educational staff and deemed sufficient for demonstrating student improvement in a brief period of time (Alberto & Troutman, 2008). The educational team determined that an AB design was an adequate method for demonstrating Arturo’s improvement, as well as provided a level of accountability appropriate for the school district’s standards. A follow-up phase was added 1 month after the intervention period to examine maintenance of acquired skills. Although the addition of a follow-up phase did not add to the experimental control of the study, it provided additional information regarding the overall clinical significance of the approach. Procedure Functional behavior assessment. I conducted a functional behavior assessment through a series of interviews, observations, and analysis of data collected by teachers. In particular, I conducted several interviews with Arturo’s family and teachers using a semistructured format adapted from O’Neill et al.’s (1997) Functional Assessment Interview. I also interviewed Arturo to gain perspective of the behavioral concerns through the student. After the interviews, I conducted observations of Arturo’s behavior across a variety of class activities. These observations included recording relevant cues of behavior, the typical sequence of events that occur before and after the behavior, and descriptions of setting-specific variables. Because threatening and aggressive behavior was not observed frequently during observations, teachers completed ABC cards for each inappropriate behavior Arturo displayed. Teachers also gathered data using the data form in Figure 3. Behavioral assessment data was gathered for 1.5 weeks before developing or implementing instructional and/or intervention strategies. Analysis of the functional behavior assessment data revealed several key findings. Interview data revealed that Arturo entered the school environment with excessive stress that was exacerbated further throughout the school day. In particular, Arturo’s family and teachers indicated that he often came to school frustrated. When he failed to complete or turn in his homework, was asked to engage in nonpreferred activities, or when presented with confusing tasks, his frustration would intensify and he would become excessively fidgety and engage in threatening and, at times, aggressive behaviors. Several of his teachers indicated that Arturo threatened to kill teachers, other students, and himself several times per week. After Arturo made threatening or aggressive behaviors (which were considered zerotolerance behaviors), he was immediately dismissed from the classroom and sent to the assistant principal’s office, where he would sleep for several periods, sometimes missing 4.5 hours of school per day. When asked directly, Arturo indicated that he was confused about school, did not always understand how to complete assignments, and didn’t like to engage in activities that he thought were boring (e.g., subjects he already mastered, advanced math). In addition,
Table 1. Summary Information Obtained From ABC Cards Trigger
Behavior
Function
. . .verbally refuse to comply and will escalate into . . .to escape or Change in routine. . . verbal or physical avoid demands aggression and gain adult Homework not attention. completed. . . Nonpreferred or confusing tasks
Arturo stated that he did not know how to control himself and was sorry when he offended or hurt others. Data obtained though the ABC cards augmented information obtained during the interviews. Specifically, data revealed consistent patterns of triggers across all classrooms and settings that elicited Arturo inappropriate behaviors and provided a frequency count of threatening and aggressive behaviors. Taken together, results of the functional behavior assessment indicated that the function of Arturo’s inappropriate behaviors were to escape task demands and gain adult attention. Table 1 provides a summary of the data gathered from the ABC cards. Intervention development and implementation. As a result of the information obtained via interviews, observations, and analysis of functional behavior assessment data, a comprehensive, multicomponent intervention plan was developed. This intervention plan consisted of three major components focused on increasing Arturo’s skills for understanding and regulating his emotions, as well as providing him with reinforcement for engaging in appropriate prosocial behaviors. First, Arturo was provided with individual counseling sessions implemented by the author. These sessions focused on teaching Arturo how to recognize, quantify, and express the level of his emotions. Specific instruction during these sessions included the following: (a) teaching the physiological effects of various emotions, (b) understanding emotions through facial expressions and tone of voice, (c) examining videotapes to label and quantify emotions in others, and (d) using problem logs to label and quantify emotions that Arturo displayed in different environments. Second, Arturo was taught to use the stress cards. Using the stress cards correctly earned Arturo points, as this prompt allowed him to keep his emotions under control without threatening others or becoming aggressive. Arturo was awarded one point for handing the card to his teacher and exiting the classroom. However, more points were awarded for returning to the classroom. In particular, Arturo was awarded 15 points for returning to the classroom during the same period, 10 points for returning the following period, and 5 points for returning the third period. Arturo could exchange his points each day for backup reinforcers by going to the guidance counselor’s office. Third, Arturo attended a small-group social-skills curriculum that was
14
Sansosti
Table 2. Change in Arturo’s Rates of Academic Engaged Time Across Phases Variable
M
SD
Min
Max
Change in behavior (%)
Nonoverlapping data (%)
Baseline Intervention Follow-up
112 304 299
5.70 32.61 11.94
105 195 280
120 320 310
— 172 –2
— 100 100
taught by a school psychology intern at the school. This small group consisted of eight boys who were identified as having anger control issues. The focus and content of these sessions was controlling anger and social problem solving. All three strategies began at the same time and were continued for a period of six weeks.
(Kazdin, 1982). In addition to these data, frequency tallies of threatening and aggressive behavior were summarized.
Results Participant’s increase in academic engaged time
Data collection. Teachers collected data during all phases, while the guidance counselor and I monitored the data daily. During baseline, teachers gathered data using the ABC Cards and the Behavior Recording Form. No intervention occurred before or during this period. During the intervention phase, teachers collected data daily using the Behavior Recording Form. If an inappropriate behavior occurred during any period, the teacher completed an additional ABC Card. One month after the intervention, examination of the maintenance of the targeted skills occurred. Follow-up data were collected in the same manner as intervention data. The follow-up phase lasted 2 weeks. Although limited amounts of data were available, this phase served as evidence of maintenance of targeted skills. Data analysis. Arturo’s behavior was graphed as the mean duration of academic engaged time per day. Data collected during baseline, intervention, and follow-up were inspected visually for changes in mean and level (immediacy of effect), as well as percentage of nonoverlapping data points
The results of the multicomponent intervention on increasing Arturo’s time spent engaged in class are displayed in Table 2 and Figure 4. Before the intervention phase, Arturo displayed relatively consistent, low rates of academic engaged time. Upon implementation of the packaged intervention, an immediate increase emerged. In particular, from the last data point during the baseline period (105 min of academic engaged time) to the initial data point during the intervention phase (275 min of academic engaged time), there was an abrupt change of 170 min. Examining the overall change in mean levels across phases also demonstrated improvement in Arturo’s behavior. During baseline, Arturo’s overall mean of academic engaged time was 112 min. Throughout the intervention phase, his level of performance increased to an average of 304 min. Two months after intervention, Arturo maintained elevated rates of academic engaged time, with an overall mean of 299 min during the follow-up phase. There was 100% nonoverlap between the intervention and baseline periods. Similarly, there was 100% nonoverlapping data points between the intervention
Fig. 4. Minutes of time spent in class (academic engaged time) during baseline, intervention, and follow-up phases.
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Reducing Aggressive Behavior Table 3. Mean Rates of Arturo’s Threatening and Aggressive Behaviors Across Phases Threats Variable Baseline Intervention Follow-up
Aggressive acts
M
Min
Max
Change in behavior (%)
M
Min
Max
Change in behavior (%)
13.67 1.75 2.20
8 0 0
18 10 4
— –87 26
3.33 0.75 0.80
2 0 0
5 4 2
— –77 7
and follow-up periods. These data suggest that Arturo not only demonstrated enhanced functioning during the intervention phase but also maintained the skills learned. Participant’s decrease in threatening and aggressive behaviors The mean rate of Arturo’s threatening and aggressive behaviors during baseline, intervention, and follow-up phases are presented in Table 3. Before intervention, Arturo frequently threatened teachers and students. In particular, Arturo demonstrated an average of 13 threats during the baseline data collection period. After implementation of the intervention package, Arturo’s mean rate of threatening behavior decreased to 1.75 instances. Most of these threats occurred during the first week of the intervention when Arturo was first learning how to use the stress card (nine threats occurred on the first day alone). During the followup phase, Arturo’s teachers reported a slight increase in the number of instances of threatening behavior to students or staff, averaging 2.2 instances of threatening behavior over the 5-day period. Data pertaining to Arturo’s mean rate of aggression followed a similar pattern (see Table 3). That is, during the baseline period, Arturo engaged in three acts of aggression per day, on average. Mean rates of aggression decreased considerably following the intervention, but demonstrated a very slight increase during the follow-up phase.
Discussion A multicomponent PBS intervention package consisting of visual supports, direct skills teaching, and reinforcement demonstrated positive effects in improving the overall behavior of a middle school student with Asperger’s syndrome. In particular, the participant’s overall academic engaged time increased and, perhaps more important, rates of threatening and aggressive behaviors decreased. During the initial days of the intervention phase, there was some variability in the participant’s performance. However, this variability was expected given the educative nature of the intervention package. That is, the student was evaluated on his behavior at the same time that he was learning how to use the skills he learned. Throughout the
intervention phase, the student used these skills more frequently, demonstrated by the consistent near-perfect days whereby few threats were perpetrated and no acts of violence occurred. At 2-month follow-up, the participant’s skills appeared to maintain, although greater variability in performance occurred and instances of threatening and aggression appeared to increase. Because this study did not demonstrate experimental control, it is important not to assume that the strategies used were responsible for the majority of behavior change observed, nor is it appropriate to assume that any one particular strategy within the intervention plan had advantage over another. However, it is important to note that the behavior change that occurred as a result of the packaged intervention was meaningful to the educational staff and prevented the participant from being placed in an alternative school for students with serious emotional disorders. Therefore, this study can serve as an exemplar of how school staff can work collaboratively to improve student performance and prevent restrictive placement of students with autism spectrum disorders within special education classrooms and/or buildings. Moreover, the results of this case study can be hypothesized to contribute to the treatment effectiveness literature for improving the behavior performance of students with Asperger’s syndrome in the following ways. First, this case study extends prior literature regarding the use of visual support strategies for students with autism spectrum disorders. Visual aids such as, daily schedules, checklists, activity plans, job cards, Social Stories, Power Cards, social scripts, and computer-adapted skills lessons, have been used to support individuals with autism to maintain attention, understand spoken language, and sequence and organize their environments. Many studies investigating the effectiveness of visual supports have demonstrated increased compliance, decreased behavioral problems, and acquisition of new skills in children with autism spectrum disorders (e.g., Bryan & Gast, 2000; Charlop-Christy & Kelso, 2003; Dooley, Wilczenski, & Torem, 2001; Ganz, Kaylor, Bourgeois, & Hadden, 2008; Krantz & McClannahan; 1998; Morrison, Sainato, BenChaaban, & Endo, 2002; Sansosti & Powell-Smith, 2006, 2008). This case study only adds to this ever-increasing research base by reporting the results of a participant who engaged in less threatening and aggressive behaviors by using a visual cue (i.e., stress card) as part of a packaged intervention.
16 Second, this case analysis provides additional support for the use of strategies such as direct skills teaching and reinforcement to teach children with Asperger’s syndrome how to regulate and control emotions. Skill training that involves the explicit teaching and reinforcement of desired target behaviors has been and continues to be a key feature of intervention for children on the autism spectrum. Treatment studies have reported the use of discrete skillbased approaches for teaching skills combined with reinforcement strategies to promote adherence to rules of conduct and reduce problem behaviors (e.g., Mruzek, Cohen, & Smith, 2007; Waters, Lerman, & Hovanetz, 2009). Third, the case study demonstrates the benefits of using combined, multicomponent intervention strategies that are aligned with the foundational principles and practices of PBS within a school setting. To date, a substantial body of research has demonstrated that the application of positive interventions for students on the autism spectrum is effective for decreasing behavior problems in home, school, and community settings (e.g., Boettcher, Koegel, McNerney, & Koegel, 2003; Clarke, Worcester, Dunlap, Murray, & Bradley-Klug, 2002; Hyman, 2009; Sansosti & PowellSmith, 2006, 2008). In the present case study, steps were taken to ensure that the philosophical approach of PBS was translated into best practices: (a) the target behavior selected enhanced the participant’s quality of life by increasing his participation in activities with nondisabled peers; (b) additional assessments were conducted, including extensive interviews and observations, to determine the function of inappropriate behavior; (c) interventions developed aimed at altering environments/reactions; and (d) the intervention plan fit with the goals, needs, and values of the school environment. Therefore, this case study adds to the extant literature base regarding the effectiveness and utility of using PBS strategies within schools. Several implications for practice can be gleaned from the implementation and results of this case analysis. First, educational staff may not familiar with the exact procedures for implementing a multicomponent, PBS intervention. Therefore, educators may require additional training on how to conduct functional assessments, as well as receive ongoing technical support for designing and implementing interventions. Second, educational staff may find it difficult to think about preventative and educative interventions for students with very difficult problem behaviors. It may be easier to use existing evidence of inappropriate behavior of a student to recommend placement into a more restrictive environment (i.e., self-contained classroom for student with emotional disturbance). To promote the widespread acceptance of such strategies, educators likely will need to present the results of single case studies, such as the one presented here, to demonstrate the power of teaming and proactive intervention development. Such efforts may be viewed as time consuming, and, without administrative support, fruitless. Therefore, it is vital that educators advocate for positive intervention approaches for students with Asperger’s syn-
Sansosti drome and use data to demonstrate to administrators and other educational the staff the clinical utility of such an approach. Last, efforts to increase the time allotted to behavior support teams are necessary, especially in secondary schools. Educators consistently mention lack of time in the school day for meetings, collaborative consultations, or collecting data when working with students with severe behavioral problems. To overcome such a barrier, efforts should be made in schools to create school-level behavioral support teams (or align PBS practices with existing student support teams) charged with providing an infrastructure of support. Despite positive connections to prior research, the findings should be interpreted with the following potential limitations in mind. First, the lack of experimental control associated with an AB design raises concerns regarding threats to internal validity (e.g., lack of control for maturational or historical effects) and external validity (e.g., lack of replication of effects). That is, results of this study fail to limit the number of alternative explanations for changes in observed behaviors. Second, because this study combined multiple treatment variables into one intervention package, it is impossible to determine the individual effect of each strategy on improving the participant’s behavior. Third, the rate of social reinforcement provided to the participant in his respective environment was not assessed. That is, the rates of positive praise provided by his teachers were not evaluated. It is possible that, as a result of increased behavioral regulation and attendance, the participant was provided with verbal praise by teachers (and, possibly by peers) for maintaining control of his behavior during class periods. Fourth, limited data are available to suggest definitive claims with regard to skill maintenance. Follow-up data occurred following the intervention for a period of 2 weeks, but demonstrated a slightly decreasing trend. Therefore, one cannot conclude that the participant’s behaviors maintained over an extended period of time (e.g., 3 months). Fifth, social validity, or the degree by which the intervention techniques used and the outcomes achieved were acceptable, relevant, and useful to educators, was not assessed. Such information would provide the teachers’ perspective for implementing a series of interventions and collecting data as described in this study. Last, as with most small-number or singleparticipant research, caution must be taken in generalizing these findings across students, settings, or other behaviors. Given the limitations of this case analysis, future studies are warranted. The fundamental concern for future research should be the use of procedures and methods that employ experimental control (e.g., multiple baseline across subjects, settings, or behaviors; alternating treatment designs). Moreover, component analyses studies, in which the therapeutic value of individual elements of multicomponent treatment interventions are systematically analyzed (e.g., visual supports, direct skills instruction, reinforcement paradigms), would be useful in identifying the critical aspects of the intervention, as well as potentially
Reducing Aggressive Behavior unnecessary steps. Further research also may investigate the contextual variables that may contribute to intervention effectiveness. That is, subsequent studies may examine the potential effect of the environment (i.e., social reinforcement by peers and teachers). Last, further research should assess the social validity of such an approach when used in school-based contexts. That is, future research should provide information regarding the attitudes and beliefs of teachers and educational teams that use PBS strategies to effect change in individuals with Asperger’s syndrome. In summary, this case analysis demonstrated the effects of a multicomponent intervention strategy that used the foundations and principles of PBS to decrease the threatening and aggressive behavior of a middle school student with Asperger’s syndrome. The results of this case support previous positive findings with regard to the use of PBS practices, visual supports, direct skills teaching, and reinforcement procedures. In addition, the results of this case analysis demonstrate the application of research to practice. It is envisioned that this case analysis will serve as the foundation for the development of larger research projects that investigate the use of assessment-driven, collaborative, multicomponent interventions for decreasing the problematic behavior of students with Asperger’s syndrome across a variety of settings.
Author note Frank J. Sansosti is an assistant professor in the School Psychology Program at Kent State University. His primary research and professional interests focus on the development and implementation of behavioral and social-skills interventions for young children with autism spectrum disorder, the use of technology for teaching students with autism spectrum disorder, best practice approaches for the inclusion of students with low-incidence disabilities, and response-to-intervention.
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