Reducing Vocal Stereotypic Behavior in a Child with Fragile X Syndrome by Implementing the Response Interruption and Redirection (RIRD) Method

Icelandic Markmið rannsóknarinnar var að minnka steglda hljóðhegðun (e. vocal stereotypy) drengs með heilkenni brotgjarns X (e. Fragile X syndrome). Rannsóknin nýtti aðferð sem kallast hegðunartruflun og endurstýring (e. response interruption and redirection) en styrkjum og sekt var bætt við aðferðina. Inngrip var framkvæmt í tveimur aðstæðum; leiktíma með spjaldtölvu og morgunmat. Í rannsókninni var einliðasniði beitt, nánar tiltekið blöndu af sniði með breytilegu viðmiði (e. changing criterion design) og sniði margþætts grunnskeiðs (e. multiple baseline design). Í spjaldtölvu aðstæðunum var styrki og sekt bætt við hegðunar truflunarog endurstýringar aðferðina en í morgunmatar aðstæðunum var bæði skilyrtum styrki og styrki bætt við aðferðina. Sjáanleg minnkun var á stegldri hljóðhegðun í báðum aðstæðum sem gefur til kynna að styrking og refsing séu mögulega góð viðbót við upprunalegu aðferðina. Stjórn á aðstæðum var greinileg þar sem hegðun var nánast engin þó að kröfur væru auknar. Þar sem fyrri rannsóknir hafa nánast einungis einblínt á einhverfa þá bætir þessi rannsókn við þekkingu um það hverjir hafa gagn af aðferðinni. Lykilorð: Fragile X syndrome, stegld hegðun, hegðunar truflun og endurstýring 4 REDUCING VOCAL STEREOTYPY WITH THE RIRD METHOD Reducing Vocal Stereotypic Behavior in a Child with Fragile X Syndrome by Implementing the Response Interruption and Redirection (RIRD) Method Vocal Stereotypic Behavior Vocal stereotypic behavior is a form of repetitive behavior that appears as noncommunicative vocalizations (Van Santen, Sproat, & Hill, 2013), which can be everything from clear words or phrases to shrieking, babbling, or grunting (Ahearn, Clark, MacDonald, & In Chung, 2007; Colón, Ahearn, Clark, & Masalsky, 2012). In general, vocal stereotypy is believed to cause self-reinforcing sensory stimulation by the sound or vibration consequences that are produced by engaging in the behavior (Ahearn et al., 2007; Rapp & Vollmer, 2005; Taylor, Hoch, & Weissman, 2005; Wolery, Kirk, & Gast, 1985). Vocal stereotypic behavior has not been researched to a great extent due to the general misconception that the behavior serves no purpose other than gaining social reinforcement and is, therefore, often ignored (Taylor et al., 2005). Vocal stereotypic behavior prevails for a long time and can hinder the development of new skills and interfere with positive social interactions (Dunlap, Dyer, & Koegel, 1983; MacDonald et al., 2007; Mayes & Calhoun, 2011; Wolery et al., 1985). Interfering with vocal stereotypic behavior can improve social functioning and is, hence, an important research subject (Ahearn et al., 2007; Dickman, Bright, Montgomery, & Miguel, 2012). The Response Interruption and Redirection (RIRD) Method Ahearn et al. (2007) first described response interruption and redirection (RIRD) which has proven to be an effective treatment for vocal stereotypic behavior (Ahrens, Lerman, Kodak, Worsdell, & Keegan, 2011; Cassella, Sidener, Sidener, & Progar, 2011; Dickman et al., 2012; Liu-Gitz & Banda, 2010; Martinez & Betz, 2013; Miguel, Clark, Tereshko, & Ahearn, 2009; Schumacher & Rapp, 2011). RIRD is a form of response blocking where the 5 REDUCING VOCAL STEREOTYPY WITH THE RIRD METHOD therapist interrupts the subject’s response by placing some form of demand and redirects the individual to emit an incompatible and more appropriate behavior response (Ahearn et al., 2007). For example a child makes an “uhhh uhhh” humming sound (vocal stereotypic behavior) and the therapist interrupts the behavior by delivering a social question which the child can easily answer (demand) thus requiring the child to stop the vocal stereotypic behavior and use an appropriate form of vocalization (redirection). Ahearn et al. (2007) showed the efficacy of the RIRD method by reducing vocal stereotypy in four children on the autism spectrum. They implemented the RIRD approach by using an ABAB design. They managed to reduce vocal stereotypic behavior for all four children compared to baseline measures as well as increasing appropriate vocalization of words for three of the four children. The mechanism responsible for the RIRD method’s effectiveness is still unclear. By implementing the RIRD method, Ahrens et al. (2011) found that the decrease of vocal stereotypic behavior was consistent with the function of a positive punisher since the method was more effective as the amount of response blocking increased. This is inconsistent with a previous study on behavioral blocking by Smith, Russo and Le (1999) which indicated that the behavior decrease is due to extinction by stopping the reinforcement of the automatic sensory reinforcement. Liu-Gitz and Banda (2010) did a systematic replication of the RIRD method on a 10 year old with autism, who had vocal stereotypy. The method successfully managed to reduce the vocal stereotypy, thus increasing the generalizability of Ahearn et al.’s (2007) findings. To evaluate the immediate and subsequent effect of RIRD on vocal stereotypy Schumacher and Rapp (2011) used a multielement design on two autistic children. Their findings indicated that RIRD method produced an immediate decrease in the vocal stereotypy of both participants and did not result in a subsequent increase. 6 REDUCING VOCAL STEREOTYPY WITH THE RIRD METHOD Although many studies have focused on vocal stereotypy reduction, most have only included autistic research subjects. Consequently, the literature is short of answers regarding which individuals could benefit from treatment (Ahearn et al., 2007; Dickman et al., 2012; Liu-Gitz & Banda, 2010; Martinez & Betz, 2013; Schumacher & Rapp, 2011). Additions to the Original RIRD Method Martinez and Betz's (2013) review of studies implementing the RIRD method showed that many therapists add reinforcers to the RIRD method. A study by Love, Miguel, Fernand and LaBrie (2012) suggests that by adding reinforcers or decreasing access to them during the RIRD intervention one can increase the effectiveness of the RIRD method. When implementing the RIRD method to reduce vocal stereotypic behavior of a 5 year old, Dickman et al. (2012) reported that when a token economy was implemented the vocal stereotypy decreased even more and appropriate vocalizations increased. Love et al. (2012) compared the RIRD method to access to matched stimulation, which includes access to objects that produce the same stimulation as the stereotypic behavior. They found that for one participant a greater suppression of vocal stereotypy occurred if both methods were used simultaneously. On the contrary, Ahearn et al. (2007) suggested that by adding reinforcers one loses the ability to assess functional control of the behavior. Adding reinforcers and punishers to the RIRD method is, hence, a topic which needs more research in order to conclude how RIRD can be implemented in the most successful manner. Untargeted Stereotypic Behavior When stereotypic behavior is reduced there are odds that response reallocation occurs and not necessarily to a more appropriate behavior (Lanovaz, Robertson, Soerono, & Watkins, 2013; Pastrana, Rapp, & Frewing, 2013; Rapp, Vollmer, St Peter, Dozier, & Cotnoir, 2004). In response to this problem, Lanovaz et al. (2013) recommended that when a certain stereotypic behavior is targeted clinicians should aim to strengthen an alternative 7 REDUCING VOCAL STEREOTYPY WITH THE RIRD METHOD appropriate behavior to replace the stereotypy. This makes the RIRD method a preferable treatment option since it redirects the targeted behavior to a more appropriate behavior.