Behavior Training Series

Bethany is a 6-year-old girl with Angelman syndrome (deletion positive). She lives with both of her parents and her typically developing sister. Over the past year, her parents noted that she has made several improvements with regard to her attention span, and her ability to sit still. She also seems to understand more. She has also started to become more independent with her toileting. She currently receives speech therapy school support services, where they are working on using pictures. She receives occupational therapy twice per week, and also receives physical therapy. She uses a friend’s iPad and may use an iPad at school, although this is not always integrated throughout her day. In spite of these clear improvements in cognition, language, and adaptive behavior skills, her parents have become increasingly concerned about her hitting and pinching behavior both at home and at school. This behavior has worsened significantly in the last few weeks. Her parents are unsure of whether changes to her medication regimen could be contributing to these behavioral difficulties. Due to her exhibiting these behaviors in school, they will have a behavior consultant attend the classroom and track her behaviors. In general, she gets along with her peers. She becomes anxious when in medical settings. Recently, a family member was hospitalized and she became very upset when seeing this individual in his hospital bed.

On formal evaluation, she walked with her parents toward the evaluation room but became very anxious upon seeing the room and examiners. She clung to her parents and vocalized. Upon entering the room, she sat on her mother’s lap. She warmed up when shown an iPhone application that played music, though at times she covered her ears (seeming sensitive to the sensory inputs). She made good eye gaze, coordinated with vocalizations and facial expressions to display her like or dislike of the music. It was quite clear that she does not have autism. She was able to transition to testing at the table though needed her mother to sit next to her. She showed good attention for tasks that were easy for her. However, once tasks became difficult, she threw the test materials or hit the examiners. She vocalized and reached for her mother to try to avoid testing. She was responsive to “If-Then” statements paired with visual cues (real objects), re-direction, ignoring of inappropriate behaviors, and some use of visual cues when paired with verbal prompts. She was somewhat tactile defensive when she was upset, and did not like the use of hand-over-hand physical prompts. She frequently gave objects to her mother or the examiner when she was done with them. She mouthed several objects during the assessment. She flapped her arms when excited.

In addition to some of the strategies that have been discussed throughout this module, we recommended that the child’s parents/teachers/therapists work to track her behaviors within the context of any changes to her medications. Specifically, we suggested the use of a functional behavioral analysis, with careful attention to when her behaviors seem to be better and what is occurring during that time. Within the context of the evaluation, her behaviors were quite manageable when she was being presented with tasks that were within her developmental level, but she exhibited several challenging behaviors as tasks became harder. Once the more detailed information has been gathered, we suggested that her parents share this information with the physicians who are monitoring her medications so that any necessary adjustments can be made as needed. They should also monitor any medical issues within the context of significant changes to her behavior.