Systematic Review of Problem Behavior Interventions

Journal of Autism and Developmental Disorders https://doi.org/10.1007/s10803-018-3591-0

ORIGINAL PAPER

Systematic Review of Problem Behavior Interventions: Outcomes, Demographics, and Settings Katherine E. Severini1 · Jennifer R. Ledford1 · Rachel E. Robertson2

© Springer Science+Business Media, LLC, part of Springer Nature 2018

Abstract Interventions designed to decrease problem behavior for students with ASD are critical and may be differentially important for students from minority groups as those students tend to be assigned more negative outcomes related to problem behavior (e.g., suspensions). School-based interventions intended to decrease problem behavior for individuals with ASD were reviewed; 46 articles including 84 single case designs and 87 participants were analyzed regarding participant demographics, settings and implementers, intervention components, and study characteristics. We assessed outcomes for 55 demonstration designs with adequate rigor. Most research was conducted with students in segregated settings and, although race and ethnicity were rarely reported, proportions were different from other reviews in that children from some minority groups were overrepresented. Keywords  Students with ASD · Problem behavior · School · Intervention · Demographics

Introduction Problem behavior is common in general and special education classrooms (Powell et al. 2007; Spaulding et al. 2010; Westling 2010). Engaging in problem behavior decreases the likelihood that students meaningfully engage in their classrooms, community, and with their peers (Horner et al. 2002). Children with autism spectrum disorder (ASD) engage in problem behavior at a higher rate than their typically-developing peers (Horner et al. 2002), and students with disabilities are more likely to be physically restrained or secluded in school (U.S. Department of Education Office for Civil Rights [USDOE] 2014). Recent research has shown that teachers perceive Black students, especially Black boys, as more likely to engage * Katherine E. Severini [email protected] Jennifer R. Ledford [email protected] Rachel E. Robertson [email protected] 1



Department of Special Education, Vanderbilt University, Peabody Box 228, Nashville, TN 37208, USA



Department of Instruction and Learning, University of Pittsburgh, 5146 Wesley W. Posvar Hall, 230 South Bouquet Street, Pittsburgh, PA 15260, USA

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in problem behavior than their White peers (Gilliam et al. 2016; USDOE 2014; U.S. Department of Health and Human Services [HSS] n.d.). Implicit bias towards certain groups likely contributes to differential disciplinary action (Gilliam et al. 2016; McIntosh et al. 2014). Both students with disabilities and Black students receive disproportionate school suspensions; they are two (students with disabilities) or three (Black students) times more likely to be suspended than their typically developing or White counterparts (USDOE 2014). Alarmingly, 20% of Black girls and 25% of Black boys with disabilities receive an out of school suspension, compared to 6% of White girls and 12% of White boys with disabilities (USDOE 2014). Suspensions and expulsions have lasting negative impacts on children, increasing the likelihood of academic failure, school dropout, and even incarceration (HSS n.d.). Single case designs have been often used in research with participants with ASD (Wong et al. 2015), and are acknowledged as appropriate for establishing causal relations (Ledford 2018; Ledford and Gast 2018; What Works Clearinghouse 2014). In single case research, race has historically been considered less important than other factors, such as baseline performance (Birnbrauer 1981; Wolery and Ezell 1993). However, given that Black students are disproportionately targeted and disciplined for challenging behavior, race may actually play a critical role in response to intervention. That is, adults may differ in their responses to Black

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students, giving them a different history of consequences when compared with other students. Thus, race should be consistently reported, particularly in relation to problem behavior. Previous reviews have indicated that authors rarely report race; when it is reported, the majority are reported as White, Caucasian, or European American, and minority participants are generally underrepresented (Pierce et al. 2014; West et al. 2016). Given that the generality of single case findings depends on the extent to which interventions will work for similar participants under similar conditions (Wolery et al. 2011), the lack of race reporting limits researchers’ ability to generalize for whom and under what conditions interventions are likely to be effective. Recent reviews of interventions for children with ASD highlight the importance of reporting demographic information of participants. Machalicek et al. (2007) reviewed school-based interventions for students with ASD and found that only 22% of included studies reported the participant’s race or ethnicity. Likewise, Pierce et al. (2014) reviewed interventions not restricted to a specific setting for children with ASD in three autism-related journals and, similarly, found race/ethnicity/nationality (REN) is rarely reported. Robertson et al. (2017) evaluated recent literature (2008–2015) for the extent to which researchers report the race of participants with ASD in parent-implemented interventions in home settings. Consistent with previous research, they found participant demographics were rarely reported. When they were, White families were included at a significantly higher proportion than that of the general population. Similarly, West et al. (2016) evaluated the extent to which REN was reported for studies included in the highly-cited Wong et al. (2015) review, which identified EBPs for individuals with ASD. They found that race was rarely reported in these studies and when it was, White children comprised the majority of participants, especially in parent-implemented interventions and social skills interventions. However, limitations of this review include that researchers: (a) only evaluated demographic information of studies published before 2012; (b) presumed the nationality of participants based on the country of implementation when the study was conducted outside of the U.S.; (c) included international participants in the same categories as minority groups in the U.S. (preventing clear comparison among U.S. groups); and (d) only included studies that demonstrated positive effects (i.e. studies that established the EBPs). This review addresses limitations apparent in previous reviews by: (a) including the most recent literature (2008–2018) in school-based settings; (b) not limiting inclusion of research to specific journals; (c) only including explicit reporting of REN in studies conducted in the United States; and (d) including studies with at least three potential demonstrations of effect, regardless of intervention effectiveness. Given associations between race and suspension/

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expulsion data, REN reporting may be especially critical for these studies. The purpose of this review is to evaluate behavioral interventions designed to reduce problem behavior for students with ASD in school settings. Research questions include: 1. What are the demographic and setting characteristics for interventions designed to decrease problem behaviors in school settings for students with ASD, and to what extent do these characteristics align with national estimates and previous research? 2. What percentage of studies show evidence of a functional relation? Is the proportion of studies with functional relations different across racial/ethnic groups?

Method Search Procedures A systematic literature search was conducted using ERIC, PsycINFO, and PsycARTICLES databases to identify peerreviewed empirical studies published from 2008 to 2018 investigating the effects of interventions for reducing problem behavior in students with ASD in schools. The year restrictions were developed to (a) be better able to compare results to those from a similar review for parent-based interventions for students with ASD (Robertson et al. 2017), and (b) improve comparability of data from studies with data from recent U.S. Census and Department of Education estimates (i.e., race and ethnicity proportions have changed over time, thus comparing old data with more recent Census estimates is not reasonable). The following search terms used to identify relevant studies yielded 3469 peer-reviewed articles: (school or class*) and (autis* or ASD or Asperger* or PDD) and (problem behavior or behavior problems or challenging behavior or disruptive behavior or function-based or externalizing or inattention or off-task or aggression or elopement or self-injury). Of these articles, 303 articles met initial screening criteria and were included for full-text review. Following full-text review, 48 articles were identified for inclusion. Although our inclusion criteria did not include use of a single case design, only one group design study (Iadarola et al. 2018) was identified; because it is difficult to compare single case and group comparison designs, and there were no other group designs, this study was not included in the analysis. An additional study was excluded because data from participants who did not respond to the intervention were not published (Hodgetts et al. 2011). The 46 remaining articles included 84 single case designs and 87 participants. Some variables of interest are reported at the article level, others at the design level, and others at the participant level. Outcomes were analyzed at the design

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level and only for designs including three potential demonstrations of effect, consistent with functional relation determination guidelines (cf. WWC 2014). The first and second authors independently conducted searches and determined eligibility for inclusion; agreement was 99%.

Article Eligibility and Selection Articles that met the following criteria were included: (a) intervention conducted in a public or private school setting (including classroom within residential setting) in the United States, (b) included at least one participant with ASD, Asperger’s, or Pervasive Developmental Disorder (PDD), (c) reported observational or standardized data on problem behavior, and (d) compared problem behavior occurrence across two conditions, at least one of which was a systematically manipulated intervention condition. Articles were excluded from the review if they: (a) included only functional assessments, functional analyses, or structural analyses rather than assessing treatment or intervention conditions, (b) were conducted in hospitals or residential settings without a school-based component, or (c) included intervention only for stereotypy, including behaviors described as perseverative or repetitive. Because consequences for stereotypy are unlikely to be similar to those for other problem behaviors (e.g., physical aggression), we expected racial distributions might be different for that behavior, even though it may be described as problematic. No child age limitations were applied (e.g., a study with a 3-year-old participant was included if the setting was school-based). For studies that included students with and without ASD, participant and intervention characteristics were coded for the participant(s) who met inclusion criteria (e.g., received intervention in school setting; diagnosed with ASD, Asperger’s, or PDD). For multiple baseline (MB) across participant studies, functional relation determinations were made including data from all participants, even if all did not meet inclusion criteria.

Coding Procedures Descriptive Coding The first and second authors (hereafter: researchers, to distinguish from authors of studies included in the review) coded articles for a range of descriptive elements, including participant characteristics, methodology, assessment, contextual, and intervention information. Researchers recorded participant demographics, including age, gender, REN, diagnosis, and school and classroom placement. Researchers recorded the diagnosis authors reported, and whether authors provided information to confirm the diagnosis (e.g., medical diagnosis by psychologist). See Table 1 for a detailed

description of codes. Interobserver agreement (IOA) data were collected for 25% of articles; average agreement across articles and codes was 92%. Disagreements were resolved via consensus. Design type was assessed separately for each participant. If participants were part of the same design (e.g., MB across participants), only one design was coded. Researchers evaluated studies for other methodological factors, including whether there were three potential demonstrations of effect, description of procedures with replicable precision, and whether IOA, procedural fidelity (PF; independent variable reliability), and social validity (evidence of social importance) data were collected. Current best practice dictates using function-based interventions to reduce problem behavior; this involves identifying what consequences reliably follow the problem behavior occurrences, identifying these consequences as the likely reason for the problem behavior, and identifying an intervention that (a) decreases the likelihood of the consequence occurring contingent on problem behavior, (b) teaches the child a different (alternative) behavior designed to access that consequence, and/or (c) changes the environment to make the behavior less likely to occur or the consequence less valuable (e.g., providing high-rate antecedent attention to a child who engages in problem behavior to get teacher attention). Interventions that are not related to the function, or interventions designed without assessing behavior function, are non-function-based. Researchers recorded the assessment method used to identify function (e.g., functional behavior assessment), and the credentials of the assessment agent. If the assessment consisted of an interview, questionnaire, or rating scale, researchers also coded the credentials of the information provider (e.g., teacher). When authors reported use of an assessment that identified a function without accompanying data, the first author recorded the named function. When data were presented (e.g., functional analysis [FA] graph), the first author independently identified the function of the behavior(s) based on the provided data. The first author narratively described each study’s intervention components. Researchers analyzed the narrative list and devised potential intervention component categories based on Wong et al. (2015) intervention characterization. The researchers collaboratively categorized interventions based on the devised codes and then consensus coded each intervention component regarding whether it was functionbased or non-function-based utilizing the previously-coded functions. Outcomes Coding Following descriptive coding, researchers visually analyzed data. For 100% of comparisons, researchers

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Table 1  Code descriptions Category

Sub-category

Description (exhaustive code list)

Participants Demographics

Age (rounded to the nearest year), gender (male, female), SES information reported (yes, no) and REN of participants or family reported (yes, no) Disability Author-reported participant’s diagnosis (ASD, Asperger’s, or PDD) and whether the diagnosis was confirmed (yes, no) Formal test results Authors report participant’s current level of academic (yes, no), intellectual (yes, no), language (yes, no), or developmental (yes, no) skills School type Type of school participant is enrolled in (public, private GE, special education school, residential facility) Placement in school Author report of participant’s placement in school (SC classroom, GE classroom, or part time SC/GE) Methods Design type Type of single case design utilized (MB withdrawal/reversal, changing criterion, ATD, combination designs, other) PD of effect Graph indicates there were three potential demonstrations of effect, evaluated separately for each design (yes, no) Description Primary comparison conditions described with replicable precision (yes, no) Definitions Operational definitions (yes, no), examples (yes, no), non-examples (yes, no) of dependent variables provided IOA IOA data collected (yes, no), collected across both primary conditions (yes, no), calculated by point-bypoint agreement (yes, no), and above 80% or .6 kappa (yes, no) PF PF data reported (yes, no), collected across both primary comparison conditions (yes, no), and above 90% (yes, no) Social validity Social validity reported (yes, no) and type (satisfaction, normative comparison, blind raters, other, none) Contextual Intervention setting Setting in which sessions were implemented (student’s usual classroom, in a separate room, both) School demographics General location and type (e.g., south rural) of school reported (yes, no), % of students receiving FRL reported (yes, no) and specific percentage (%), REN composition of school reported (yes, no) and specific REN composition (%) Implementer Credentials (teacher, TA, researcher, BCBA, other, multiple, unclear NR), education reported (yes, no), training reported (yes, no), REN reported (yes, no), and whether he/she is school staff (yes, no) Assessment Type Pre-intervention assessment type (Functional Behavior Assessment, Structural Analysis, functional analysis, rating scale, ABC data, other, none) Agent Assessment agent reported (yes, no), his/her credentials (teacher, TA, researcher, BCBA, other, multiple, NR), and whether he/she was school staff (yes, no) PB topography Specific topography of PB (physical aggression, self-injury, verbal aggression, disruption, off-task, or elopement) Function of PB Authors identified function of participant’s PB (yes, no) Type of intervention implemented (IM, FCT, visual support, social stories, prompts, PC, NC, choice, NCA, Intervention Type restricted access, material alteration, PMI, sensory-based, SST, modeling) Function-based Intervention component addresses identified function of the behavior (yes, no) REN race/ethnicity/nationality, PDD Pervasive Development Disorder, GE general education, SC self-contained, PD potential demonstrations, NR not reported, IM instructional modification, FCT functional communication training, PC positive consequence, NC negative consequence, NCA noncontingent access, PMI peer-mediated intervention, SST social skills training

independently identified the presence of a functional relation (yes or no), defined as a consistent change in data when and only when condition changes occurred, with at least three demonstrations of effect in a single design, suggesting a causal relation between the intervention and changes in behavior. They discussed any disagreements and reached consensus. For one design, visual analysts agreed there was a difference between conditions; because this difference was in the contra-therapeutic direction, it was coded as no functional relation. Agreement for yes/ no decisions was 98%.

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Results Participant Demographics Reviewed studies included 87 participants: 78 with ASD (90%), 7 with PDD (8%), and 2 with Asperger’s (2%). Authors rarely specified the professional or context associated with the diagnosis (21%; n = 18); that is, authors generally did not report whether ASD was a diagnosis or educational eligibility, and whether the diagnosis was provided by a medical professional or other non-researcher. Average participant age was 8 years (range 3–19); age was reported for

Journal of Autism and Developmental Disorders

98% of participants and grade was reported for the remaining two participants. The majority of participants were 3–8 years old (n = 51; 59%); 18 participants were between 3 and 5 years old (21%; preschool), 61 were between 6 and 12 years old (70%; elementary school), and 8 were 13 years old or older (9%; middle and high school). REN was reported for 31 participants (36%); of these participants, 14 were identified as Caucasian (45%), 7 as African American (23%), 4 as Hispanic (13%), 4 as Asian (13%), 1 as Indian (3%), and 1 as Middle Eastern (3%). No studies reported the socioeconomic status of participants’ families, and no study reported inclusion of any multi-racial participants. White students were underrepresented (48% of identified participants in this review, including one participant identified as Middle Eastern; 72% of the population, U.S. Census Bureau 2016) and Black or African American children were overrepresented (23% in our review; 12.6% of the U.S. population, U.S. Census Bureau 2016). Asian students were also overrepresented (13% in our review—this does not include one student identified only as “Indian” because we were unable to confirm whether this student was an American Indian or Asian Indian; 4.8% of the U.S. population, U.S. Census Bureau 2016). In the latest Report to Congress (US DOE 2014), the Department of Education reported that African American students comprised 18% of students aged 3–21 receiving special education services; thus, the 23% representation in this review is thus over-representative based on both national Census and Department of Education data. Most participants’ problem behavior included disruption (70%; n = 61) or verbal and/or physical aggression (n = 35; 40%). Other problem behavior topographies included elopement (n = 13; 15%), off-task behaviors (n = 13; 15%), and self-injury (n = 13; 15%).

Setting and Implementer Characteristics School type was reported for most participants (n = 56; 64%). Of those participants, across ages, most were enrolled in a private special education school (n = 31; 54%), while others received educational services in a public school (n = 18, 32%), residential facility (n = 5, 9%), or in a private general education school (n = 3, 5%). Considerably fewer participants over 12 years old (14%) were enrolled in public schools while more (29%) were educated in residential facilities. Classroom placement was not reported for 29% (n = 25) of participants; when it was reported, 65% (n = 40) of participants were in self-contained classrooms (similar across genders; 69% of female participants and 63% of male participants), 21% (n = 13) were in general education classrooms, and 15% (n = 9) were reported to receive educational services in both types of classrooms (23% of female participants and 10% of male participants). Fewer preschool-aged participants

(7%) received services in both types of classrooms; they were more often educated in self-contained settings (73%). All participants over 12 years old (100%) were enrolled in self-contained classrooms. Of the studies that reported educational setting, about 2/3 of participants were served in placements identified as segregated, and the remaining 1/3 were served in general education settings for all (17%) or part (15%) of the time. This is considerably different from the national data, which suggests nearly 2/3 of students with ASD spend more than 80% of the time in general education settings and only about 13.5% of students with ASD spend more than 40% of their time in segregated settings (US DOE 2014). The number is even lower for 3–5 year olds, only 23% of whom are educated in a separate class (US DOE 2014), compared to 73% of participants in this review. Similarly, a large proportion of participants in the review attended a private school setting, either general education (5%) or special education (54%). This is considerably discrepant from national data suggesting that only 5% of students with disabilities attend private schools and that only 3% attend private schools designated as special education-focused (National Center for Education Statistics 2016). Only one study (Anderson et al. 2016) reported SES at the school level; they reported 47% of students in the school received free or reduced price lunch. Similarly, only one study (Flynn and Lo 2016) reported the REN of the participants’ school (65% minority students). For 36% of participants (n = 31), authors did not report the implementers or did not report enough information to gauge whether the implementer was an indigenous adult or a researcher. When reported with adequate detail, researchers (n = 28; 50%) or teachers/teaching assistants (n = 24; 43%) implemented most interventions. Two interventions were implemented by a peer (4%) and one was implemented by a therapist (2%). Implementers’ education, training, and REN were rarely reported; 5 studies (11%) reported education, 7 studies (15%) reported training, and 2 studies (4%) reported REN of each of their two implementers (African American and Bangladeshi; African American and Caucasian). Functional behavioral assessments are considered critical when designing interventions for reducing problem behavior. For many participants, assessments were not conducted (n = 26; 30%) or assessment agent was not reported (n = 16; 18%). When reported, researchers were the primary assessors (n = 35; 78%); others included teachers (n = 7; 17%), behavior support staff (n = 3; 7%), or an unspecified therapist (n = 1; 2%). When assessment included a rating scale (n = 31; 36%), the information provider was the teacher and parent (n = 7), teacher (n = 7), teacher and teaching assistant (n = 4), behavior support therapist (n = 3), or multiple (n = 1; researcher, teacher, teaching assistant, participant); remaining raters were unclear or unreported (n = 9).

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Intervention Components Interventions for most participants (n = 52; 60%) consisted of multiple treatment components. The most frequently used stand-alone interventions were social narratives (n = 11; 31%), functional communication training (FCT; n = 6; 17%), and non-contingent reinforcement (n = 6; 17%). Other interventions used in isolation were positive (n = 3) and negative (n = 2) consequences and antecedent choice interventions (n = 2). Across intervention combinations and participants, common components were restricted access (i.e., ignoring, blocking, redirecting; n = 35), positive consequences (e.g., rewards, including those identified as preferred or reinforcing; n = 30), FCT (n = 22), and non-contingent access to reinforcement (n = 21). Prompting (n = 17), social narratives (n = 13), modeling (n = 10), instructional modification (n = 6), choice (n = 6), visual supports (n = 4), sensory-based interventions (n = 4), peer-mediated interventions (n = 4), material alteration (n = 2), and peer social skills training (n = 1) were less prevalent. Intervention components that were most frequently function-based were FCT (n = 21; 95%), restricted access (n = 24; 69%), negative consequences (n = 6; 55%), and non-contingent access (n = 11; 52%; see Table 2). Intervention components that were exclusively non-function-based were visual supports, material alterations, social narratives, peer-mediated interventions, sensory-based interventions, and social skills training. Remaining components were used in function-based interventions for some participants (i.e., intervention matched identified function), but were most Table 2  Frequencies of intervention components by FB and NFB Intervention component

Choice FCT Instructional modification Material alteration Modeling Negative consequences Non-contingent access Peer-mediated Positive consequences Prompting Restricted access Sensory-based Social narratives Social skills training Visual support

Function-based FB

NFB

3 21 3 0 2 6 11 0 13 4 24 0 0 0 0

3 1 3 2 8 5 10 4 11 13 11 4 13 1 4

FB function-based, NFB non-function-based, FCT functional communication training

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often used in non-function-based interventions (i.e., did not match function or function was not identified).

Study Characteristics In the 46 included studies, most authors used alternating treatments designs (n = 12; 26%); A–B–A–B designs (n = 11; 24%); or MB designs, either MB across participants variation (n = 8; 17%) or across contexts variation (n = 1; 2%). Less frequently used designs were changing criterion designs (n = 2; 4%) and multitreatment designs (n = 1; 2%). Twelve authors (26%) used non-experimental designs (i.e., designs without three potential demonstrations of effect). One author (O’Reilly et al. 2012) used multiple separate designs (A–B–A–B; ATD). Excluding one study, all authors collected IOA data, but only 22 (48%) collected IOA data across both primary conditions and 26 (57%) calculated IOA using point-by-point agreement. Most authors reported IOA above 80% or .6 kappa (n = 44; 96%). The majority of studies (n = 27; 59%) did not report PF data. Of the studies that did, 9 (47%) collected PF data across both primary comparison conditions and 17 (89%) reported fidelity above 90%. Social validity data were collected in 13 studies (28%), and data were primarily collected via satisfaction surveys (n = 11). One study used surveys plus choice and another used surveys plus a pre-intervention interview. Results were positive for studies reporting general outcomes (e.g., total scores or summary statements; n = 2) and were also positive for studies specifically reporting on importance of goals (n = 2), feasibility (n = 4), acceptability of procedures, (n = 2), and plans for continued use (n = 2). However, results were mixed for all studies assessing perceived outcomes, with one study reporting consistently positive scores in this area (n = 4). Authors identified the function of most participants’ behavior (n = 58; 67%). Of those reported, functions of participants’ problem behaviors were multiple (n = 20; 34%), tangible (n = 15; 26%), attention (n = 11; 19%), escape/ demand (n = 10; 17%), and automatic (n = 2; 3%). Many used FAs (n = 31) or a combination of assessments including an FA (n = 8). Other assessment methods included teacher rating scale (n = 6), reinforcer assessment (n = 3), structural analysis (n = 1), observation (n = 1), interview (n = 1), or multiple types without an FA (n = 13). Many interventions (n = 38; 44%) consisted of all non-function-based components (including participants for whom no function was identified and those for whom there was a mismatch between intervention and identified function), 32 interventions (37%) consisted of all function-based components, 12 interventions (14%) consisted of both non-function-based and functionbased components, and 5 interventions (6%) consisted of function-based components and reinforcement contingent

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on problem behavior (e.g., provided a verbal redirection contingent on problem behavior when attention was one of the functions).

Visual Analysis of Outcomes Researchers visually analyzed data for 55 designs (73%): those with at least three potential demonstrations of effect and that answered a demonstration question. We defined a demonstration question as either: (a) a comparison between author-reported “baseline” and “intervention” conditions (n-42; 76%), or (b) a comparison between two treatment conditions, one of which included at least one functionbased component (intervention) and one of which included no function-based components (baseline; n = 13; 24%). Functional relations were present for 43 (78%) designs and were not present for 12 (22%) designs in 8 (17%) studies. There were only 17 participants for whom race was reported and data were visually analyzed (11 White, 4 Black, 2 Asian). About half of the White (n = 6) and Asian participants (n = 1) were either part of a design with a functional relation (e.g., multiple baseline designs) or individually responded to intervention (e.g., ATDs), compared to 100% of Black participants. Of the 29 designs that used interventions that were not function-based, only 6 showed no functional relation (21%; see Table 3). Only 7 studies used both function-based and non-function-based interventions and 4 included reinforcement for problem behavior; all 11 showed functional relations. The designs with no functional relations included various intervention components: FCT (n = 4), prompts (n = 2), restricted access (n = 4), positive (n = 4) and negative (n = 2) consequences, visual supports (n = 1), sensory-based strategies (n = 1), instructional modifications (n = 1), and peermediated interventions (n = 1). Dependent variables were similarly distributed for designs with and without functional relations, with many including measurement of disruption (32% with a functional relation; 40% without), self-injury (13% with a functional relation; 20% without), and physical aggression (27% with a functional relation; 25% without).

Table 3  Visual analysis results for function-based and non-functionbased interventions

FB FB + NFB NFB

No functional relation

Functional relation

6 0 6

9 7 23

FB function-based, NFB non-function-based, 4 studies with reinforcement contingent on problem behavior are excluded

The designs with no functional relations generally did not show ineffective interventions; rather, they (a) used an inappropriate design (e.g., MB across contexts that resulted in covariation among tiers, prohibiting functional relation determination) or (b) had baseline data that suggested intervention was not needed. Only two designs included outcomes that suggested analysis of ineffective interventions. In most of the studies with no functional relation (n = 10; 83%), there was a functional relation present for another participant in the study (but not necessarily a participant with ASD in a school setting) or another dependent variable (e.g., engagement).

Discussion The purpose of this review was to evaluate research regarding problem behavior for students with ASD in school settings to determine the characteristics of participants, settings, and intervention components. Several important findings emerged regarding intervention settings and demographic characteristics of participants. First, there is relatively little research for improving problem behavior for individuals with ASD in typical school settings. Specifically, many studies were conducted in private settings, which is highly discrepant from national data. This discrepancy between typical settings for students with ASD and the contexts in which research is conducted has the potential to considerably limit the extent to which this research is applicable in public schools. This is a critical gap, given the negative outcomes associated with problem behavior (Horner et al. 2002), that teachers report problem behavior as a considerable concern for students with ASD (Azad and Mandell 2016), and that teachers do not have adequate resources for behavior management (Browers and Tomic 2000). Secondly, the findings regarding race and ethnicity are somewhat different than previous reviews of evidence-based practices for individuals with ASD (West et al. 2016); they also differ from a review regarding parent-implemented interventions for children with ASD exhibiting problem behaviors (Robertson et al. 2017) which has several shared characteristics with this review (e.g., dependent variable, participant search terms). Specifically, we found that race and ethnicity reporting were rare (36%), but instead of underrepresentation of minority groups, we found that there was overrepresentation. These discrepancies across racial groups are concerning because it may confirm that teachers may be biased towards identifying Black students as having behavior that is problematic (Gilliam et al. 2016, US DOE 2014). The pattern of overrepresentation in special education may impact participant selection in school-based research; other reviews have not exclusively included school-based interventions. Black children may be disproportionately

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placed in self-contained settings and these settings may be more often used for research on problem behavior interventions. Because reporting is relatively rare, it may also be that single case researchers are more likely to report REN for non-white participants; in future research, it is critical that authors report REN for all participants. Reasons for discrepancies are not readily apparent, in part because authors reported minimal information on recruitment and enrollment. Our third notable finding was that research regarding problem behavior for individuals with ASD was conducted with children, rather than with adolescents. This aligns with previous research indicating most ASD research is conducted with young children (e.g., Ledford et al. 2017; Pierce et al. 2014). However, there was less research for preschool-aged than elementary-aged children, which is discrepant from other reviews (Ledford et al. 2017). Additional research is needed regarding preventing and reducing problem behavior for young children with ASD, given the prevalence and associated negative outcomes (Crick et al. 2006; Searle et al. 2014). With regards to rigor, we identified 36 articles with at least three potential demonstrations of effect and at least three data points per condition; this is a minimal criterion for methodological rigor (Ledford and Gast 2018). Most studies measured dependent variable reliability (98%), although fewer reported adequate collection across conditions (48%). Many (61%) did not include adequate fidelity measurement and reporting (consistent with other reviews). Overall, many studies included sufficient potential demonstrations of effect and offered at least minimal evidence of reliability, but some problems were noted. Specifically, for 10 of the 12 designs for which we identified that no functional relation was present, experimental concerns rather than (or in addition to) insufficient behavior change was noted. For example, in at least one study, each of the following problems were present: (1) researchers used MB designs across behaviors or contexts, and behavioral covariation was present; (2) one or more tiers included baseline responding that indicated intervention was not needed (i.e., problem behavior reductions did not occur because low levels were present in baseline); and (3) insufficient data were collected during one or more conditions, reducing confidence in experimental control. Additional studies that meet contemporary rigor guidelines are needed. A larger percentage of studies including Black participants had functional relations compared to those with White participants. It is possible that different histories of access to effective interventions result in differential effectiveness when systematic interventions are applied; it is also possible that this difference in effectiveness is due to other factors, especially given the small set of studies on which these data are based. Additional research is needed regarding participants’ access

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to intervention and/or non-therapeutic contingencies prior to intervention implementation—this could systematically vary according to race due to bias, but current data and reporting are insufficient to support this possibility. We characterized functional relations using visual analysis. Of 55 designs that answered a demonstration question and included at least three demonstrations, 43 (78%) were identified as demonstrating a functional relation. This is consistent with similar studies that have identified success rates of 74% for social skills interventions for children with ASD (Ledford et al. 2017), and 67% of problembehavior interventions for young children with ASD (Horner et al. 2002). Perhaps the most interesting finding regarding functional relations was that a large proportion of non-function-based interventions was determined to be effective via demonstration of a functional relation (79%), while a smaller proportion of function-based interventions was effective (60%). There are a few possible explanations for the differential effectiveness of function-based and non-functional based interventions: (a) studies that both did not assess function of problem behavior nor demonstrated functional relations may have been more likely to be subject to publication bias due to perceived lack of quality. Similarly, studies that did identify a function but failed to demonstrate a functional relation because of inappropriate design (e.g., covariation present in MB design) or participant selection (e.g., problem behavior was low in baseline, thus behavior change was not needed) may have been more likely to be perceived valuable despite the lack of functional relation. (b) For participants for whom a function of problem behavior was not identified (26%), we classified the interventions as automatically being non-function-based. As described above, although they were not explicitly based on function, they might have included components based on the underlying but unidentified function. (c) Function-based interventions may have been used for more severe problem behaviors; these behaviors may be more resistant to change. Analysis of dependent variables suggests similar rates of behaviors that might be considered to be more severe (i.e., self-injury and physical aggression) addressed by function-based and non-function-based interventions. (d) Function-based interventions may be perceived as intensive and infeasible (Stormont et  al. 2005); thus, researchers may be more likely to evaluate simple, feasible interventions in schools, especially as a first resort. Given the relative success rates of non-function-based interventions, perhaps simple non-function-based antecedent interventions should be implemented while problem behavior assessments are developed, since this is often a resourceintensive process (Sugai et al. 2000). Additional research is needed in this area.

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Limitations and Need for Future Research Several notable limitations to the current review include: (a) restricted publication dates, which limit the comprehensiveness of the findings; (b) a group of studies with relatively heterogeneous independent variables; (c) relatively little data regarding race and settings, so findings and conclusions about these data should be considered preliminary, and (d) no information was analyzed regarding maintenance or generalization of behavior outcomes. In addition, we excluded non-published studies, including theses and dissertations; this allowed for more direct comparisons with previous reviews that have assessed differences in REN reporting in published research studies with individuals with ASD. Finally, we did not assess whether interventions included implementers held relevant certifications (i.e., as a behavior analyst), which may have also impacted outcomes. Similar to previous reviews (Pierce et al. 2014; Robertson et al. 2017; West et al. 2016), we found relatively poor reporting of race and ethnicity and virtually no reporting of socio-economic status. This lack of reporting occurred despite the recent focus on participant demographics, suggesting that historical reporting guidelines were not the primary problem (i.e., studies were published recently). Given that these variables may be important in understanding interventions for problem behavior, it is critical that researchers collect and report these data. This improves consumers’ ability to understand for whom given interventions are likely to be effective, and under what conditions. Similarly, it is essential for research to occur in the settings in which students are typically served. Given that behavior management is often cited as a reason for leaving the teaching profession (Ingersoll and Smith 2003), identifying interventions likely to be effective in typical contexts is critically important and is a crucial, immediate research need.

Conclusions This review contributes to our understanding of the state of school-based interventions for problem behavior for individuals with ASD. Specifically, it points to potential discrepancies in the participation of students belonging to minority groups; this overrepresentation is in contrast to underrepresentation found in several other reviews of non-school-based problem behavior interventions. In addition, it emphasizes the need for applied research assessing the impacts of interventions on problem behaviors in typical contexts. Finally, it identified a potential discrepancy in the effectiveness of function-based and non-function-based interventions, in a direction opposite of what was expected. Additional highquality research is needed to assess intervention effectiveness for students with ASD in schools.

Author contributions  KS assisted in study design, served as the primary coder, and drafted portions of the manuscript. JL participated in the study conception and design, served as a secondary coder, and drafted portions of the manuscript. RR participated in the study conception and design and assisted in drafting and revising the manuscript.

Compliance with Ethical Standards  Conflict of interest  Katherine Severini, Jennifer Ledford and Rachel E. Robertson declare that they have no conflicts of interest. Research Involving Human Participants  This article does not contain any studies with human participants performed by any of the authors.

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