Research in Developmental Disabilities 35 (2014) 3386–3391
Contents lists available at ScienceDirect
Research in Developmental Disabilities
Review article
Treating aggression in persons with autism spectrum disorders: A review Johnny L. Matson, Jina Jang * Louisiana State University, United States
A R T I C L E I N F O
A B S T R A C T
Article history: Received 1 August 2014 Accepted 19 August 2014 Available online
Aggression is one of the most frequent and debilitating problems observed among persons with autism spectrum disorders (ASD). It is common and can be more problematic than many core symptoms of ASD. Thus, treating the behavior is a high priority. A surprisingly limited number of studies have addressed treatment when taken in the context of the vast ASD literature. This paper reviews many of these papers and describes the types of interventions that have been used and the characteristics of the people who have been studied. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Aggression Applied behavior analysis Autism spectrum disorders Pharmacotherapy Treatment
Contents 1. 2.
Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Results and discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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The field of developmental disabilities has seen tremendous positive change in the last few decades. Once considered untreatable, major advances have occurred with respect to intervention such that all persons with developmental disabilities are now considered good candidates for multiple therapies (Carr & Durand, 1985; Halle, Marshall, & Spradlin, 1979; Matson, Dixon, & Matson, 2005; Matson & LoVullo, 2009; Matson, Mahan, & LoVullo, 2009). Among the developmental disabilities, autism spectrum disorders (ASD) are now considered to be among the most prevalent and debilitating (Bromley & Blacher, 1991; Matson & Dempsey, 2008; Matson & Kozlowski, 2011). Core features of ASD include deficits in communication and social skills as well as rituals and stereotypies (Baranek, David, Poe, Stone, & Watson, 2006; Horovitz & Matson, 2010; Matson, Belva, Horovitz, Kozlowski, & Bamburg, 2012; Matson, Boisjoli, Hess, & Wilkins, 2010; Matson, Gonzales, Wilkins, & Rivet, 2008a; Matson, Kozlowksi, Hattier, Horovitz, & Sipes, 2012; Worley & Matson, 2012). In multiple instances, the many co-occurring problems seen with ASD can be very debilitating as well. Sleep problems, feeding problems, general adaptive skill deficits, gastrointestinal disorders, and fine and gross motor issues are among the daily living and health problems that can commonly occur (Goldman, Richdale, Clemons, & Malow, 2012; Malow, McGrew, Harvey, Henderson, & Stone, 2006; Matson, Dempsey, & Fodstad, 2009; Matson, Dixon, et al., 2005; Matson, Rivet, Fodstad,
* Corresponding author at: Department of Psychology, Louisiana State University, Baton Rouge, LA 70803, United States. Tel.: +1 9098150565. E-mail address: [email protected] (J. Jang). http://dx.doi.org/10.1016/j.ridd.2014.08.025 0891-4222/ß 2014 Elsevier Ltd. All rights reserved.
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Dempsey, & Boisjoli, 2009; Molloy & Manning-Courtney, 2003; Symons, Davis, & Thompson, 2000). Intellectual disabilities also often co-occur with ASD and can exacerbate core symptoms of ASD, such as social behaviors (Matson, Carlisle, & Bamburg, 1998; Matson, LeBlanc, & Weinheimer, 1999; Matson, Smiroldo, & Bamburg, 1998; Njardvik, Matson, & Cherry, 1999). Other serious issues include co-occurring psychopathology and challenging behaviors (Lecavalier, 2006; Matson, Rush, et al., 1999; Matson & Smiroldo, 1997; Paclawsky, Matson, Bamburg, & Baglio, 1997). Of the challenging behaviors, aggression is among the most common and most disruptive (Kanne & Mazurek, 2011; Matson & Boisjoli, 2007). This behavior is so problematic that it may frequently take priority over some core symptoms of ASD. Because of these issues, aggression has become a priority for clinicians and researchers. Therefore, the purpose of this paper was to review evidence-based interventions for persons with ASD who also engage in aggressive acts. 1. Methods A Scopus search was conducted using the keywords: aggression, autism, treatments, PDD-NOS, Asperger’s and challenging behaviors. Review papers on the topic were cross-referenced for additional studies. Only primary source papers that used actual treatments for aggression were included. Some of these papers only treated aggression, while others also included other challenging behaviors such as self-injury, adaptive skills, and core symptoms of ASD. 2. Results and discussion Using the methods described above, 27 papers were identified. These studies are presented in Table 1. Early intensive behavioral interventions were not included in the review. In some instances, aggression has been focused on in these papers, but core symptoms of ASD, adaptive behavior, attention, and compliance tend to be most frequently addressed. The treatment literature on ASD tends to mirror the research on other topics in ASD; the focus is almost exclusively with children and adolescents. Of the 27 papers reviewed, only five studies focused on adults (Hittner, 1994; King & Davanzo, 1996; Lundqvist, Andersson, & Viding, 2009; McDougle et al., 1996, 1998). As pointed out in reviews on related topics, the bulk of a persons’ life is spent as an adults. Thus, the majority of people with ASD are adults. Additionally, a problem such as aggression is potentially much more serious and debilitating in adults. The types of interventions are likely to differ for adults, and they may have a longer history of evincing the aggressive behavior. Thus, the aggression in adults is often more serious and debilitating than what would typically be observed with children. The number of participants in the reviewed studies was much smaller in general than what occurs with assessment, epidemiological, demographic, or cognitive studies. This result should come as no surprise to the reader. Intervention studies by their very nature are more time, labor, and resource intensive than just about any other type or research conducted with individuals who are diagnosed with ASD. This issue is compounded when discussing aggression due to the potential for harm, and the fact that these behaviors often are highly entrenched and difficult to mange. Thus, the range of participant numbers across studies varied from one to 218. Thirteen of the papers reported on the treatment of one or two individuals (Braithwaite & Richdale, 2000; Davis et al., 2013; Falcomata, Roane, Muething, Stephenson, & Ing, 2012; Fisher, Lindauer, Alterson, & Thompson, 1998; Foxx & Garito, 2007; Foxx & Meindl, 2007; Hittner, 1994; Kern, Carberry, & Haidara, 1997; Kuhn, Hardesty, & Sweeney, 2009; Luiselli, Blew, Keane, Thibadeau, & Holzman, 2000; Matson, LoVullo, Boisjoli, & Gonzales, 2008; Robertson, Wehby, & King, 2013; Sigafoos & Meikle, 1996), and two studies involved 100 or more people (Marcus et al., 2009; Silverman et al., 2014). The higher number of participated studies involved drug treatments (Arnold et al., 2003; Hellings et al., 2005; King & Davanzo, 1996; Marcus et al., 2009; McDougle et al., 1996; McDougle, Kem, & Posey, 2002; McDougle et al., 1998; Owen et al., 2009; Silverman et al., 2014; Troost et al., 2005), while the low number studies were largely psychologically based interventions. Again, this makes sense in that drug interventions for aggression are far less time intensive than psychologically based treatments. Additionally, most of the psychologically based studies adhered to applied behavior analysis (ABA) principles and procedures. Researchers who endorse this intervention model also often prefer to use single case research designs versus group designs. Following this model would also result in more papers with small numbers of participants but with many more data points for each person studied. Target behaviors all fell within the overall term aggression. For the drug studies in particular, multiple other behaviors were also studied. Self-injurious behavior, irritability (which can mean about anything within the scope of challenging behaviors), externalizing behaviors, and impulsivity were among the behaviors that were co-studied. Since medication is a much blunter instrument than psychological interventions tailored to a given ‘‘target behavior,’’ this approach is also very understandable. For psychologically based therapies, more detail about the aggression was usually evident. Behaviors targeted for intervention have included hitting, kicking, punching, hair pulling, property destruction, grabbing clothing, tantrums, spitting, throwing objects, and pushing. Multiple medications have been tested for persons with ASD. These include aripiprazole, ziprasidone, risperidone, imipramine, valproate, clomipramine, atomoxetine, fluvoxamine, dextromethorphan, and buspirone. Thus, not only have at least ten different drugs been tested for efficacy for persons with ASD, but they also cross drug classes. Thus, the theorized mechanisms of action appear to be compromised. At this point, whether these drugs are simply sedating the individual with ASD and aggression or are directly affecting specific mechanism that promote or trigger aggression is an open question. Psychological treatments are generally less intrusive and cause fewer harmful side effects. Thus, in clinical setting, medication is rarely used along. Rather, it is used in combination with various psychologically based treatments. Thus, a
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Table 1 Treatment studies using the early intensive behavioral interventions. Author(s)
Diagnosis
Arnold et al. (2003) Braithwaite and Richdale (2000) Davis et al. (2013) Falcomata et al. (2012)
Autism Autism
Number of Age participants 94 1
Target behavior
Treatment(s)
5–17 years old 7 years old
Aggression Aggression
Risperidone Extinction, functional communication Functional analysis, weighted vest Functional communication training, chained schedules of reinforcement, replacement behavior Experimental functional analysis, reinforcement of replacement behavior Reinforcement, tokens, choice making, contingent exercise, overcorrection Reinforcement, tokens, choice making, response cost, overcorrection, physical restraint Experimental functional analysis, reinforcement methods, replacement behavior Experimental functional assessment, functional communication training, teaching tolerance and compliance to tasks Valproate
Autism Asperger’s syndrome, Autism
1 2
Child 8 years old
Aggression Aggression
Fisher et al. (1998)
Autism, intellectual disability (ID)
2
7, 15 years old
Property destruction
Foxx and Garito (2007)
Autism
1
12 years old
Aggression, dangerous disruptive behavior
Foxx and Meindl, 2007
Autism
1
13 years old
Aggression, property destruction
Fulton et al. (2014)
Autism, PDD-NOS
3–5 years old
Aggression, tantrums
Hanley et al. (2014)
Autism
3
3–11 years old
Hitting
Hellings et al. (2005)
30
6–20 years old
Aggression, property destruction
Hittner (1994)
Pervasive developmental disorders Autism
Adult
Aggression
Kern et al. (1997)
Autism, ID
1
King and Davanzo (1996) Kuhn et al. (2009)
Autism, ID Autism, ID
26 1
Luiselli et al. (2000)
Autism
1
Lundqvist et al. (2009)
Autism
20
Marcus et al. (2009) Matson et al. (2008a,b)
Autism Autism
218 1
McDougle et al. (1996) McDougle et al. (2002)
Autism Autism or PDD-NOS
30 12
McDouble et al. (1998) Owen et al. (2009) Robertson et al. (2013)
Autism Autism Autism
31 47 2
Sigafoos and Meikle (1996) Autism
2
36
5–17 years old
Aggression, tantrums
Risperidone
8
9–17 years old
Aggression
Dextromethorphan
Silverman et al. (2014) Troost et al. (2005) Woodward, Groden, Goodwin, and Bodfish (2007)
Autism, PDD-NOS, Asperger’s syndrome Autism, PDD-NOS, Asperger’s syndrome Autism
38
1
128
Imipramine, behavior modification Experimental functional 15 years old Aggression: grabbing clothing of another person, analysis, gradual delay of reinforcers, mand training typically around the neck communication as replacement behavior Adults Aggression Buspirone 16 years old Hitting, kicking, punching, Experimental functional analysis, hair pulling functional communication training, blocking 12 years old Severe aggression resulting Clomipramine in multiple staff injuries 22–57 years Self injury, stereotypies, Music old aggression 6–17 years Tantrums, aggression Aripiprazole 11 years old Aggression Differential reinforcement of other behaviors, compliance training, extinction, functional communication Adults Aggression Fluvoxamine 8–20 years old Aggression, property Ziprasidone destruction 18–43 years old Aggression Risperidone 6–17 years old Aggression, tantrums Aripiprazole 2, 5 years old Spitting, throwing objects, Experimental functional analysis hitting, kicking, pushing, pulling hair 8 years old Aggression Replacement behaviors via mands, experimental functional analysis 5–13 years old Aggression Atomoxetine, parent training
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particularly disappointing finding was that the studies that evaluated combined drug and psychological intervention trials were rare; only two studies were identified. For example, Hittner (1994) described a combination of imipramine and behavior modification for one adult with autism, and Silverman et al. (2014) described the use of atomoxetine and parent training for 128 children with autism, PDD-NOS, or Asperger’s syndrome. This area is one that deserves a lot more attention from researchers and funding bodies. Sixteen of the reviewed studies used psychologically based therapies; one paper employed music (Lundqvist et al., 2009) while the other 15 papers relied on ABA principles and procedures (Braithwaite & Richdale, 2000; Davis et al., 2013; Falcomata et al., 2012; Fisher et al., 1998; Foxx & Garito, 2007; Foxx & Meindl, 2007; Fulton, Eapen, Walter, & Rogers, 2014; Hanley, Jin, Vanselow, & Hanratty, 2014; Hittner, 1994; Kern et al., 1997; Kuhn et al., 2009; Matson, Gonzales, et al., 2008; Matson, LoVullo, et al., 2008; Robertson et al., 2013; Silverman et al., 2014; Sigafoos & Meikle, 1996). Two papers that used punishment procedures (i.e., overcorrection, physical restraint) were papers by Foxx and colleagues (Foxx & Garito, 2007; Foxx & Meindl, 2007). Both studies treated one child (12 and 13 years old). Clearly the trend is toward using functional assessments and training coping skills and competing behaviors. Eight of the 16 papers described a functional assessment approach (Davis et al., 2013; Fisher et al., 1998; Fulton et al., 2014; Hanley et al., 2014; Kern et al., 1997; Kuhn et al., 2009; Robertson et al., 2013; Sigafoos & Meikle, 1996). Functional communication training was reported in five papers (Braithwaite & Richdale, 2000; Falcomata et al., 2012; Hanley et al., 2014; Kuhn et al., 2009; Matson, Gonzales, et al., 2008; Matson, LoVullo, et al., 2008). Typically, these frequently used methods were paired with one or more additional methods. These procedures included blocking, gradual delays of reinforcers, teaching tolerance and compliance to tasks, training specific replacement behaviors, using chained schedules of reinforcement, token economies, teaching choice making, extinction, and differential reinforcement of other behaviors (DRO). Two other studies that used rather unorthodoxed methods were also paired with ABA. In one study, a weight vest was used (Davis et al., 2013), and in another instance, contingent exercise was paired with several other treatment components (Foxx & Garito, 2007). When looked at its totality, several additional points regarding this body of research are worth mentioning. First, researchers have been aware of this problem for some time; this phenomenon has been studied for over 20 years. Second, while the available data provide us with some guidance, the current information is far short of a critical mass of information. The data is not particularly systematic, and while functional assessment and functional communication training are the most studied methods to date, they still only constitute a handful of studies on the treatment of aggression among persons with ASD. Funding bodies have also missed the boat on this issue. Establishing aggression as a high priority over an extended time period would be very helpful in establishing intervention priorities that match real world needs. The bulk of the treatment dollars are flowing to programs for small children. This approach has become the norm. These kids need and deserve the best possible services the professional community can provide. However, the bulk of the population of persons with ASD is not small children; these older individuals are not cured, and many of them evince aggression. More research in the older adult population is warranted. Finally, insurance bodies and state and federal government money should not be going to treatments with no empirical support. This problem and its practice are rampant at this writing. Resources are relatively scarce given the magnitude of the problem. As a result, it is critical to use that money to promote best practices. It is also important to promote treatment strategies that are not only effective but also efficient.
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Contents lists available at ScienceDirect
Research in Developmental Disabilities
Review article
Treating aggression in persons with autism spectrum disorders: A review Johnny L. Matson, Jina Jang * Louisiana State University, United States
A R T I C L E I N F O
A B S T R A C T
Article history: Received 1 August 2014 Accepted 19 August 2014 Available online
Aggression is one of the most frequent and debilitating problems observed among persons with autism spectrum disorders (ASD). It is common and can be more problematic than many core symptoms of ASD. Thus, treating the behavior is a high priority. A surprisingly limited number of studies have addressed treatment when taken in the context of the vast ASD literature. This paper reviews many of these papers and describes the types of interventions that have been used and the characteristics of the people who have been studied. ß 2014 Elsevier Ltd. All rights reserved.
Keywords: Aggression Applied behavior analysis Autism spectrum disorders Pharmacotherapy Treatment
Contents 1. 2.
Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Results and discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
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The field of developmental disabilities has seen tremendous positive change in the last few decades. Once considered untreatable, major advances have occurred with respect to intervention such that all persons with developmental disabilities are now considered good candidates for multiple therapies (Carr & Durand, 1985; Halle, Marshall, & Spradlin, 1979; Matson, Dixon, & Matson, 2005; Matson & LoVullo, 2009; Matson, Mahan, & LoVullo, 2009). Among the developmental disabilities, autism spectrum disorders (ASD) are now considered to be among the most prevalent and debilitating (Bromley & Blacher, 1991; Matson & Dempsey, 2008; Matson & Kozlowski, 2011). Core features of ASD include deficits in communication and social skills as well as rituals and stereotypies (Baranek, David, Poe, Stone, & Watson, 2006; Horovitz & Matson, 2010; Matson, Belva, Horovitz, Kozlowski, & Bamburg, 2012; Matson, Boisjoli, Hess, & Wilkins, 2010; Matson, Gonzales, Wilkins, & Rivet, 2008a; Matson, Kozlowksi, Hattier, Horovitz, & Sipes, 2012; Worley & Matson, 2012). In multiple instances, the many co-occurring problems seen with ASD can be very debilitating as well. Sleep problems, feeding problems, general adaptive skill deficits, gastrointestinal disorders, and fine and gross motor issues are among the daily living and health problems that can commonly occur (Goldman, Richdale, Clemons, & Malow, 2012; Malow, McGrew, Harvey, Henderson, & Stone, 2006; Matson, Dempsey, & Fodstad, 2009; Matson, Dixon, et al., 2005; Matson, Rivet, Fodstad,
* Corresponding author at: Department of Psychology, Louisiana State University, Baton Rouge, LA 70803, United States. Tel.: +1 9098150565. E-mail address: [email protected] (J. Jang). http://dx.doi.org/10.1016/j.ridd.2014.08.025 0891-4222/ß 2014 Elsevier Ltd. All rights reserved.
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Dempsey, & Boisjoli, 2009; Molloy & Manning-Courtney, 2003; Symons, Davis, & Thompson, 2000). Intellectual disabilities also often co-occur with ASD and can exacerbate core symptoms of ASD, such as social behaviors (Matson, Carlisle, & Bamburg, 1998; Matson, LeBlanc, & Weinheimer, 1999; Matson, Smiroldo, & Bamburg, 1998; Njardvik, Matson, & Cherry, 1999). Other serious issues include co-occurring psychopathology and challenging behaviors (Lecavalier, 2006; Matson, Rush, et al., 1999; Matson & Smiroldo, 1997; Paclawsky, Matson, Bamburg, & Baglio, 1997). Of the challenging behaviors, aggression is among the most common and most disruptive (Kanne & Mazurek, 2011; Matson & Boisjoli, 2007). This behavior is so problematic that it may frequently take priority over some core symptoms of ASD. Because of these issues, aggression has become a priority for clinicians and researchers. Therefore, the purpose of this paper was to review evidence-based interventions for persons with ASD who also engage in aggressive acts. 1. Methods A Scopus search was conducted using the keywords: aggression, autism, treatments, PDD-NOS, Asperger’s and challenging behaviors. Review papers on the topic were cross-referenced for additional studies. Only primary source papers that used actual treatments for aggression were included. Some of these papers only treated aggression, while others also included other challenging behaviors such as self-injury, adaptive skills, and core symptoms of ASD. 2. Results and discussion Using the methods described above, 27 papers were identified. These studies are presented in Table 1. Early intensive behavioral interventions were not included in the review. In some instances, aggression has been focused on in these papers, but core symptoms of ASD, adaptive behavior, attention, and compliance tend to be most frequently addressed. The treatment literature on ASD tends to mirror the research on other topics in ASD; the focus is almost exclusively with children and adolescents. Of the 27 papers reviewed, only five studies focused on adults (Hittner, 1994; King & Davanzo, 1996; Lundqvist, Andersson, & Viding, 2009; McDougle et al., 1996, 1998). As pointed out in reviews on related topics, the bulk of a persons’ life is spent as an adults. Thus, the majority of people with ASD are adults. Additionally, a problem such as aggression is potentially much more serious and debilitating in adults. The types of interventions are likely to differ for adults, and they may have a longer history of evincing the aggressive behavior. Thus, the aggression in adults is often more serious and debilitating than what would typically be observed with children. The number of participants in the reviewed studies was much smaller in general than what occurs with assessment, epidemiological, demographic, or cognitive studies. This result should come as no surprise to the reader. Intervention studies by their very nature are more time, labor, and resource intensive than just about any other type or research conducted with individuals who are diagnosed with ASD. This issue is compounded when discussing aggression due to the potential for harm, and the fact that these behaviors often are highly entrenched and difficult to mange. Thus, the range of participant numbers across studies varied from one to 218. Thirteen of the papers reported on the treatment of one or two individuals (Braithwaite & Richdale, 2000; Davis et al., 2013; Falcomata, Roane, Muething, Stephenson, & Ing, 2012; Fisher, Lindauer, Alterson, & Thompson, 1998; Foxx & Garito, 2007; Foxx & Meindl, 2007; Hittner, 1994; Kern, Carberry, & Haidara, 1997; Kuhn, Hardesty, & Sweeney, 2009; Luiselli, Blew, Keane, Thibadeau, & Holzman, 2000; Matson, LoVullo, Boisjoli, & Gonzales, 2008; Robertson, Wehby, & King, 2013; Sigafoos & Meikle, 1996), and two studies involved 100 or more people (Marcus et al., 2009; Silverman et al., 2014). The higher number of participated studies involved drug treatments (Arnold et al., 2003; Hellings et al., 2005; King & Davanzo, 1996; Marcus et al., 2009; McDougle et al., 1996; McDougle, Kem, & Posey, 2002; McDougle et al., 1998; Owen et al., 2009; Silverman et al., 2014; Troost et al., 2005), while the low number studies were largely psychologically based interventions. Again, this makes sense in that drug interventions for aggression are far less time intensive than psychologically based treatments. Additionally, most of the psychologically based studies adhered to applied behavior analysis (ABA) principles and procedures. Researchers who endorse this intervention model also often prefer to use single case research designs versus group designs. Following this model would also result in more papers with small numbers of participants but with many more data points for each person studied. Target behaviors all fell within the overall term aggression. For the drug studies in particular, multiple other behaviors were also studied. Self-injurious behavior, irritability (which can mean about anything within the scope of challenging behaviors), externalizing behaviors, and impulsivity were among the behaviors that were co-studied. Since medication is a much blunter instrument than psychological interventions tailored to a given ‘‘target behavior,’’ this approach is also very understandable. For psychologically based therapies, more detail about the aggression was usually evident. Behaviors targeted for intervention have included hitting, kicking, punching, hair pulling, property destruction, grabbing clothing, tantrums, spitting, throwing objects, and pushing. Multiple medications have been tested for persons with ASD. These include aripiprazole, ziprasidone, risperidone, imipramine, valproate, clomipramine, atomoxetine, fluvoxamine, dextromethorphan, and buspirone. Thus, not only have at least ten different drugs been tested for efficacy for persons with ASD, but they also cross drug classes. Thus, the theorized mechanisms of action appear to be compromised. At this point, whether these drugs are simply sedating the individual with ASD and aggression or are directly affecting specific mechanism that promote or trigger aggression is an open question. Psychological treatments are generally less intrusive and cause fewer harmful side effects. Thus, in clinical setting, medication is rarely used along. Rather, it is used in combination with various psychologically based treatments. Thus, a
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Table 1 Treatment studies using the early intensive behavioral interventions. Author(s)
Diagnosis
Arnold et al. (2003) Braithwaite and Richdale (2000) Davis et al. (2013) Falcomata et al. (2012)
Autism Autism
Number of Age participants 94 1
Target behavior
Treatment(s)
5–17 years old 7 years old
Aggression Aggression
Risperidone Extinction, functional communication Functional analysis, weighted vest Functional communication training, chained schedules of reinforcement, replacement behavior Experimental functional analysis, reinforcement of replacement behavior Reinforcement, tokens, choice making, contingent exercise, overcorrection Reinforcement, tokens, choice making, response cost, overcorrection, physical restraint Experimental functional analysis, reinforcement methods, replacement behavior Experimental functional assessment, functional communication training, teaching tolerance and compliance to tasks Valproate
Autism Asperger’s syndrome, Autism
1 2
Child 8 years old
Aggression Aggression
Fisher et al. (1998)
Autism, intellectual disability (ID)
2
7, 15 years old
Property destruction
Foxx and Garito (2007)
Autism
1
12 years old
Aggression, dangerous disruptive behavior
Foxx and Meindl, 2007
Autism
1
13 years old
Aggression, property destruction
Fulton et al. (2014)
Autism, PDD-NOS
3–5 years old
Aggression, tantrums
Hanley et al. (2014)
Autism
3
3–11 years old
Hitting
Hellings et al. (2005)
30
6–20 years old
Aggression, property destruction
Hittner (1994)
Pervasive developmental disorders Autism
Adult
Aggression
Kern et al. (1997)
Autism, ID
1
King and Davanzo (1996) Kuhn et al. (2009)
Autism, ID Autism, ID
26 1
Luiselli et al. (2000)
Autism
1
Lundqvist et al. (2009)
Autism
20
Marcus et al. (2009) Matson et al. (2008a,b)
Autism Autism
218 1
McDougle et al. (1996) McDougle et al. (2002)
Autism Autism or PDD-NOS
30 12
McDouble et al. (1998) Owen et al. (2009) Robertson et al. (2013)
Autism Autism Autism
31 47 2
Sigafoos and Meikle (1996) Autism
2
36
5–17 years old
Aggression, tantrums
Risperidone
8
9–17 years old
Aggression
Dextromethorphan
Silverman et al. (2014) Troost et al. (2005) Woodward, Groden, Goodwin, and Bodfish (2007)
Autism, PDD-NOS, Asperger’s syndrome Autism, PDD-NOS, Asperger’s syndrome Autism
38
1
128
Imipramine, behavior modification Experimental functional 15 years old Aggression: grabbing clothing of another person, analysis, gradual delay of reinforcers, mand training typically around the neck communication as replacement behavior Adults Aggression Buspirone 16 years old Hitting, kicking, punching, Experimental functional analysis, hair pulling functional communication training, blocking 12 years old Severe aggression resulting Clomipramine in multiple staff injuries 22–57 years Self injury, stereotypies, Music old aggression 6–17 years Tantrums, aggression Aripiprazole 11 years old Aggression Differential reinforcement of other behaviors, compliance training, extinction, functional communication Adults Aggression Fluvoxamine 8–20 years old Aggression, property Ziprasidone destruction 18–43 years old Aggression Risperidone 6–17 years old Aggression, tantrums Aripiprazole 2, 5 years old Spitting, throwing objects, Experimental functional analysis hitting, kicking, pushing, pulling hair 8 years old Aggression Replacement behaviors via mands, experimental functional analysis 5–13 years old Aggression Atomoxetine, parent training
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particularly disappointing finding was that the studies that evaluated combined drug and psychological intervention trials were rare; only two studies were identified. For example, Hittner (1994) described a combination of imipramine and behavior modification for one adult with autism, and Silverman et al. (2014) described the use of atomoxetine and parent training for 128 children with autism, PDD-NOS, or Asperger’s syndrome. This area is one that deserves a lot more attention from researchers and funding bodies. Sixteen of the reviewed studies used psychologically based therapies; one paper employed music (Lundqvist et al., 2009) while the other 15 papers relied on ABA principles and procedures (Braithwaite & Richdale, 2000; Davis et al., 2013; Falcomata et al., 2012; Fisher et al., 1998; Foxx & Garito, 2007; Foxx & Meindl, 2007; Fulton, Eapen, Walter, & Rogers, 2014; Hanley, Jin, Vanselow, & Hanratty, 2014; Hittner, 1994; Kern et al., 1997; Kuhn et al., 2009; Matson, Gonzales, et al., 2008; Matson, LoVullo, et al., 2008; Robertson et al., 2013; Silverman et al., 2014; Sigafoos & Meikle, 1996). Two papers that used punishment procedures (i.e., overcorrection, physical restraint) were papers by Foxx and colleagues (Foxx & Garito, 2007; Foxx & Meindl, 2007). Both studies treated one child (12 and 13 years old). Clearly the trend is toward using functional assessments and training coping skills and competing behaviors. Eight of the 16 papers described a functional assessment approach (Davis et al., 2013; Fisher et al., 1998; Fulton et al., 2014; Hanley et al., 2014; Kern et al., 1997; Kuhn et al., 2009; Robertson et al., 2013; Sigafoos & Meikle, 1996). Functional communication training was reported in five papers (Braithwaite & Richdale, 2000; Falcomata et al., 2012; Hanley et al., 2014; Kuhn et al., 2009; Matson, Gonzales, et al., 2008; Matson, LoVullo, et al., 2008). Typically, these frequently used methods were paired with one or more additional methods. These procedures included blocking, gradual delays of reinforcers, teaching tolerance and compliance to tasks, training specific replacement behaviors, using chained schedules of reinforcement, token economies, teaching choice making, extinction, and differential reinforcement of other behaviors (DRO). Two other studies that used rather unorthodoxed methods were also paired with ABA. In one study, a weight vest was used (Davis et al., 2013), and in another instance, contingent exercise was paired with several other treatment components (Foxx & Garito, 2007). When looked at its totality, several additional points regarding this body of research are worth mentioning. First, researchers have been aware of this problem for some time; this phenomenon has been studied for over 20 years. Second, while the available data provide us with some guidance, the current information is far short of a critical mass of information. The data is not particularly systematic, and while functional assessment and functional communication training are the most studied methods to date, they still only constitute a handful of studies on the treatment of aggression among persons with ASD. Funding bodies have also missed the boat on this issue. Establishing aggression as a high priority over an extended time period would be very helpful in establishing intervention priorities that match real world needs. The bulk of the treatment dollars are flowing to programs for small children. This approach has become the norm. These kids need and deserve the best possible services the professional community can provide. However, the bulk of the population of persons with ASD is not small children; these older individuals are not cured, and many of them evince aggression. More research in the older adult population is warranted. Finally, insurance bodies and state and federal government money should not be going to treatments with no empirical support. This problem and its practice are rampant at this writing. Resources are relatively scarce given the magnitude of the problem. As a result, it is critical to use that money to promote best practices. It is also important to promote treatment strategies that are not only effective but also efficient.
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