Stony Brook University

The official electronic file of this thesis or dissertation is maintained by the University Libraries on behalf of The Graduate School at Stony Brook University. A Allll R Riig gh htts sR Re es se er rv ve ed db by yA Au utth ho or r..

Temperament Intervention for Problem Behavior in Children with Autism Spectrum Disorders

A Dissertation Presented by Lauren Adamek in Partial ulfillment of the !e"uirements for the De#ree of Doctor of Philosophy in Clinical Psycholo#y Au#ust $%&&

Stony Brook University The 'raduate School

Lauren Adamek (e) the dissertation committee for the above candidate for the Doctor of Philosophy de#ree) hereby recommend acceptance of this dissertation*

Dr. Daniel Klein Dissertation Advisor Professor, Department of Psychology

Dr. Joanne Davila hairperson of Defense Professor, Department of Psychology

Dr. !verett "aters Professor, Department of Psychology

Dr. Shana #ichols linical Director and $esearcher, %ay J. &indner enter for A'tism and Developmental Disa(ilities

This dissertation is accepted by the 'raduate School

Lawrence +artin Dean of the 'raduate School

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Abstract of the Dissertation Temperament Intervention for Problem Behavior in Children with Autism Spectrum Disorders by Lauren Adamek Doctor of Philosophy Clinical Psycholo#y Stony Brook ,niversity $%&& Problem behavior is a ma-or barrier to #ood "uality of life for families who have children with Autism Spectrum Disorders .ASD/* The concept of modifyin# the environment to produce a better match with a child0s temperament is commonly used to inform interventions in the child development field* 1owever) temperament has not yet been inte#rated into problem behavior interventions for children with ASD) nor have temperament2based strate#ies been evaluated in a systematic way* The purpose of the present study was to employ temperament2based interventions to modify problematic environmental conte3ts so that they are a better fit for the temperament styles of hi#hly e3traverted children and to evaluate these interventions to determine whether they result in a reduction of problem behavior and an increase in "uality of life* Si3 hi#hly e3traverted children with ASD who display problem behavior participated* Assessments of problem behavior) e3traversion) and "uality of life were conducted and parents were tau#ht to miti#ate challen#in# situations to make them a better fit for their child0s temperament* A multiple baseline e3perimental desi#n was used to evaluate intervention

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effects for specific hi#h priority conte3ts* !esults indicated that modifyin# the environment to better fit a child0s temperament was associated with decreased problem behavior and increased percenta#e of task steps completed correctly* Subse"uent to the e3perimental demonstration) a clinical e3tension of the intervention methodolo#y was applied for each child to an additional problem conte3t in order to further enhance intervention benefits* T2test results of ancillary pre and post intervention measures indicate that intervention was associated with a decrease in overall problem behavior* This research hi#hli#hts the importance of understandin# temperament when assessin# and treatin# problem behavior in children with ASD*

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Dedication This dissertation is dedicated to Dr. Edward (Ted) Carr. Ted was a brilliant thinker and researcher, whose work forever changed the lives of those with autism and their families. Ted always thought ahead of the field by questioning the status quo and diligently seeking to understand fields outside of autism, in order to more fully solve roblems related directly to autism. !t was with Ted"s guidance that ! sought to understand tem erament and its relationshi to roblem behavior in children with #$D. Ted taught me to think broadly, write clearly, and do work that will make a ositive im act on others. ! ho e that this dissertation, and work to come, will be a tribute to the life of Ted Carr.

Table of Contents List of Tables....................................................................................................................viii List of Figures.....................................................................................................................ix Acknowledgements..............................................................................................................x I. Introduction..............................................................................................................1 Overview of the Tem erament Construct................................................................! "xtraversion#$urgenc% and "xternali&ing 'roblem (ehavior in )eurot% ical *outh........................................................................................................................+ "xtraversion#$urgenc% in *outh with A$,............................................................."xtraversion#$urgenc% and "xternali&ing (ehavior in *outh with A$,................. Intervention for 'roblem (ehavior/ Tem erament 'ers ectives.............................0 $ ecific Com onents of Tem erament1(ased Intervention....................................2 The 'resent $tud%..................................................................................................13 II. 4ethod...................................................................................................................11 'artici ants.............................................................................................................11 'rocedure...............................................................................................................1+ Com letion of 're1Intervention 4easures.................................................1+ Identification of Intervention Contexts.....................................................1(aseline for "x erimental Contexts..........................................................15 's%choeducation about Tem erament.......................................................16 Overview of Intervention for "x erimental Contexts...............................16 Clinical "xtensions....................................................................................!. Com letion of 'ost1Intervention 4easures...............................................!2 III. 7esults...................................................................................................................!6 "x erimental Contexts...........................................................................................!6 Clinical Contexts....................................................................................................+3 Interrater 7eliabilit%...............................................................................................+1 Ancillar% 4easures................................................................................................+1 I8. ,iscussion..............................................................................................................++ Intervention "fficac%9.........................................................................................++ Conce tual Issues..................................................................................................+. "cological 8alidit%................................................................................................+0 Future ,irections...................................................................................................+5 Tables.....................................................................................................................+2

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Figures....................................................................................................................-7eferences..............................................................................................................-6 A endix ................................................................................................................2

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List of Tables Table 1 Table ! Table + Table 'artici ant Characteristics at (aseline.......................................................+2 Task Anal%ses of "x erimental Contexts. ................................................+6 Intervention Fidelit% Checklists for "x erimental Contexts.....................-1 ,ifferences between 're1Intervention and 'ost1Intervention 4easures...-+

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List of Figures Figure 1 The ercent of activit% ste s com leted and latenc% to session termination for the first three artici ants :grou 1; during baseline and intervention................................................................................................-. The ercent of activit% ste s com leted and latenc% to session termination for the second three artici ants :grou !; during baseline and intervention................................................................................................-0 The ercent of activit% ste s com leted for all six artici ants :grou 1 and !;.........................................................................................................-5 The latenc% to session termination for all six artici ants :grou 1 and !; during clinical contexts..............................................................................-2

Figure !

Figure + Figure -

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Acknowledgements I wish to acknowledge the following people, without whom, the successful completion of this project would not have been possible. A mentor and friend, Ted Carr taught me how to be a scientist, and inspired me to use science to improve the lives of those with disabilities and their families. Countless hours of excited conversation about temperament-based intervention led to this project. Shana Nichols. When I needed guidance with this project, hana stepped in without hesitation. hana is trul! rare in that she is an expert researcher and clinician, and therefore, her feedback throughout the stud! was expansive and invaluable. "urther, hana was not just a mentor for this project, but provided me with career development advice, and was a supportive figure both professionall! and personall!. Dan Klein. I have alwa!s admired #an for his expansive knowledge, wellarticulated feedback, and kindness. It was m! pleasure to work more closel! with him on this dissertation, and his comments on this project, and previous temperament projects, made them better. Joanne Davila. $oanne has supported m! growth and development through coursework, clinical supervision, and now b! providing feedback on m! research. %er insight was extremel! beneficial. Everett Waters. &verett has provided feedback on several temperament projects, and his comments reflect immense thought and prompt me to think more deepl! about the constructs. Caitlin Walsh. Caitlin provided intervention to a famil! in this stud!. he was an excellent therapist, worked diligentl!, and alwa!s strived to provide top 'ualit! care and research integrit!. Caitlin provided several intervention ideas for other families during our length!, weekl! talks. Samara Tetenbaum. amara and I became a (dissertation team) and both motivated one another to continue to strive for excellence. amara has incredible creative abilit! when designing high-intensit! interventions or visual aids. *hese contributions made the intervention strategies more desirable to the children in the stud!. Lauren Moskowit . +! consultations with ,auren when first planning this intervention stud! were imperative to maintaining research integrit! while also achieving efficienc!. "urther, ,auren is more familiar with the past and current autism literature that an!one I know and she alerted me to relevant studies. Sarah !arber"#uest$ Sara !u%%erd$ Care& Dowlin'$ and Jen Tomlinson. *hese women were with me ever! step of the wa!, encouraging me to keep persevering- from stats exams to first clients to committee meetings, and so much more. *he unconditional love and support given to me b! these great friends has allowed me to become a more confident researcher, a better advocate for m! clients, and a more balanced individual. Sam Cook. "or this project, m! fianc., am, pla!ed the role of statistics consultant and patientl! discussed statistics implications with me. +ore importantl!, am considers m! clinical and research goals e'ual to his own career goals, and has provided the utmost support for an! new endeavors. Mitch and Linda (damek. +! parents have taught me the importance of education, hard work, and kindness/ three ideals that were necessar! for m! graduate career.

The )amiles. ix special families welcomed me in their homes and inspired me with their dedication and love for their children. *hese families, and the families in the two previous temperament and A # studies, have contributed to the bod! of knowledge that will hopefull! help to improve the 'ualit! of life of man! children with autism and their families.

I. Introduction Problem behaviors, such as aggression, tantrums, self-injury, and property destruction are commonly displayed by people with developmental disabilities (Emerson et al., 2 !". #uch behavior can negatively impact education, sociali$ation, community

inclusion and employment (%ruinin&s, 'ill, ( )orreau, !*++, -oegel, -oegel, ( .unlap, !**/". %ecause of its deleterious effects on 0uality of life, problem behavior has been a major focus of research and intervention. 1he reduction of problem behavior is essential for individuals with developmental disabilities to achieve valued outcomes and a high 0uality of life. 2n emerging model of intervention for problem behavior in the disabilities field focuses on enhancing conte3tual fit. 4onte3tual fit refers to the degree of match between an individual5s competency and the performance re0uirements of the environment (4arr, 4arlson, 6angdon, )agito )c6aughlin, ( 7arbrough, !**+". Poor conte3tual fit results when an individual5s s&ills do not match the demands of the environment. 2s a result, the individual may be more li&ely to display problem behavior. 1his model of conte3tual fit is useful because it suggests that one can intervene either with respect to the individual (competency building" or with respect to the environment (environmental modification". 2 concept similar to conte3tual fit, referred to as goodness-of-fit, is discussed in the developmental literature. 8oodness-of-fit is defined by the degree of match between a child5s temperament and the performance re0uirements of the environment (4hess ( 1homas, !**!". 9hen the child5s temperament is a poor fit with the environment, problem behavior is more li&ely to occur. #ince temperament is moderately stable throughout childhood (:ovosad ( 1homan, !***, ;oberts ( .el<ecchio, 2 ", it is

0uite plausible that temperament may be relatively resistant to change. 1hus, intervention efforts might focus more profitably on environmental modification that creates a better match between the child5s temperament and his=her environment. 1o date, temperamentbased interventions have not been systematically applied to children who have 2#.. 1his study attempts to address this gap by investigating the impact of temperament-based intervention strategies on problem behavior and 0uality of life of children who have 2#.. Overview of the Temperament Construct 1emperament is a major focus of the literature on child development. 4urrently, theorists view temperament as individual differences in a child5s response to various situations in his or her self-regulation of attention, emotion, and activity (;othbart ( %ates, 2 /". 2 central tenet in the study of temperament is that genetic influences

greatly impact the e3pression of temperament traits. In the field of behavior genetics, heritability estimates are used to e3press the proportion of the observed temperament trait that is due to genetic factors. >ne large study of twins found the overall heritability of temperament to be about .? , with individual temperament traits ranging from a heritability of .!+ to .@@ (>nis$c$en&o, Aawad$&i, #trelau, ;iemann, 2ngleitner, ( #pinath, 2 2". 2nother crucial finding in the study of temperament is the moderate

stability of temperament throughout early childhood. 2 recent meta-analysis yielded cross-time correlations of .?2 from B to ?.* years of age (;oberts ( .el<ecchio, 2 1emperament can be defined in terms of three factorsC negative affectivity, e3traversion=surgency, and effortful control (;othbart, 2hadi, 'ershey, ( Disher, 2 !". ".

:egative affectivity=emotionality is defined as the li&elihood that an individual will react

to situations with negative emotional states. Effortful control is defined as Ethe efficiency of e3ecutive attention, including the ability to inhibit a dominant response and=or to activate a subdominant response, to plan, and to detect errorsF (;othbart ( %ates, 2 /,

p. !B/". E3traversion=surgency refers to a given individual5s tendency to be more active, enjoy higher intensity activities, be more impulsive, and act less shy than his=her peers (;othbart, et al., 2 !". Efficacy of temperament based-interventions has not yet been

evaluated with children who have 2#., therefore, it is important and clinically meaningful to investigate the efficacy of such interventions with respect to one or more temperament dimensions. 1his study focuses on the temperament dimension of e3traversion=surgency. Extraversion/Surgency and Externalizing Problem ehavior in !eurotypical "outh 1he factor of e3traversion=surgency, as well as individual subscales that contribute to this factor, have been found to predict problem behavior (e.g., aggression, delin0uent behavior" in neurotypical youth. In one study, aggression was positively related to high e3traversion in children ages B-@ years old (;othbart et. al., 2 !". In a

group of male and female college students, greater e3traversion predicted a greater li&elihood of assaulting others (Edmunds, !*@@". In addition, female college students who were more e3traverted were more li&ely to engage in verbal and indirect aggression, and display irritability. #everal specific constructs associated with e3traversion=surgency are predictive of e3ternali$ing problem behavior. In one sample of children, high impulsivity predicted e3ternali$ing problem behavior (Eisenberg et al., 2 ?". In another sample,

children who preferred higher intensity activities were more li&ely to engage in e3ternali$ing problem behavior (>rmel et al., 2 ?". 2dditionally, in families with

parental psychopathology, children with a high activity level were more li&ely to show behavior problems ()un, Dit$gerald, <on Eye, Puttler, ( Auc&er, 2 !". 6astly, in a

recent large sample of preschoolers, high e3traversion=surgency was strongly associated with scores on the 2ttention .eficit 'yperactivity scale and the >ppostitional .efiant Problems scale on the 4hild %ehavior 4hec&list (.ePauw, )ervielde, ( <an 6eeuwen, 2 *".

Extraversion/Surgency in "outh with #S$ )uch of the focus of research thus far in the field of autism has been on group differences, namely, identifying how temperament differs between neurotypical children and those with disabilities. 1he research is inconclusive regarding whether group differences e3ist in e3traversion=surgency between children with autism and neurotypical children. In a longitudinal study of infants, children with an autism diagnosis at 2G months old had been previously rated by their parents at / months as demonstrating lower activity level than children without an autism diagnosis (Awaigenbaum, %ryson, ;ogers, ;oberts, %rian, ( #$atmari, 2 ?". In contrast, a study of G2 children from ages B to!

years old found no differences in e3traversion=surgency when comparing children with 2#. to those without (-onstantareas ( #tewart, 2 /". 1his similarity in activity level

between children with 2#. and neurotypical children was also found in another study involving B to + year olds (%ailey, 'atton, )esibov, ( 2ment, 2 ". >ther research has

shown that children with 2#. have higher e3traversion=surgency, and in particular, higher activity level than neurotypical children ('epburn ( #tone, 2 Awaigenbaum, #mith, %rian, ;oberts, et al., 2 *". /, 8aron, %ryson,

Extraversion/Surgency and Externalizing ehavior in "outh with #S$ 8iven the breadth of literature on temperament in developmental psychology, and the growing literature on group temperament differences in 2#., one might presume that the lin& between temperament and problem behavior has also been e3amined in the disabilities field, however, little research on these potential lin&s has been conducted. >ne recent study e3amining the relationship between temperament and problem behavior found that effortful control and negative affectivity, but not e3traversion=surgency predicted e3ternali$ing problem behavior in children between + and !/ years of age with high-functioning autism, as measured by the %ehavior 2ssessment #cale for 4hildren (#chwart$ et al., 2 *". In another study, greater e3traversion=surgency was found to

predict problem behavior in children between B and @ years of age who had 2#. (2dame&, :ichols, 1etenbaum, %regman, Pon$io, ( 4arr, 2 ! ". In addition, children with a higher activity level, as well as children who preferred high intensity pleasure activities, were more li&ely to show problem behavior. 2n observational study also found that children ages B to @ years showed problem behavior when as&ed to participate in low intensity situations (2dame& ( 4arr, 2 ! ". #pecifically, two children low in e3traversion and two children high in e3traversion were observed when as&ed to participate in low intensity activities (e.g., boo&, pu$$le, board game" or high intensity activities (e.g., bas&etball, bi&e riding, trampoline". 1he children with low e3traversion temperament styles did not show problem behavior in either situation. 1he children with high e3traversion temperament styles did not engage in problem behavior in the high intensity situations but displayed outbursts of problem behavior within ? minutes of being as&ed to engage in the low intensity activity. 1he differing results of these studies

indicate that lin&s between e3traversion=surgency and e3ternali$ing behavior need to be e3amined further. %ntervention for Problem ehavior& Temperament Perspectives In the developmental literature, there are three critical concepts central to understanding children5s temperament and applying this &nowledge to assessment and intervention. #pecifically, the concepts of set point, goodness-of-fit, and niche pic&ing create a framewor& for analy$ing the interplay between individual temperament characteristics and the conte3ts in which children must function. #et point is Ea personal baseline that remains constant over timeF (Dujita ( .iener, 2 ?". 2pplied to temperament, set point can be understood as a child5s average

way of behaving based on his=her genetic predisposition to various temperament characteristics. 1o illustrate, in the study of body weight regulation, various interventions (e.g., restricting food inta&e or consuming particular nutrients" can alter weight within a small range around the set point but, over time, body weight tends to be stable around that set point ('arris, !** ". #imilarly, in the study of children5s temperament, various medical, behavioral, and educational interventions might plausibly alter undesirable temperament characteristics within a small range around the set point but would not drastically shift temperament characteristics far from the set point. Dor e3ample, consider a child whom we will call ;oger, who is impulsive, full of energy and prefers activities such as shooting a bas&etball or playing tag. ;oger has a high set point for surgency=e3traversion. %ehavioral procedures and=or medication may somewhat decrease ;oger5s e3traversion, but, compared to other children, ;oger5s level of e3traversion will still be higher than average.

2s previously noted, goodness-of-fit refers to how well a child5s temperament matches the situation in which he=she has to cope (4hess ( 1homas, !**!". If activities or situations are a poor fit with a child5s temperament, problem behavior will li&ely occur. 4onsider our e3ample of a highly e3traverted child, ;oger. 1o teach ;oger to identify his colors, his parents and teachers as& him to sit at a table, prompt him to name the correct colors (red, blue, green", and reward him when he chooses correctly. In response to this sedentary activity, ;oger throws tantrums and hits his parents and teachers when they sit him down to learn colors. 1he situation does not allow ;oger to be e3traverted, and therefore, constitutes a poor fit with ;oger5s temperament. 2s e3pected, ;oger engages in high levels of problem behavior in the situation that is incongruent with his temperament. :iche pic&ing is defined as choosing a situation that best fits an individual5s temperament (#uper ( 'ar&ness, !**G". 1ypical children often niche pic& to choose situations that are the best fit for their temperament. Dor e3ample, a child could choose to join a football team or a chess team, based on his=her temperament traits. 4hildren with autism, however, are often unable to select their own niche due to demands placed on them by parents and teachers and because of difficulties communicating their wants and needs. 1hus, niche-pic&ing interventions for children with autism re0uire parents and staff to assess a child5s temperament and then choose niches that are li&ely to be a good fit for the child and structure academic and home demands to be congruent with this niche. 1o illustrate niche pic&ing, consider ;oger again. In order to niche pic&, a parent or teacher must alter the environment in order to allow ;oger to be more e3traverted within a given situation. 1his strategy wor&s with ;oger5s temperament, rather than

against it. 1hus, a parent or teacher could, for e3ample, tape red, blue, and green s0uares to a wall and as& ;oger to Erun to red,F Erun to blue,F etc. 1his situation would represent a good niche because ;oger could engage in high intensity activity while learning colors at the same time. Specific Components of Temperament' ased %ntervention >ne clinical trial has tested the effectiveness of temperament-based intervention. In this clinical trial, groups of mothers of B-? year old neurotypical children with difficult temperament characteristics (e.g. negative mood, high-intensity emotionality, or high activity level" received a temperament parent training program. 1his included psychoeducation about temperament, identification of their child5s temperament profile, e3planations of how to ma&e their demands more similar to their child5s temperament characteristics, and behavior management techni0ues (#heeber ( Hohnson, !**G". 1he mothers who received this intervention reported fewer child behavior problems, increased satisfaction in their relationship with their child, and greater perceived parental competence as compared to the mothers in the waitlist control group. 1here are also 0ualitative reports of the outcomes of temperament-based interventions. Dor instance, in the :ew 7or& 6ongitudinal #tudy (:76#", 4hess and 1homas met with parents for an average of 2-B sessions to provide them with goodness-of-fit suggestions based on their children5s temperament (!*+/". 2ppro3imately ? I of cases were considered successful based on clinical judgment of parental change and improvement in the child5s behavior. In another temperament intervention program, temperament was assessed, strategies for strengthening the parent-child relationship were introduced, and specific parenting advice using goodness-of-fit principles were delivered (#mith, !**G". 2fter completing this

program, @*I of parents indicated that they were helped Emuch or very much by the programF. )ost temperament-based intervention programs contain three elementsC (!" general educational discussions with parents to increase their awareness and understanding of the concept of temperament, (2" identification of the particular child5s temperament profile to provide a more organi$ed and objective picture, (B" interventions that influence the temperament J environment interaction by improving goodness-of-fit (4arey, !**G". (eneral educational discussions about temperament should include defining individual differences, e3plaining various types of temperament differences, giving parents an understanding of why it is better to wor& with rather than against a child5s temperament, and advising parents that different strategies wor& with different temperament styles (4hess ( 1homas, !*+/". 1hese discussion points can alleviate parents5 guilt about their children5s behavior and can shift parents5 cognitive or motivational e3planations to a temperament-based e3planation (-eogh, !**G". 1o identify and teach parents about a child5s temperament profile, one can employ various assessment methods. >ne commonly used assessment method is parent 0uestionnaires (;othbart et al., 2 !". Parents=caregivers spend a large amount of time

with their children, and therefore, have a broad &nowledge of their child5s temperament that can be reported through 0uestionnaires. In addition, it can be helpful to observe the child, either informally or with a temperament rating system, in order to assess temperament ()ajadand$ic ( van den %oom, 2 /". ;egardless of which method is

used, it is important to assess the child5s behavior in a wide range of situations in order to

identify their temperament style (4hess ( 1homas, !*+/". 1he child5s temperament profile should then be e3plained thoroughly to the parents. 9hen improving the goodness'of'fit between the child5s temperament and his=her environment, temperament intervention researchers suggest that clinicians begin by choosing only one or two situations to improve (4hess ( 1homas, !*+/". 1hen, clinicians should counsel parents on the specific details of the environment that will be modified, as well as what outcome to e3pect as a result of the intervention. Dor e3ample, for a child with a high activity level, temperament interventionists suggest see&ing after school programs that emphasi$e active play, not e3pecting the child to sit during an entire dinner or a lengthy car ride, and giving the child errands to run during school to get a reprieve from sitting at a des& (4hess ( 1homas, !**!". The Present Study 1he present study investigated the effectiveness of temperament-based intervention for highly e3traverted=surgent children with 2#. in reducing problem behavior and improving family 0uality of life.

II. )ethod Participants Participants in this study were si3 children diagnosed with an autism spectrum disorder. 1he inclusion criteria for this study were as followsC (!" individuals must have been diagnosed with 2#., (2" individuals must have been between the ages of B-@, (B" individuals must have had a history of problem behavior (score K!/.? on the Irritability #cale of the 2berrant %ehavior 4hec&list, see below for discussion", and (G" individuals must have had highly e3troverted temperament styles (score K?.B! on the e3traversion=surgency factor of the 4hild %ehavior Luestionnaire, see below for discussion". .iagnosis of 2#. was verified through home or school records and was based on either a prior evaluation by a psychologist or psychiatrist through use of the 2utism .iagnostic >bservation #chedule (2.>#, 6ord, ;utter, .i6avore, ( ;isi, 2 or based on .#)-I< criteria (2merican Psychiatric 2ssociation, !**G". 'istory of problem behavior was verified through parent report on the Irritability #cale of the 2berrant %ehavior 4hec&list (2%4, 2man ( #ingh, !*+/, 2ppendi3 2". 1he 2%4 is fre0uently used to assess problem behavior in people with developmental disabilities. 1he irritability subscale is a !? item measure that assesses severe problem behaviors, for e3ample, items include Einjures self on purposeF and Eaggressive to other children or adultsF. Each item is scored on a -B 6i&ert scale ranging from Enot at all a problemF to Ethe problem is severe in degree.F 1he scale has good internal consistency demonstrated by a coefficient alpha of .*2 (2man, #ingh, #tewart, ( Dield, !*+?". Interrater reliability of the subscale, using #pearman correlation coefficients, ranges from .B* to .@ , dependent on rater pairings. 1est-retest reliability of the irritability subscale !"

!!

using a #pearman correlation has been found to be .*+ (2man, #ingh, #tewart, ( Dield, !*+?". 1he researchers previously gathered scores on the 2%4 from a sample of !!B children with 2#., ages 2 to * years of age (2dame& et al., 2 ! ". Drom this previous sample, a @?th percentile cutoff score for problem behavior of !/.? was determined. E3traversion was verified through parent reports on the 2ctivity 6evel, Impulsivity, 'igh Intensity Pleasure, and #hyness subscales that contribute to the e3traversion=surgency factor of the 4hild %ehavior Luestionnaire (4%L-short form, Putnam ( ;othbart, 2 /, see 2ppendi3 %". 1his 6i&ert-type scale for assessing

temperament in children ages B-@ years has 2? items. 1he subscales of the e3traversion=surgency factor of the 4%L-short have good internal consistency, with coefficient alphas over .@G for the four subscales (;othbart et al., 2 !". Interrater

reliability coefficients of mothers and fathers range from .?! to .@* for the G subscales. 1he researchers previously gathered scores on the 4%L from a sample of !!B children with 2#. (2dame& et al., 2 ! ". Drom this previous sample, a @?th percentile cutoff score for e3traversion of ?.B! was determined. Participant characteristics are reported in 1able !. 1hese characteristics includeC name of child (all names have been changed for confidentiality", age, gender, diagnosis, full scale IL, score on the 2berrant %ehavior 4hec&list, and score on the e3traversion scales of the 4hild %ehavior Luestionnaire. Participants ranged in age from B.! to @.2 years. Dive children were male, and one child was female. 2ll children had an autism spectrum diagnosis. Dull scale IL scores ranged from G to !!2. >ne family was unable to provide IL score information because their child was unable to engage in any test items during two separate evaluations attempts. 2ll si3 children5s scores on the 2berrant

!2

%ehavior 4hec&list were above the @?th percentile cutoff of !/.? and ranged from !+ to B?. 2ll si3 children5s scores on the E3traversion subscales of the 4hild %ehavior Luestionnaire were above the @?th percentile cutoff of ?.B! and ranged from ?.BB to /.2+. Procedure Completion of Pre'%ntervention )easures Damilies were recruited for this study by letters distributed to local agencies and schools for children with 2#., and through advertisements on autism listserves. .uring the initial meeting, parents signed consent forms and completed a battery of 0uestionnaires. Parents completed the Irritability #cale of the 2berrant %ehavior 4hec&list (2%4" as well as the 2ctivity 6evel, Impulsivity, 'igh Intensity Pleasure, and #hyness subcales of the 4hild %ehavior Luestionnaire (4%L". In addition, families completed a battery of pre-intervention ancillary 0uality of life measures. 1he Parenting #tress Inventory J #hort Dorm (P#I=#D, 2bidin, !**@, 2ppendi3 4" measures the amount of stress parents encounter on a daily basis. 1he scale contains B/ parent-report items that produce three factorsC Parental .istress (P.", Parent-4hild .ysfunctional Interaction (P4.I", and .ifficult 4hild (.4". 1est-retest reliability has been computed between scores at ! year apart (r M .@?, p N . !, 'as&ett, 2hern, 9ard, ( 2llaire, 2 /". 1he

'ome #ituations Luestionnaire ('#L, %ar&ley, !*+!, 2ppendi3 ." measures how much the child5s problem behavior disrupts home situations such as mealtime or bathtime. It contains !/ parent-report items that are scored on a -* li&ert scale ranging from EabsentF to EsevereF. 1he scale has good internal consistency demonstrated by a coefficient alpha of .*B, and good test-retest reliability (#pearman 4orrelation *!, .uPaul ( %ar&ley, !**2". 1he Parental 6ocus of 4ontrol #cale (P64#, 4ampis, 6yman, ( Prentice-.unn,

!B

!*+/, 2ppendi3 E" measures how much parents feel in control of their children. It contains items that are scored on a !-? 6i&ert scale ranging from Estrongly disagreeF to Estrongly agreeF. In previous wor&, items were shown to be internally consistent, with an alpha coefficient of .+! and have good test-retest reliability, with a reliability coefficient of .+B (;oberts, Hoe, ( ;owe-'allbert, !**2". %dentification of %ntervention Contexts Each family participated in a follow up assessment to identify intervention conte3ts. 1he researcher (a Ph. student in clinical psychology" gave e3amples of what constitutes a low intensity situation, such as those found in 2ppendi3 D. 1hrough a discussion with parents, low intensity activities that were typically problematic for their child and typically yielded high instances of problem behavior were identified. Parents were then as&ed to identify one top priority conte3t as the e3perimental conte3t, while the other conte3ts were considered for later clinical e3tensions. 1he intervention in the e3perimental conte3t employed temperament intervention strategies and included e3tensive data collection. %dentification of %ntervention Contexts& )ichael* )ichael was a ?-year-old boy diagnosed with 2utistic .isorder (2." who attended a special education class and lived at home with his mother, father, twin brother, and two older brothers. 'e communicated through the use of single words and gestures as well as limited use of a Picture E3change 4ommunication #ystem (PE4#, %ondy ( Drost, !**G". 9hen presented with a list of low intensity activities, his parents identified playing a game as a conte3t they were concerned about, therefore, it was selected as the e3perimental conte3t. #pecifically, )ichael5s parents reported that )ichael engaged in problem behavior (e.g., tantrums,

!G

aggression, self-injury, and noncompliance" when playing board games. 1ypically, )ichael would throw the game pieces, bang his head, or run away when as&ed to play. %dentification of %ntervention Contexts& +obbie* ;obbie was a @-year-old boy diagnosed with 2. who attended a special education class and lived at home with his mother, father and younger brother. 'e was nonverbal and communicated through the use of gestures as well as limited use of PE4#. 9hen discussing low intensity conte3ts with the researcher, his mother identified coloring as a primary conte3t she was concerned about. #pecifically, ;obbie5s mother reported that ;obbie engaged in problem behavior (e.g., tantrums, aggression, self-injury, and noncompliance" when instructed to color. 1ypically, ;obbie would refuse to color at all, and when prompted to color, he would tantrum, bang his head, or hit his mother or brother. %dentification of %ntervention Contexts& $anny* .anny was a ?-year-old boy diagnosed with Pervasive .evelopmental .isorder-:ot >therwise #pecified (P..-:>#" who attended a special education class and lived at home with his mother, father, younger brother, and younger sister. 'e communicated through the use of complete, short sentences. 'is parents identified dinnertime as the most problematic low intensity conte3t for their family. #pecifically, .anny5s parents reported that he engaged in problem behavior (e.g., tantrums, noncompliance" when instructed to eat his dinner at the table. .anny5s parents would try to redirect him to the table, but most often .anny would continue to tantrum or run away. %dentification of %ntervention Contexts& Eli,ah* Elijah was a B-year-old boy diagnosed with P..-:># who attended a typical preschool and received after school early intervention services through a local agency for children with developmental

!?

disabilities. 'e lived at home with his mother and father and communicated through the use of simple words and gestures. 9hen presented with a list of low intensity activities, his parents identified coloring as an important conte3t that was difficult for Elijah. #pecifically, Elijah5s parents reported that Elijah engaged in problem behavior (e.g., tantrums and noncompliance" when as&ed to color. 1ypically, Elijah would refuse to begin coloring, run away from the coloring materials, or throw a tantrum. %dentification of %ntervention Contexts& -elicia* Delicia was a /-year-old girl diagnosed with 2. who attended a special education class and lived at home with her mother, father, and older sister. #he communicated through the use of complete, short sentences. .uring discussions with the researcher, Delicia5s mother identified reading a boo& as a problematic, low intensity conte3t that was important to their family. #pecifically, Delicia5s mother reported that she engaged in problem behavior (e.g., tantrums and noncompliance" when instructed to listen to a boo& being read to her. 1ypically, Delicia would refuse to even begin listening to a story being read, and if her mother further prompted her to sit and listen, Delicia would throw a long, intense tantrum. %dentification of %ntervention Contexts& Connor* 4onnor was a G-year-old boy diagnosed with P..-:># who received early intervention services through a local agency for children with developmental disabilities and lived at home with his mother, father, and younger sister. 'e was fully verbal and communicated through the use of complete, comple3 language. 9hen presented with a list of low intensity activities, his mother identified playing a board game with others as an important, problematic conte3t. #pecifically, 4onnor5s mother reported that 4onnor engaged in problem behavior (e.g., tantrums, aggression, and noncompliance" when playing games. 1ypically, 4onnor would

!/

successfully begin a game, but in the middle of the game would refuse to play, throw a tantrum, or hit his mother or sister. aseline for Experimental Contexts 2 multiple baseline design was used across participants ('ersen ( %arlow, !*@/". 1he si3 participants were randomly assigned to be in group ! or group 2, and were assigned to have the researcher complete B, G, or ? baseline observations. In single subject research, replication is often achieved through the use of a reversal design by alternating baseline and treatment periods, however, due to ethical concerns about withdrawing the treatment as well as worries about carryover effects, a multiple baseline design was employed ()organ ( )organ, 2 !". 1he staggered introduction of

intervention strategies aims to improve internal validity by showing that behavior change occurs at various time-points (-a$din, 2 B". Past researchers have established that a

minimum of two baseline sessions per participant is necessary, therefore we chose B-? baseline sessions ('ersen ( %arlow, !*@/". )ultiple baseline designs are commonly implemented across three participants. 1wo groups of three participants were used to more 0uic&ly deliver intervention to families and to replicate the findings across groups. )ultiple baseline observations were conducted in the top priority, e3perimental conte3t identified by the researcher and parents. Parents were as&ed to complete two !-@ 6i&ert scale items assessing the fre0uency and intensity of their child5s problem behavior during this conte3t in the past month. 1he scale for the first item ranges from Einfre0uentF to Ee3tremely fre0uentF and the second item ranges from Enot intenseF to Ee3tremely intenseF. 1hese items can be found in 2ppendi3 8. %aseline observations in the low intensity conte3t assessed latency to problem behavior and percent of the tas&

!@

completed. Dor latency to problem behavior, observers recorded the amount of time from the beginning of the tas& to the onset of problem behavior (4arr ( 4arlson, !**B". 1ypical problem behaviors are tantrums, noncompliance, or disruptive behavior. If these occurred during baseline, the low intensity activity was stopped and parents were as&ed to carry out the natural procedures that they typically use when their child engages in problem behavior. If no problem behavior occurred, the researcher recorded the amount of time from the beginning of the tas& to the completion of the tas&. Dor tas& completion, the researcher developed a tas& analysis for each e3perimental tas& that bro&e down the tas& into its component steps. 2ll tas& analyses are outlined in 1able 2. Dor some tas&s, such as coloring, there was no clear end point. 1herefore, tas& components spanning a certain amount of time (e.g., color for ! minute" were created. 1hese time increments were chosen with parent input so that the total duration of time was appro3imately twice as long as the child had ever been able to spend doing that particular activity. .uring baseline, the researcher recorded the number of steps the participant successfully completed without problem behavior. 2t the conclusion of the tas&, the researcher divided the number of steps successfully completed by the total number of steps in the tas& to derive the percent of tas& completed. 1he investigator and a parent collected reliability data on the relevant study variables during one baseline session. 2 binary reliability inde3 was used to assess agreement on percentage of tas& steps completed and latency to session termination. 1hus, for each session, reliability was scored as either perfect agreement or no agreement. 2greement was defined as both observers recording

!+

the same number of tas& steps completed and latency measures that were within ? seconds of one another. Psychoeducation about Temperament .irectly following baseline, the researcher met with the parents to teach them about temperament, and temperament-based intervention. 2 temperament curriculum (2ppendi3 '" was used as a guide during this session. 1his curriculum was supplemented by a variety of e3amples presented to parents, as well as detailed discussion to ensure parents5 understanding. Overview of %ntervention for Experimental Contexts #trategies to improve the fit between the e3perimental conte3t and the child5s e3troverted temperament were developed with the help of the parents during a problem solving session (.5Aurilla ( :e$u, 2 !, #tiebel, !***". .uring this session, parents and

the researcher wor&ed their way, systematically, through a problem-solving template (2ppendi3 I" applied to the conte3t of interest. Parents were &nowledgeable about which strategies were most feasible within their family, which can be an important asset in developing a treatment plan (6ucyshyn, 2lbin, ( :i3on, !**@, <aughn et al., !**@". Dollowing a problem solving session that yielded temperament intervention strategies, parents were trained to implement the intervention in !-2 sessions. 1hen, parents completed the intervention independently of the researcher while the researcher observed. 2n intervention decision tree (2ppendi3 H" was used to determine when the family needed additional training, when to move on to clinical e3tension interventions, and when intervention was complete. 1hroughout the intervention, integrity chec&s were performed, that is, intervention fidelity chec&lists were developed based on the

!*

intervention components for each participant. 1he investigator and parent recorded chec&mar&s whenever a specific component of the intervention was implemented by the parent. Hust as in baseline observations, both the parent=s and researcher assessed latency to problem behavior and percent of the tas& completed each time the intervention was used. 2lso similar to baseline, the investigator and a parent collected reliability data on the relevant study variables during 2?I (B of !2 intervention sessions". 2 binary reliability inde3 was used to assess agreement on intervention fidelity, percentage of tas& steps completed, and latency to session termination. 2fter the intervention in the e3perimental conte3t was complete, parents rated the overall fre0uency and intensity of their child5s problem behavior during the past month using the 6i&ert scale item previously used during baseline. 2 summary of the intervention fidelity chec&lists can be found in 1able B and more detailed descriptions of the intervention strategies can be found below. %ntervention Strategies for a (ame& )ichael* )ichael5s parents chose the game E#nails, Pace, ;aceF as the e3perimental conte3t. 1his game is typically played by rolling a small, colored, dice and moving a snail with the corresponding color one space. 1his is a poor match for a child with a surgent temperament because the game is sedentary, typically played sitting at a table, does not involve physical activity, and re0uires fine motor s&ills rather than gross motor movements. >ne intervention strategy was to replace the small dice provided with the game with a / inch colored dice that could be tossed in the air. 1his encouraged standing, throwing and gross motor play. In addition, )ichael5s parents helped him hold a snail after he threw the dice, and e3claim, E(color" snail, OOOOOO snail, OOOOOO snail, bouncePF while jumping with )ichael. 1his made the game

more interactive, and allowed )ichael to move around. )ichael5s parents provided him with surgent praise (e.g., hugs, high fives, pats on the bac&, tic&les". 1his gave )ichael positive, physically active interactions with his parents. 6astly, intervention included singing a song about snails a few times throughout the game. )ichael5s parents sang this song to him while swinging him bac& and forth. 1his engaged )ichael in energetic activity at various times throughout the game. %ntervention Strategies for Coloring& +obbie* ;obbie5s mother chose coloring as the e3perimental conte3t. 4oloring, as it is typically presented, is a poor match for a child with a surgent temperament because it is done while sitting and re0uires little gross movements or high-intensity actions. 1he intervention was established so that ;obbie alternated between two coloring stations. 'is mother chased him between these stations. 1his allowed ;obbie to ta&e short brea&s from the low-intensity activity of coloring during the time he was being chased. >ne coloring station included a rubber disc filled with air to sit on and a vibrating pen to color with. ;obbie bounced on the disc in his seat while coloring with the vibrating pen. 1he other station included large white paper taped to the wall and large, triangular crayons. 9ith these materials ;obbie could run the length of the wall while coloring with crayons that were easier to manipulate than typical crayons. %ntervention Strategies for $innertime& $anny* .anny5s parents chose eating dinner at the table as the e3perimental conte3t. Eating dinner is a poor match for a child with a surgent temperament because it is typically done while sitting and does not involve any high-intensity activity. 1he intervention included the use of a surgent visual schedule. It should be noted that during baseline, .anny5s parents used a visual schedule, therefore,

2!

this behavioral strategy was enhanced within a temperament framewor& by ma&ing the visual schedule a better fit for a surgent child. 1he visual schedule consisted of pictures of one-fourth, one-half, three-fourths, and all of the food on a plate eaten. :e3t to these pictures were musical greeting cards. 9hen .anny ate a fourth of his food, he was allowed to stand up from his seat, wal& to the visual schedule, open a greeting card, and dance to the ! -2 second clip of music. 'e then was re0uired to return to his seat and eat the ne3t fourth of food before getting up again. 1hese scheduled, controlled bursts of surgent activity helped .anny to be able to sit while eating his dinner. In addition, .anny5s parents provided him with surgent praise (e.g., hugs, high fives, pats on the bac&, tic&les" when he returned to his seat. 1his gave .anny positive, physically active interactions with his parents. 6astly, the intervention strategies included replacing the edible reinforcer that .anny5s parents previously gave him with a more active reinforcer. 9e chose activities such as playing with a toy steering wheel that made racing noises, and jumping on a trampoline as positive reinforcement for .anny eating his entire dinner without any problem behavior. %ntervention Strategies for Coloring& Eli,ah* Elijah5s parents chose coloring as the e3perimental conte3t. 4oloring, as it is typically presented, is a poor match for a child with a surgent temperament because it is done while sitting and re0uires little gross movements or high-intensity actions. >ne of the main elements of the intervention was the use of a Ecolor me a songF board. 1his toy has buttons that ma&e sounds when pressed, and when colored on, it plays music to the pace of the coloring. Elijah was as&ed to push a colored button and color with the same colored crayon as the button. #mall crayons were replaced with large, triangular crayons. Elijah was encouraged to color as

22

0uic&ly as possible. 1he use of this board allowed coloring to be more active than when done with typical paper and crayons. .uring baseline, Elijah5s parents often used a monotone tone of voice when giving instructions or praise. .uring intervention, they were taught to use an enthusiastic tone of voice to be more engaging and intense for Elijah. 6astly, Elijah5s parents provided him with surgent praise (e.g., hugs, high fives, pats on the bac&, tic&les" when he was coloring. 1his gave Elijah positive, physically active interactions with his parents. %ntervention Strategies for +eading& -elicia* Delicia5s mother chose listening to a boo& being read as the e3perimental conte3t. 6istening to a boo& is a poor match for a child with a surgent temperament because it is typically a sedentary activity done while sitting and re0uires very little action or input from the child. .uring intervention Delicia was instructed to choose from three interactive boo&s. 1hese boo&s were about cars, trains, and princesses, and included sound buttons to push, flaps to move, or pu$$les to complete. %y using boo&s that re0uired Delicia to do something, rather than to only sit and listen, it became a more surgent activity. Delicia5s mother learned to as& Delicia 0uestions about characters in the boo&s, to as& her to ma&e noises or movements about characters in the boo&, and to as& her to push buttons, move flaps, or do pu$$les. In addition, Delicia5s mother prompted Delicia to get a toy that went along with the boo& (e.g., car, train, princess wand". #he then as&ed Delicia to play with the toy when appropriate in the conte3t of the story (e.g., E)ove 1homas the train 0uic&ly across the tableP 'e has to get to Percy the trainPF". 6astly, Delicia5s mother would say, E!-2-B, turn the pagePF and prompt Delicia to turn the page. Encouraging Delicia to turn the pages,

2B

play with a toy, and interact with the boo& made listening to a boo& a higher energy activity. %ntervention Strategies for a (ame& Connor* 4onnor5s mother chose board games as the e3perimental conte3t. 9e decided to use E#piderman 4hutes and 6addersF and E.ora the E3plorer 4andy 6andF as the board games for intervention. 1hese games are a poor match for a child with a surgent temperament because they are sedentary, typically played sitting at a table, do not involve physical activity, and re0uire fine motor s&ills. >ne intervention strategy was to encourage 4onnor to wear a &ing hat and pretend to be the E&ing of the gameF and e3plain the rules to everyone playing. 1his made the beginning of the game more interactive. 9hen playing 4hutes and 6adders, 4onnor5s mother encouraged him to tell and act out stories about the super hero characters in the game. 1he spinner in the game was replaced with a / inch foam dice that could be thrown in the air. 9hen 4onnor landed on a ladder, he climbed on a stepstool that we pretended was a ladder. 9hen 4onnor landed on a chute, he rolled on the ground to pretend that he was going down the chute. 9hen playing 4andy 6and, 4onnor5s mother encouraged him to tell and act out stories about .ora the E3plorer characters. 1he cards in the game were put into a large fishbowl, rather than a small pile. 6aminated color s0uares were placed around the room and when 4onnor drew a colored card he would move his character and go jump on the corresponding colored s0uare himself. 9hen playing either game, 4onnor was prompted to say, EB-2-!, blast offPF (one of his favorite sayings", and jump in the air when ta&ing a turn. 2ll of these intervention strategies helped to include rowdy, active, and imaginative play in the conte3t of the board games.

2G

Clinical Extensions 2fter parents demonstrated intervention mastery for the e3perimental conte3t (based on e3perimenter observation and intervention fidelity chec&list", the researcher met with the parents to discuss additional low intensity conte3ts where intervention was needed. 1he researcher developed temperament-based intervention strategies for these clinical e3tensions. 4linical e3tensions are important because they help create multicomponent interventions that promote the use of intervention strategies across a variety of conte3ts (4arr ( 4arlson, !**B". Interventions that address multiple conte3ts are more li&ely to produce general decreases in problem behavior as well as improvements in overall family 0uality of life. Dre0uency and intensity of child problem behavior in each conte3t was assessed before and after the implementation of intervention in the clinical conte3t. Intervention fidelity chec&lists, based on the intervention components for the additional conte3ts, were developed to evaluate intervention integrity for these conte3ts. 1he researcher observed ! session of baseline and 2 sessions of intervention for each clinical e3tension conte3t and completed the intervention fidelity chec&list as well as assessed latency to problem behavior and percent of tas& completed. Clinical Extension& )ichael* )ichael5s parents had also identified going to a restaurant as a low-intensity, problematic conte3t for )ichael. 9e first employed intervention strategies in a fast food restaurant. )ichael5s parents were instructed to use a surgent visual schedule that consisted of a magnetic board with pictures of restaurant activities (e.g. wait in line, ta&e our food to a table, sit in a chair, eat", and empty spots for )ichael to place magnetic letters on the board when he completed a restaurant activity. 9hile in line, )ichael5s parents played E#imon saysF with him and prompted )ichael to

2?

do active movements such as, Ejump up and downF or Etouch your toesF. 9hen in his seat, )ichael sat on an inflatable, rubber dis& that he could bounce on. If )ichael ate his dinner and did not e3hibit any problem behavior, his parents played a surgent activity with him when they returned home (e.g., tag, spin in circles". Eventually, the intervention was e3tended further to include going to a sit-down family restaurant in addition to fast food restaurants. Clinical Extension& +obbie* ;obbie5s mother identified eating a snac& at the table as a second problematic conte3t for ;obbie. >ne intervention strategy was to use food that was shaped li&e animals, or other characters. ;obbie5s mother was taught to prompt ;obbie to play games related to the food, such as ma&ing a cat noise after eating a crac&er shaped li&e a cat. 2 counting coo&ie jar toy was also used to ma&e eating the snac& more energetic. 2fter ;obbie ate a bite of food, he placed a toy coo&ie into the coo&ie jar. In addition, ;obbie sat on a vibrating cushion on his chair to provide him with physical input. 6astly, ;obbie5s mother was taught to use surgent praise (e.g., hugs, high fives, pats on the bac&, tic&les" when he was sitting in his chair and eating his snac& without any problem behavior in order to give him a positive, physically active interaction. Clinical Extension& $anny* .anny5s parents identified playing E4hutes and 6addersF as another difficult, low intensity conte3t for .anny. 1his intervention included the same concept of climbing a stepstool when landing on a ladder on the board and rolling on the ground when landing on a chute on the board as was used with 4onnor. Durther, the spinner in the game was replaced with a / inch foam dice that could be thrown in the air. In addition, a large turn board was used that was adhered to the wall.

2/

.anny would get up and place a picture of himself, his mother, his father, or his brother on the turn board to show that it was that person5s turn. 1hese brea&s which included getting up from the table and changing the picture on the turn board allowed .anny to be more lively during the game. 6astly, .anny5s parents were encouraged to provide him with surgent praise (e.g., hugs, high fives, pats on the bac&, tic&les". Clinical Extension& Eli,ah* Elijah5s parents chose tracing letters as another problematic conte3t. >ne intervention strategy was to allow Elijah to stand, rather than re0uiring him to sit while tracing letters. In addition, wor&sheets and small crayons were replaced with large, colorful posterboards and large, triangular crayons. 1he original wor&sheets included letters to trace and animals or objects that corresponded with the letter being traced. 1he poster boards also included these elements, and Elijah was prompted to imitate the animal or object by using noises or movement. 6astly, Elijah5s parents provided him with surgent praise (e.g., hugs, high fives, pats on the bac&, tic&les" when he was tracing letters. 1his gave Elijah positive, physically active interactions with his parents. Clinical Extension& -elicia* Delicia5s mother chose going to the grocery store as another difficult, low intensity conte3t for Delicia. >ne intervention strategy used during the car ride was for Delicia5s mother to play games with her. 1his included ma&ing voices of .isney characters and singing some of Delicia5s favorite songs. >nce at the store Delicia5s mother gave her a boo& of pictures of grocery store items and had her find items in a particular aisle. 1his gave Delicia an active tas& to be engaged with rather than wal&ing through the store with nothing to do. 2lso, when wal&ing down the aisles, Delicia was encouraged to s&ip or hop, rather than wal&. 9hen Delicia successfully

2@

completed a trip to the grocery store, she was provided a surgent reward (e.g., going to a play space, driving on a bumpy road". Clinical Extension& Connor* 4onnor5s mother chose completing academic wor&sheets as a problematic, low intensity conte3t for 4onnor. .uring baseline, wor&sheets were used that re0uired 4onnor to circle the smallest or largest picture. .uring intervention, the wor&sheets targeting smallest were placed on the &itchen table and the wor&sheets targeting largest were placed on 4onnor5s des& in the living room. 9hen completing the wor&sheets 4onnor was as&ed to act out the pictures on the wor&sheets (e.g., bu$$ li&e a bee, fly li&e a jet". 2fter completing a wor&sheet targeting smallest at the &itchen table, 4onnor was told to race to the middle of the living room and choose the smallest of three balls. >nce he correctly pic&ed the smallest ball, he ran to the des& in the living room and completed a wor&sheet targeting largest. 1hen, 4onnor raced to the middle of the living room and chose the largest of three balls. 1his continued until four of each wor&sheet was completed. %y encouraging 4onnor to race, move around the room, manipulate objects (balls", and act out pictures from the wor&sheets, the concepts of smallest and largest were practiced while allowing 4onnor to be more active. Completion of Post'%ntervention )easures 2fter the interventions for the e3perimental conte3t were employed for !2 wee&s and the clinical e3tensions were conducted for at least 2 wee&s, a post intervention assessment battery of 0uestionnaires was administered to the parents. 1hese included the #urgency items of the 4hild %ehavior Luestionnaire, the Irritability #cale of the 2berrant %ehavior 4hec&list, the Parenting #tress Inventory, the 'ome #ituations Luestionnaire, and the Parental 6ocus of 4ontrol #cale.

2+

III. ;esults Experimental Contexts Percent Tas. Steps Completed* 1he percentage of activity=routine steps completed for the three participants in group ! are shown in Digure !, and for the three participants in group 2 in Digure 2. )ichael completed an average of BB.B I of the steps that constituted playing a board game during baseline. 'owever, during intervention, he completed an average of *?.?I of the steps. ;obbie completed a mean of 2@.+I of the steps associated with coloring during baseline. 'owever, during intervention, he completed ! I of the steps. .uring baseline, .anny completed a mean of B?I of the I of the

steps involved in eating dinner. 'owever, during intervention, he completed !

steps. Elijah completed !*I of the steps that constituted coloring during baseline. 'owever, he completed *+I of steps during intervention. Delicia completed 2?I of the steps involved in being read a boo& during baseline. 'owever, she completed ! I of

the steps during intervention. 4onnor completed GB I of steps associated with playing a board game during baseline. 'owever, he completed **I of the steps during intervention. /atency to Session Termination* Digure ! and Digure 2 present data on the amount of time that elapsed before the session was terminated (due to problem behavior or successful completion of the activity" for the si3 participants. Dor )ichael, the mean latency to problem behavior during baseline was 2 minutes, ! seconds. .uring intervention sessions when )ichael engaged in problem behavior (B out of !2 sessions", the mean latency to problem behavior was !! minutes, ?B seconds. .uring intervention sessions with no problem behavior (* out of !2 sessions", successful completion of

2*

playing the board game occurred at !/ minutes and * seconds. Dor ;obbie, the mean latency to problem behavior for coloring at baseline was 2G seconds. .uring intervention, there was no problem behavior and latency to successful completion of coloring was B minutes, 2@ seconds. Dor .anny, during baseline, the mean latency to problem behavior during dinnertime was G minutes, 2 seconds. .uring intervention, .anny did not engage in problem behavior and latency to successful completion of eating dinner was !@ minutes, B* seconds. Dor Elijah, during baseline, the mean latency to problem behavior for coloring was 2 seconds. .uring intervention, Elijah did not engage in problem behavior and latency to successful completion of coloring was @ minutes, GG seconds. Dor Delicia, during baseline, the mean latency to problem behavior for reading was G minutes, 2 seconds. .uring intervention, Delicia did not engage in problem behavior and latency to successful completion of being read a boo& was * minutes, ?G seconds. Dor 4onnor, the mean latency to problem behavior at baseline was 2 minutes, ! seconds. .uring intervention sessions when 4onnor engaged in problem behavior (! out of !2 sessions", the latency to problem behavior was !G minutes, * seconds. .uring intervention sessions with no problem behavior (!! out of !2 sessions", successful completion of playing the board game occurred at a mean of 2 minutes and G+ seconds. Clinical Contexts Percent Tas. Steps Completed* 1he percent of activity=routine steps completed during clinical conte3ts for all si3 participants (group ! and 2" is shown in Digure B. .uring the baseline session, participants completed between 2 -B I of tas& steps. 'owever, during intervention sessions, participants completed ! I of tas& steps.

/atency to Session Termination* 6atency to session termination during clinical conte3ts for all si3 participants (group ! and 2" is shown in Digure G. .uring the baseline session, latency was short, and all si3 participants engaged in problem behavior. 'owever, during intervention sessions, participants did not engage in any problem behavior, and latency to session termination increased at least G participants. %ntervention -idelity* .uring baseline, a mean of I of the intervention components were implemented by each respective parent for all conte3ts. .uring intervention, for the e3perimental conte3ts, a mean of ! I of the intervention I across all

components were implemented by each respective parent. .uring intervention for the clinical e3tension conte3ts, a mean of ! implemented by each respective parent. %nterrater +eliability 1he investigator and a parent collected reliability data on the relevant study variables during one baseline session and three intervention sessions for the e3perimental conte3ts and during one baseline session and one intervention session for the clinical conte3ts. 2greement on intervention fidelity, percentage of tas& steps completed, and latency to session termination was noted for ! across all participants. #ncillary )easures In addition to outcome measures related to latency to problem behavior=successful completion of routines, data were collected to measure the I of baseline and intervention sessions I of the intervention components were

B!

differences between pre and post measures of conte3t specific problem behavior, global problem behavior, temperament, parental stress, the child5s disruption of home situations, and perceived parental control. Paired sample t-tests were performed on all ancillary measures to compare scores during baseline with those following intervention. In addition, effect si$es using 4ohen5s d were calculated incorporating the correlation between measures for each set of variables (.unlap, 4ortina, <aslow, ( %ur&e, !**/". 2s can be seen in 1able G, following intervention, there was a significant decrease in the conte3t specific fre0uency of problem behavior in both e3perimental and clinical conte3ts as measured by a 6i&ert type item measuring fre0uency t (?" M +. , p N . !, d M B.!B and

t (?" M !!./2, p N . !, d M B.2! respectively. In addition, there was a significant decrease in the conte3t specific intensity of problem behavior in both e3perimental and clinical conte3ts as measured by a 6i&ert type item measuring intensity t (?" M ! .*?, p N . !, d M ?.@* and t (?" M /./G, p M . !, d M 2.B respectively. 8lobal perception of the level of serious problem behavior as measured by the Irritability subscale of the 2%4 significantly decreased following intervention, t (?" M *.*!, p N . !, d M 2.!G. 1here were no significant differences in temperament between pre and post intervention scores on the surgency=e3traversion scale of the 4%L, t (?" M . @, p M .*?, d M . G. 2lthough all three measures of 0uality of life (Parenting #tress Inventory, 'ome #ituations Luestionnaires, and Parental 6ocus of 4ontrol #cale" improved from pre to post intervention assessment, none of the differences were significant, however, all three had effect si$es K ./?, indicating that an effect may be present but was not detectable using t-tests with such a small sample si$e.

B2

I<. .iscussion %ntervention Efficacy 9ithin two groups of three children and their families, a temperament-based intervention for problem behavior in children with autism spectrum disorders was implemented and evaluated in home and community settings. Intervention included !" general educational discussions with parents to increase their awareness and understanding of the concept of temperament, 2" identification and e3planation of their child5s temperament profile, and, B" mitigating the environmental demands to improve the goodness-of-fit between the child5s temperament and the environment. 2ll si3 children who participated showed substantial behavioral improvement in conte3ts identified by their parents as the most problematic. .uring baseline, latency to problem behavior was short and the percent of tas& components completed was small. 2fter intervention, problem behavior was greatly reduced in the e3perimental conte3ts for all children, and the children were consistently able to complete the tas&. 2dditionally, parents rated the fre0uency and intensity of their child5s problem behavior as lower. #imilar results including a reduction in problem behavior, improvements in tas& completion, and decreased parental ratings of fre0uency and intensity of problem behavior were found for the clinical conte3ts across participants. :otably, there was also evidence of more global reductions in problem behavior as reflected by the significant difference in scores on the 2%4 Irritability #cale. 4hoosing the most difficult conte3ts for parents, wor&ing on multiple conte3ts, and improving problem behavior by using temperament-based strategies, may generali$e to other situations to reduce overall problem behavior.

BB

Improvements in problem behavior and tas& completion were observed across participants in the current sample. 1hese participants were diverse in gender, age, cognitive ability, and communication s&ills. 1o summari$e, participants included ? boys and ! girl, who were B to @ years of age, with IL5s ranging from G to !!2, and verbal abilities ranging from non-verbal to conversationally verbal. 1emperament-based strategies that target the fit between temperament characteristics and the environment can be fle3ible in regard to other individual characteristics of the child. #o, strategies for an older child with a higher IL and more advanced verbal abilities can be more comple3 than those for a younger child with a lower IL and little verbal s&ills. #ince temperamentbased strategies can be applied uni0uely for particular children these strategies can be successful in decreasing problem behavior regardless of gender, age, cognitive ability, and verbal s&ills. 1emperament, as measured by the 4%L, did not change following intervention. 1his is consistent with previous findings that temperament is moderately stable over time (;oberts ( .el<ecchio, 2 ". It also suggests that the intervention strategies targeted

problem behavior by improving the fit between temperament and the environment, rather than targeting temperament itself. Parenting stress, problematic home routines, and perceived parental control did not significantly improve following intervention, however, all three improved from pre to post assessment, and all had effect si$es in the moderate range. #tudies with larger sample si$es, and more intensive interventions that target greater than two conte3ts, as well as intervention strategies that target family difficulties in addition to child problem behavior, may be needed to significantly improve these areas.

BG

Conceptual %ssues 1his study investigated a temperament-based framewor& in which to assess and treat problem behavior in children with 2#.s. 1he importance of goodness-of-fit between a child5s temperament and the performance re0uirements of the environment was e3amined, and intervened upon. Dor all si3 children high in surgency=e3traversion, problem behavior was consistently present in low intensity situations during baseline observations. 9hen interventions were provided that improved goodness-of-fit by mitigating aspects of the environment, problem behavior was eliminated, or significantly decreased. 1hese data suggest that the concept of goodness-of-fit may be valuable in guiding assessment and intervention of problem behavior in young children with 2#.. Qsing standardi$ed assessment instruments to identify general problematic conte3ts is best practice when targeting problem behavior in children who have 2#.s, however, these general assessment tools have typically not included temperament. In order to assess problematic goodness-of-fit between a child5s temperament and his=her environment, clinicians, parents, or teachers could complete an assessment of temperament, such as the 4%L. Drom the temperament profile generated from this assessment, problem conte3ts could be identified related to the child5s temperament, enabling parents to gain a better understanding of why some situations result in problem behavior and others do not. Dor e3ample, by completing the 4%L, parents may discover that their child has high surgency=e3traversion and could better understand why their child has difficulty doing a pu$$le, reading a boo&, or sitting at the dinner table. Drom this assessment parents, teachers, and others can choose conte3ts that best fit with a child5s temperament and avoid conte3ts that are a poor fit in order to decrease

B?

problem behavior. #ome conte3ts cannot be avoided, and for those conte3ts, interventions can be designed that increase the goodness-of-fit between the child5s temperament and the situations in which he=she has to cope. Drom the present study, general themes and more specific strategies were identified for increasing goodness-of-fit for children high in surgency=e3traversion. 2ctivities for children high in this temperament dimension can be engineered to be more energetic and active, include gross motor play and decrease fine motor play, and increase physical interaction (e.g. hugs, high-fives, pats on the bac&" between children and their parents. 1emperament-based intervention strategies are not intended to replace standard educational or behavioral interventions. Instead, understanding the role of temperament, and increasing goodness-of-fit between a child5s temperament and a particular environment or activity may increase the efficacy of educational and behavioral interventions during that activity. Ecological 0alidity 1he interventions implemented in this study were employed in natural settings (e.g., family homes, restaurants, grocery stores", using natural intervention agents (e.g. parents and grandparents", to modify natural activities and routines (e.g., reading, playing board games, dinner". 1his stands in direct contrast to many intervention studies that target problem behavior in 2#. by utili$ing discrete trial methodology in a controlled or laboratory setting (Iwata, .orsey, #lifer, %auman, ( ;ichman, !*+2". 1hese studies fail to address 0uestions about generali$ation to natural environments (4arr et al., 2 2". %y

utili$ing natural settings, intervention agents, and activities, and through the completion of clinical e3tensions, the results of the current study demonstrate that temperament-

B/

based strategies are ecologically valid and can be generali$ed to many real-world situations. -uture $irections 1his is the first empirical study of temperament-based intervention for children with 2#.. 1herefore, additional studies that e3amine temperament-based interventions are necessary to further investigate the efficacy of this approach. 2dditional intervention research should include a greater number of participants and children with a greater variability in their characteristics (e.g., age, gender, temperament profile". Dor e3ample, a randomi$ed clinical trial comparing outcomes of children who receive temperamentbased intervention to children on a waitlist would be useful. 2mong neurotypical children, lin&s have been found between specific temperament profiles and internali$ing problems, social difficulties, and poor academic functioning ()uris, )eesters, ( %lijlevens, 2 2 @, #pinrad, et al., 2 @, <aliente, 6emery-4halfant #wanson, ( ;eiser,

+". Duture temperament intervention research should target these outcomes, in

addition to problem behavior. Durther, temperament interventions could be evaluated within a classroom setting. 6astly, many behavioral intervention strategies have e3tensive support and are included in muticomponent intervention pac&ages for children with 2#.s (4arr ( 4arlson, !**B". It would be valuable to include temperament-based strategies in these multicomponent pac&ages as a comprehensive approach to behavior change

B@

1able ! Participant Characteristics at aseline

:ame 2ge 8ender .iagnosis Dull #cale IL ()M! , #.M!?" 2%4 ()M! , #.M! " 4%L ()M G.@ , #.M .@*, from an 2#. sample" ?./G

)ichael

?.

)ale

2utistic .isorder

Qnable to >btain

2@.

;obbie

@.2

)ale

2utistic .isorder

#tanford%inetC G

B .

/.!B

.anny

?.?

)ale

Pervasive .evelopmental .isorder, :># Pervasive .evelopmental .isorder, :># 2utistic .isorder

#tanford%inetC @

2+.

/.2+

Elijah

B.!

)ale

%ayleyC *

!+.

?.BB

Delicia

/./

Demale

#tanford%inetC?*

2G.

?.GG

4onnor

G./

)ale

Pervasive .evelopmental .isorder, :>#

9PP#IIIIC !!2

B?.

?.@2

1Stanford inet 2 Stanford' inet %ntelligence Scale& -ifth Edition 13PPS%'%%% 2 3echsler Preschool and Primary Scale of %ntelligence 4 Third Edition 1 ayley 2 ayley Scales of %nfant and Toddler $evelopment 4 Third Edition

B+

1able 2 Tas. #nalyses of Experimental Contexts :ame )ichael 1as& Play the game E#nails, Pace, ;aceF 1as& 4omponents !. 4ome to the table in the living room. 2. Put the snails on the starting spots. B. ;oll the dice. G. )ove a snail. ?. 9ait while )om ta&es a turn. /. ;epeat steps B-?. @. ;epeat steps B-?. +. ;epeat steps B-?. *. ;epeat steps B-?. ! . ;epeat steps B-? until a snail wins. !!. Put the game pieces bac& into the bo3. !. 4ome to the materials at the &itchen table. 2. Pic& up a crayon=pen=mar&er. B. 4olor on the paper for ! seconds. G. 4olor on the paper for another ! seconds. ?. 4olor on the paper for another ! seconds. /. 4olor on the paper for another ! seconds. @. 4olor on the paper for another ! seconds. +. 4olor on the paper for another ! seconds. *. 8ive the materials to )om or sign Eall doneF. !. Put plate on the dining room table. 2. #it down at the table. B. Eat R of the food on his plate. G. Eat another R of food on his plate. ?. Eat another R of food on his plate. /. Eat last R of food on his plate. @. 8et a reward. +. Put plate in the &itchen. !. 4ome to the table. 2. Pic& up crayon. B. 4olor on paper for ! minute. G. 4olor on paper for another minute. ?. 4olor on paper for another minute. /. 4olor on paper for another minute. @. 4olor on paper for another minute or until he says, E2ll doneF. !. 4ome to the couch=bed=chair. 2. 4hoose a boo&. B. #it with )om while she reads 2 pages.

;obbie

4oloring

.anny

Eating .inner

Elijah

4oloring

Delicia

6istening to a boo& read by her

B*

)om

4onnor

Play a board game with )om

G. 1urn the page. ?. ;epeat steps B-G. /. ;epeat steps B-G. @. ;epeat steps B-G. +. ;epeat steps B-G until the boo& is finished. *. Put the boo& away. !. 4ome to the game on the living room floor. 2. Place the game pieces on starting spots. B. 4hoose a card, spin the spinner, or roll the dice. G. )ove a game piece. ?. 9ait while )om ta&es a turn. /. ;epeat steps B-?. @. ;epeat steps B-?. +. ;epeat steps B-?. *. ;epeat steps B-?. ! . ;epeat steps B-?. !!. ;epeat steps B-?. !2. ;epeat steps B-G until someone wins the game. !B. Put the game pieces bac& in the bo3.

1able B %ntervention -idelity Chec.lists for Experimental Contexts

:ame )ichael

Intervention 4omponents !. Qse the giant dice. 2. #ay, E(color" snail, OOOOO snail, OOOOOO snail, bouncePF and help )ichael bounce. B. Qse surgent praise (hugs, high fives, pats on the bac&, tic&les". G. #ing the snail song while playing. !. Qse the bouncy seat.

4ompletedS

;obbie 2. Qse triangular crayons. B. Qse the wiggly pen. G. Put large white paper on the wall. ?. 4hase ;obbie from one station to another. !. #how .anny the surgent visual schedule. .anny 2. 2fter .anny finishes each fourth of his food, prompt him to open a music card on the surgent visual schedule. B. Qse surgent praise (hugs, high fives, pats on the bac&, tic&les". G. 9hen he finishes dinner, present .anny with the racing wheel, trampoline, or other active reinforcer. !. Qse an enthusiastic tone when giving Elijah instructions. 2. Qse the E4olor me a #ongF board. B. Instruct Elijah to push the color buttons in between coloring. G. Qse large, triangular crayons. B. Qse surgent praise (hugs, high fives, pats on the bac&, tic&les".

Elijah

G!

!. Qse an interactive boo&. Delicia 2. Prompt Delicia to push the sounds=do the pu$$le. B. 2s& Delicia 0uestions about the boo&. G. 2s& Delicia to ma&e noises=movements to go along with the boo&. ?. Prompt Delicia to pic& a prop=doll=toy to go along with the boo&. /. #ay E!-2-B, 1urn the pagePF in an e3cited voice and then have Delicia turn the page. !. 'ave 4onnor dress up as E&ing of the gameF. 4onnor 2. Prompt 4onnor to tell stories about the characters in the game. B. )a&e materials larger (large dice, fish bowl". G. Encourage gross motor play (color road, step stool". ?. Prompt 4onnor to say EB-2-!-%last offPPF before his turn.

G2

1able G $ifferences between Pre'%ntervention and Post'%ntervention )easures OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO

)easure Pre-Intervention )ean Post-Intervention )ean t- value 4ohen5s d

OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO
Dre0uency of Problem %ehavior (E3perimental 4onte3t" Intensity of Problem %ehavior (E3perimental 4onte3t" Dre0uency of Problem %ehavior (4linical 4onte3t" Intensity of Problem %ehavior (4linical 4onte3t" 8lobal Problem %ehavior (2%4 irritability subscale" #urgency=E3traversion (4%L" Parenting #tress (P#I" 'ome #ituations ('#4" Parental 4ontrol (P64#" /.BB ?.BB ?.+B ?.BB 2@. ?.@/ ! @.BB ?*.BB /*.? !.+B !.BB 2.+B 2.!@ !?. ?.@+ *!. G/.+B @@.? +. TT B.!B ?.@* B.2! 2.B 2.!G . G ./? .@/ .//

! .*?TT !!./2TT /./GTT *.*!TT . @ !./? !.+ !.!?

OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO T pN. ? TT pN. !

GB

Digure 4aptions -igure 5. 1he percent of activity steps completed and latency to session termination for the first three participants (group !" during baseline and intervention. 1he solid blac& bars denote sessions that included problem behavior. 1he grey bars denote sessions in which the activity was successfully completed without any problem behavior. -igure 6. 1he percent of activity steps completed and latency to session termination for the second three participants (group 2" during baseline and intervention. 1he solid blac& bars denote sessions that included problem behavior. 1he grey bars denote sessions in which the activity was successfully completed without any problem behavior. -igure 7. 1he percent of activity steps completed for all si3 participants (group ! and 2" during clinical conte3ts. E2F is the percent of activity steps completed in baseline and E%F is the mean percent of activity steps completed during intervention. -igure 8* 1he latency to session termination for all si3 participants (group ! and 2" during clinical conte3ts. 1he solid blac& bars denote baseline sessions that included problem behavior. 1he grey bars denote intervention sessions in which the activity was successfully completed without any problem behavior. It should be noted that )ichael and Delicia5s clinical conte3ts (restaurant and grocery store" ta&e considerable more time than the other clinical conte3ts (snac&, board game, and academic tas&s" when successfully completed.

GG

Digure !
&aseline
100

'nter(ention

Percent Steps Completed

80 60 40 20 0 20

Latency Min!"

15 10 5 0

Michael

0
100

10

11

12

13

14

15

16

17

Percent Steps Completed

80 60 40 20 0 6

Latency Min!"

5 4 3 2 1 0

#o$$ie

0
100

10

11

12

13

14

15

16

17

Percent Steps Completed

80 60 40 20 0

16 14 12 10 8 6 4 2 0

Latency Min!"

%anny

10

11

12

13

14

15

16

17

Sessions

G?

Digure 2
&aseline 'nter(ention

Percent Steps Completed

100 80 60 40 20 0 12

Latency Min!"

)li*ah

10 8 6 4 2 0

0
100 80 60 40 20 0 12 10 8 6 4 2 0

10

11

12

13

14

15

16

17

Percent Steps Completed

Latency Min!"

+elicia

0
100 80 60 40 20 0 25

10

11

12

13

14

15

16

17

Percent Steps Completed

Latency Min!"

20 15 10 5 0

Connor

10

11

12

13

14

15

16

17

Sessions

G/

Digure B

100

80

Percent Steps Completed

60 Michael #o$$ie %anny )li*ah +elicia Connor

40

20

0 , &

&aseline and 'nter(ention Mean

G@

Digure G

30 25 &aseline 'nter(ention

Latency Min!"

20 15 10 5 0 Michael #o$$ie %anny )li*ah +elicia Connor

Participants

G+

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?2

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?B

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temperament in early childhood. :ournal of Personality; D@; !2!-!/+. )artin, 8., ( Pear, H. (2 B". ehavior modification& 3hat it is and how to do it* :ew

HerseyC Prentice 'all. )organ, ..6. ( )organ, ;.-. (2 Psychologist; @A; !!*-!2@. )ullins, H., ( 4hristian, 6. (2 !". 1he effects of progressive rela3ation training on the !". #ingle-participant research design. #merican

disruptive behavior of a boy with autism. +esearch in $evelopmental $isabilities; 66, GG*-G/2. )un, E.7., Dit$gerald, '.E., <on Eye, 2., Puttler, 6.I., ( Auc&er, ;.2. (2 !".

1emperamental characteristics as predictors of e3ternali$ing and internali$ing child behavior problems in the conte3ts of high and low parental psychopathology. %nfant )ental ?ealth :ournal; 66; B*B-G!?.

?G

)uris, P., )eesters, 4., ( %lijlevens, P. (2

@". #elf-reported reactive and regulative

temperament in early adolescenceC relations to internali$ing and e3ternali$ing problem behavior and Ebig threeF personality factors. :ournal of #dolescence; 7>; ! B?-! G*. :ovosad, 4., ( 1homan, E.%. (!***". #tability of temperament over the childhood years. #merican :ournal of Orthopsychiatry; A=; G?@-G/G. >nis$c$en&o, 9. Aawad$&i, %., #trelau, H., ;iemann, ;., 2ngleitner, 2., ( #pinath, D.). (2 2". 8enetic and environmental determinants of temperamentC 2 comparative

study based on Polish and 8erman samples. European :ournal of Personality; 5D; 2 @-22 . >rmel, H., >ldehin&el, 2.H., Derdinand, ;.D., 'artman, 4.2., .e9inter, 2.D., <eenstra, ;., <ollenbergh, 9., )inderaa, ;.%., %uitelaar, H.-., ( <erhulst, D.4. (2 ?".

Internali$ing and e3ternali$ing problems in adolescenceC general and dimensionspecific effects of famili ! loadings and preadolescent temperament traits. Psychological )edicine; 7@; !-!!. Putman, #.P. ( ;othbart, ).-. (2 /". .evelopment of the short and very short forms of

the children5s behavior 0uestionnaire. :ournal of Personality #ssessment; <D; ! 2!!2. ;oberts, %.9., ( .el<ecchio, 9.D. (2 ". 1he ran&-order consistency of personality

traits from childhood to old ageC 2 0uanitiative review of longitudinal studies. Psychological ulletin; 56A; B-2?. ;oberts, ).9., Hoe, <.4., ( ;ow-'allbert, 2. (!**2". >ppositional child behavior and parental locus of control. :ournal of Clinical Child Psychology; 65; !@ -!@@.

??

;othbart, ). -., 2hadi, #. 2., 'ershey, -. 6., ( Disher, P. (2

!". Investigations of

temperament at B-@ yearsC 1he 4hildrenXs %ehavior Luestionnaire. Child $evelopment; D6, !B*G-!G +. ;othbart, ). -., ( %ates, H. E. (2 /". 1emperament. In :. Eisenberg, 9. .amon, ( ;.

6erner (Eds.", ?andboo. of child psychology; 0ol* 7& Social; emotional; and personality development (pp. **-!//". 'obo&enC Hohn 9iley and #ons Inc. #chmit, H., 2lper, #., ;asch&e, .., ( ;ynda&, .. (2 ". Effects of using a photographic

cueing pac&age during routine school transitions with a child who has autism. )ental +etardation; 7<, !B!-!B@. #chwart$, 4.%., 'enderson, '.2., Inge, 2.P., Aah&a, :.E., 4oman, ..4., -oj&ows&i, :.)., 'ileman, 4.)., ( )undy, P.4. (2 *". 1emperament as a predictor of

symptomotology and adaptive functioning in adolescents with high-functioning autism. :ournal of #utism and $evelopmental $isorders; 7=; +G2-+??. #heeber, 6.%., ( Hohnson, H.'. (!**G". Evaluation of a temperament-focused, parenttraining program. :ournal of Clinical Child Psychology; 67; 2G*-2?*. #mith, %. (!**G". 1he temperament programC 4ommunity-based prevention of behavior disorders in children. In 9.%. 4arey ( #.4. )c.evitt (Eds.". Prevention and early intervention& %ndividual differences as ris. factors for the mental health of children (pp. 2?@-2//". :ew 7or&C %runner=)a$el. #pinrad, 1.6., Eisenberg, :., 8aertner, %., Popp, 1., #mith, 4.6., -upfer, 2., 8reving, -., 6iew, H., ( 'ofer, 4. (2 @". ;elations of maternal sociali$ation and toddlers5

effortful control to children5s adjustment and social competence. $evelopmental Psychology; 87; !!@ -!!+/.

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#tiebel, .. (!***". Promoting augmentive communication during daily routinesC 2 parent problem-solving intervention. :ournal of Positive ehavior %nterventions; 5, !?*!/*. #uper, 4. ). ( 'ar&ness, #. (!**G". 1emperament and the developmental niche. In 9.%. 4arey ( #.4. )c.evitt (Eds.", Prevention and early intervention& %ndividual differences as ris. factors for the mental health of children& # festschrift for Stella Chess and #lexander Thomas Bpp* 55@'56@C* PhiladelphiaC %runner=)a$el Inc. 1homas, 2., 4hess, #., ( %irch, '.8. (!*@ ". 1he origin of personality. Scientific #merican; 667; ! 2-! *. <aliente, 4., 6emery-4halfant, -., #wanson, H. ( ;eiser, ). (2 +". Prediction of

children5s academic competence from their effortful control, relationships, and classroom participation. :ournal of Educational Psychology; 5>>; /@-@@. <aughn, %. H., .unlap, 8., Do3, 6., 4lar&e, #., ( %ucy, ). (!**@". Parent-professional partnership in behavioral supportC 2 case study of community-based intervention. :ournal of the #ssociation for Persons with Severe ?andicaps; 66, !+/-!*@. Awaigenbaum, 6., %ryson, #., ;ogers, 1., ;oberts, 9., %rian, H., ( #$atmari, P. (2 ?".

%ehavioral manifestations of autism in the first year of life. %nternational :ournal of $evelopmental !euroscience; 67; !GB-!?2.

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2ppendi3 2 2berrant %ehavior 4hec&list J Irritability #ubscale

.ateC OOOOOOOOOOOOOOOO Parent :ameC OOOOOOOOOOOOOOOOOOOOOOO

1his set of 0uestions refers to OOOOOOOOOOOOOOOOOOOOOO5s behavior over the P2#1 )>:1'. Please rate your child5s behavior for the last four wee&s when they5re not in school. Dor each item, decide whether the behavior is a problem and circle the appropriate numberC M not at all a problem ! M the behavior is a problem but slight in degree 2 M the problem is moderately serious B M the problem is severe in degree 9hen judging your child5s behavior, please &eep the following points in mindC (a" 1a&e the relative freEuency into account for each behavior specified. Dor e3ample, if your child averages more temper outbursts than most other children with autism you &now, it is probably moderately serious (2" or severe (B" even if these occur only once or twice a wee&. >ther behaviors, such as noncompliance, would probably have to occur more fre0uently to merit an e3treme rating. (b" If you have access to this information, consider the e3periences of other adults with this child. If the child has problems with others but not with you, try to ta&e the whole picture into account. (c" 1ry to consider whether a given behavior interferes with his=her development, functioning, or relationships. Dor e3ample, body roc&ing or social withdrawal may not disrupt other children or adults, but it almost certainly hinders individual development or functioning. .o not spend too much time on each item J your first reaction is usually the right one. !. Injures self on purpose 2. 2ggressive to other children or adults (verbally or physically" B. #creams inappropriately G. 1emper tantrums=outbursts ?. Irritable and whiny /. 7ells at inappropriate times @. .epressed mood +. .emands must be met immediately *. 4ries over minor annoyances and hurts ! ! ! ! ! ! ! ! ! 2 2 2 2 2 2 2 2 2 B B B B B B B B B

?+

! . )ood changes 0uic&ly !!. 4ries and screams inappropriately !2. #tamps feet or bangs objects or slams doors !B. .eliberately hurts himself=herself !G. .oes physical violence to self !?. 'as temper outbursts or tantrums when he=she does not get own way

! ! ! ! ! !

2 2 2 2 2 2

B B B B B B

?*

2ppendi3 %
Y2 )ary -. ;othbart, Qniversity of >regon 2ll ;ights ;eserved

Children's Behavior Questionnaire

#ubject :o. OOOOOOOOOOO .ate of 4hildXs %irthC OOOOOOOOOOOO 2ge of 4hild OOOOOO

1odayXs .ate OOOOOOOOOOOO #e3 of 4hild OOOOOOOOOOOO

InstructionsC Please read carefully before startingC >n the ne3t pages you will see a set of statements that describe childrenXs reactions to a number of situations. 9e would li&e you to tell us what your childXs reaction is li&ely to be in those situations. 1here are of course no ZcorrectZ ways of reacting, children differ widely in their reactions, and it is these differences we are trying to learn about. Please read each statement and decide whether it is a ZtrueZ or ZuntrueZ description of your childXs reaction within the past si3 months. Qse the following scale to indicate how well a statement describes your childC 4ircle [ l 2 B G ? / @ If the statement isC e3tremely untrue of your child 0uite untrue of your child slightly untrue of your child neither true nor false of your child slightly true of your child 0uite true of your child e3tremely true of your child

If you cannot answer one of the items because you have never seen the child in that situation, for e3ample, if the statement is about the childXs reaction to your singing and you have never sung to your child, then circle :2 (not applicable". Please be sure to circle a number or :2 for every item.

G ? / @ :2 neither slightly 0uite e3tremely not true nor true true true applicable untrue OOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOOO )y childC !. #eems always in a big hurry to get from one place to another. l 2. 2 B G ? / @ :2

! e3tremely untrue

2 0uite untrue

B slightly untrue

6i&es going down high slides or other adventurous activities. l 2 B G ? / @ :2

B.

Qsually rushes into an activity (\without thin&ing about it". l 2 B G ? / @ :2

G.

6i&es to play so wild and rec&lessly that s=he might get hurt.
l 2 B G ? / @ :2

?.

#eems to be at ease with almost any person.

l 2 B G ? / @ :2

/.

1ends to run, rather than wal&, from room to room.

l 2 B G ? / @ :2

@.

9hen outside, often sits 0uietly.

l 2 B G ? / @ :2

+.

)oves about actively (runs, climbs, jumps" when playing in the house.
l 2 B G ? / @ :2

*.

>ften rushes into situations.

l 2 B G ? / @ :2

! .

Enjoys activities such as being chased, spun around by the arms, etc.
l 2 B G ? / @ :2

/!

!!.

1a&es a long time in approaching situations.

l 2 B G ? / @ :2

!2.

Is sometimes shy even around people s=he has &nown a long time.
l 2 B G ? / @ :2

!B.

Is slow and unhurried when transitioning from one activity to another.

l 2 B G ? / @ :2

!G.

#ometimes seems nervous when tal&ing to adults s=he has just met.
l 2 B G ? / @ :2

!?.

Prefers 0uiet activities to energetic activities.

l 2 B G ? / @ :2

!/.

2cts shy around new people.

l 2 B G ? / @ :2

!@.

Is comfortable approaching other children to play.

l 2 B G ? / @ :2

!+.

;arely gets upset when told s=he has to sit 0uietly

l 2 B G ? / @ :2

!*.

6i&es to go high and fast when pushed on a swing.

l 2 B G ? / @ :2

2 .

#ometimes turns away shyly from new ac0uaintances.

l 2 B G ? / @ :2

2!.

.isli&es rough and rowdy games.

l 2 B G ? / @ :2

22.

Is among the last children to try out an activity.

l 2 B G ? / @ :2

/2

2B.

Is full of energy, even in the evening.

l 2 B G ? / @ :2

2G.

Enjoys riding a tricycle or bicycle fast and rec&lessly.

l 2 B G ? / @ :2

2?.

6i&es to sit 0uietly and watch people do things.

l 2 B G ? / @ :2

Please chec& bac& to ma&e sure you have completed all the pages of the 0uestionnaire. 1han& you very much for your helpP

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2ppendi3 4 Parenting #tress Inde3

#2 M #trongly 2gree .isagree 2M2gree :#M:ot #ure .M.isagree #2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 #.M#trongly :# :# :# :# :# :# :# :# :# :# :# :# :# :# :# :# :# :# . . . . . . . . . . . . . . . . . . #. #. #. #. #. #. #. #. #. #. #. #. #. #. #. #. #. #.

!. I often have the feeling that I cannot handle things very well

2. I find myself giving up more of my life to meet my children5s needs than I ever e3pected #2 B. I feel trapped by my responsibilities as a parent G. #ince having this child, I have been unable to do new and different things ?. #ince having a child, I feel that I am almost never able to do things that I li&e to do /. I am unhappy with the last purchase of clothing I made for myself @. 1here are 0uite a few things that bother me about my life +. 'aving a child has caused more problems that I e3pected in my relationship with my spouse (or male=female friend" *. I feel alone and without friends ! . 9hen I go to a party, I usually e3pect not to enjoy myself !!. I am not as interested in people as I used to be !2. I don5t enjoy things as I used to !B. )y child rarely does things for me that ma&e me feel good !G. #ometimes I feel my child doesn5t li&e me and doesn5t want to be close to me !?. )y child smiles at me much less than I e3pected #2 #2 #2 #2 #2 #2 #2 #2 #2 #2 #2 #2 #2

!/. 9hen I do things for my child, I get the feeling that my efforts are not appreciated very much #2 !@. 9hen playing, my child doesn5t often giggle or laugh !+. )y child doesn5t seem to learn as 0uic&ly as most children #2 #2

/G

!*. )y child doesn5t seem to smile as much as most children 2 . )y child is not able to do as much as I e3pected 2!. It ta&es a long time and it is very hard for my child to get used to new things

#2 #2 #2

2 2 2

:# :# :#

. . .

#. #. #.

Dor the ne3t statement, choose your response from the choices E!F to E?F belowC 22. I feel that I amC !. not very good at being a parent ! 2. a person who has some trouble being a parent B. an average parent G. a better than average parent ?. a very good parent 2B. I e3pected to have closer and warmer feelings for my child than I do and this bothers me 2G. #ometimes my child does things that bother me just to be mean #2 #2 2 B G ?

2 2 2 2 2 2 2 2 2

:# :# :# :# :# :# :# :# :#

. . . . . . . . .

#. #. #. #. #. #. #. #. #.

2?. )y child seems to cry or fuss more often than most children #2 2/. )y child generally wa&es up in a bad mood 2@. I feel that my child is very moody and easily upset 2+. )y child does a few things which bother me a great deal 2*. )y child reacts very strongly when something happens that my child doesn5t li&e B . )y child gets upset easily over the smallest thing B!. )y child5s sleeping or eating schedule was much harder to establish than I e3pected #2 #2 #2 #2 #2 #2

Dor the ne3t statement, choose your response from the choices E!F to E?F belowC B2. I have found that getting my child to do something or stop doing something isC !. much harder than I e3pected 2. somewhat harder than I e3pected B. about as hard as I e3pected G. somewhat easier than I e3pected ?. much easier than I e3pected ! 2 B G ?

/?

Dor the ne3t statement, choose your response from the choices E! ]F to E!-BF BB. 1hin& carefully and count the number of things which your child does that bothers you ! ] +-* /-@ G-? !-B BG. 1here are some things that my child does that really bother me a lot #2 2 2 2 :# :# :# . . . #. #. #.

B?. )y child turned out to be more of a problem than I e3pected #2 B/. )y child ma&es more demands on me than most children #2

//

2ppendi3 . 'ome #ituations Luestionnaire InstructionsC .oes your child present any problems with compliance to instructions, commands, or rules for you in any of these situationsS If so, please circle the word "ES and then circle a number beside that situation that describes how severe the problem is for you. If your child is not a problem in a situation, circle !O and go on to the ne3t situation on the form.
#ituations 9hile playing alone 9hile playing with other children 2t mealtimes 8etting dressed 9ashing and bathing 9hile you are on the telephone 9hile watching television 9hen visitors are in your home 9hen you are visiting someone5s home In public places (restaurants, stores, church, etc." 9hen father is home 9hen as&ed to do chores 9hen as&ed to do homewor& 2t bedtime 9hile in the car 9hen with a babysitter 1otalC 7es=:o :=2 )ild 7es :o :=2 ! 7es 7es 7es 7es 7es 7es 7es 7es 7es 7es 7es 7es 7es 7es 7es :o :o :o :o :o :o :o :o :o :o :o :o :o :o :o :=2 :=2 :=2 :=2 :=2 :=2 :=2 :=2 :=2 :=2 :=2 :=2 :=2 :=2 :=2 ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! If yes, how severeS #evere 2 B G ? / @ + 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 B B B B B B B B B B B B B B B G G G G G G G G G G G G G G G ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? / / / / / / / / / / / / / / / @ @ @ @ @ @ @ @ @ @ @ @ @ @ @ + + + + + + + + + + + + + + +

* * * * * * * * * * * * * * * *

)ean #coreC

/@

2ppendi3 E Parenting 6ocus of 4ontrol #cale

InstructionsC Please rate the degree to which you agree=disagree with the following statements.
#trongly #trongly .isagree .isagree :eutral 2gree 2gree

!. 9hat I do has little effect on my child5s behavior 2. 9hen something goes wrong between me and my child, there is little I can do to correct it B. If your child tantrums no matter what you try, you might as well give up G. )y child usually ends up getting his=her way, so why try ?. I am often able to predict my child5s behavior in situations /. It is not always wise to e3pect too much from my child because many things turn out to be a matter of good or bad luc& anyway @. 9hen my child gets angry, I can usually deal with him=her if I stay calm +. 9hen I set e3pectations for my child, I am almost certain that I can help him=her meet them *. 9hen my child is well-behaved, it is because he=she is responding to my efforts ! . I am responsible for my child5s behavior !!. )y life is chiefly controlled by my child !2. )y child does not control my life !B. )y child influences the number of friends I have !G. I feel li&e what happens in my life is mostly determined by my child !?. 9hen I ma&e a mista&e with my child I am usually able to correct it !/. Even if your child has fre0uent tantrums, a parent should not give up !@. I always feel in control when it comes to my child !+. )y child5s behavior is more than I can handle !*. #ometimes I feel that my child5s behavior is hopeless 2 . It is often easier to let my child have his=her way than to put up with a tantrum 2!. I find that sometimes my child can get me to do things I really did not want to do 22. )y child often behaves in a manner very different from the way I would want him=her to behave 2B. #ometimes when I5m tired, I let my child do things I normally wouldn5t 2G. #ometimes I feel that I do not have enough control over the direction my child5s life is ta&ing 2?. I allow my child to get away with things

! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! !

2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2 2

B B B B B B B B B B B B B B B B B B B B B B B B B

G G G G G G G G G G G G G G G G G G G G G G G G G

? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ? ?

/+

2ppendi3 D E3amples of 6ow Intensity 2ctivities Home Activities: 1a&ing baths ;eading Playing a board game 1al&ing with parents Preparing for bed Community Activities: )ovies=museum=library Parents5 office=place of wor& 4ar=train=bus=plane rides

.oing homewor& Playing computer games 4oloring=drawing #itting down at table=eating dinner 9atching a movie ;estaurants .octors5 offices ;eligious services

/*

2ppendi3 8
4onte3t #pecific Problem %ehavior Please answer the following two items based upon your child5s problem behavior, in the identified activity, during the past month.

!. .uring this activity, my child5s problem behavior isC

G
#omewhat Dre0uent

@
E3tremely Dre0uent

Infre0uent

2. .uring this activity, my child5s problem behavior isC

!
:ot Intense

G
#omewhat Intense

@
E3tremely Intense

2ppendi3 ' Crucial Components of a Psychoeducational Temperament Curriculum (4hess ( 1homas, !*+/" (!" 4hildren are born with many individual differences. Hust as children loo& different from one another, they also have different styles of behavior (called temperament" from birth. (2" 1hese behavioral differences can be e3pressed in many ways. 1hey can be seen by the way your child reacts to something difficult, the intensity of your child5s emotions, or the type of activities your child enjoys. T(B" 7our child is active, impulsive, prefers high intensity activities, and is not shy. 1his type of temperament style is called e3troversion, or surgency (;othbart et al., 2 (G" 1hese differences in temperament are normal. (?" #ome of these differences may ma&e it easier or harder to manage your child5s routines. (/" Parents should not focus all of their effort in trying to change their child5s temperament. It is unli&ely for temperament to change. (@" Parents should not e3pect that there is one set of parenting rules that will wor& for all children. 4hildren5s differences in temperament ma&e it li&ely that certain strategies will wor& better for some children than others. (+" )ost importantly, parents should not feel incompetent if their child has more difficult temperament characteristics than other children. Instead, parents should understand that difficult behaviors are the result of a poor match between the temperament of their child and the environment, not because of parental s&ill deficits. T(*" Parents can modify conte3ts that are difficult for their children in order to ma&e these conte3ts more compatible to their temperament, and reduce problem behavior (4hess ( 1homas, !**!, #uper ( 'ar&ness, !**G". T 1hese items have been added by the researchers from additional sources to supplement the curriculum provided by 4hess ( 1homas (!*+/". !".

@!

2ppendi3 I Problem #olving 1emplate (from #tiebel, !***" !. Identifying the problematic routine. 2. Identifying possible reasons for problem behavior in that routine. B. %rainstorming solutions. G. .iscussing pros and cons of each solution. ?. #electing the solution that fits best with the routine of interest. /. Planning a strategy for implementing the solution. @. ;eviewing &ey 0uestions relevant to the solutionC a. 9hat are the family goals for the routineS b. .o the solutions support your goals for the routineS c. 9ill the solutions wor& over an e3tended period of time (/-!2" monthsS d. 2re you comfortable with what you5ll be doingS +. Planning a follow-up meeting to discuss progress and to troubleshoot.

@2

2ppendi3 H .ecision 1ree for Intervention Protocol !. 2. B. G. ?. 2dminister 2%4, 4%L and ancillary 0uality of life measures. Psychoeducational session with family to discuss temperament Problem solving session with family to develop the intervention. 1each family intervention(s" for e3perimental conte3t, !-2 sessions of teaching by the e3perimenter. Damily must run B intervention sessions independently of researcher. 2t session G, has family mastered interventions for e3perimental conte3t (based on e3perimenter observation and I< integrity chec&"S If 7E#, EWPE;I)E:126 P>#1-1;2I:I:8C provide family with interventions for clinical e3tension conte3ts. If :>, provide additional training to family for one session. ;epeat #tep B as needed. 2fter B additional wee&s, does family report having mastered interventions for clinical conte3tsS If 7E#, complete 2 spot chec&s to confirm application of interventions. If :>, provide additional training to family for one session. ;epeat #tep G as needed. 'as family been observed during 2 spot chec&s to be implementing interventions for clinical e3tension conte3tS If 7E#, 46I:I426 EW1E:#I>: P>#1-1;2I:I:8 %E8I:#. If :>, continue to do spot chec&s until family has been observed 2 times applying the interventions. ;epeat #tep ? as needed. Post training data collection should occur for appro3imately !2 wee&s. .uring the final wee& of post intervention data collection, administer the 2%4, 4%L, and ancillary 0uality of life measures. :oteC I< M Independent variable

/.

@.

+.

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