to the presentation handouts.

Planting Two Trees with One Seed:
AAC Supports for Problem Behaviour
in Children with ASD
April 29, 2016
Speech-Language and Audiology Canada (SAC) Conference
Halifax, NS
Pat Mirenda, Ph.D., BCBA-D
University of British Columbia
([email protected])
Problem Behavior and ASD
n 
Problem behavior is not uncommon in
individuals with ASD because:
n 
n 
n 
n 
They have difficulty processing social, languagebased, and transient information
They are more comfortable in situations that are
highly predictable and/or unchanging
They may have co-occurring anxiety, affective/mood,
and/or attention disorders
They learn exactly what they are taught, including
how to get what they want/need by engaging in
problem behavior
Assumption #1
n 
There is a clear relationship between
problem behavior and communication
n 
n 
people communicate in the most efficient and
effective manner available to them at any
given point in time
Some people have no way to
communicate except through problem
behavior
n 
individuals with limited or no functional speech
who use augmentative and alternative
communication (AAC)
© Pat Mirenda, Ph.D., April 2016
1
Communication and Problem
Behavior
n 
Some people have other ways to communicate,
but no one really "listens" until they use problem
behavior
n 
n 
individuals whose usual communication behaviors are
subtle or otherwise difficult to interpret
Some people have other ways to communicate,
but don’t know how or are unable to access those
other ways in some situations
n 
individuals whose problem behavior is triggered by
situations that are frustrating, stressful, or anxietyprovoking
Assumption #2
Problem behaviour results from a mismatch between the person and the
environment
n  We need to understand the
environmental “triggers” and the
function (i.e., “communicative message”)
of problem behaviour in order to provide
effective support
n 
Setting Event
Person
Antecedent
Behavior
Consequence
How??? Functional behavior assessment
(FBA)
n  Goal is to identify
n 
The problem behaviours(s) of concern
Relevant setting events, if any
n  Antecedent(s) that trigger the behaviours
n  Maintaining consequences and functions of
behavior
n 
n 
© Pat Mirenda, Ph.D., April 2016
2
A
A
C
DETOUR!!
FBA: A BRIEF (VERY BRIEF!)
PRIMER
Person
n 
Critical, in order to design interventions that are
individualized and effective
n 
n 
n 
n 
n 
n 
who is this individual as a person? as a learner?
what are this person's strengths or gifts?
who does this person prefer to be around? what
does his/her social network look like? (is there a
social network?)
where does this person like to go?
what types of activities does this person enjoy?
how does this person learn best?
Person
Behaviour
n 
Behaviour: an observable, measurable act
n 
n 
n 
n 
what does it look like? (topography)
how often does the person do it? (frequency,
duration)
how serious/dangerous/disruptive is it? (intensity)
how are behaviours related, if there are several?
n 
n 
n 
n 
Do several occur at once?
Do they occur in a predictable "chain"?
Do they occur in response to similar or different situations?
Critical to ensure clear understanding and
assessment
© Pat Mirenda, Ph.D., April 2016
3
Setting Event
Person
Behavior
n 
Setting Events: ecological events that
set the stage for or increase the
likelihood of problem behaviour
Setting Event
Person
Behavior
n 
Four main categories:
n 
n 
n 
n 
n 
Behavioral histories (recent aversive interaction or
event)
Biological/physiological conditions (tiredness, hunger,
thirst, pain, effects of medication, etc.)
Ecological/task conditions (environmental variables;
few opportunities for choices; unpredictable schedule,
etc.)
Underlying skill deficits (poor social skills, poor reading
skills, etc.)
Setting Event
Person
Antecedent
Behavior
Antecedent: any stimulus (event, action,
etc.) that occurs immediately before
problem behavior and “triggers” or
predicts its occurrence
© Pat Mirenda, Ph.D., April 2016
4
Person
Setting Event
Antecedent
Behavior
Many types of antecedent triggers
n 
demands
difficult/boring/repetitive, etc. tasks
n  adult/peer paying attention to someone else
n  transition from one activity to the next
n 
n 
May be difficult to identify (behavior may
appear to be “random”)
n 
SE + A “Math”
n 
n 
n 
Setting events don’t guarantee that problem
behaviour will occur -- they simply increase its
likelihood
Antecedents are the real trigger
Setting events “math”:
n 
n 
n 
A
Problem Behavior
SE + A
Problem Behavior
SE
Problem Behavior
Setting Event
Person
Antecedent
Behavior
n 
n 
Consequence(s)
Consequence: an event that contingently
follows a behavior and affects whether it will
increase or decrease over time
Bottom line: If a problem behaviour is
increasing over time, or if it is maintaining at a
steady rate, the consequence is acting as a
reinforcer
© Pat Mirenda, Ph.D., April 2016
5
Function
n 
Function = How the behavior functions for
the person who is engaging in it
n 
In other words, what does the person get or
avoid by engaging in the behavior?
The function is defined in terms of the
maintaining consequence (reinforcer)
Person
Setting Event
n 
Antecedent
Behavior
Consequence
Four Functions of Behaviour
Tangible (R+)
Attention (R+)
Escape/Avoid (R-)
Automatic R+, R-
Tangible (R+): Item, Activity, Etc.
“When Fred’’s teacher
tells him to stop working
on the computer, he hits
her. His teacher often
allows him an extra 5
minutes on the
computer, to calm him
down. Fred hits now
more often than he used
to in this situation.”
© Pat Mirenda, Ph.D., April 2016
6
Attention (R+): Social Interaction
“When Susie sees other kids
at recess, she gets very
excited and gives them bear
hugs (hard enough to cause
them pain). When she does
this, the playground
supervisor reprimands her
and the kids tell her to stop.
Susie gives bear hugs more
often than she used to in this
situation.”
Escape/Avoidance (R-)
“When he is
presented with
written work, Kent
swears and refuses.
His teacher sends
him to the principal’s
office. Kent swears
and refuses more
often than he used
to in this situation.”
Automatic R+, R“When he has nothing to do and no one
to interact with, Seth makes noises and
hits his head with his fist. No one
responds to him when he does this. This
happens more than it used to when Seth
has nothing to do and no one is around.”
“After 10 minutes of handwriting (a
difficult talk for Jordan), Jordan rocks
back and forth quietly in his seat. No one
notices him and, after a few minutes, he
goes back to work. Jordan rocks more
often than he used to in this situation.”
© Pat Mirenda, Ph.D., April 2016
7
Function is Not Enough!
Function is NOT always obvious
n  Plus, the “why” question also needs to be
answered
Person
Setting
Event
n 
Antecedent
n 
Behavior
Consequence
One more time: a thorough functional
behaviour assessment (FBA) is required!
A
A
C
END OF DETOUR!
AAC and Problem Behavior
n 
n 
Augmented input supports to aid
comprehension
n  Visual schedules
Functional communication training (FCT) and
contingency maps
n  Choice-making and other communication
supports
n  Wait signals
n  Conversation books
© Pat Mirenda, Ph.D., April 2016
8
Visual Schedules
n 
n 
n 
Used to organize sequences of time or steps in
a task
Real objects, photographs, picture symbols (like
Picture Communication Symbols, PCS), or
written words can be used to represent the
activities or environments
VERY useful for transitions between
environments and/or activities for many
individuals (Bopp, Brown, & Mirenda, 2004)
Visual Schedule Research
(Lequia et al., 2012)
Reviewed 18 methodologically strong
studies, 43 participants with ASD, ages
3-18
n  Calculated Non-overlap of all pairs (NAP)
to evaluate strength of the evidence
n  Target behaviors addressed:
n 
Self-regulation: 4 studies; NAP M .96
Independence: 3 studies; NAP M .94
n  Transitions: 7 studies; NAP; M .95
n  Play: 4 studies; NAP M .97
n 
n 
Lequia et al. (2012)
n 
Positive outcomes were reported for 90%
of participants in school settings and for
100% at home
n 
n 
All participants described as “nonverbal” or
with severe communication deficits had
positive outcomes
No trends regarding the type of symbol
Photographs
Line drawing symbols
n  Video-based
n 
n 
© Pat Mirenda, Ph.D., April 2016
9
Conclusion
n 
“Regardless of ASD
severity and
comorbid diagnoses,
the majority of
participants (95%)
demonstrated
decreased
challenging
behavior…” (Lequia
et al. 2012, p. 487)
Within-Activity Schedules: Alisa
(Mirenda & Fossett, 2015)
n 
n 
n 
Young woman with ASD, lived in a supported
apartment, communicated with PCS
PBs in the morning, during bath and dressing
routines: screaming, stomping her feet, hitting
support staff or the wall, biting her hand
Function: escape from independent bathing- and
dressing-related demands; staff helped her with
both tasks, to avoid PB
Alisa
Setting Event???
Demand
(independent
bathing,
dressing)
Alisa (age
27, ASD)
Scream
Stomp
Hit staff
Bite hand
© Pat Mirenda, Ph.D., April 2016
Staff provide
assistance
(function is
escape from
demands)
10
Intervention
n 
Within-activity schedules were developed
to support Alisa to predict and make
choices during the bathing and dressing
routines
The order of washing each body part
Who would be responsible for washing each
body part
n  The type of tool that she would use to wash
each body part (choice)
n  What to wear
n 
n 
Result
PB eliminated within one month
Managed own dressing routine within one
month
n  Able to bathe independently within 3
months
n  Visual schedules were also developed to
assist her with cooking, household chores,
other tasks
n 
n 
Between-Activity Schedules
Choiceworks for iPad
© Pat Mirenda, Ph.D., April 2016
11
Jake
5-years old, ASD, severe intellectual
disability, and very low vision (“legally blind”)
n  Problem behaviour: severe tantrums
(screaming, biting staff, and falling to the
floor)
n  Antecedent trigger: preschool staff telling
him that an activity is finished and another
one will begin
n 
FCT/AAC
Functional communication training (FCT)
involves “both the assessment of the
function of the challenging behavior and
the teaching of a more appropriate form
that serves the same
function . . .” (Durand, 1990, p. 23)
n  FCT/AAC interventions are those in which
the “more appropriate form” involves AAC
(Mirenda, 1997)
n 
Ron (Durand, 1999)
Age 9 1/2, had autism and “severe
mental retardation”
n  Spoke a few words, out-of-context
n  Very aggressive; hit teachers, other
students, family members
n  Variety of other interventions had failed
(DRO, DRI, time-out, restraint, etc.)
n 
© Pat Mirenda, Ph.D., April 2016
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Assessment
Functional behaviour assessment
conducted to identify function of problem
behaviors
n  Appeared to be attention-motivated -Ron engaged in the behaviour to get
attention from his teacher or other adults
n 
teacher
Intervention
n 
Provided with a SGD (BIGmack) that
was programmed to make a request that
would result in attention:
Would you help me
with this, please?
Instruction
n 
Instruction provided during regular
classroom routines that were appropriate
to the message being taught
graduated guidance prompts and fading used
to teach
n  brief attention (in the form of “help”) was
provided when communication device was
activated
n 
© Pat Mirenda, Ph.D., April 2016
13
Results
Key Requirements for FCT/AAC
n 
Identify the specific function of the
problem behavior
Tangible: “I want item/activity”
Attention: “I want social interaction”
n  Escape: “I don’t want item/activity/person”
n 
n 
n 
How? Functional behavior assessment
(e.g., O’Neill et al., 2015)
Key Requirements
n 
Identify a related “message” that will be
acceptable to the people and in the
contexts where it will be used
e.g., “Pay attention to me” vs “Would you
help me with this?” vs. “Can I help you?”
vs “Am I doing good work?” for attentionmotivated behavior
n  How? Input from and negotiation with
parents, teachers, etc. in the settings
where the behavior occurs
n 
© Pat Mirenda, Ph.D., April 2016
14
Key Requirements
n 
Identify an AAC technique that will
enable the person to communicate the
“message” to both familiar and
unfamiliar partners
Manual sign/gesture
Object/picture symbol
n  Written word
n 
n 
n 
How? Symbol assessment, input from
speech-language pathologist
Key Requirements
n 
Teach use of the new communicative
behavior in context
Look for “whispers” of the problem
behavior
n  Provide “clean” instruction before the
problem behavior occurs
n  Be sure the new behavior results in the
same (desired) consequence!
n 
FCT: Matt (Mirenda, 2003)
n 
n 
n 
19 years old, lived at home at beginning of
intervention, integrated in regular high school
classes with support
Some speech (1-2 word phrases) but not when
stressed
Problem behavior: severe aggressive outbursts
toward family, support staff over several years
n  at least one episode per week serious enough
to cause bruising
© Pat Mirenda, Ph.D., April 2016
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Assessment
n 
Functional behaviour assessment to
determine the functions of the behavior
tangibles: “I want ----”: Matt wanted
something (food, activity) and had no way to
ask for it; aggression led to “20 questions”
n  escape: “I don’t want ----”: Matt was offered
a food or activity and did not want it
n  escape: “I don’t understand”: the schedule
of activities was unpredictable
n 
choose
Intervention
n 
n 
Picture Communication Symbols were provided to
n  clarify what choices were available
n  enable Matt to initiate and make choices, and
thereby reduce the frequency of having to tell
him what would happen next
Within- and between-task visual schedules were
also provided to increase predictability
© Pat Mirenda, Ph.D., April 2016
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Stong’s
chicken leg
walk
Stong’s
mashed potatoes
walk
salad
frozen yogurt
home
bus
gym class
art class
reading
lunch
bus
park
work
© Pat Mirenda, Ph.D., April 2016
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get materials
paint
make sculpture
listen to
directions
draw
watch the
teacher
cut & paste
talk to friends
put away
FCT: Marco
n 
n 
n 
n 
n 
5-year-old boy with autism, in kindergarten
Communicated primarily with gestures (and
problem behavior); some symbols and manual
signs
PBs: tantrums (crying, running away, screaming,
hitting)
n  One day, he ran away from his aide at school,
was hit by a car and broke his leg
Trigger: loud, sudden noises (crying children,
sirens, alarms, motorcycles, etc.)
Function: escape from unpleasant noise
FCT Intervention
n 
Teach Marco to
cover his ears with his hands if he hears a
loud noise, and
n  ask to leave the environment by signing or
pointing to a “break” symbol
n 
Aide provided verbal, physical prompts to
teach
n  No change in Marco’s behavior after 2
weeks
n 
© Pat Mirenda, Ph.D., April 2016
18
Contingency Maps
n 
Goal: to provide information about the
“current” (i.e., problem) and “new/
desired” behavioral pathways related to
problem behavior
n 
The aim is to help the individual understand
what will happen if he/she engages in the
behaviors associated with the “new/
desired” behaviour pathway
Contingency Map
n 
A contingency map depicts
The antecedent that typically triggers a
problem behavior
n  The problem behavior
n  The consequences that will follow if it
occurs
n  A functionally-related (desired) alternative
behavior
n  The consequences that will follow if the
alternative behaviour occurs
n 
Contingency Map
© Pat Mirenda, Ph.D., April 2016
19
Result
Shown to him at the
beginning of the day
and every 1-1.5 hours
thereafter
n  Immediate, dramatic
increase in desired
behavior and decrease
in problem behavior
n 
FCT: Antonia
n  Grade
2 student with autism, little speech
for half of the day; remainder in
resource room because of problem behavior
n  Problem behaviors: head-butting, hitting, and
pinching classmates and adults when she had
to wait
n  Included
n For
her turn during buddy reading
line
n For the computer to boot up, etc.
n Waiting was also an enormous problem at home
n In
n Function:
escape from waiting
Wait Signal
Antonia’s speech-language pathologist,
Vicki, decided to teach her to wait, using a
“wait symbol” (a red circle that
symbolized “wait”)
n  Vicki provided systematic instruction in a
simulated “buddy reading” activity to
teach her the meaning of the red circle:
“you will get what you want, but not quite
yet…”
n 
© Pat Mirenda, Ph.D., April 2016
20
Generalization
n 
Once Antonia learned what the wait signal
meant in buddy reading, contingency
maps were created to help her generalize
this understanding to other situations at
school and at home….
Contingency Map: Waiting in Line
Contingency Map: Computer
© Pat Mirenda, Ph.D., April 2016
21
One More FCT Application:
Conversation Books
n 
Based on the work of Pam Hunt and
colleagues (Hunt et al., 1988, 1991)
n 
Paula, Peter, Mary; all engaged in “silly”
behaviour around peers
n  Giggling,
making silly noises, ducking head,
grimacing, calling names of absent people, talking to
imaginary other people imitating animals, getting on
furniture
Assessment
Observations, interviews of staff and peers
at school
n  FBA indicated that behaviours were
primarily maintained by attention (not
usually positive!) from peers
n  The “message” of the behaviour was:
n  “I want to interact with you/Pay attention
to me”
n 
Intervention
n 
Provided students with “conversation
books” to facilitate appropriate social
interaction
use activity remnants, photographs of
students in favourite activities, etc.
n  include written captions with comments
and questions
n 
n  “Here
I am with my dog, Sharma. Do you have
a dog?”
n  “This is me at my 16th birthday party. When is
your birthday?”
© Pat Mirenda, Ph.D., April 2016
22
Conversation Book
n 
n 
update book
regularly, so topics
are dynamic
be sure book is
portable, so that it
can be carried around
easily
Conversation Book
n 
Teach use of conversation books
n 
n 
n 
n 
n 
n 
n 
n 
short (2-5 min.) teaching sessions
natural settings for conversation
use student, partner, and coach
provide partner with basic information
Prompt responses, comments, AND questions
Teach turn-taking during conversations
Teach “fillers” (uh-huh, yeah, etc.)
Don’t be rigid with the structure
Results
© Pat Mirenda, Ph.D., April 2016
23
Punchline: FCT
n 
Depending on the function of the problem
behaviour
Increase predictability (visual/tangible schedules)
Teach a better way to achieve the function/meet
the need (choice making, asking for a break,
using a conversation book)
n  Teach an direct alternative to the problem
behaviour (waiting)
n  If necessary, use a contingency map as backup/
supplementary
n 
n 
Punchline
AAC interventions play a key role in
interventions for problem behavior
n  Need to base communication supports on
information from functional behavior
assessment
n  Need to individualize for easy access and
minimal learning
n 
Selected References
Brown, F., Anderson, J., & De Pry, R. (Eds.) (2015), Individual positive behavior supports: A standards-based
guide to practices in school and community-based settings. Baltimore: Paul H. Brookes Publishing Co.
Brown, K., & Mirenda, P. (2006). Contingency mapping: Use of a novel visual support strategy as an adjunct
to functional equivalence training. Journal of Positive Behavior Interventions, 8, 155-164.
Durand, M. (1999). Functional communication training using assistive devices: Recruiting natural
communities of reinforcement. Journal of Applied Behavior Analysis, 32, 247-267.
Hunt, P., Alwell, M., & Goetz, L. (1988). Acquisition of conversation skills and the reduction of inappropriate
social interaction behaviors. Journal of The Association for Persons with Severe Handicaps, 13, 20–27.
Hunt, P., Alwell, M., & Goetz, L. (1991b). Interacting with peers through conversation turntaking with a
communication book adaptation. Augmentative and Alternative Communication, 7, 117–126.
Lequia, J., Machalicek., W., & Rispoli, M. (2012). Effects of activity schedules on challenging behavior
exhibited by children with autism spectrum disorders: A systematic review. Research in Autism Spectrum
Disorders, 6, 480-492.
Mirenda, P. (2008). Contingency maps: A visual support strategy for individuals with autism and problem
behavior. Autism News of Orange County & the Rest of the World, 4(3), 17-19.
Mirenda, P. (2003). Using AAC to replace problem behavior. Augmentative Communication News, 15 (4),
10-11.
Mirenda, P., & Fossett, B. (2015). Visual supports as antecedent and teaching interventions. In F. Brown, J.
Anderson, & R. De Pry (Eds.), Individual positive behavior supports: A standards-based guide to practices
in school and community-based settings (pp. 347-360). Baltimore: Paul H. Brookes Publishing Co.
O'Neill, R., Horner, R., Albin, R., Sprague, J., Storey, K., & Newton, S. (2015). Functional assessment and
program development for problem behavior, 2nd ed. Pacific Grove, CA: Brooks/Cole.
© Pat Mirenda, Ph.D., April 2016
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