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In November, OAR’s Board of Directors authorized funding for five applied autism research studies in 2022. These new grants, totaling $196,272, bring OAR’s total research funding to more than $4.4 million since 2002. This article is the last of five previews to be featured in The OARacle this year.  

Almost all (93.7% according to one study) autistic children demonstrate some kind of severe problem behavior, such as self-injury, aggression, and disruptive behavior. If it is not dealt with, it can cause strained relationships within the family and difficulties at school and other places. It can also result in a lower quality of life, limited access to community and educational resources, and higher parental stress. 

Parents may try to prevent the behavior by avoiding places and situations that lead to these behaviors and agreeing to requests from the child (i.e. making accommodations). Avoidance and accommodation, while understandable, lead to the continuation of the behavior(s) and possibly worsening problem behavior. 

In this OAR-funded two-year study, Craig Strohmeier, Psy.D., BCBA-D, a psychologist in the neurobehavioral unit at Kennedy Krieger’s outpatient clinic and an assistant professor in the psychiatry and behavioral sciences department at Johns Hopkins University School of Medicine, proposes to test the effectiveness of the Defuse Experience Accept and Live (DEAL) protocol he developed. The goals of the study, Contextual Behavioral Strategies to Help Parents Adhere to Behavior Plans for Children with Autism, are to determine: 

  • If the DEAL protocol, used with treatment as usual, increases parental adherence to the strategies to reduce severe problem behavior while also decreasing parental accommodation.  
  • How the protocol will affect experiential avoidance and fusion. Fusion occurs when verbal, self-generated rules overshadow problem-solving strategies. For example, a parent may follow the rule, “If I avoid the grocery store, I can avoid feeling like a bad parent if my child tantrums in public.” Although the parent experiences relief when avoiding the store, they miss an opportunity to complete their shopping and help the child develop more tolerance for nonpreferred activities. Experiential avoidance seeks to avoid a negative event or discussion of a negative event that ended in problem behavior.  

Dr. Strohmeier and his research team will recruit 25 parents from the neurobehavioral unit at Kennedy Krieger’s outpatient clinic. Standard treatment for autistic children with severe problem behavior runs for 12 to 16 weeks at the clinic, with a parent and their child attending two-hour sessions twice weekly. Clinical services include a preference assessment, a functional analysis, development and evaluation of an individualized function-based treatment, and behavioral skills training to teach parents how to correctly implement the treatment.  

Dr. Strohmeier will evaluate parents’ eligibility to participate in the study after the functional analysis. Selected parents will participate in behavioral skills training for four treatment components:  

  1. Three-step prompting 
  2. Descriptive praise 
  3. Differential reinforcement of alternative behavior 
  4. Function-based strategies to reduce or eliminate the problem behavior 

Once they start the training, parents will be randomly assigned to the DEAL protocol group or the treatment-as-usual group.   

Parents in the DEAL group will participate in five weekly 45-minute sessions with a therapist who will implement the DEAL protocol. The protocol uses components of acceptance and commitment therapy as well as behavioral activation to help parents adhere to behavioral treatment plan components. The sessions include education, experiential training, and homework assignments related to experiential avoidance and acceptance, fusion and defusion, committed action/behavioral action, and values clarification: 

  • Session 1: The therapist provides education explaining the connection between experiential avoidance and severe problem behaviors.
  • Session 2: Experiential training includes specific exercises to help the parent identify and disconnect from their rules around severe problem behavior and accept their negative feelings and aversion related to past occurrences of severe problem behavior.
  • Session 3: The therapist introduces the parent to a process that will guide their selection of components to support their behavioral activation plan in relevant contexts.
  • Sessions 4 and 5: The parent shares examples of selecting behavioral treatment plan components in relevant contexts and following through with behavioral activation plans, with therapist feedback.

By gradually exposing parents to previously avoided situations, the protocol helps them to create a repertoire of behavior management skills and strategies. In doing so, they learn how to put that repertoire into practice and receive positive reinforcement in situations they previously avoided.  

Practical Relevance

This research will set the stage for redefining the goal of parent training from a perspective of resolving skills deficits, to that of shaping parent behaviors that involve approaching, rather than avoiding, the conditions necessary for child behavior change. Overall, this study will provide a springboard for future clinical applications of contextual behavioral strategies directed towards parents, shifting the agenda from child-directed to parent-directed treatments. This shift opens a new avenue for clinical application of strategies that can significantly influence the quality and durability of interventions to reduce severe problem behavior for autistic children. 

Sherri Alms is the freelance editor of The OARacle, a role she took on in 2007. She has been a freelance writer and editor for more than 20 years.