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Medimond - Monduzzi Editore International Proceedings Division

World Psychiatric Association

PLURALISM IN PSYCHIATRY
I. DIVERSE APPROACHES AND CONVERGING GOALS

Editors Constantin Soldatos


Pedro Ruiz
Dimitris Dikeos
Michelle Riba

MEDIMOND

International Proceedings

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Pluralism in Psychiatry

Systemic Behavior Analytic Applications For The


Treatment Of Children With ASD: Pilot Results
Depicting Naturalistic Parent-Child Interaction*
Gena A.1.2, Galanis P.1.2, Alai-Rosales S.3, Michalopoulou E.1
1

National and Kapodistrian University of Athens, Greece


Institute of Systemic Behavior Analysis, Athens, Greece
3
University of North Texas, United States
2

Summary
In the past ten years the diagnosis of Autism Spectrum Disorders (ASD) has reached epidemic
proportions. This, in conjunction with limited resources in the field of mental health due to serious world-wide
financial constraints, has created the need in the field of autism to identify procedures that help us reach ultimate
outcomes with minimal resources. Thus, we have begun to construct a series of studies that aims at identifying
procedures drawing from the theoretical frameworks of both General Systems Theory and Behavior Analysis. A
hybrid study in this line of research is presented here as it gives us some preliminary and promising results
toward the direction of providing effective and efficient treatment for children with ASD.

Introduction
A systemic understanding of families helps us appreciate how relations form within the family system
in such complex ways that may not be reduced to an analysis based on linear causality. The latter, by looking at
how an independent variable may impede change in a dependent variable provides an insufficient means that
does not allow us to explore how a subsystem (e.g., the parent) within the family system goes through constant
change in its attempt to change another subsystem (e.g., the child). In the systemic understanding, on the other
hand, systems and subsystems are going through constant change as they interact, and it is considered that such
changes cannot be fully explored within a paradigm that employs a linear rather than a circular causality1.
Circular causality allows us to analyze how one variable (e.g., parent behavior), as it is set out to change another
variable (e.g., child behavior), changes itself along with the variable it is set out to change. This process of cochanging variables is constant and lasts throughout their interaction or even beyond it. In addition, when we
focus on family dynamics, we come to realize that families exist in a social ecology; the actions and conditions
of one member impede change upon other members as well as on the relations that form between all members of
the family. Specifically for children with Autism Spectrum Disorder (ASD) as members of families, we are
presented with a series of challenges that have been addressed both research-wise as well as clinically.
In the late 1960s the challenge was to get children with ASD out of psychiatric asylums thus, the
emphasis on childrens behavior led to a science, a rich toolbox of therapeutic technology known as Applied
Behavior Analysis. This advancement has led us to the realization that children with ASD, when provided with
appropriate intervention, may be raised within the family context and they do not require hospitalization. Yet,
raising a child with ASD presents great challenges to the family. Those challenges go beyond the scope of
treatment designed to address solely the childs behavior. Thus, as we progress in the field of ASD, we are
beginning to address more and more systematically, not only child issues, but family issues as well, which arise
mainly due to being exposed to highly stressful family conditions.
About 15 years ago, a shift started to emerge in the field of ASD; relying only on clinical, empirical,
and theoretical questions that address methods to change the childs behavior and account for the mechanisms
and reasons for those changes, gave way to exploring how we can empower parents by helping them to become
co-therapists, i.e. equal members of the treatment team. This shift led to a great number of studies that aimed to
identify procedures which educate parents to address directly the challenges posed by the aberrant behavior of
their children with ASD as well as their learning difficulties in all the domains of child development2.
* This research project has been made possible by generous sponsorships of the Onassis Foundation (USA) and the Onassis
Foundation (Greece).

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At the empirical level, the research emphasis has been similar, with studies focusing on the childs
susceptibility to and magnitude of behavior change, on the domains of behavior change and on how the child
interacts (primarily by increasing communication and adaptive skills and decreasing challenging behavior), with
some emphasis on the role of the family in the change process3.
While this has been a productive venue, both clinically and empirically, we propose, yet another shift,
that is to teach parents, as their child advances in therapy, to revert to normal parental role by abandoning
some of the not so naturalistic and directive ways of treating their child. The latter may be important in the initial
therapeutic steps, yet they may hold the child back later as his/her socialization becomes a primary goal. This
premise led us to design a series of studies that explore the potential of such a shift. The work presented here
provides a hybrid conceptualization and new measures, both aimed at producing favorable changes within the
family dynamics and understanding how those changes come about.
This work combines the theoretical background of General System Theory and Behavior Analysis.
General system theory introduced a new paradigm for our understanding of both the physical world as well as
human thought, emotion, and behavior aiming to explore wholes and wholeness, not as metaphysical
notions, but as scientific entities that may be explored through empirical study1. Behavior Analysis is also a
distinct paradigm based on the epistemology of logical positivism and empiricism, aiming to stress the
importance of posing empirical questions on small units of behavior that will allow us to study behavior
concisely, as a product that abides to the laws of nature. The ultimate aim of behavior analysis is to demonstrate
the unity between physical phenomena and human behavior (observable behavior as well as private events) and
to contribute toward developing psychology as a natural science4,5.
The combination of the two paradigms allows us to focus on both the analysis of small units of
behavior, which facilitates therapeutic intervention on severe types of psychopathology (such as those often met
within the autistic spectrum), without ignoring the significance of the whole (all systems involved in the life of a
child with severe psychopathology), in producing ultimate therapeutic outcomes and meaningful (clinically
significant) changes for the child and the systems with which he/she dynamically interacts. Thus, it is suggested
that the behavior analytic paradigm and general system theory have complementary qualities which, in
combination, may lead to ultimate therapeutic gains for children with autism and their families. We refer to this
approach as Systemic Behavior Analytic Intervention.
A theoretical construct within behavior analysis, the behavioral cusp, may be useful in melding the two
paradigms. The behavioral cusp is a conceptualization of development that involves the individual and respective
changes to the environment in which the individual operates6-9. Rosales-Ruiz and Baer10 described the behavioral
cusp as an entry point for behavior change that, once initiated, so profoundly alters, displaces, or transforms
ones behavioral repertoire that it renders preexisting behavioral repertoires obsolete and provides the learner
with new opportunities.
The current project is an empirical pursuit, informed by behavioral conceptualizations of development
and methodologies and systems theory conceptualization of organizations of complex systems, i.e. family
ecologies. Improvement should be evaluated in the temporal and local contexts and include measures not only of
as many members of the system as possible, but also measures that have properties of behavioral cusp for the
family system.
Given the constrains of the length of this publication, we will present very briefly a preliminary study
with two subjects and their parents that aims to assess how an intervention aiming to change the parent-child
way of interacting may contribute to changes in child behavior, parent behavior, as well as in the relation
between the two. These three types of variables are treated as separate for the purposes of data collection, yet, we
consider them to be interrelated and inseparable and to function as behavioral cusp. Specifically, we aimed to
explore how a more naturalistic rather than directive, and at the same time more positive rather than corrective or
punishing type of interaction between parent and child, may attribute to child improvement as well as to
improvement in the parent-child relationship.

Method
Participants and Settings
Two children with ASD as well as their mothers and fathers participated in this pilot study. At the
beginning of the study Antony** was 2,1 and Maria** 4,4 years old. Both children had rather mild autistic
symptomatology, but minimal language, poor social and communication skills, and severe behavioral problems,
such as temper tantrums. The study was conducted at the participants homes.

** Pseudonyms are used to ensure anonymity

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Response Definitions
Target responses, though all interrelated, for the purposes of the study were split into 3 categories: child
behavior, parent behavior, and parent-child interaction. Child behavior measures included: (a) on-task behavior,
(b) functional and symbolic play, (c) vocalizations, and (d) play accompanied by vocalizations. Parent behavior
measures included: (a) a naturalistic, non-directive style of interaction, (b) provision of reinforcement (c)
corrective feedback, and (d) reprimands provided by parents. Parent-child interaction measures were considered
to be the following: (a) child on-task behavior while interacting with parent, (b) imperative and declarative joint
attention, and (c) motor, vocal, and combined motor with vocal imitation.
All dependent measures were operationally defined. For example, joint attention was defined as the
ability to coordinate attention between interactive social partners with respect to objects or events in order to
share awareness of the objects or events11. It has been described as triadic attention with observed behaviors
that include gaze following, alternate eye gaze, and directing the attention of others through the use of comments
and gestures. Responding to joint attention involves the child responding to the interaction partners pointing by
shifting his/her attention toward the direction of the pointing. Initiating joint attention refers to the childs
attempt to direct the interaction partners attention toward an object or activity by pointing at it, shifting his/her
gaze toward it, or by talking about it excluding requests for the object or for engagement in the activity.

Procedure and data collection


An AB single-case quasi experimental design was used to assess the effects of the intervention on target
responses, where A stands for baseline and B for intervention. During baseline, each parent was asked to play
with his/her child as they normally play at home. No other instructions or suggestions were provided.
The basic premise of the intervention was for parents to adopt a more naturalistic, non-directive,
supportive rather than corrective style of interaction. Specifically, each parent received training on the following:
(a) to use affirmative language and avoid commands and repeated questions during play, (b) to allow the child to
select play activity, (c) to reinforce child verbal utterances during play, (d) to reinforce imitation of parental
models as well as child initiations for interaction, and (e) to use a variety of stimuli rather than repeatedly the
same objects12. The training procedure included: giving direct instructions to parents, in vivo modeling by the
therapist, repeated practice, guidance, and feedback mostly reinforcing and less corrective. Each parent received
training separately in order to discourage competition between mothers and fathers and to help them identify
their own ways of interaction (have their own style). There was also a psychoeducational component in the
parent training that entailed describing and explaining to parents the rational for their training and the value of
non-directive, yet, systematic parenting. After ensuring that the parents understood the rational and consented to
the goals of parent training, they were offered ample examples of possible ways of naturalistic play interactions
by the therapist using in-vivo modeling and other procedures as they were described above. The frequency of
parent training sessions was approximately twice per month and the videotaped part of the session had a 5minute duration for each parent. The length of training was 3 months for Antonys parents and 4 months for
Marias.
Follow-up data were collected 10-11 months after intervention using the same procedures as in baseline.
All sessions throughout the 3 phases (baseline, training, intervention) were videotaped. Data were
collected separately for mothers and for fathers through observation of the videotaped sessions. The total number
of sessions with Antonys parents were 10 and with Marias were six. A 30-sec momentary time sampling
procedure was used, as well as frequency counts, to measure occurrences of the dependent variables. Interobserver agreement data were collected for all the experimental sessions; agreement was above 80%.

Results
Tables 1-3 depict the frequency of occurrences of the dependent measures. As can be seen on the
Tables, almost all dependent measures changed in the desired direction. That is, non-naturalistic responding
decreased following the introduction of intervention, whereas naturalistic types of responding increased
systematically. This assertion holds for both children as well as for their parents.

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Table 1. Average responses of child-behavior measures, during interaction with parents before and after the intervention and
during follow up

Table 2. Average responses of parent-behavior measures, during interaction with child before and after the intervention and
during follow up

Table 3. Average responses of parent-child interaction measures before and after the intervention and during follow up

Concluding note
Our data from this hybrid study provide indications that there may be some merit in identifying
behavioural cusps within the families and in introducing appropriate shifts, since, with a very small number of
brief sessions, a great number of changes occurred in all the systems targeted: the child, the mother, the father
and the relations that form between parent and child. Further research efforts are in progress to replicate and
expand these preliminary findings.

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