Neely, L., Carnett, A., Cantrell, K., Stegemann, S., & Svoboda, M. (2022) Functional communication training for toddlers at‐risk for autism with early problem behavior. Advances in Neurodevelopmental Disorders, 6, 537-548.

Reviewed by: Smrithi Thyagarajan (Extern) & Kate McKenna, MEd, MSEd, MS, BCBA, LBA

Why research this topic?

A review of study titled Functional Communication Training for Toddlers At‐Risk for Autism with Early Problem Behavior

Young children with autism can experience difficulties with social communication and emotion regulation which can lead to the demonstration of problem behavior when attempting to express their wants and needs. Although typically developing toddlers (12-36 months) will exhibit crying, screaming, and aggressive behaviors, those behaviors tend to decrease as language develops and functional communication is established. However, in toddlers at-risk for autism, these behaviors can persist and evolve into increasingly more socially inappropriate behaviors that can negatively impact the child’s academic success and the development of friendships as the child begins school. Ongoing challenging behavior is also a strong predictor of parent and family stress (Zaidman-Zait, el., 2014).

Functional communication training (FCT) is an evidenced-based procedure that involves first determining the function of the challenging behavior and then teaching the child a socially appropriate behavior that will serve the same purpose (Hume, et al., 2021). FCT has been demonstrated to be effective, both in classrooms (e.g., Andzik et al., 2016) and in the home, when teachers and caregivers have been trained to implement the procedures (Gerow et al., 2018c).

Research supports early intervention in autism treatment, as the years before age three are critical for brain, language, and social development. The purpose of this study was to evaluate the use of FCT with children under the age of three who were at-risk for an autism diagnosis. Two questions were investigated: What effect does FCT training in combination with delay training have on early problem behavior (EPB) and what effect does FCT with delay training have on the toddlers’ use of a functional communicative response? This study also examined the use of the delay and denial procedure introduced by Hanley and colleagues (Hanley, et al., 2001).

What did the researchers do?

Four children, Abigail, Lorenzo, Chaplin, and Emeriwho were considered at-risk for autism and their mothers participated in this study. Two of the toddlers had an older sibling with an autism diagnosis and two were reported to be at-risk because of persistent challenging behavior. Parents of all four children reported that the children’s behavior negatively impacted daily life (difficulty completing daily tasks) at home, as children could not cope with the temporary withdrawal of parental attention. Examples of challenging behavior include crying, screaming, floppy, aggression, and self-injurious behavior. A trial-based functional analysis (TBFA), during which parents were asked to play with their children and then contrive an excuse to step away, resulted in displays of target behaviors, validating the parents’ beliefs that the behavior was maintained by caregiver attention.

A unique functional communication response was selected for each child. Abigail and Lorenzo were each taught to use a speech-generating device by pressing a picture of their mother’s face. Chaplin was taught to use a picture exchange by placing the picture of his mother in the researcher’s hand. Emeri used a combination of a speech-generating device and vocal requesting. 30-minute sessions took place twice a week for 15 weeks at a university-based clinic. Sessions were attended by two researchers, the caregiver, and the toddler. Sessions lasted approximately 30 min and took place twice a week for up to 15 weeks. A 10-min free operant preference assessment, during which toddlers were observed while playing with their toys, was conducted at the beginning of each session to establish a hierarchy of preferred toys. All sessions were recorded by a research assistant. A treatment fidelity checklist (included in the article) was used to ensure that coaching and prompting procedures were carried out according to the treatment plan.

During baseline, the mothers played with the children. After 60 seconds, mothers made a brief statement indicating they were going to step away (e.g., “I’ll be right back.”). If the child engaged in the early problem behavior (EPB) the mother immediately returned to play. Additional soothing attention such as back rubs, hugs, and cuddles was also provided. The trial ended after an additional 60 seconds if the EPB was not demonstrated.

The two-part intervention phase involved teaching the FCR and adding a delay to reinforcement. During each of the five trials in the session, the mother engaged with her toddler and, after 60 seconds, made a statement as in baseline, and moved away from the child. If the EPB occurred, the researcher prompted the child with most-to-least prompting to engage in the FCR, after which the mother returned to the play area immediately. After approximately three minutes of play, the next session was initiated.

Mastery criteria of two consecutive sessions with 100% independent use of the FCR and no EPB were required to move to the next segment of intervention, the delay to reinforcement. In this phase, procedures were identical to the initial teaching protocol, but when the child engaged in the FCR, they were asked to wait for a short period of 3 to 10 seconds – progressively. At the end of the delay, mothers returned and praised the child for waiting. Mastery criteria to move through the delay levels (i.e., 3, 5, and 10 seconds) were two consecutive five-trial sessions with 100% independent use of the FCR and zero levels of EPB. The researchers included a reversal phase to test for the maintenance of the FCR and see if the EPB would reemerge, which they did for all participants except Abigail. At the end of the reversal phase, intervention procedures were reinstated. Families were contacted when their child turned three. All four participants had received a diagnosis of autism. Parents further reported that all participants developed some spoken language.

What did the researchers find?

The results of this study add to the literature highlighting the effectiveness of FCT for very young children with EPB. Baseline data indicated that all participants engaged in high levels of EPB and low-to-non-effective communicative responses. All four participants were able to learn the replacement functional communicative response, and results show decreases to zero level of EPB for all participants. Additionally, participants were able to learn to tolerate a brief delay to reinforcement, indicating that a consistent, reliable response to the FCT may result in a tolerance to waiting for reinforcement that could be lengthened.

What are the strengths of the study?

The TBFA results indicated that the toddlers’ behavior was maintained by their need for attention from their mothers, indicating that the caregiver’s involvement is crucial to modifying and noting these behaviors effectively. This study emphasizes the significance of outlining precise treatment parameters and the necessity for effective intervention implementation. Previous research (e.g., Gerow et al., 2019) has highlighted the effectiveness of training programs that were designed to teach parents how to conduct functional analyses and provide them with strategies to help their child’s EPB. Additionally, these studies demonstrate how relatively simple assessment and intervention strategies can lead to improvements in the children’s social behavior at home.

This study confirms the need to include parents in training and provide them with the coaching needed to learn to implement the procedures with fidelity. This level of training may lead to the maintenance and generalization of the acquired skills as the child grows older. The research on training caregivers to implement interventions with toddlers is limited. This study adds to that research and provides validation for efforts to respond as early as possible to communication delays and the possible early problem behavior that may arise.

What are the limitations of the study?

Due to the small number of participants, the ability to generalize the results is limited. Future research should include more participants to determine if the results hold for a larger group. Future research with young children in different settings with a variety of caregivers is needed. In addition, the study only looked at short waiting times for reinforcement which limits what we can learn from it. For further research, it’s important to explore how this delay of different waiting times affects a child’s ability to wait while an adult finishes a task. This will help us learn how to gradually increase waiting times and build tolerance to frustration. This necessity of evaluating the effects of FCT for toddlers across various behavioral functions, such as access to tangibles and an escape from demands is critical.

What do the results mean?

Intervening early can prevent the escalation of EPB that is being used as a form of communication. In this study, we see that two of the participants did not demonstrate a return to EPB in the reversal phase despite a relatively short period of teaching (12-15 sessions, 6-8 hours of treatment). These results seem to indicate that a brief intervention may yield long-term results. This is seen also in participants’ responses to the delay of reinforcement, in which only one participant repeatedly engaged in EPB. It is worth noting that teaching procedures worked with an array of communication modalities, demonstrating the effectiveness of the procedures. Including the caregivers in the intervention and adding the delay to reinforcement shows that the treatment is successful under the situation a toddler may experience at home when caregivers, in this case the mother, are not able to immediately attend to their bids for attention, adding to the social validity of the treatment. Additionally, this study demonstrates the importance and effectiveness of an early intervention for function-based treatment of EPB.

In summary, this study demonstrated the effectiveness of early intervention to address EPB. This study notably examined the effectiveness of FCT in ameliorating behavior that interfered with the daily life of the family, showing that toddlers may use EPB consistently as communication and this negatively impacts the family. It is important to develop interventions that are family-friendly, low-cost, and easily maintainable by families.

Citation for this article:

References

Andzik, N., Cannella-Malone, H., & Sigafoos, J. (2016). Practitioner- implemented functional communication training: A review of the literature. Research and Practice for Persons with Severe Disabilities, 41(2), 79-89. https://doi.org/10.1177/1540796916633874

Gerow, S., Rispoli, M., Ninci, J., Gregori, E. V., & Hagan-Burke, S. (2018c). Teaching parents to implement functional communication training for young children with developmental delays. Topics in Early Childhood Special Education, 38(2), 68-81. https://doi.org/10.1177/0271121417740637

Hanley, G. P., Iwata, B. A., & Thompson, R. H. (2001). Reinforcement schedule thinning following treatment with functional communication training. Journal of Applied Behavior Analysis, 34(1), 17-38. https://doi.org/10.1901/jaba.2001.34-17

Hume, K., Steinbrenner, J. R., Odom, S. L., Morin, K. L., Nowell, S. W., Tomaszewski, B., Szendrey, S., McIntyre, N. S., Yucesoy-Ozkan, S. & Savage, M. N. (2021). Evidence-based practices for children, youth, and young adults with autism: Third generation review. Journal of Autism and Developmental Disorders, 1-20.

Zaidman-Zait, A., Mirenda, P., Duku, E., Szatmari, P., Georgiades, S., Volden, J., Zwaigenbaum, L., Vaillancourt, T., Bryson, S., Smith, I., Fombonne, E., Roberts, W., Waddell, C., & Thompson, A. (2014). Examination of bidirectional relationships between parent stress and two types of problem behavior in children with autism spectrum disorder. Journal of Autism and Develop- mental Disorders, 44(8), 1908-1917. https://doi.org/10.1007/s10803-014-2064-3

Citation for this article:

Thyagarajan, S., & McKenna, K. (2024). Research Synopsis: Functional communication training for toddlers at‐risk for autism with early problem behavior. Science in Autism Treatment, 21(8).

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