Abstract: Cognitive Behavior Therapy (CBT) for bulimia nervosa (BN) requires patient skill utilization (use of treatment skills) and skill acquisition (successful skill use) for symptom improvement. Treatment outcomes are unsatisfactory, possibly due to poor skill acquisition and utilization by post-treatment. Just-in-time adaptive interventions (JITAIs), momentary interventions delivered at opportunities for skill practice, may improve skill acquisition and utilization. Participants (N = 56 individuals with bulimia-spectrum eating disorders) completed electronic self-monitoring in CBT+ and received JITAIs or no JITAIs alongside 16 sessions of CBT. Feasibility, acceptability, target engagement, and treatment outcomes were evaluated. JITAIs demonstrated feasibility and acceptability. Treatment outcomes and target engagement did not differ between conditions. The lack of group differences in target engagement and treatment outcomes may be explained by skill use self-monitoring promoting skill utilization and acquisition or low statistical power. Our findings suggest that JITAIs are feasible and acceptable during CBT for BN and warrant additional study.

Abstract: The purpose of this paper was to review the current state of the behavior analytic feeding intervention literature. We highlight studies that we found to be important contributions to the recent literature in the following areas: food selectivity, chewing, packing, and food refusal/tube weaning and provide suggestions for future research and clinical work in these areas. We also discuss several current topics relevant to the field in hopes to further advance research and clinical practice. These topics include considering the benefits of innovative models of service delivery such as telehealth and caregiver-implemented interventions, the importance of evaluating long-term outcomes of behavioral feeding interventions, and lastly, ethical issues to consider in the designing and implementation of behavioral feeding interventions and training of practitioners in our field.

Abstract: Children with autism spectrum disorder (ASD) often experience skill deficits that can negatively affect long-term outcomes. Interventions based on applied behavior analysis (ABA) yield improvements in targeted skills. However, families often have difficulty accessing ABA services. The purpose of this study was to evaluate the efficacy of a caregiver coaching program delivered via telehealth. Thirty children with ASD and their caregivers (e.g., parents, grandparents) participated in all phases of the study. The program consisted of therapists providing coaching in English or Spanish to caregivers of children with ASD via synchronous video call telehealth visits, typically provided one to two times per week. Caregivers received coaching in interventions (e.g., functional communication training, discrete trial teaching, total task chaining, and naturalistic teaching) to address individualized goals. We collected data on caregiver treatment fidelity and child outcomes (i.e., Vineland-3, observation, and analysis of time series data). Caregivers implemented intervention procedures with 95% accuracy on average. The single-case effect sizes calculated based on the time series baseline and intervention data yielded medium, large, or very large improvements for 85% of goals addressed. Results indicated that the children improved on appropriate engagement (measured via observation), but there was no statistically significant improvement for the remaining pre-post measures. These results, along with the results of previous studies, provide preliminary support for the use of telehealth to provide ABA services. However, there is a need for additional research evaluating the efficacy of these types of programs.

Abstract: Improvements in the quantification and visual analysis of data, plotted across non-standardized graphs, are possible with the equations introduced in this paper. Equation 1 (an expression of graphi...

Abstract: In recent years, virtual manipulatives have been explored and used as an alternative to concrete manipulatives in mathematics for students on their own and as part of manipulative-based instructional sequences. Researchers examining virtual manipulative-based instructional sequences tend to focus on students documented with disabilities, as opposed to students at-risk or struggling with mathematics, as well as students’ acquisition of the target skill, despite students experiencing learning in four stages: acquisition, fluency, maintenance, and generalization. This study explored the virtual-representational-abstract (VRA) instructional sequence across four stages of learning for three elementary students struggling in mathematics. In the single-case design study, researchers found a functional relationship between the VRA instructional sequence delivered online via explicit instruction and students’ computational accuracy in their targeted area of mathematics need. Researchers also found limited influence on fluency rate or generalization to word problem accuracy but that students did maintain.

Abstract: Making treatment decisions based upon graphed data is important in helping professions. A small amount of research has compared usability between equal-interval and semi-log graphs, but no prior studies have compared different types of semi-log graphs. Using a randomized, cross-over, experimental design with 72 participants, this study examined the relative usability and acceptability of three types of graphs: Regular (equal-interval), Standard Celeration Chart (SCC; semi-log), and Standard Behavior Graph (SBG; semi-log). All participants used each graph across three usability tasks (Plotting Data, Writing Values, and Interpreting Trends). For the Plotting and Writing tasks, the equal-interval graph produced the greatest rate of correct responses. However, for the Interpreting task the SBG produced the greatest rate of corrects, while the equal-interval graph produced the smallest rate. User acceptability mainly favored the equal-interval and SBG graphs. Study findings and implications are discussed with respect to graph usability and acceptability during day-to-day practice.

Abstract: Chained and tandem schedules are a common method for thinning schedules of reinforcement following functional communication training (FCT) in the treatment of problem behavior. We conducted a systematic literature review and meta-analysis of chained and tandem schedules following FCT to describe treatment characteristics and evaluate effects. We identified 38 articles and found reductions in problem behavior across four measures. Results of a random-effects multilevel meta-analysis of rigorous evaluations showed a significant effect of chained or tandem schedules + FCT on problem behavior relative to baseline. We observed resurgence in 77% of cases and 31% of schedule-thinning transitions. Results showed chained schedules resulted in greater reductions in problem behavior relative to tandem schedules. Exploratory moderator analyses suggested extinction, combined reinforcement, and delay and denial tolerance training procedures were associated with greater reductions in problem behavior relative to other treatment characteristics. Implications for practice and future research are discussed.

Abstract: Our main purpose in this review was to determine the extent to which ecological validity was demonstrated and assessed in single-case experimental design (SCED) studies examining the effectiveness ...

Abstract: Applied behavior analysts have traditionally relied on visual analysis of graphic data displays to determine the extent of functional relations between variables and guide treatment implementation. The present study assessed the influence of graph type on behavior analysts’ (n = 51) ratings of trend magnitude, treatment decisions based on changes in trend, and their confidence in decision making. Participants examined simulated data presented on linear graphs featuring equal-interval scales as well as graphs with ratio scales (i.e., multiply/divide or logarithmic vertical axis) and numeric indicators of celeration. Standard rules for interpreting trends using each display accompanied the assessment items. Results suggested participants maintained significantly higher levels of agreement on evaluations of trend magnitude and treatment decisions and reported higher levels of confidence in making decisions when using ratio graphs. Furthermore, decision making occurred most efficiently with ratio charts and a celeration value. The findings have implications for research and practice.

Abstract: This randomized controlled trial evaluated the acceptability and additive effects of self-monitoring avoidant and valued functions of behavior, in the context of self-monitoring physical activity a...

Abstract: Successful feeding intervention ultimately requires generalization and adoption of treatment into the home. Treatment models, however, differ regarding how and when caregivers are integrated into care delivery process. Some treatments involve a primary model of parent training with caregivers serving as co-therapist at the onset of intervention, while others involve a complimentary model where a therapist delivers the intervention and caregiver training occurs once the child’s behavior is stable. This review systematically evaluates the evidence-base regarding behavioral feeding intervention for children with autism spectrum disorder (ASD), with a specific focus on interventions involving parent training. Results provide further evidence regarding the potential benefits of behavioral intervention to improve feeding concerns in ASD, while also highlighting growing attention to documenting and/or evaluating parent training within the treatment literature. Important questions remain regarding factors guiding the use of a primary or complimentary model of parent training.

Abstract: Shame is considered central in body dysmorphic disorder (BDD) and empirical accounts highlight the link between shame and BDD symptoms as well as common negative psychosocial effects of the disorder, yet there is a lack of interventions addressing shame in this context. In the past decade, Acceptance and commitment therapy (ACT) and interventions that foster self-compassion have shown promise for reducing the negative effects of shame in a range of clinical problems. The aim of the present study was to develop and evaluate an acceptance and compassion-based treatment specifically targeting shame in BDD. Using a randomized nonconcurrent multiple baseline design, the 12-session intervention, ACT with Compassion (ACTwC), was examined in a psychiatric outpatient sample of five adults diagnosed with BDD. The daily ratings showed marked reductions in BDD-behaviors and self-criticism at posttreatment for four of five participants, while three participants demonstrated decreases in body shame compared to baseline. Improvements were maintained at 6-months follow-up. The intervention also led to reliable long-term improvements in general shame, overall BDD-symptoms, depressive symptoms, and quality of life for four of five participants. All treatment responders showed significant gains in psychological flexibility and self-compassion. Participants reported high credibility and satisfaction with the treatment. These preliminary results suggest that ACTwC may be a promising approach to treating shame in BDD, worthy of further investigation.

Abstract: The current article presents the findings from a systematic review of the available reliability and validity evidence supporting the use of criterion-referenced assessments based on the applied behavior analysis framework. We identified 46 studies that reported reliability and/or validity evidence for six assessments, 37 of which presented reliability evidence and 43 presented validity evidence. Additionally, we extracted and summarized information related to participant characteristics (e.g., age, sex, diagnosis), geographic location, and research setting (e.g., residential facility, home). Overall, we found conflicting support for the use of the assessments. When coupled with the reported usage by behavior analysis professionals, our findings suggest a misalignment between the reportedly used assessments and the number of published studies providing validity and/or reliability evidence. We found inconsistent use of measurement-related vocabulary and that many studies could have been strengthened by conducting different statistical analyses. We provide a summary of studies, findings, and offer recommendations for clinical practice and future measurement research.

Abstract: A component analysis is an approach where two or more independent variables are evaluated as a package and independently. The approach is used to assess and identify which component of a treatment package is the most effective. The purpose of this review is to document the application of component analyses to improve or mitigate non-academic behaviors with individuals with disabilities. We identified 21 research articles that used a component analysis to evaluate treatment packages with students who were identified as having or at-risk for a disability in classroom and/or alternative settings. Results from reviewing 21 articles (22 cases) indicate that 11 intervention packages had a single component that was critical for successful behavior change. Two articles suggested the entire intervention package was necessary while nine articles did not report a critical component or had variable results pertaining to critical components. The benefits and drawbacks of using component analyses for single case research are discussed. Implications for future research are also presented.

Abstract: The present study evaluated the effectiveness of using telehealth technologies to remotely train caregivers of children with ASD to conduct discrete-trial instruction (DTI). We used a multiple-baseline-across-participants design to evaluate caregiver correct implementation of the DTI procedures and child emission of independent correct tacts as dependent measures. We observed robust and immediate improvements for all three caregivers and two of three children. Treatment effects were maintained during follow-up and generalization probes. We discuss the benefits of telehealth technologies and other remote treatment applications.

Abstract: Exposure therapy has been investigated as a treatment for eating disorders, but prior research has largely neglected core fears underlying the disorder such as rejection, abandonment, disgust, and loss of control. We tested the feasibility and acceptability of using imaginal exposure to target disordered eating related fears by randomizing participants (N = 47) with disordered eating to: imaginal exposure (IE), imaginal exposure preceded by a brief food exposure (IE + Food), or an assessment control. Participants attended two in-person visits and completed pretreatment, posttreatment, and one-month follow-up questionnaires. IE was rated more acceptable than IE + Food. Retention was high across conditions. Habituation occurred for subjective distress and believability of feared outcomes, suggesting that imaginal exposure effectively activates core fears. Distress tolerance and confidence in ability to change improved. Disordered eating symptoms, fears, preoccupations, and rituals decreased in all conditions, indicating that IE was not specifically responsible for improvement.

Abstract: Problematic smartphone use (PSU) is smartphone usage that is, in some way, damaging to the user. PSU represents a growing public health concern that could be addressed via behavioral intervention. We recruited six college students who reported negative side effects of smartphone use and sought to decrease their PSU. The effects of a contingency management (CM) + deposit contract intervention on PSU was evaluated. During the CM + deposit contract condition, participants deposited $40 and had the opportunity to earn back their entire deposit by meeting daily smartphone usage goals. To promote adherence to study protocols, participants also had the opportunity to earn a $20 cooperation bonus. For all participants, lower levels of PSU were observed during intervention relative to baseline. The CM + deposit contract intervention produced consistent decreases in PSU for four participants (mean reduction percentages above 40% were obtained) and had inconsistent effects on PSU for two participants (mean reduction percentages below 20%). Maintenance of intervention effects was limited for all participants. Although preliminary, results suggest that CM + deposit contract interventions could be a viable, low-cost approach to addressing PSU. Potential explanations for our findings and avenues for future research are discussed.

Abstract: Children diagnosed with pediatric feeding disorder (PFD) or avoidant/restrictive food intake disorder (ARFID) may present with comorbid oral-motor delays that often contribute to their failure to consume an adequate volume and/or variety of foods. Once the food enters the mouth, these children may exhibit additional problematic behavior such as expulsion and packing that further averts oral intake. Previous research has evaluated the impact of modified-bolus placement methods, including flipped spoon and NUK® brush, in comparison to upright spoon on expulsion and packing. Whether responses are due to performance or skill deficits, researchers hypothesize that modified-bolus placement may assist with reducing the response effort associated with swallowing. This retrospective consecutive controlled case series assessed the clinical application of an additional modified-bolus placement method, underspoon, to increase food consumption and decrease problematic behavior that interfere with mouth clean for children with PFD or ARFID.

Abstract: Behavioral problems, such as noncompliance and aggression, are a common referral reason to mental health services for young children. Behavioral parent training (BPT) is the leading intervention for addressing behavioral problems and leads to benefits in a variety of parental factors (e.g., parenting efficacy and parenting stress). While the COVID-19 pandemic dramatically shifted service delivery toward telehealth services, limited work has evaluated the effectiveness of BPT when delivered in a brief, group format through telehealth. The current retrospective chart review study evaluated the engagement to and preliminary effectiveness of a brief version of BPT delivered through telehealth to 64 families of 3- to 7-year-olds referred for behavioral problems. Families attended an average of 4.55 of 6 sessions and most families had two caregivers who engaged in the intervention. Significant reductions in caregivers’ report of children’s behavioral problems and improvements in parenting self-efficacy resulted. Future research and clinical implications are discussed.

Abstract: Maximizing the discrepancy between expected and actual outcomes during exposure (i.e., expectancy violation) is thought to optimize inhibitory learning. The current study examined Craske et al.’s suggestion that engaging in cognitive restructuring (CR) before exposure prematurely reduces expectancy and mitigates outcomes. Participants (N = 93) with claustrophobia were randomly assigned to either 15 minutes of CR before exposure (CR Before) or 15 minutes of CR after exposure (CR After). Although the CR Before condition experienced greater expectancy reduction before exposure than the CR After condition, both groups experienced similar overall expectancy reduction by the end of the intervention. Groups experienced similar gains, with large significant improvement at posttreatment and follow-up. Results suggest that both cognitive therapy and exposure therapy lead to expectancy reduction, but that the order of these interventions does not impact outcome. Clinicaltrials.org registration #NCT03628105.

Abstract: During the COVID-19 pandemic, many insurance companies approved the funding of telehealth-based behavior analytic services for both training and direct-care purposes. Activity schedules are a simple and effective intervention that can be used in the home environment to improve independence for children with ASD. Recent efforts have shifted the format of activity schedules from paper-based schedules to digital platforms that make the schedules more portable and provide easier access for both the caregiver and the Board Certified Behavior Analyst (BCBA). Google Slides® is a readily available web-based platform that has been used to design and deliver behavior analytic instruction during the COVID-19 pandemic. A non-concurrent multiple baseline design across three child-caregiver dyads was used to evaluate the effectiveness of a caregiver-implemented digital activity schedule intervention on the independent play behaviors of children with ASD. The activity schedule was created and shared on the Google Slides® platform and caregivers received bug-in-ear (BIE) coaching from practitioners to implement the intervention. Regardless of some minor treatment implementation difficulties attributed to the remote service delivery and the digital format, the digital platform and coaching intervention were effective in increasing independent schedule following with minimal training on the part of the caregiver. We hope that the results of this study provide BCBAs with additional guidance on effective interventions and procedures for remote service delivery.

Abstract: Individuals diagnosed with autism spectrum disorder (ASD) exhibit deficits in social interaction and communication. Kronfli, Vollmer, et al. developed an in-person assessment to evaluate participant response to social cues indicating uninterest in a conversation. In the current study, we sought to extend these procedures to the assessment of conversation skills via telehealth given the ongoing pandemic and so that participants in remote areas could receive services. Participants were exposed to a hierarchy of social cues of uninterest ranging in salience from one-word responses to a clear verbal statement of uninterest until they demonstrated sensitivity to a social cue. One participant who did not demonstrate sensitivity to any cues received instruction using Behavioral Skills Training. Initial results support the utility of using a remote assessment model to screen for sensitivity to specific social cues in conversations and to provide services to participants via telehealth.

Abstract: Telehealth behavioral interventions are increasingly necessary when in-person services are not accessible (e.g., due to geographic location, time, cost, and health and safety restrictions). There is a growing evidence-base for the effectiveness of telehealth interventions but few demonstrations of telehealth interventions for pediatric feeding disorders. The purpose of this study was to evaluate a telehealth caregiver training package to teach caregivers to implement a feeding intervention, in their home as primary interventionists, to treat their children’s food selectivity. To address some previously documented caregiver concerns regarding some intervention procedures (e.g., nonremoval of the spoon or escape extinction) and ensure caregivers could safely/feasibility implement intervention, the intervention included differential reinforcement of bites consumed within a 3-minute opportunity. All three caregivers demonstrated high levels of correct performance following training and all children demonstrated increases in the number of bites consumed and decreases in disruptive behaviors. Findings suggest training caregivers via telehealth may be a viable option to treat some children’s food selectivity without first requiring in-person services.

Abstract: Behavioral technicians (BT) within the field of applied behavior analysis may be at greater risk for experiencing burnout and stress due to the nature of their clients, job demands, and work environments. Burnout and stress may negatively impact BT’s work performances, more specifically, their treatment integrity. Acceptance and Commitment Training (ACT) may be a useful tool to address the private events as well as the covert and overt behaviors associated with burnout and stress. The purpose of this study was to investigate the effects of an ACT intervention on improving treatment integrity and reducing work-related burnout and stress amongst BTs. Four BTs participated in an ACT workshop, and their treatment integrity as well as their burnout and stress levels were measured prior to and following the ACT workshop. Treatment integrity increased for all participants, suggesting that ACT-based interventions may be an effective approach to improving work performance (i.e., treatment integrity) amongst BTs who may experience workplace burnout and stress.

Abstract: This study piloted the use of ACT-informed exposure as an adjunct to habit reversal training (HRT) for excoriation disorder (ExD). Using a nonconcurrent multiple baseline single case design, four participants completed sessions of exposure and HRT. Repeated measures and self-report data were collected on skin picking and psychological flexibility. Two participants completed HRT followed by exposure, and two participants completed exposure followed by HRT. Results support the effectiveness of HRT in reducing picking. Results suggest exposure may have some impact in reducing picking, but effects were weaker compared to HRT. Contrary to predictions, repeated measures and self-report data did not indicate consistent improvement in psychological flexibility during exposure phases. As any reduction in picking may be clinically meaningful and all participants maintained gains at follow-up, there is some indication that exposure may be a second-line treatment worth further study. Limitations and future areas of research are discussed.

Abstract: Caregiver training is an important component of behavioral intervention; however, many barriers exist for in-person training. Alternatively, behavioral therapists may use telehealth as a service delivery method. To effectively train caregivers through telehealth, therapists should receive explicit training, but there has been limited research on effective methods for teaching this skill. The purpose of the current study was to evaluate video modeling with voice-over instruction (VMVO) to train therapists to implement 11 component skills of caregiver training through telehealth to teach confederate caregivers to implement a guided compliance procedure. We measured the therapist’s implementation of the component skills during a scripted role-play before and after video-model training within a multiple baseline design across participants. We also conducted maintenance and generalization probes to a novel skill. All seven therapists learned the skill, but three therapists required a feedback component in addition to the VMVO. The results suggest that VMVO may be an efficient and effective method for training therapists to conduct caregiver training via telehealth. Furthermore, results indicate that component skill analyses may be valuable to monitor skills that require remediation.

Abstract: The Caught Being Good Game (CBGG) is a classroom management intervention which is described as a variation of the classic Good Behavior Game (GBG). It is based on the principle of positive reinforcement, such that teams of students can earn points for following the class rules during the game. Points are awarded by the teacher at different intervals during the game and these intervals were the focus of the current study. We aimed to determine if the CBGG is effective with an initially dense schedule of reinforcement which is progressively thinned. The efficacy of the CBGG in targeting academic engagement and disruptive behavior was demonstrated for one primary school class and for two target students in that class. The game remained effective when the reinforcement schedule was thinned from 2 minutes, up to 5 minutes. This has potential implications for teacher time saving while playing the game.

Abstract: In the present study a comprehensive protocol to assess chewing in four children with Down syndrome is provided and described. One baseline and four assessment meals were conducted across four textures of foods to investigate the presence or absence of components of chewing (bite down, chew and tongue lateralization), as well as movements associated with the development of chewing. Results showed that at baseline all participants ate their typical diet (i.e., pureed food) but no chewing components or movements were observed. The findings of the assessment protocol indicated that it offers a prescriptive assessment of chewing and its components across different food textures. The results of the assessment provided useful information for clinicians by identifying a potential starting point for interventions to address chewing deficits. Furthermore, the findings add to the existing literature on the role of tongue lateralization and specific tongue movements in chewing. Implications of the findings for chewing interventions and future research are discussed.

Abstract: Behavioral interventions to decrease problem behavior often involve the use of single-case experimental designs in which an individual’s responding during a treatment condition is compared to responding during a control or baseline condition. It is possible that during the initial introduction of treatment, problem behavior continues to occur at baseline rates before behavior reduction is observed; this phenomenon is called a transition state. Evaluated the prevalence of transition states in the Journal of Applied Behavior Analysis and found that they occurred within 5.3% of the published literature. The current study replicated and extended Brogan et al. by evaluating the prevalence of transition states in unpublished clinical data of patients admitted to an inpatient hospital for the treatment of severe problem behavior. Using a retrospective consecutive-controlled case series, transition states were observed in 3% of cases for an average duration of 4.8 sessions. We discuss factors that may affect transitional behavior between phases and relevant implications for practice and research.