Evaluating the Long-Term Efficacy of a Trauma-Informed Approach to Addressing Challenging Behavior in the Home
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| Title: | Evaluating the Long-Term Efficacy of a Trauma-Informed Approach to Addressing Challenging Behavior in the Home |
|---|---|
| Language: | English |
| Authors: | Aaron Leyman, Phoebe MacDowell (ORCID |
| Source: | Research and Practice for Persons with Severe Disabilities. 2026 51(1):6-25. |
| Availability: | SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: https://sagepub.com |
| Peer Reviewed: | Y |
| Page Count: | 20 |
| Publication Date: | 2026 |
| Document Type: | Journal Articles Reports - Research |
| Descriptors: | Child Behavior, Behavior Problems, Program Effectiveness, Trauma Informed Approach, Autism Spectrum Disorders, Behavior Modification, Interpersonal Communication, Cooperation |
| DOI: | 10.1177/15407969251319255 |
| ISSN: | 1540-7969 2169-2408 |
| Abstract: | Behavioral interventions for challenging behavior often rely on the results of a functional analysis to identify environmental contributors. Multiple functional analysis formats have been developed to improve qualities of the process such as practicality, efficiency, and safety. More recently, the performance-based, interview-informed synthesized contingency analysis (IISCA) was developed as a functional analysis format that incorporates a trauma-informed framework. The performance-based IISCA (a) introduces evocative events following periods of calm to reduce dangerous escalation, (b) includes moment-to-moment measures of challenging behavior to allow for ongoing visual analysis of data, and (c) maintains measures of positive affect. We conducted this study to evaluate the treatment utility of the performance-based IISCA when it is used to inform a skill-based treatment. The performance-based IISCA was conducted for the challenging behavior of three autistic children before teaching communication, toleration, and cooperation during skill-based treatment in the home setting. Challenging behavior was reduced for all participants across different therapists and across time (1-, 2-, 3-month treatment extension). The results support the extension and longevity of treatment informed by the performance-based IISCA. |
| Abstractor: | As Provided |
| Entry Date: | 2026 |
| Accession Number: | EJ1497561 |
| Database: | ERIC |
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| FullText | Links: – Type: pdflink Url: https://content.ebscohost.com/cds/retrieve?content=AQICAHj0k_4E0hTGH8RJwT4gCJyBsGNe_WN95AvKlDbXJGqwxwHB3hEM6FLQTg_--IhYj-QrAAAA4zCB4AYJKoZIhvcNAQcGoIHSMIHPAgEAMIHJBgkqhkiG9w0BBwEwHgYJYIZIAWUDBAEuMBEEDGyZ7jyzlyTUS8Z8kgIBEICBm-KqIDg4560bSJDLmC4GFge2J3GbTdsWFU8FvMURKBL-NIB1MzbvzD3NSScLkRZKTbnWt6ePG7JyYtzuHAldTZYdMPx_9-aav7YjcCrhXK5VrQHeEqn-1qeqNKXv7iTvQt3QXKHfz87vs2lF_hcNt6kH6rg-7bP9GwR0SyL2X9UjlPwZaeWKnpoRtqwTKdEyVXmprQbr0IY7T2Wu Text: Availability: 1 Value: <anid>AN0191375864;myx01mar.26;2026Feb09.00:39;v2.2.500</anid> <title id="AN0191375864-1">Evaluating the Long-Term Efficacy of a Trauma-Informed Approach to Addressing Challenging Behavior in the Home </title> <p>Behavioral interventions for challenging behavior often rely on the results of a functional analysis to identify environmental contributors. Multiple functional analysis formats have been developed to improve qualities of the process such as practicality, efficiency, and safety. More recently, the performance-based, interview-informed synthesized contingency analysis (IISCA) was developed as a functional analysis format that incorporates a trauma-informed framework. The performance-based IISCA (a) introduces evocative events following periods of calm to reduce dangerous escalation, (b) includes moment-to-moment measures of challenging behavior to allow for ongoing visual analysis of data, and (c) maintains measures of positive affect. We conducted this study to evaluate the treatment utility of the performance-based IISCA when it is used to inform a skill-based treatment. The performance-based IISCA was conducted for the challenging behavior of three autistic children before teaching communication, toleration, and cooperation during skill-based treatment in the home setting. Challenging behavior was reduced for all participants across different therapists and across time (<reflink idref="bib1" id="ref1">1-</reflink>, 2-, 3-month treatment extension). The results support the extension and longevity of treatment informed by the performance-based IISCA.</p> <p>Keywords: challenging behavior; functional analysis; treatment extension; trauma-informed care</p> <p>Children with autism spectrum disorder (ASD) are more at risk for engaging in various topographies of challenging behavior compared with other children, typically developing or not ([<reflink idref="bib11" id="ref2">11</reflink>]; [<reflink idref="bib19" id="ref3">19</reflink>]). Quality of life for children who exhibit such behavior is of concern, as all facets of life may be impacted, including the safety of the child and others, the development of necessary life skills, and opportunities for social inclusion. As a child develops aberrant repertoires of chronic challenging behavior throughout their lifetime, the more likely they are to encounter restrictive settings and interventions, including seclusion and various forms of restraint (i.e., mechanical, physical, chemical). Psychotropic medications, despite showing inconsistent effectiveness in successfully decreasing challenging behavior ([<reflink idref="bib18" id="ref4">18</reflink>]), continue to be prescribed for children and are accompanied by the development of sequelae that may also directly influence the quality of one's life, including weight gain, tardive dyskinesia (i.e., involuntary motor movements), and insomnia.</p> <p>The impairment in quality of life stemming from challenging behavior and its associated environmental consequences may result in the experience of trauma. Trauma, as defined by the [<reflink idref="bib1" id="ref5">1</reflink>], is an experience with associated feelings of fear, helplessness, or confusion. The intensity of the event and associated feelings may be such that it results in some form of adaptation to the individual's functioning, with an impact on both biological processes and observable behavior. Although not all challenging behavior develops because of a traumatic event, it may certainly be a symptom of it for some children, particularly if the event repeatedly occurs within the child's environment. Children with ASD experience disrupted development due to the nature of their developmental disability and may already engage in some form of challenging behavior, leaving them at a greater risk for experiencing some form of maltreatment, further developmental interruptions, and the development of psychiatric symptoms.</p> <p>The potential for maltreatment is ever present when relegating a child to more restrictive settings and interventions for the sake of managing challenging behavior. Repeated physical management, restraint, or seclusion may be potentially traumatic due to the child's loss of control and potential emotions associated with such an experience (e.g., fear, helplessness), possibly resulting in negative consequences, including the development of psychiatric comorbidities or novel topographies of challenging behavior. Given the risks of using physical management, restraint, or seclusion, reported prevalence rates are concerning. Lifetime rates of restrictive intervention use (including physical, chemical, and mechanical) range from 36% to 66%, whereas yearly rates of these practices range from 6% to 78% ([<reflink idref="bib29" id="ref6">29</reflink>]). Younan et al. also reported on prevalence rates of seclusion, noting a wide range of 5% to 46%. While the reported statistics encapsulate lifetime prevalence rates, prevalence rates across shorter timeframes are also of great concern.</p> <p>Trauma-informed care (TIC) was first coined by [<reflink idref="bib14" id="ref7">14</reflink>], with wider conceptualization and dissemination in 2014 by the Substance Abuse and Mental Health Services Administration ([<reflink idref="bib27" id="ref8">27</reflink>]). Substance Abuse and Mental Health Services Administration's conceptualization included the development of six guiding principles to the implementation of TIC: safety, trustworthiness and transparency, peer support, collaboration and mutuality, empowerment (choice), and awareness of cultural, historic, and gender issues. In [<reflink idref="bib23" id="ref9">23</reflink>] established a TIC framework for the field of behavior analysis developed from SAMHSA's original six principles. With its specificity, the framework extends theory to practical application within the assessment and treatment of challenging behavior.</p> <p>[<reflink idref="bib23" id="ref10">23</reflink>] suggested that applying TIC begins by first <emph>acknowledging trauma</emph>—or the potential for it—and its impact. Clinicians supporting children who engage in challenging behavior may do so by acknowledging that children within their care may have trauma histories they are unaware of, and acknowledging the likelihood of the child encountering a potentially traumatic event as a result of their disability status and their challenging behavior. <emph>Ensuring safety and trust</emph> is a critical component of TIC, particularly as a means of preventing a child from experiencing some form of trauma or re-traumatization at any point within the assessment and treatment process. When possible, <emph>choice</emph> is embedded into the process to allow children the ability to communicate their preferences ([<reflink idref="bib23" id="ref11">23</reflink>]). Such choice is incorporated through allowing the child opportunities to indicate their play preference during reinforcement intervals (such as choosing to play independently or with an adult) or by allowing the child to leave the treatment area if assent is withdrawn. Both assent and choice are prerequisites to <emph>shared governance</emph>, as continued treatment following the withdrawal of assent does not contribute to a trusting relationship ([<reflink idref="bib2" id="ref12">2</reflink>]). Finally, as Rajaraman and colleagues note, behavior analysts are experts in developing interventions that emphasize <emph>skill building</emph>. Communicating one's needs, tolerating delays to some needs being met, and cooperating with instructions are necessary for continued access to environments; not developing these skills may restrict the child's access to enriched environments.</p> <p>With the occurrence of challenging behavior, children are typically referred for assessment and treatment. Functional behavior assessment is a process in which the variables associated with challenging behavior are identified to best inform treatment. It is often recommended that the process includes a functional analysis (i.e., a method of determining a cause-and-effect relationship between environmental variables and challenging behavior). There are some formats of functional analyses that are compatible, but not directly aligned, with the principles of TIC. For example, the trial-based functional analysis ([<reflink idref="bib25" id="ref13">25</reflink>]) does not assess the variables of challenging behavior across sessions but rather trials of test segments (i.e., attention, escape, tangibles, alone) and control segments in which no triggering event is presented. The trial-based functional analysis differs from session-based formats in that it can be more efficient. Trials are quick, occurring based on both the passage of time and the occurrence of challenging behavior in the test segment. Moreover, the trial-based functional analysis includes a control segment of which is ecologically relevant to the child's environment in which they are already experiencing challenging behavior. However, the trial-based functional analysis often includes multiple trials per each condition to obtain experimental control. For example, [<reflink idref="bib26" id="ref14">26</reflink>] demonstration of the trial-based functional analysis in family homes found that the data became redundant at various cut-off points for each child, suggesting that it is likely not necessary to delay treatment by committing to such a high number of trials for each condition to be tested. [<reflink idref="bib8" id="ref15">8</reflink>] provided evidence for this as well, with their results suggesting that more than 10 trials may not provide that much more insight into the function of the child's challenging behavior. Regardless of the specific number of trials required to identify a functional relation, the trial-based functional analysis bases the termination of individual trials on the child's performance; however, the termination of the analysis is often dependent upon the predetermined number of trials. In another example, the interview-informed synthesized contingency analysis (IISCA) is a functional analysis variation conducted during the practical functional assessment (PFA) process that is representative of the relevant contingencies hypothesized to evoke and maintain challenging behavior, as described by the caregiver from an open-ended interview ([<reflink idref="bib13" id="ref16">13</reflink>]; [<reflink idref="bib17" id="ref17">17</reflink>]). The IISCA includes just two conditions, control and test, the latter of which directly evaluates the evocative context for the child receiving assessment. During the test condition, both dangerous behavior and associated nondangerous behaviors are reinforced with the delivery of synthesized reinforcers in an open-response class (i.e., any topography of challenging behavior that serves the same function) to increase safety and diminish the likelihood of dangerous escalation. However, while some aspects of the functional analysis do align with principles of TIC (i.e., ensuring safety and trust, promote choice, emphasize skill building), the trial-based functional analysis and the IISCA were not specifically designed to fully embody a TIC framework.</p> <p>The performance-based IISCA leverages a sort of trial-based format and was specifically designed to include components of TIC. [<reflink idref="bib20" id="ref18">20</reflink>] highlighted safety as a defining feature of performance-based IISCA. In this format, children access their synthesized reinforcers indefinitely until the presentation of the triggering event. Clinicians can establish safety and trust by way of providing access to the child's most important reinforcers prior to presenting the triggering event, with trigger presentation contingent only upon the child appearing calm and not having engaged in challenging behavior for at least 30 s. The delivery of the triggering event and reinforcement contingency ultimately falls under the control of the individual experiencing the assessment. With this additional component and reinforcement of an open-response class (i.e., targeting associated nondangerous behavior in the assessment), escalation of dangerous behavior is minimized.</p> <p>[<reflink idref="bib15" id="ref19">15</reflink>] first evaluated the performance-based IISCA at a clinic in Italy, noting that the analysis allows for clinicians to prioritize the child's safety by choosing to present or withhold the triggering event based on the child's behavior during the reinforcement interval. Safety is further prioritized with termination of the analysis contingent upon the child's performance rather than the passage of time. [<reflink idref="bib16" id="ref20">16</reflink>] extended empirical support for the performance-based IISCA, evaluating concurrent validity with the original IISCA and treatment utility when informing subsequent function-based procedures for reducing challenging behavior. Following an open-ended interview, all participants experienced the performance-based IISCA, with a subset of participants also experiencing the same contingency but within the original IISCA. Comparison of the performance-based IISCA and original IISCA indicates that results of both analyses corresponded with one another. While the outcomes did not differ, efficiency and safety did. Jessel et al. found the format of the performance-based IISCA contributed to significant reductions in the duration of the analysis, time to establish functional control, and reduced rates of dangerous behavior. The authors then used the results of the performance-based IISCA to inform communication training for a subset of their participants. The findings from the treatment validation indicate decreases in challenging behavior following the acquisition of communication skills across all participants, validating the utility of the performance-based IISCA in informing function-based treatment in a clinic setting.</p> <p>Both [<reflink idref="bib15" id="ref21">15</reflink>] and [<reflink idref="bib16" id="ref22">16</reflink>] laid the groundwork for strengthening empirical support for the performance-based IISCA. but were removed from the relevant environments where the treatments were intended to be effectively introduced. In addition, the current literature is limited to dense schedules of reinforcement in controlled settings, calling into question the performance-based IISCA's utility in informing skill-based treatment (SBT) that (a) teaches communication, tolerance, and cooperation skills ([<reflink idref="bib13" id="ref23">13</reflink>]); (b) incorporates increasing behavioral expectation to socially significant levels; and (c) occurs within environments in which children typically engage in challenging behavior. The experimental questions we set out to answer are as follows:</p> <p></p> <ulist> <item> Can a trauma-informed assessment of challenging behavior (i.e., the performance-based IISCA) be used to design SBT procedures that reduce challenging behavior and teach skills?</item> <p></p> <item> Can treatment be extended to additional therapists who typically work with the child?</item> <p></p> <item> Will home therapists who typically work with the participants find the assessment and treatment process socially acceptable?</item> </ulist> <hd id="AN0191375864-2">Method</hd> <p></p> <hd id="AN0191375864-3">Participants and Recruitment</hd> <p>We included three participants and their home therapists in this study. Participants were recruited from a local, home-based applied behavior analysis (ABA) agency by the second author (clinical supervisor) who made the referrals to the researcher (first author). The referrals were made due to the need for additional assessment and treatment services for challenging behavior. Participants were included in the study if (a) they engaged in challenging behaviors and (b) the results of their performance-based IISCA were differentiated and indicative of a socially mediated function. Participants were not required to have experienced traumatic events for participation. All three participants referred for participation in the study were included. None of the participant's caregivers disclosed trauma histories; however, Diego's caregivers discussed financial adversity and stress they faced. Furthermore, one of his caregivers made note of their own mental health diagnosis of anxiety (formal diagnostic evaluation was not disclosed). Both financial adversity and having a parent with a mental illness are adverse circumstances that may impact children.</p> <p>Ally was a 5-year-old girl diagnosed with ASD and a sensory processing disorder. In addition, Ally exhibited speech and language impairments and gastrointestinal difficulties, as noted by caregivers. She was nonspeaking and required the use of an augmentative and alternative communication (AAC) device to communicate. Ally did not attend school as she engaged in challenging behaviors when exposed to new environments and novel individuals. She received ABA services from therapists in her home for approximately 30 hr each week. Ally's mother reported Ally exhibited dangerous behaviors in the form of self-injurious behavior (SIB) and associated nondangerous behaviors in the form of whining and crying.</p> <p>Diego was an 11-year-old boy with ASD. He spoke in full sentences and could engage in reciprocal conversations, displaying an age-appropriate vocal repertoire. He attended his local public school full-time in addition to receiving ABA services in his home twice a week for a total of 4 hr. It was reported that Diego became visibly distressed and exhibited challenging behaviors in the home and in school environments when items were removed from his possession and instructions were provided. In addition, he demonstrated difficulty tolerating interruptions during preferred routines. Diego exhibited dangerous behavior in the form of SIB and associated nondangerous behaviors in the form of whining, crying, and noncontextual vocalizations (i.e., howling, roaring).</p> <p>Chad was a 3-year-old boy with ASD. He was nonspeaking and required the use of an AAC device (e.g., TouchChat) to communicate. He attended a special education preschool with a 1:1 aid. It was reported that Chad engaged in challenging behaviors during academic instructions and during the removal of reinforcers. His dangerous challenging behaviors included SIB and aggression, whereas his nondangerous behaviors included whining. Chad received ABA services in his home for approximately 15 hr per week.</p> <p>Ally's home therapist was a 24-year-old White, non-Hispanic woman who held a bachelor's degree in psychology and credentialing as a Registered Behavior Technician. She had been working as a home therapist for 4 months at the time of the study with prior experience with children with autism in a service-learning course implementing ABA via telehealth for approximately 4 months at her undergraduate university. Diego's home therapist was a 28-year-old White, Hispanic woman. She had a high school diploma and was pursuing a bachelor's degree in psychology. Diego's home therapist had prior experience working with adults in residential settings and worked in a special education school in a 1:1 setting. She had been working as a home therapist for 1 year prior to the study. Chad's home therapist was a 20-year-old White, non-Hispanic man. He was a Registered Behavior Technician and undergraduate psychology student. At the start of the study, he had been working as a home therapist for 1 year. The clinical supervisor (second author) for all three participants held a master's degree in education and credentialing as a Board Certified Behavior Analyst.</p> <p>The researcher was trained by a doctoral-level Board Certified Behavior Analyst (third author) to implement PFA and SBT in a university-based outpatient clinic prior to the study. The researcher conducted interviews with Ally's mother and Diego's mother via video conferencing to reduce contact during the COVID-19 pandemic. The interview with Chad's mother was conducted in the family home by the clinical supervisor. All procedures occurred in the home when the participants were receiving ABA services or immediately after. Caregivers were allowed to attend sessions at their discretion. Treatment sessions were conducted by the researcher for Ally and Diego, while the clinical supervisor implemented Chad's sessions. Treatment extension sessions were conducted by the researcher, clinical supervisor, and home therapist for Ally. Similarly, the researcher, clinical supervisor, and one of Diego's home therapists conducted treatment extension sessions for Diego. Both Chad's clinical supervisor and home therapist conducted treatment extension sessions.</p> <hd id="AN0191375864-4">Setting</hd> <p>Each participant's intervention took place in their family home. Ally's sessions were conducted in a playroom where her ABA services were provided. The room consisted of a child-sized desk and chair, two cribs, and various toys. Ally's clinical supervisor and/or home therapists were present during all sessions. Diego's sessions were held in the main area of the home, comprising both the living and dining space. The area consisted of a dining table with six chairs, two couches, a TV, a plastic bin with toys, and two shelving units with academic supplies and materials. Diego's clinical supervisor, home therapists, and his mother or father were present for all sessions. Chad's sessions occurred in a playroom where Chad's ABA services were provided. The playroom consisted of a couch, shelving with toys, an indoor trampoline, and a worktable with two chairs and academic materials. Chad's clinical supervisor and home therapist were present for all sessions.</p> <hd id="AN0191375864-5">Materials</hd> <p>We used a video camera and a laptop computer with camera capabilities equipped with data collection software to record sessions and analyze data. A worktable and two chairs were used to conduct academic instructions. Preferred items for Ally included a tablet with preferred videos and games, and stuffed animals. Diego's reinforcers included a phone, a crocodile game, and a ball pit. Chad's reinforcers included a trampoline, hairbrush, chips, and various small toys. The therapist had two timers to signal the end of the session and to signal the end of the reinforcement interval.</p> <hd id="AN0191375864-6">Dependent Variables and Measurement</hd> <p>Our study had six primary dependent variables: (a) challenging behaviors, (b) communication responses, (c) the tolerance response, (d) cooperation training, (e) treatment extension, and (f) social validity of procedures. We categorized challenging behaviors as dangerous or associated nondangerous. Dangerous behaviors were topographies that could result in physical harm to the participant, other individuals, or property. This included SIB and aggression. Ally's SIB was defined as any instance in which she made forceful contact between the palm of her hand(s) and her head from a distance of 3 in or greater paired with a negative affect (i.e., frowning, furrowed eyebrows). Diego's SIB was defined as any instance in which he made forceful contact between his closed fist(s) and his chest from a distance of 3 in or more. We defined Chad's SIB as any instance in which he made forceful contact between his head and a hard surface or closed fist(s) from a distance of 3 in or more paired with a negative facial affect. In addition, Chad engaged in aggression, defined as any instance in which he made forceful contact between his open palm and the body of another person from a distance of at least 3 in or more with a negative facial affect.</p> <p>Associated nondangerous behaviors were those that did not result in physical harm to the participant, other individuals, or property but were still considered by the family members to be problematic and difficult to manage. This included whining, crying, and noncontextual vocalizations. We defined Ally's crying as any instance (with an onset and offset of 3 s) in which she engaged in high-pitched vocalizations above typical conversational volume indicative of distress with the occurrence of tear production. Whining followed the same definition as crying, with the exclusion of tear production. Diego's crying was defined as any instance with an onset and offset of 3 s in which Diego engaged in high-pitched vocalizations indicative of distress with statements such as "But, but, but I don't want to!" while engaging in a negative facial affect paired with tear production. Whining also included high-pitched, distressed vocalizations with a negative facial affect, but with the absence of tear production. Diego's noncontextual vocalizations included instances in which he would engage in howling, roaring, other animal noises paired with a negative facial affect. Chad's nondangerous behavior included whining, defined as any instance in which Chad engaged in a high-pitched vocalization above typical conversational volume consisting of the following vowel-consonant combination "ma-ma-ma-ma" while holding his right hand to his right ear. The vocal approximations were not determined to be functional requests for his mother. We recorded the frequency of challenging behavior in the performance-based IISCA by counting each instance. The performance-based IISCA measures the frequency of challenging behavior to make inferences regarding challenging behavior and attainment of functional control (or lack thereof) in the moment, making this analysis format entirely dependent upon child performance ([<reflink idref="bib20" id="ref24">20</reflink>]). Furthermore, this aids in reducing exposure to potential stressors ([<reflink idref="bib21" id="ref25">21</reflink>]). We calculated the rate of challenging behavior within SBT using data collection software, which divided the total instances of challenging behavior by the total duration of the session.</p> <p>The therapist taught communication responses and tolerance responses to increase each child's communication repertoire. Both Ally and Chad used picture icons during communication training because they were unable to communicate vocally. The simple communication response was a 4-in by 4-in "My Way" icon. The intermediate communication response was a 2-in by 2-in "My Way" icon. The complex communication response was a 2-in by 2-in "My Way" icon attached to a small binder by Velcro that required the participant to pull the icon off of the board and hand it to the therapist. The tolerance response was a "thumbs up" icon attached to the inside of the binder by Velcro. Participants were required to open the binder, remove the icon, and hand it to the therapist. Diego's communication responses consisted of vocal responses. The simple communication response was, "My turn please." The intermediary communication response taught was, "Can I have my turn please?" The complex communication response taught was, "Excuse me?" followed by a pause for the therapist to initiate conversation, then, "Can I have my turn please?" For the tolerance response, Diego was taught to say, "OK." The therapist calculated the rate of responding by dividing the frequency by the duration of the session.</p> <p>Instructions were provided using a three-step prompting procedure (i.e., verbal, model, and physical). We defined cooperation with instructions as the participant engaging in the specified response independently within 10 s of the first or second prompt to complete the instruction. That is, completion of an instruction requiring a physical prompt was not scored as cooperation. We tallied each instance of cooperation within a session and divided the sum by the total number of instructions provided to calculate a percentage.</p> <p>We also tracked secondary measures indicative of participant assent (calmness, reinforcement, engagement, and interactive behavior) during the performance-based IISCA across all participants. We defined calmness as any period during which the child used a positive or neutral tone of voice and body language in the absence of challenging behavior or visible emotional distress, including whining, crying, SIB, and animal noises. This may be paired with a neutral (e.g., relaxed brows, mouth neither up nor downturned) or positive (e.g., upturned corners of mouth) facial affect. Reinforcement was defined as the period during which the triggering event was discontinued, and the participant had access to their preferred items. We defined engagement as the participant interacting with a reinforcing item and/or caregiver. Interactive behavior was defined as any instance in which the participant initiated or responded to a bid for social communication with the researcher, clinical supervisor, or home therapist(s), excluding the following: communication response, tolerance response, or cooperation with instructions.</p> <hd id="AN0191375864-7">Interobserver Agreement and Treatment Integrity</hd> <p>A primary and secondary observer collected data across all conditions for the three participants. The primary observer collected data for all sessions, whereas a secondary observer collected data for at least 33% of sessions. We calculated partial agreement interobserver agreement (IOA) using computer software. Each recorded session was divided into intervals of 10 s. The smaller value was divided by the larger value within each interval and a mean was calculated for each session. IOA for challenging behavior, whether dangerous or associated nondangerous, was 100% for all participants during the performance-based IISCA except Ally. The IOA for Ally's associated nondangerous behavior was 94%. The mean IOA across participants for calmness, engagement, and reinforcement was 94% (range = 90%–98%), 95% (range = 92%–98%), and 95% (range = 92%–98%), respectively. IOA for challenging behavior, whether dangerous or associated nondangerous, during SBT was 100% for all participants. The mean IOA for communication response, tolerance, cooperation, and reinforcement across participants was 99% (range = 98%–100%), 98% (range = 96%–100%), 98.1% (range = 96.3%–99%), 97.3% (range = 96%–99%), respectively. IOA for challenging behavior, whether dangerous or associated nondangerous, was 100% for all participants during treatment extension. The mean IOA for communication response, tolerance, cooperation, and reinforcement across participants was 98.3% (range = 97%–99%), 99.4% (range = 98.3%–100%), 98.4% (range = 98%–99%), 97% (range = 95%–99.1%), respectively.</p> <p>We calculated treatment integrity in at least 33% of the total sessions for each participant. The primary and secondary recorders completed a form that broke down the procedures for each phase of treatment into steps. Recorders then watched session videos for each phase while checking if each step was completed accurately by the therapist. The recorder marked a step correct if all the trials in the session were implemented as described in the treatment integrity form and marked a step incorrect if the therapist conducted different procedures. For example, if the therapist provided reinforcement for 30 s for one trial and provided 1 min for a different trial, the entire step for reinforcement would have been marked as incorrect for that session. The treatment integrity was 100% across phases for most participants. Ally's communication training treatment integrity was 93.3% (range = 66.7%–100%). The lower value of the range was due to the therapist not presenting instructions using a three-step prompting sequence for one trial of the session. IOA of the treatment integrity was then calculated by comparing the primary and secondary recorder data. IOA for treatment integrity was 100% across all participants. A full summary of all IOA and treatment integrity for each participant is available as Supplemental Material.</p> <hd id="AN0191375864-8">Experimental Design</hd> <p>The performance-based IISCA uses the logic of a multi-element design to demonstrate functional control ([<reflink idref="bib15" id="ref26">15</reflink>]; [<reflink idref="bib16" id="ref27">16</reflink>]; [<reflink idref="bib20" id="ref28">20</reflink>]). Multi-element designs are typically used to assess the variables maintaining behavior and can inform effective treatment procedures ([<reflink idref="bib9" id="ref29">9</reflink>]). The performance-based IISCA rapidly alternates between intervals in which the triggering event was present, or reinforcement was present. Experimental control is demonstrated when challenging behavior reliably occurs in the presence of the triggering event and does not occur in the presence of the reinforcers. We used a brief reversal probe to demonstrate experimental control during SBT. The reversal probe followed the first phase of communication training, following the structure of an A-B-A-B design ([<reflink idref="bib9" id="ref30">9</reflink>]). The reversal probe did not consist of repeated measurement of challenging behavior, only a single session prior to returning to communication training ([<reflink idref="bib16" id="ref31">16</reflink>]). In addition, because Diego could freely exhibit any targeted vocal communication responses across treatment phases, we included a multiple baseline design across communication responses. That is, reinforcement was introduced in a staggered fashion across communication skills of increasing complexity (i.e., simple communication response, intermediary communication response, complex communication response, and tolerance response) and experimental control was demonstrated when the target communication occurred only when it was reinforced ([<reflink idref="bib9" id="ref32">9</reflink>]).</p> <hd id="AN0191375864-9">Procedures</hd> <p>Typical PFA and SBT procedures were modified to specifically incorporate key elements of a TIC framework (see Table 1). PFA comprised an open-ended interview with each child's caregiver prior to conducting the performance-based IISCA. SBT incorporated a package treatment of communication training and cooperation training (procedures discussed in detail next).</p> <p>Table 1. Alignment of Assessment and Treatment Procedures with TIC Principles.</p> <p>Graph</p> <p> <ephtml> &lt;table&gt;&lt;colgroup&gt;&lt;col align="left" /&gt;&lt;col align="char" char="." /&gt;&lt;col align="char" char="." /&gt;&lt;col align="char" char="." /&gt;&lt;/colgroup&gt;&lt;thead&gt;&lt;tr&gt;&lt;th align="left" colspan="2"&gt;Trauma-informed care principles&lt;/th&gt;&lt;th align="center"&gt;Practical functional assessment&lt;/th&gt;&lt;th align="center"&gt;Skill-based treatment&lt;/th&gt;&lt;/tr&gt;&lt;/thead&gt;&lt;tbody&gt;&lt;tr&gt;&lt;td rowspan="4"&gt;&lt;xref ref-type="bibr" rid="bibr23"&gt;Rajaraman et al. (2022)&lt;/xref&gt;&lt;/td&gt;&lt;td&gt;Acknowledge Trauma and its Potential Impact&lt;/td&gt;&lt;td&gt;1. Identified prior experiences of adverse or potentially traumatic events during interview.2. Limited exposure to adverse contingencies and problem behavior during analysis.&lt;/td&gt;&lt;td&gt;1. Avoided physical management.2. Introduced tasks in a progressive manner; instructions that could be related to potentially adverse events were reserved until the child had demonstrated tolerance across other events.3. Rapport building occurred every day prior to each session and was based on child preferences and requests.&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td&gt;Ensure Safety and Trust&lt;/td&gt;&lt;td&gt;1. Free access to reinforcers prior to the analysis.2. Access to reinforcers briefly interrupted during analysis with reliable, immediate return prior to escalation to dangerous behavior.3. Access to reinforcers was extended based upon child performance.4. Analysis only required five demonstrations of challenging behavior.&lt;/td&gt;&lt;td&gt;1. Free access to reinforcers prior to the start of training blocks and treatment evaluation sessions.2. Expectations to earn reinforcement were apparent, making the delivery of reinforcement more predictable while still increasing tolerance skills.&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td&gt;Promote Choice and Shared Governance&lt;/td&gt;&lt;td&gt;1. Assent could be withdrawn at any time.2. All reasonable requests were honored during the reinforcement intervals.&lt;/td&gt;&lt;td&gt;1. Assent could be withdrawn at any time.2. All reasonable requests were honored during the reinforcement intervals.3. Responded to participant performance during treatment by incorporating individualized modifications to procedures.4. Social validation of procedures following treatment occurred with Diego to identify preferences and methods to improve treatment.&lt;/td&gt;&lt;/tr&gt;&lt;tr&gt;&lt;td&gt;Emphasize Skill Building&lt;/td&gt;&lt;td&gt;1. Results of PFA informed the development of function-based interventions incorporating skill building&lt;/td&gt;&lt;td&gt;1. Communication responses taught to replace challenging behavior, terminate triggering events, and access reinforcers.2. Tolerance response taught to increase tolerance to experiencing denials to accessing preferred items.3. Cooperation training to increase tolerance of delays to accessing preferred items.4. Treatment extension over 1, 2, and 3 months conducted to ensure skills sustained over time.&lt;/td&gt;&lt;/tr&gt;&lt;/tbody&gt;&lt;/table&gt; </ephtml> </p> <hd id="AN0191375864-10">Practical Functional Assessment</hd> <p>The PFA began with an open-ended interview with the caregiver(s) via video conferencing or in person (for a list of open-ended questions, see the appendices of [<reflink idref="bib12" id="ref33">12</reflink>]. The open-ended interview revealed the likely triggering events and putative reinforcers contributing to challenging behavior. The interview is aligned with the TIC principle of acknowledging trauma and its potential impact, as it allowed us to identify any prior experiences of adverse events and therefore limit exposure to those events or contingencies during the analysis. We used the information collected during the open-ended interview to arrange an individualized contingency included in the performance-based IISCA. Ally's reinforcement included independent play with a tablet and stuffed animals. The triggering event included the therapist removing the toys and presenting the instruction to transition to the work table to complete discrete trial instructions. Diego had independent access to his phone and any requests would have been granted during reinforcement. Following the introduction of the triggering event, the therapist removed the phone, denied any requests, and provided the instruction to transition to the work table. At the work table, the therapist presented academic materials to improve skills such as expressive identification of the meaning of idioms and receptive identification of the functions of safety signs. Reinforcement for Chad involved engaging in stereotypy with a hairbrush and free access to any ritualistic behavior. When the therapist presented the triggering event, the ritualistic behavior was blocked, and he was instructed to transition to the work table where he completed sorting tasks.</p> <p>The performance-based IISCA was the second step of the PFA process and involved a single session consisting of five presentations of the triggering event, with reinforcement delivered following the occurrence of any challenging behavior (dangerous or associated nondangerous). We incorporated principles of TIC in several ways. First, to ensure safety and trust, we allowed each child access to free play for at least 5 min prior to beginning the analysis. During the analysis, to maintain safety and trust, we only interrupted play long enough for the child to demonstrate one instance of challenging behavior prior to the child's return to play. We extended the child's access to play dependent upon the child's performance (i.e., the reinforcement interval was set for 30 s of calm behavior and continued to be reset until the participant was calm for the entire 30 s). To promote choice and shared governance, the participant could withdraw assent to participate in the performance-based IISCA at any time by walking away from area. Had this occurred, the therapist would have presented the reinforcers and asked if the participant would want to stay and play. However, the therapist would never physically block the path of the participant. None of the participants indicated a withdrawal of assent during the performance-based IISCA.</p> <p>A timer signaled the end of the reinforcement interval, at which time the therapist presented the triggering event (e.g., "OK, break's over"), followed by the removal of putative reinforcers. Once challenging behavior was observed, the therapist provided verbal reassurance (e.g., "It's OK, here you go"), the removal of any instructions, and the return of any putative reinforcers. If challenging behavior was not observed immediately after the removal of the putative reinforcers, the triggering event progressed to the presentation of instructions and instructions continued until challenging behavior occurred or until 10 min had elapsed. The therapist provided praise for any cooperation with the instructions. The triggering event and reinforcement sequence was repeated five times (aligning with ensuring safety and trust by maintaining an efficient analysis), after which the assessment was complete.</p> <hd id="AN0191375864-11">Skill-Based Treatment</hd> <p>The process of SBT involves teaching increasingly complex communication skills during communication training and tolerance and cooperation skills during cooperation training. SBT heavily emphasizes skill building, a component of TIC, by replacing challenging behavior with more communication skills and teaching the child to tolerate previously triggering events. This reduces potential exposure to adverse events associated with more dangerous topographies of challenging behavior, including restraint, seclusion, and more restrictive intervention practices or settings. SBT was introduced following the completion of a baseline phase. See Figure 1 for schematic representative of treatment process.</p> <p>Graph: Figure 1. Schematic of Skill-Based Treatment Trials. Note. SBT incorporates five randomized trials within a session in which participants (a) access reinforcement immediately upon engaging in the communication response (one trial); (b) emit the communication response, encounter a denial from the therapist (e.g., "Not right now"), and emit tolerance response (e.g., "OK") prior to accessing reinforcement (one trial); or (c) emit the communication response, experience a denial, emit the tolerance response, and are presented with simple, moderate, or complex instructions prior to accessing reinforcement (three trials split across the instructional levels).</p> <hd id="AN0191375864-12">Baseline</hd> <p>The baseline sessions were 3 min and began with the reinforcers being removed while the therapist simultaneously presented the triggering event. If the participant engaged in challenging behavior after the triggering event was presented, the triggering event was terminated, and the participant was provided access to the reinforcers for 30 s to maintain the child's safety and trust. The therapist continued to present instructions if challenging behavior did not occur. Upon the occurrence of appropriate communication (e.g., "I want to keep playing"), the therapist acknowledged the request and redirected the participant to the task (e.g., "I am sorry, not right now. Let's go to the table").</p> <hd id="AN0191375864-13">Communication Training</hd> <p>Each participant completed training blocks for each phase of communication training until they achieved two consecutive training blocks of independent responding. The therapist did not reinforce challenging behaviors during training blocks. The training blocks consisted of five trials each with 30 s of reinforcement following independent or prompted communication responses. The therapist used the same reinforcers based on the results of the performance-based IISCA. During the first trial, the therapist presented the triggering event and immediately prompted the participant to engage in the communication response. For Ally and Chad, their training blocks consisted of most-to-least prompting to hand over the communication response icon to the therapist. Diego's training blocks consisted of verbal prompts (e.g., "Say, 'my turn please'") to engage in the communication response. The therapist faded the instruction to a single word (e.g., "My") until independent responding occurred. Participants were required to independently emit the taught response for four out of five trials to move on to the evaluation of communication training.</p> <p>The mastery of each targeted communication response (i.e., simple, intermediate, and complex) was evaluated sequentially during 3-min sessions. The therapist did not provide any prompts during this time; however, much like training, challenging behavior no longer produced the synthesized reinforcers. The session began with the therapist presenting the triggering event and removing the synthesized reinforcers. The therapist stated, "OK, break's over," and the participant was then expected to emit the target communication response before the reinforcers were returned. Behavior-specific praise was provided (i.e., "Great job saying, 'My way,' you can have your way!"). The therapist provided access to the reinforcers for 30 s, after which the triggering event was presented again. The completion of the communication training evaluation resulted in the initiation of training for the next communication response. All data from the treatment evaluation of communication training for each participant are reported on further.</p> <hd id="AN0191375864-14">Cooperation Training</hd> <p>Following the communication training evaluation of the complex communication response, participants were taught to provide a tolerance response in the presence of denied access to reinforcers. The training blocks for the tolerance response phase were similar to those in communication training; however, training blocks consisted of half of the trials in which reinforcers were provided contingent on the complex communication response and reinforcers provided contingent on a tolerance response in the other half of the trials. After the denial of the complex communication response, the therapist immediately prompted the tolerance response (e.g., "Say, 'OK'"). Access to reinforcers was then provided for 30 s. Mastery criteria for the tolerance training blocks were four out of five tolerance trials with independent responding and no challenging behavior. Once the participants met the mastery criteria during the training blocks, they moved on to the tolerance evaluation. Sessions were 3 min and consisted of alternating between the reinforcement of the complex communication response and tolerance response. Challenging behavior did not result in reinforcement and the therapist no longer provided prompts for the target communication responses (i.e., complex communication response or tolerance response).</p> <p>The therapist then introduced delays in accessing reinforcement after the evaluation of the tolerance response. Cooperation training sessions at this point had no set duration requirement and sessions consisted of five (i.e., Ally and Chad) or six trials (i.e., Diego). Diego's six trials included increased reinforcement for communication based upon his performance as behavioral expectations increased and his own request, aligning with the TIC value of promoting choice and shared governance during treatment. The reinforcement duration was extended to 1 min. The therapist immediately reinforced the complex communication response in one trial. In one other trial, the therapist reinforced the tolerance response. In the remaining trials, the therapist presented instructions following the tolerance response. The therapist pulled trials from a bag and wrote down the order in which they occurred in the session. Throughout the session challenging behavior never produced reinforcement.</p> <p>Prior to the beginning of each session, each participant was actively engaged with their synthesized reinforcers. To begin the session, the therapist presented the triggering event (i.e., "OK [name], break's over" while removing reinforcers). During trials with instructions, participants were first told to transition from the play area to the work table. Instructions for all participants at the work table began with simple instructions (i.e., gross motor imitation) and progressed to more complex instructions (i.e., receptive and expressive identification, fine motor imitation, and sorting tasks). Ally and Diego's terminal goal was to complete 30 instructions in a session, whereas Chad's terminal goal was to complete 11 instructions. The goals were individually determined based on collaborative communication with relevant stakeholders including home therapists and caregivers. The therapist systematically increased the number of instructions following sessions with consistent usage of complex communication responses and tolerance response with cooperation to adult instruction in the absence of any challenging behavior.</p> <hd id="AN0191375864-15">Treatment Extension</hd> <p>Following the completion of SBT, the intervention was conducted across additional implementers for all three participants. The treatment extension for Ally and Diego was conducted with their clinical supervisor and home therapists, whereas Chad's treatment extension was conducted with just his home therapist. Behavioral skills training (i.e., instructions, modeling, and role-play with in situ feedback) was used to train the home therapists on all elements of SBT. The home therapists conducted treatment extension once they completed five consecutive trials without errors. Treatment extension consisted of the clinical supervisor or home therapist(s) leading a session of the last instruction level mastered during cooperation training. This was done to ensure the intervention transferred to the staff who typically work with the participant throughout the week. Treatment extension sessions were also conducted over time for all three participants. The researcher conducted a 1-month treatment extension session with Diego; 1- and 2-month treatment extension sessions with Ally; and 1-, 2-, and 3-month treatment extension sessions with Chad.</p> <hd id="AN0191375864-16">Social Validity</hd> <p>Each participant's home therapist completed multiple social validity questionnaires following treatment extension. The Usage Rating Profile-Assessment (URP-A; [<reflink idref="bib5" id="ref34">5</reflink>]) and the Usage Rating Profile-Intervention (URP-I; [<reflink idref="bib4" id="ref35">4</reflink>]) forms were used to evaluate the following: (a) acceptability, (b) understanding, (c) home school collaboration, (d) feasibility, (e) system climate, and (f) system support. The forms rated the assessment and intervention on a 6-point Likert-type scale ranging from 1 (e.g., <emph>strongly disagree</emph>) to 6 (e.g., <emph>strongly agree</emph>). The Children's Usage Rating Profile-Intervention form (CURP; [<reflink idref="bib3" id="ref36">3</reflink>]) was completed by Diego independently at the end of the intervention. The 4-point Likert-type scale ranged from 1 = <emph>I totally disagree</emph> to 4 = <emph>I totally agree</emph>; the use of 4-point rather than 6-point scale made the measure more child-friendly by simplifying the response options. Furthermore, regarding children's ratings, both the directions and items listed within the form used child-friendly language. The scale assessed (a) understanding of the intervention, (b) repeatability, (c) desirability, and (d) complexity of the intervention.</p> <p>The researchers developed and used two additional social validity forms for both the assessment and intervention (available upon request). The assessment form included questions relating to acceptability, safety, representation of challenging behavior, and experience with trauma. The treatment form included questions relating to satisfaction with the intervention, acceptability, and helpfulness. The forms rated the assessment and intervention on a 7-point Likert-type scale ranging from 1, the lowest score, to 7, the highest score. A section for additional comments was also available.</p> <p>In addition to the home therapists and participant, three independent clinicians were given access to the participants' recorded assessment and intervention sessions. Clinicians were randomly assigned to a participant and watched the participants' performance-based IISCA recording. Following this, the clinicians were asked to complete the clinic assessment questionnaire before watching and completing the clinic treatment questionnaire on randomly selected videos representative of the entire SBT process. Each clinician held a master's degree (two in ABA and the third in liberal arts with a concentration in ABA) and certification as a Board Certified Behavior Analyst. The mean age of the clinicians was 32 years old (range = 30–36 years old) and the mean years in the field was 9.3 (range = 8–12 years).</p> <hd id="AN0191375864-17">Results</hd> <p>Results of the performance-based IISCA for all participants are displayed in Figure 2. Across all three participants, challenging behavior only occurred directly following the presentation of the triggering event. Both Ally and Diego did not immediately engage in challenging behavior upon presentation of the triggering event. Participants did not exhibit dangerous behavior during the assessment. The triggering events demonstrated a direct influence on challenging behavior across all participants. Throughout reinforcement intervals, all participants remained calm while accessing their synthesized reinforcers. However, Diego did require additional time with his reinforcers during the third presentation. Diego's reinforcer (i.e., phone) stopped working early into the reinforcement interval, after which Diego chose an alternate reinforcer. The reinforcement interval was expanded to approximately 1 min and 20 s to allow time with the newly chosen reinforcer. None of the participants engaged in interactive behavior. The total duration for each of the participants' performance-based IISCA was 6 min (Ally), 5.2 min (Diego), and 4.7 min (Chad). A socially mediated function was identified in each and was used to inform the SBT procedures.</p> <p>Graph: Figure 2. Results of the Performance-Based IISCA for All Participants. Note. Gray circles indicate instances of challenging behavior. Horizontal purple and blue lines depict the duration of engagement with reinforcers and activities and calmness during the reinforcement interval. Green horizontal lines represent the duration of the reinforcement interval. Each participant engaged in nondangerous challenging behavior following the triggering event, without escalation to instances of dangerous behavior.</p> <p>Figures 3–5 represent the results of SBT for all participants. During baseline, challenging behavior occurred at elevated rates. Challenging behavior was eliminated, and the simple communication response was emitted at stable levels following the introduction of simple communication training. The return to baseline resulted in the return of challenging behavior and it immediately decreased once simple communication training was re-introduced. Challenging behavior remained eliminated for the remainder of communication training when the intermediary communication response and complex communication response were acquired. Challenging behavior continued to be nearly eliminated during cooperation training while the complex communication response gradually decreased. The tolerance response occurred at stable levels and the participants cooperated with all instructions. During treatment extension, challenging behavior was low. The participants continued to emit the complex communication response and tolerance response, and cooperation was high. By the end of SBT, Ally was completing 30 instructions with three different therapists 2 months after her last SBT session with the researcher, Diego was completing approximately 30 instructions across two different therapists, and Chad was completing 11 instructions with his home therapist 3 months after his last SBT session with his clinical supervisor.</p> <p>Graph: Figure 3. Results of Skill-Based Treatment and Treatment Extensions for Ally. Note. Behavioral expectation levels correspond to the sequence of instructions for cooperation. Rates of challenging behavior are depicted within the first panel. Challenging behavior was seen during baseline and the reversal probe. It remained low throughout treatment and treatment extension. The middle panel depicts rates of communication responses, and the bottom panel represents tolerance responses. Communication and tolerance responses did not occur during baseline nor the reversal probe but did occur throughout their respective teaching sessions. As expected, communication and tolerance responses decreased throughout cooperation training.</p> <p>Graph: Figure 4. Results of Skill-Based Treatment and Treatment Extensions for Diego. Note. Behavioral expectation levels correspond to the sequence of instructions for cooperation. Challenging behavior is depicted in the top panel. The communication responses are depicted in the second, third, and fourth panels in the order in which the communication responses increased in complexity. The tolerance response and cooperation training are represented in the bottom panel.</p> <p>Graph: Figure 5. Results of Skill-Based Treatment and Treatment Extensions for Chad. Note. Behavioral expectation levels correspond to the number of instructions for cooperation. Challenging behavior was observed within baseline and the reversal probe, remaining infrequent throughout treatment and follow up. Communication and tolerance responses were acquired during communication and tolerance training. These responses decreased as cooperation training progressed.</p> <p>Following the completion of the treatment extension, three home therapists and one participant (i.e., Diego) completed social validity forms. Individual URP-A and URP-I scores are included within Supplemental Materials. Ally and Chad's home therapists each completed the URP-A to rate the performance-based IISCA. Their ratings indicated they found the assessment to be highly acceptable (<emph>M</emph> = 5.27; <emph>SD</emph> = 0.75), understandable (<emph>M</emph> = 6), and feasible (<emph>M</emph> = 4.25; <emph>SD</emph> = 0.5), with little support needed (<emph>M</emph> = 1.5; <emph>SD =</emph> 0.54; i.e., almost no additional support required). They rated the environment in which the assessment was conducted as highly supportive (<emph>M</emph> = 5.57; <emph>SD</emph> = 0.53). Following treatment, Ally, Diego, and Chad's home therapists rated SBT, using the URP-I, as highly acceptable (<emph>M</emph> = 5.69; <emph>SD</emph> =.47), understandable (<emph>M</emph> = 6), and feasible (<emph>M</emph> = 5.61; <emph>SD</emph> = 0.97). The home therapists indicated the support needed to implement SBT as being low (<emph>M</emph> = 2.77; <emph>SD</emph> = 1.78), while the climate of the environment was rated as supportive for the intervention's use <emph>(M</emph> = 5.69; <emph>SD</emph> = 0.48). Using the CURP-I, Diego rated SBT as highly personally desirable (<emph>M</emph> = 4), understandable (<emph>M</emph> = 3.4; <emph>SD</emph> =.5), and feasible (<emph>M</emph> = 3.9; <emph>SD</emph> =.4).</p> <p>Two home therapists (i.e., of Ally and Chad) completed the clinic assessment social validity form (provided as a Supplemental Material). Overall, the home therapists found the performance-based IISCA to be highly acceptable (<emph>M</emph> = 6.5; <emph>SD</emph> =.71), safe (<emph>M</emph> = 7), accurate in identifying the context in which challenging behavior occurred in the home (<emph>M</emph> = 6.5; <emph>SD</emph>=.71), and not at all traumatic (<emph>M</emph> = 1). Each participant's home therapist completed the clinic intervention social validity form (see Supplemental Materials), rating their satisfaction in improvements in challenging behavior (<emph>M</emph> = 6) and communication skills highly (<emph>M</emph> = 5.6; <emph>SD</emph> = 0.6). The home therapists perceived SBT as highly acceptable (<emph>M</emph> = 7), very helpful (<emph>M</emph> = 5.3; <emph>SD</emph> = 2.1), and not traumatic (<emph>M</emph> = 1). Home therapists who completed the optional comment section expressed that they felt no trauma occurred during assessment or intervention, that they could see a difference with reduced challenging behavior, and that the participant communicated more effectively to access reinforcers.</p> <p>In addition to the home therapists, three independent clinicians completed the clinic social validity assessment and treatment forms. Social validity questions and individual scores are listed within Supplemental Materials. All three clinicians found the performance-based IISCA to be very acceptable (<emph>M</emph> = 7), very safe (<emph>M</emph> = 7), and not traumatic (<emph>M</emph> = 1.3; <emph>SD</emph> =.6). The independent clinicians also indicated that they felt very comfortable (<emph>M</emph> = 6.7; <emph>SD</emph> =.6) while watching the performance-based IISCA. Furthermore, after watching videos of SBT, the clinicians reported a high degree of satisfaction with the improvement in challenging behavior and communication skills (<emph>M</emph> = 6.7; <emph>SD</emph> =.52) and found SBT to be very acceptable (<emph>M</emph> = 7), very helpful (<emph>M</emph> = 6.7; <emph>SD</emph>=.6), and not traumatic (<emph>M</emph> = 1). One clinician completed the optional comment section and noted that the participant was completely safe throughout the performance-based IISCA and that tolerating delayed access to reinforcers was a very helpful skill for the participant to learn.</p> <hd id="AN0191375864-18">Discussion</hd> <p>The performance-based IISCA informed an efficacious, function-based treatment for three children with ASD, furthering support for the inclusion of TIC principles within behavior analytic assessment. It is important to note that none of the participants escalated to dangerous behavior during the performance-based IISCA. Safety was prioritized and maintained by adhering to a TIC framework. Following the acquisition of communication and tolerance skills, challenging behavior was effectively reduced for all participants within their family homes. In addition, challenging behavior remained low throughout extension to the participant's typical clinical team and across multiple months.</p> <p>All home therapists indicated their support, noting both the assessment and treatment process as acceptable and safe. Three independent clinicians unfamiliar with the participants indicated their satisfaction with the improvement in challenging behavior following the acquisition of communication and tolerance skills. The clinicians further indicated their belief that the participants did not experience trauma as a result of the assessment and treatment process. These results establish further support for both the performance-based IISCA's treatment utility and the inclusion of a TIC framework within practice.</p> <p>TIC is not a singular concept or procedure, but rather a framework consisting of several constructs (i.e., safety, trust, choice, shared governance, and skill building). In fact, [<reflink idref="bib21" id="ref37">21</reflink>] further outlined principles of TIC, expanding our current framework for TIC described by [<reflink idref="bib23" id="ref38">23</reflink>] to include the following: (a) builds healthy relationships between the child and at least one peer and adult; (b) incorporation of family, culture, and community in the treatment process; and (c) emphasis on the prioritization of collaboration between providers on the child's care team. The emphasis on collaboration between those providing services to the child across various domains aligns well with the notion that to provide high-quality care, collaboration is necessary ([<reflink idref="bib7" id="ref39">7</reflink>]; [<reflink idref="bib22" id="ref40">22</reflink>]), particularly given that children with developmental disabilities tend to have a greater number of service providers than their typically developing siblings ([<reflink idref="bib22" id="ref41">22</reflink>]).</p> <p>While the performance-based IISCA is the only current functional analysis format specifically designed with TIC principles in mind ([<reflink idref="bib15" id="ref42">15</reflink>]; [<reflink idref="bib16" id="ref43">16</reflink>]; [<reflink idref="bib20" id="ref44">20</reflink>]), it is not a demonstration of the only way in which TIC may be applied. In addition, we only evaluated a trauma-informed assessment; however, literature exists in support of TIC principles applied to treatment. For example, [<reflink idref="bib28" id="ref45">28</reflink>] introduced "kind extinction" as a modification to the traditional operant extinction process. Like conventional extinction procedures, kind extinction involves withholding reinforcement contingent upon the occurrence of challenging behavior, but unlike traditional extinction, it includes the delivery of individualized, empathetic statements to validate the child's experience of emotional distress.</p> <p>[<reflink idref="bib24" id="ref46">24</reflink>] provided another example of TIC embedded within a behavioral treatment the researchers defined as the Enhanced Choice Model. The Enhanced Choice Model is a variation of SBT in which children are provided with choices regarding their participation in addition to learning functional communication and tolerance skills. Children may choose to participate in instructional activities to earn their synthesized reinforcers, "hang out" in another area away from instructional activities with access to other valued reinforcers, or leave the treatment setting altogether. Through the provision of choices, particularly assent (i.e., one's choice to participate), clinicians may establish safety and trust with a learner, ensuring the maintenance of an emotionally and physically safe learning environment and the acquisition of relevant skills.</p> <p>In fact, [<reflink idref="bib2" id="ref47">2</reflink>] specifically underscored assent as a fundamental human right, regardless of one's status as an individual with a disability or not. They advocate for assent-based treatment, highlighting more than 20 accommodations that can be made in the face of assent withdrawal. This is in line with therapeutic alliance literature, which suggests directly intervening when the alliance has fractured. Assent and its withdrawal may provide clinicians with useful information regarding a child's treatment. Initial and continued assent may be indicative of a harmonious therapeutic relationship between the child and clinician, while the child's act of withdrawing assent may communicate that the collaborative learning process has not occurred or has been disrupted ([<reflink idref="bib2" id="ref48">2</reflink>]).</p> <hd id="AN0191375864-19">Limitations</hd> <p>A limitation of this study is the lack of parent participation. We conducted the treatment extension primarily with the researcher and each child's home-based clinical team. Parents were invited to participate to the extent to which they felt comfortable; however, extenuating circumstances prevented participation from occurring. It is likely that the caregivers felt as though this study was more relevant for the home therapists, the ones who were expected to provide the clinical services, and that their participation was unnecessary.</p> <p>An additional limitation surrounds the use of un-signaled probabilistic reinforcement rather than signaled compound-schedule arrangements. For children with prior histories of trauma, clinicians should consider making schedules transparent to the child. Certainly, multiple or chained schedules of reinforcement may be considered to be more trauma-informed; however, SBT is meant to be an individualized process, and applying principles of TIC further individualizes it. For example, though we used un-signaled probabilistic reinforcement across all three participants initially, we ultimately modified Diego's treatment at his request and allowed him access to a clicker for him to count trials until he accessed reinforcement. The researcher explained how many trials Diego would need to complete immediately upon transitioning to the work table, and Diego clicked upon completion of each trial.</p> <p>While the empirical literature may certainly indicate that SBT is efficacious, as [<reflink idref="bib10" id="ref49">10</reflink>] noted, efficacy is not necessarily indicative of effectiveness. The continuum of effectiveness is wide and can be impacted by a variety of variables when treatment is delivered in a less tightly controlled setting, such as a family home, or by individuals without explicit clinical training. Treatment within this study was provided by clinicians with experience in implementing behavior analytic procedures. The extent to which treatment may result in the reduction of challenging behavior and acquisition or maintenance of functional skills when implemented by parents without a background in behavior analysis is an important question left to be answered. It speaks to the need for future work to (a) assess for generalization of treatment across more naturally occurring contexts and (b) assess the degree to which behavior change endures over time in these contexts. In the present study, we did not assess generality and endurance of procedures to participants parents or typical caregivers within more natural, unstructured settings—a limitation of our work.</p> <hd id="AN0191375864-20">Future Research</hd> <p>Based on the noted limitations, future work might incorporate generalization of assessment and treatment procedures to parents and an evaluation of the extent to which parents find the process beneficial in the acquisition of communication and tolerance skills and reduction of challenging behavior. While demonstrations of generality following SBT informed by the full IISCA exist (see [<reflink idref="bib6" id="ref50">6</reflink>] for review), the generality of function-based treatment informed by the performance-based IISCA has yet to be fully evaluated. Researchers may also want to consider measurement of the occurrence of restrictive procedures (i.e., restraint and seclusion), injuries, or other negative outcomes associated with challenging behavior, as a reduction in the occurrence of potentially traumatic events may impact the child's quality of life.</p> <p>Incorporating a trauma-informed framework within the assessment and treatment of challenging behavior is feasible for clinicians to implement and advantageous for the child and broader intellectual and developmental disability community. In light of recent critiques of behavior analytic procedures, it is necessary that TIC principles be applied to our assessments and interventions to reshape the behavior analytic landscape. This study contributes to the growing body of evidence that exists in support of a trauma-informed approach. Subsequent work may identify further assessment and treatment adaptations in which a TIC framework is applied.</p> <hd id="AN0191375864-21">Supplemental Material</hd> <p>Graph: Supplemental material, sj-docx-1-rps-10.1177_15407969251319255 for Evaluating the Long-Term Efficacy of a Trauma-Informed Approach to Addressing Challenging Behavior in the Home by Aaron Leyman, Phoebe MacDowell and Joshua Jessel in Research and Practice for Persons with Severe Disabilities</p> <ref id="AN0191375864-22"> <title> References </title> <blist> <bibl id="bib1" idref="ref1" type="bt">1</bibl> <bibtext> American Psychological Association. (n.d.). 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Advances in Neurodevelopmental Disorders, 8(1), 1–19. https://doi.org/10.1007/s41252-023-00367-w</bibtext> </blist> </ref> <ref id="AN0191375864-23"> <title> Footnotes </title> <blist> <bibtext> The data that support the findings of this study are available from the corresponding author upon reasonable request.</bibtext> </blist> <blist> <bibtext> The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: Aaron Leyman declares no conflict of interest. Phoebe MacDowell declares no conflict of interest. Joshua Jessel declares a former part-time consultation position at FTF Behavioral Consulting.</bibtext> </blist> <blist> <bibtext> The author(s) received no financial support for the research, authorship, and/or publication of this article.</bibtext> </blist> <blist> <bibtext> All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki Declaration and its later amendments or comparable ethical standards.</bibtext> </blist> <blist> <bibtext> Informed consent was obtained from all individual participants included in the study.</bibtext> </blist> <blist> <bibtext> Phoebe MacDowell</bibtext> </blist> <blist> <bibtext>Graph</bibtext> </blist> <blist> <bibtext>https://orcid.org/0000-0002-8056-6682 Joshua Jessel</bibtext> </blist> <blist> <bibtext>Graph https://orcid.org/0000-0002-1649-2834</bibtext> </blist> <blist> <bibtext> Supplemental material for this article is available online.</bibtext> </blist> <blist> <bibtext> Editor-in-Charge: Elizabeth Biggs</bibtext> </blist> </ref> <aug> <p>By Aaron Leyman; Phoebe MacDowell and Joshua Jessel</p> <p>Reported by Author; Author; Author</p> <p></p> <p>Aaron Leyman received his master's degree from Queens College, City University of New York. His research interests include the assessment and treatment of challenging behavior.</p> <p>Phoebe MacDowell is a doctoral student at Queens College and The Graduate Center, City University of New York. Her research addresses trauma-informed care practices with individuals with developmental disabilities.</p> <p>Joshua Jessel is an assistant professor at Brock University. His current research interests include the development of safe assessments of challenging behavior and evaluation of skill-based treatments informed by those assessments.</p> </aug> <nolink nlid="nl1" bibid="bib11" firstref="ref2"></nolink> <nolink nlid="nl2" bibid="bib19" firstref="ref3"></nolink> <nolink nlid="nl3" bibid="bib18" firstref="ref4"></nolink> <nolink nlid="nl4" bibid="bib29" firstref="ref6"></nolink> <nolink nlid="nl5" bibid="bib14" firstref="ref7"></nolink> <nolink nlid="nl6" bibid="bib27" firstref="ref8"></nolink> <nolink nlid="nl7" bibid="bib23" firstref="ref9"></nolink> <nolink nlid="nl8" bibid="bib25" firstref="ref13"></nolink> <nolink nlid="nl9" bibid="bib26" firstref="ref14"></nolink> <nolink nlid="nl10" bibid="bib13" firstref="ref16"></nolink> <nolink nlid="nl11" bibid="bib17" firstref="ref17"></nolink> <nolink nlid="nl12" bibid="bib20" firstref="ref18"></nolink> <nolink nlid="nl13" bibid="bib15" firstref="ref19"></nolink> <nolink nlid="nl14" bibid="bib16" firstref="ref20"></nolink> <nolink nlid="nl15" bibid="bib21" firstref="ref25"></nolink> <nolink nlid="nl16" bibid="bib12" firstref="ref33"></nolink> <nolink nlid="nl17" bibid="bib22" firstref="ref40"></nolink> <nolink nlid="nl18" bibid="bib28" firstref="ref45"></nolink> <nolink nlid="nl19" bibid="bib24" firstref="ref46"></nolink> <nolink nlid="nl20" bibid="bib10" firstref="ref49"></nolink> |
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| Items | – Name: Title Label: Title Group: Ti Data: Evaluating the Long-Term Efficacy of a Trauma-Informed Approach to Addressing Challenging Behavior in the Home – Name: Language Label: Language Group: Lang Data: English – Name: Author Label: Authors Group: Au Data: <searchLink fieldCode="AR" term="%22Aaron+Leyman%22">Aaron Leyman</searchLink><br /><searchLink fieldCode="AR" term="%22Phoebe+MacDowell%22">Phoebe MacDowell</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-8056-6682">0000-0002-8056-6682</externalLink>)<br /><searchLink fieldCode="AR" term="%22Joshua+Jessel%22">Joshua Jessel</searchLink> (ORCID <externalLink term="https://orcid.org/0000-0002-1649-2834">0000-0002-1649-2834</externalLink>) – Name: TitleSource Label: Source Group: Src Data: <searchLink fieldCode="SO" term="%22Research+and+Practice+for+Persons+with+Severe+Disabilities%22"><i>Research and Practice for Persons with Severe Disabilities</i></searchLink>. 2026 51(1):6-25. – Name: Avail Label: Availability Group: Avail Data: SAGE Publications. 2455 Teller Road, Thousand Oaks, CA 91320. Tel: 800-818-7243; Tel: 805-499-9774; Fax: 800-583-2665; e-mail: journals@sagepub.com; Web site: https://sagepub.com – Name: PeerReviewed Label: Peer Reviewed Group: SrcInfo Data: Y – Name: Pages Label: Page Count Group: Src Data: 20 – Name: DatePubCY Label: Publication Date Group: Date Data: 2026 – Name: TypeDocument Label: Document Type Group: TypDoc Data: Journal Articles<br />Reports - Research – Name: Subject Label: Descriptors Group: Su Data: <searchLink fieldCode="DE" term="%22Child+Behavior%22">Child Behavior</searchLink><br /><searchLink fieldCode="DE" term="%22Behavior+Problems%22">Behavior Problems</searchLink><br /><searchLink fieldCode="DE" term="%22Program+Effectiveness%22">Program Effectiveness</searchLink><br /><searchLink fieldCode="DE" term="%22Trauma+Informed+Approach%22">Trauma Informed Approach</searchLink><br /><searchLink fieldCode="DE" term="%22Autism+Spectrum+Disorders%22">Autism Spectrum Disorders</searchLink><br /><searchLink fieldCode="DE" term="%22Behavior+Modification%22">Behavior Modification</searchLink><br /><searchLink fieldCode="DE" term="%22Interpersonal+Communication%22">Interpersonal Communication</searchLink><br /><searchLink fieldCode="DE" term="%22Cooperation%22">Cooperation</searchLink> – Name: DOI Label: DOI Group: ID Data: 10.1177/15407969251319255 – Name: ISSN Label: ISSN Group: ISSN Data: 1540-7969<br />2169-2408 – Name: Abstract Label: Abstract Group: Ab Data: Behavioral interventions for challenging behavior often rely on the results of a functional analysis to identify environmental contributors. Multiple functional analysis formats have been developed to improve qualities of the process such as practicality, efficiency, and safety. More recently, the performance-based, interview-informed synthesized contingency analysis (IISCA) was developed as a functional analysis format that incorporates a trauma-informed framework. The performance-based IISCA (a) introduces evocative events following periods of calm to reduce dangerous escalation, (b) includes moment-to-moment measures of challenging behavior to allow for ongoing visual analysis of data, and (c) maintains measures of positive affect. We conducted this study to evaluate the treatment utility of the performance-based IISCA when it is used to inform a skill-based treatment. The performance-based IISCA was conducted for the challenging behavior of three autistic children before teaching communication, toleration, and cooperation during skill-based treatment in the home setting. Challenging behavior was reduced for all participants across different therapists and across time (1-, 2-, 3-month treatment extension). The results support the extension and longevity of treatment informed by the performance-based IISCA. – Name: AbstractInfo Label: Abstractor Group: Ab Data: As Provided – Name: DateEntry Label: Entry Date Group: Date Data: 2026 – Name: AN Label: Accession Number Group: ID Data: EJ1497561 |
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| RecordInfo | BibRecord: BibEntity: Identifiers: – Type: doi Value: 10.1177/15407969251319255 Languages: – Text: English PhysicalDescription: Pagination: PageCount: 20 StartPage: 6 Subjects: – SubjectFull: Child Behavior Type: general – SubjectFull: Behavior Problems Type: general – SubjectFull: Program Effectiveness Type: general – SubjectFull: Trauma Informed Approach Type: general – SubjectFull: Autism Spectrum Disorders Type: general – SubjectFull: Behavior Modification Type: general – SubjectFull: Interpersonal Communication Type: general – SubjectFull: Cooperation Type: general Titles: – TitleFull: Evaluating the Long-Term Efficacy of a Trauma-Informed Approach to Addressing Challenging Behavior in the Home Type: main BibRelationships: HasContributorRelationships: – PersonEntity: Name: NameFull: Aaron Leyman – PersonEntity: Name: NameFull: Phoebe MacDowell – PersonEntity: Name: NameFull: Joshua Jessel IsPartOfRelationships: – BibEntity: Dates: – D: 01 M: 03 Type: published Y: 2026 Identifiers: – Type: issn-print Value: 1540-7969 – Type: issn-electronic Value: 2169-2408 Numbering: – Type: volume Value: 51 – Type: issue Value: 1 Titles: – TitleFull: Research and Practice for Persons with Severe Disabilities Type: main |
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