The Clinical Application of Applied Behavior Analysis in a Child With Partial Fetal Alcohol Syndrome

Standardized Assessment of Intellectual Functioning

To gauge Kate’s level of intellectual functioning, she was administered the Differential Ability Scale, Second Edition (DAS-2) at the time of initial evaluation. The DAS-2 is a norm-referenced assessment used to report an individual’s level of cognitive functioning across several domains, compared with aged-matched peers. For all ability clusters (i.e., General Conceptual Ability, Verbal cluster, Non-Verbal Reasoning cluster, and Spatial cluster), scores are reported as standard scores, with a mean score of 100 (SD = 15). A summary of Kate’s scores on the DAS-2, assessed at each time point, appear in Table 1.

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Table 1.

Standardized Assessment of Intellectual Functioning.

Measure	Pretreatment	Month 9 of treatment	Month 23 of treatment
DAS-2	M = 100SD = 15	M = 100SD = 15	M = 100SD = 15
General conceptual ability	49	54	50
Verbal cluster	35	63	61
Non-Verbal Reasoning cluster	71	73	71
Spatial cluster	58	47	38
DAS-2 subscale scores	M = 50SD = 10	M = 50SD = 10	M = 50SD = 10
Verbal Comprehension	15	23	24
Picture Similarities	45	37	45
Naming Vocabulary	10	33	30
Pattern Construction	28	10	14
Matrices	21	32	20
Copying	20	25	10

Note. DAS-2 = Differential Ability Scale, Second Edition.

The pretreatment assessment of Kate’s cognitive abilities, as reported on the DAS-2, indicated that her abilities across most measured domains fell within the extremely low range (i.e., General Conceptual Ability, Verbal cluster, and Spatial cluster). Of note, a review of medical records indicated there were no other medical factors or genetic conditions identified at the time of the evaluation that would impact her cognitive functioning, such as the presence of visual impairments that may negatively affect visual-spatial performance. An area of relative strength for Kate was reported in her Non-Verbal Reasoning skills, which fell within the borderline range. Overall, Kate’s intellectual functioning was significantly below those of her same-aged peers, indicating that she likely required high levels of individualized support in educational settings. Performance on cognitive assessments was consistent with Kate’s initial clinical presentation and her performance on behavioral assessments conducted prior to starting treatment; the results of the psychological evaluation were likely an accurate representation of her level of global functioning.

Standardized Assessment of Adaptive Functioning

Adaptive functioning describes an individual’s ability to complete daily-living tasks at a level that is expected based on age and developmental level. Adaptive behavior encompasses conceptual skills (academic skills, communication, and understanding of concepts such as time and money), social skills, and practical life skills (e.g., personal hygiene, feeding, and occupational skills). The Vineland Adaptive Behavior Scale, Second Edition (Vineland-2) is a measurement of adaptive functioning that is administered in an interview format; parents, caregivers, and teachers serve as respondents during the administration of the Vineland-2 and provide reports of the individual’s behavior and functioning. Kate was administered the Vineland-2 on three separate occasions and her primary caregiver was the informant. Scores on the Vineland-2 are reported as standard scores (M = 100; SD = 15) and include an overall Adaptive Composite, as well as four separate domains: Communication, Daily Living, Socialization, and Motor. Kate’s level of adaptive functioning as reported by the Vineland-2 appear in Table 2.

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Table 2.

Standardized Assessment of Adaptive Functioning.

Vineland Adaptive Behavior Scale, 2nd Edition	Pretreatment	Month 9 of treatment	Month 23 of treatment
	M = 50SD = 10	M = 50SD = 10	M = 50SD = 10
Adaptive Composite	65	75	72
Communication	59	72	72
Daily Living	75	79	83
Socialization	68	90	70
Motor	70	72	78

At the time of initial assessment, Kate displayed impaired levels of adaptive functioning and her performance on most of the assessed areas was significantly below those of same-aged peers. Her overall level of adaptive functioning (Adaptive Composite) was in the below average range, with most significant impairments present in the areas of Communication and Socialization. She also displayed lower-than-expected levels of functioning in the areas of Daily-Living Skills and Motor Skills. Overall, Kate’s initial level of adaptive functioning was consistent with her reported level of intellectual functioning, which suggested that she was likely to require high levels of support across most areas of functioning.

Standardized Assessment of Emotional/Behavioral Functioning

Several standardized measures of Kate’s emotional/behavior functioning were obtained throughout the course of her treatment and were reported by her parent and teacher on several occasions. The first set of parent and teacher ratings of Kate’s behavior included the Achenbach Child Behavior Checklist–Preschool (CBCL-Preschool), which assesses the behavior of children aged 18 months to 5 years of age and compares scores to a normative sample based on the child’s age. Scores on the CBCL are reported as T-scores, with the average score being 50 (SD = 10). A composite score is provided for Total Problems, as well as an Internalizing domain and Externalizing domain. Composite scores are derived from subscales including Emotional Reactivity, Anxious/Depressed, Somatic Complaints, Withdrawal, Sleep Problems, Attention Problems, and Aggressive Behaviors. Parent and teacher reports of Kate’s behavior, as measured on the CBCL-Preschool, are summarized in Table 3.

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Table 3.

Standardized Assessments of Emotional/Behavioral Functioning.

Child Behavior Checklist (CBCL)	Pretreatment	Month 9 of treatment	Month 23 of treatment		Month 9 of treatment	Month 23 of treatment
Caregiver rating form	M = 50SD = 10	M = 50SD = 10	M = 50SD = 10	Teacher rating form	M = 50SD = 10	M = 50SD = 10
Summary scores				Summary scores
Total problems	86	59	69	Total problems	61	70
Internalizing	79	58	52	Internalizing	57	62
Externalizing	71	52	65	Externalizing	59	69
Subscale scores				Subscale scores
Emotional Reactivity	80	59		Emotional Reactivity	56
Anxious/Depressed	66	55	50	Anxious/Depressed	51	55
Somatic Complaints	72	62	61	Somatic Complaints	50	57
Withdrawn	88	60	56	Withdrawn	64	68
Sleep Problems	94	64		Sleep Problems
Social Problems			64	Social Problems		61
Thought Problems			75	Thought Problems		70
Attention Problems	80	67	70	Attention Problems	62	81
Rule-Breaking Behavior			66	Rule-Breaking Behavior		70
Aggressive Behavior	66	50	63	Aggressive Behavior	58	68

At the time of the baseline assessment, Kate was not yet enrolled in school; as a result, a pretreatment report of behavior was not obtained from a teacher. Changes in behavior throughout treatment, as reported by Kate’s parent and teacher, appear in Table 3. Prior to starting treatment, Kate’s emotional/behavioral functioning, as reported by her caregiver, was significantly impaired. Kate was reported to display elevated levels of both Internalizing and Externalizing problems, resulting in a clinically significant level of Total Behavior Problems. Specific areas of problem behaviors were reported in the following areas: Emotional Reactivity, Somatic Complaints, Withdrawal, Sleep Problems, and Attention Problems. All of these reported areas of emotional/behavior problems commonly occur in clinically impaired populations, including individuals with developmental disabilities. No baseline level of emotional/behavioral functioning within the school environment was obtained because Kate was not yet enrolled in school and the time of initial admission.

Results of all standardized assessments conducted on three separate occasions (i.e., before and during treatment) are reported in Table 1, Table 2, and Table 3. Upon initial examination, Kate demonstrated lower-than-expected cognitive abilities and adaptive functioning, and clinically significant impairments in emotional and behavioral functioning. Given Kate’s level of impairment across cognitive and adaptive functioning, intensive intervention to target these deficits was warranted.

Criterion-Referenced Assessment of Behavior and Language

Upon initial admission, Kate was administered the Assessment of Basic Language and Learning Skills–Revised (ABLLS-R; Partington & Sundberg, 1998), which is a multi-method, multi-component criterion based assessment used to track skills in individuals with developmental delays. The ABLLS-R measures skills across 25 domains, assessing prerequisite communication skills and readiness to benefit from individualized instruction. Nine of the 25 domains were used to measure Kate’s language development, and subsequently used to develop an individualized treatment plan and monitor progress. The ABLLS-R was implemented by a clinical specialist assigned to Kate’s treatment team, under the supervision of a licensed psychologist.

Kate’s performance on the ABLLS-R at the time of initial admission indicated skill deficits across the nine assessed domains. Kate’s early language skills such as requesting preferred items/activities, labeling items/objects, making spontaneous vocalizations, and providing responses to questions and statements made by others were largely impaired. Kate indicated preference for items/activities by looking at items and reaching toward items. Preferred items were identified initially based on semi-structured parent interviews and behavioral observations of Kate in the natural environment. During session, Kate was presented with small arrays of two to three preferred items and given the opportunity to select an item; informal preference assessments occurred every 15 to 20 min throughout the session. Kate spontaneously vocalized sounds, but few recognizable words were emitted. Kate demonstrated slightly stronger receptive language skills, such that she was able to respond to her name, follow simple instructions, and was able to identify familiar items when presented in an array. For example, the therapist presented an array of objects and said, “Show me the car.” Kate was able to select the car, and therefore able to discriminate the car from other objects in the array. When examining Kate’s skills in visual performance, she demonstrated significant impairments in this area. Her existing skills were quite minimal, and although she was able to successfully complete simple visual-performance tasks (e.g., single-piece inset puzzles and matching identical items), she did not demonstrate fluent matching skills (e.g., matching non-identical items). Kate was unable to sort objects by their feature, function, or class; lacked seriation skills; and was unable to complete complex puzzles (e.g., puzzles with multiple/non-identical pieces).

Supervision and Staffing

During her admission in the day treatment program, Kate’s intervention was developed and monitored by a team of clinicians. The director of the clinic, a licensed psychologist and doctoral-level board certified behavior analyst (BCBA-D), served as the primary case supervisor and provided clinical oversight for all decisions made regarding Kate’s treatment and planning. An experienced, master’s-level BCBA functioned as the case manager, provided daily treatment monitoring, and reported directly to the psychologist. Treatments were directly implemented by bachelor’s-level therapists including an entry-level clinician, responsible for treatment implementation, and an experienced bachelor’s-level clinician (i.e., Clinical Specialist) who was responsible for treatment implementation and oversight, data entry, and providing progress updates to the case manager. Staff training procedures for direct service staff are described below. The clinical team met weekly to discuss Kate’s treatment and progress.

Staff Training

To ensure a high level of treatment integrity, staff providing direct services to clients in the day treatment program participated in a comprehensive training program prior to implementing any clinical procedures. Behavioral Skills Training (BST), a behaviorally based instructional model (Reid & Parsons, 1995), was used to train staff to proficiency in implementing treatment protocols. BST consists of providing verbal/written instructions, modeling, role-playing, and coaching and feedback. Trainees were required to pass written competency exams on the content of the didactic training with 80% accuracy. In the next phase of training, trainees received 2 days of in-vivo training through modeling and role-playing. During role-plays, trainers modeled appropriate teaching and intervention procedures. Trainees were then provided with opportunities for practice and feedback with the trainer. Skills assessed during role-plays included session preparation, correct presentation of targets, pace of instruction, probing and recording responses, prompt fading, and behavior management procedures. To progress to subsequent role-play sessions, trainees were required to implement procedures with 100% accuracy across three consecutive sessions. After successfully passing all role-play assessments, staff were then systematically faded into the therapy sessions. During the first day on the unit, trainee–client contact was limited to data collection, while an experienced clinician conducted the therapy session while also collecting data. Trainees were required to demonstrate 80% inter-observer agreement with the primary data collector. Once trainees met this criteria, they then spent time systematically fading into the therapy session—the first day conducting one third of the session with 80% treatment fidelity and were then provided with positive and corrective feedback from the case manager. On the second day, the staff member was required to implement the entire session with 80% treatment fidelity before moving on, and the final day conducting the entire session with 80% accuracy under the observation of a case manager. Staff training continued throughout the entirety of Kate’s admission, such that remediation was provided when necessary and changes in treatment protocols were accompanied by specific protocol training for all treatment team members.

Overview of Treatment and Behavior Change Procedures

Kate received 15-hr of intensive one-on-one ABA therapy each week for 23 months. At the beginning of her admission, Kate participated in a thorough intake assessment and behavioral skills assessment. Performance during the baseline language and behavior assessments were used to inform the clinical team of Kate’s areas of strengths and weakness, and to identify intervention targets based on her level of skills deficit. Initially, formal treatment procedures took place in a highly structured clinical environment with a 1:1 therapist–child ratio (though at times additional clinical personnel observed, assisted with data collection, or provided the therapist with supervision). Kate had an area within a therapy room designated as her workspace for sessions in clinic that included a small table with preferred items and activities available and use of partitions when a less distracting teaching environment was needed. However, intervention also occurred outside of the therapy room, with teaching trials taking place in areas of the clinic that are more similar to the natural environment (e.g., playroom, playground). As Kate began to demonstrate mastery of targeted skills, these skills were practiced in other environments to ensure that generalization of these skills occurred outside of the highly controlled environment of the therapy room.

Target skills were identified based on deficits indicated in behavioral and functional assessments. The development of a functional communication system was of primary importance in Kate’s admission based on the referral concern and the nature of clinical services provided at the program in which she was admitted. However, many functional and daily-living skills were also targeted (e.g., toilet training and compliance) to enhance Kate’s level of independent functioning. As in most intervention programs targeting deficits in verbal behavior, requesting skills were among the first language skills targeted for Kate. It was of primary importance that Kate develop skills in requesting preferred items and activities to establish Kate’s motivation to participate in other instructional activities.

Another skill that was targeted upon initial admission was Kate’s motor imitation skills. Motor imitation skills are often included in the instructional programming for patients with minimal functional skills because the target responses can often be easily prompted and acquired. When teaching motor imitation, the therapist may say, “Kate, do this . . . ” while the therapist knocks on the table. If Kate was not able to independently emit the response of knocking, the therapist could use hand-over-hand physical prompting by taking Kate’s hand and knocking it on the table. As soon as Kate emitted the response, albeit prompted by the therapist, she was provided with access to reinforcement (i.e., the therapist immediately handing Kate a preferred item) so she begins to pair the response (knocking when the therapist says “Do this” while knocking) with reinforcement. As Kate began to demonstrate mastery of motor imitation skills, the therapist was able to fade to less intrusive prompts until Kate was able to independently provide the correct response. The development of skills such as motor imitation could then be used to develop a general imitative repertoire (being able to mimic any action demonstrated by another person) to be transferred to other imitation skills (such as imitating others’ language).

Once requesting and imitation skills were established within Kate’s behavioral repertoire, therapists were able to begin to target more complex skills such as vocal imitation (e.g., The therapist states, “Say what I say . . . ” and Kate repeats what is said by the therapist), expressive labeling (e.g., Kate correctly labels an item when therapist asks, “What is it?” while showing a picture/object), receptive identification (e.g., Therapist presents an array of three objects and tells Kate to “point to the car.” Kate points to the car), visual performance (e.g., match-to-sample tasks in which the therapist tells Kate to “match it”; sequencing, puzzles, etc.), and more sophisticated language skills (e.g., requiring Kate to request preferred items by saying, “I want cookie” instead of “Cookie,”). These skills were targeted using similar procedures to those described above for teaching motor imitation skills. When teaching new skills, the therapist presented a demand (e.g., “Match it”) and the correct responses were prompted by the therapist (e.g., providing hand-over-hand prompting to match the objects). As Kate demonstrated increasing independence in correctly responding, the therapist was able to fade to a less intrusive prompt (e.g., gesturing, rather than doing hand-over-hand physical prompting).

Daily Progress Data

Data on skills targeted as part of Kate’s VB program were collected during every treatment session. Most often, data were collected at the start of Kate’s session, through a data collection procedure known as a “cold probe” (Lerman, Dittlinger, Fentress, & Lanagan, 2011). The cold probe was conducted at the beginning of the session, before any formal opportunities for teaching and practice were conducted within the session. The purpose of measuring Kate’s performance through a cold probe assessment was to determine whether she had truly acquired and maintained the skill, and to ensure that successful responding was not the result of repeated practice immediately prior to data collection. Specifically, at the start of Kate’s therapy sessions, the treatment team probed the target skills and recorded whether Kate provided a correct or incorrect response. If she responded correctly, this may have suggested that Kate had begun to maintain skills that were taught in the previous therapy sessions. For most targets, criteria for mastery were set at three accurate responses; that is, for three consecutive days, Kate had to provide the correct response to the cold probe. At the conclusion of daily data collection, the treatment team spent time teaching Kate and practicing any skills missed during the cold probe using teaching procedures such as most-to-least prompting (Libby, Weiss, Bancroft, & Ahearn, 2008) and interspersing of mastered tasks (Koegel, Koegel, & Carter, 1998). Members of the treatment team served as the primary data collectors. Data were frequently reviewed by the case manager, with the oversight of the licensed psychologist assigned to the case. If data indicated that Kate was not making progress toward mastery, as expected, instructional procedures were adjusted to ensure that Kate was participating in the most efficient interventions and to promote generalization of these skills to other settings. The duration of each targeted skill area appears in Figure 1.

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Figure 1.

Skill areas targeted during day treatment admission.

Treatment Progress

When placed in a structured teaching environment in which Kate’s verbal behavior was intensely targeted, Kate nearly immediately began acquiring new language and related skills at a rapid rate. Given the complexity of a comprehensive treatment program, such as the one that Kate participated in, it is not uncommon for priorities of the treatment to shift over time. As a result, plateaus in treatment progress may be observed across skill areas at particular times throughout the admission (Figure 2). Oftentimes, the clinician may prioritize a particular skill that will have a positive effect on the child’s overall level of adaptive functioning. For example, teaching a child to request may be heavily targeted at the beginning of the admission, given the functional utility of this skill (i.e., the child is able to request preferred items and activities), while programming of other skill areas (e.g., expressive labeling, visual-perceptual skills) may receive less attention until the child has a sufficient repertoire for requests. Then, the clinician may integrate the child’s vocal requesting skills into the teaching of other skills (e.g., expressive labeling, visual-perceptual skills) as preferred items can be requested by the child, and potentially serve as reinforcement for teaching new skills. As Kate developed more verbal skills, treatment priorities shifted toward vocal/verbal skills based on parent priorities and treatment planning, with less emphasis placed on visual-perceptual or motor imitation tasks.

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Figure 2.

Cumulative progress of verbal behavior.

A summary of Kate’s progress is illustrated in Figure 2, which reflects Kate’s progress in response to treatment. Data in Figure 2 are presented as a cumulative graph, a type of visual representation common in single-case research conducted by behavior analysts (Kazdin, 2011). Using cumulative record graphs, the level of performance of the participant over time is graphed in an additive fashion. In the current study, the impact of the intervention is displayed through the cumulative number of skills (e.g., vocal requests, labels, etc.) that Kate acquired throughout her treatment admission.

Intellectual Functioning

Following 9 months of treatment, Kate underwent a follow-up psychoeducational evaluation to assess any changes in cognitive functioning as measured by a standardized, norm-referenced assessment of functioning that could be attributed to her participation in an intensive ABA intervention. Change scores are presented in Table 1. Although Kate’s overall cognitive functioning remained stable, clinically significant increases in her verbal abilities (approximately two standard deviations) were observed after only 9 months of treatment. The most prominent area of improvement in Kate’s verbal abilities occurred in the area of naming vocabulary, which is consistent with the behavioral data that tracked Kate’s daily acquisition of labeling skills. Kate also demonstrated a slight improvement in her level of verbal comprehension, though these changes were minor. Kate’s overall level of verbal abilities remained in the below average range at the time of the follow-up assessment, but marked improvements were observed. No clinically significant changes occurred in Kate’s non-verbal or spatial abilities; though these skills were not targeted at the same level of intensity as interventions used to target Kate’s verbal ability based on the nature of the treatment program.

Kate’s intellectual functioning was, again, assessed after 23 months of treatment (Table 1). The assessment was administered 1 month before Kate was discharged from treatment. Changes that were observed in Kate’s verbal abilities at 9 months of treatment remained stable during the final assessment, suggesting that she continued to acquire verbal skills at a similar rate as demonstrated in her first 9 months of treatment. Her non-verbal reasoning skills remained stable across all three assessment points. There was a decline in Kate’s visual-spatial and spatial-motoric abilities, which can be partially explained by her deficits in visualization and spatial skills, characteristic of children with FASD, as well as low global cognitive functioning.

Adaptive Functioning

Throughout her treatment admission, Kate demonstrated substantial gains across all areas of adaptive functioning, based on caregiver report on the Vineland-2 (Table 2). Although Kate initially was reported to have significant impairments across nearly all adaptive domains at the time of baseline, after 9 months of treatment her caregiver reported improvements in all areas of adaptive functioning. Areas of greatest change occurred in the areas of Communication (borderline range) and Socialization (average range), which were areas of primary importance in the development and implementation of Kate’s treatment. Upon discharge, all improvements in adaptive functioning were maintained, with the exception of Socialization, which was in the borderline range. Kate’s reported levels of adaptive functioning across all domains were consistent with her intellectual functioning, with some areas exceeding her reported cognitive abilities (e.g., Daily-Living Skills).

Emotional/Behavioral Functioning

Kate’s level of emotional/behavioral functioning was again assessed after 9 months of treatment through both caregiver and teacher report. Clinically significant improvements in all assessed areas of emotional/behavioral functioning were reported by Kate’s caregiver after 9 months of treatment. No elevated levels of emotional/behavioral problems were reported by Kate’s caregiver, and all scores fell within the average range (Table 3). Teacher ratings of emotional/behavioral functioning were also obtained after 9 months of treatment (Table 3), and no significant problem areas were reported to occur within the school environment.

On discharge (i.e., 23 months of treatment), reports of emotional/behavioral functioning were largely consistent across caregiver and teacher reports. At the time of treatment discharge, Kate no longer met the age requirements of the CBCL-Preschool assessment and her parent and teacher, instead, completed the CBCL-School Age form. All composite scores for the School Age form are consistent with those on the Preschool form (i.e., Total Problems, Internalizing, and Externalizing), with some minor differences in subscale scores, including the addition of a Rule-Breaking Behavior scale and omission of the Emotional Reactivity scale. Internalizing and Externalizing behaviors were reported to fall within the average range. However, both caregiver and teacher reports indicated elevated levels of Thought Problems and Attention Problems. These findings were not surprising, given that children with lower-than-average cognitive functioning often exhibit problems with attention. Kate’s teacher also reported an increase in Kate’s Rule-Breaking behavior. It is not clear if the increases in problem behaviors reflected changes in classroom demands as Kate progressed in grade levels, differences in teachers’ expectations, or developmental changes.