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REDIRECTION AND SERTRALINE ON VOCAL STEREOTYPY CAIO F. MIGUEL, KATHY CLARK, LISA TERESHKO, AND WILLIAM H. AHEARN Although response interruption and redirection (RIRD) has been shown to be successful inreducing vocal stereotypy, recent reports have suggested that selective serotonin reuptakeinhibitors (SSRIs) may also reduce these behaviors. The purpose of the current investigation wasto examine the effects of RIRD with and without sertraline on automatically maintained vocalstereotypy of a 4-year-old boy with autism. Results suggested that vocal stereotypy decreasedwhen RIRD was implemented and that sertraline did not affect the participant’s vocal stereotypy.
autism, response interruption, selective serotonin reuptake inhibitors, _______________________________________________________________________________ Serotonin dysfunction has been hypothesized showed improvement on self-injury as mea- as being implicated in a variety of behaviors sured by a clinical rating scale (Hellings, Kelley, displayed by individuals with autism, including Gabrielli, Kilgore, & Shah, 1996). In the third stereotypy (e.g., McDougle et al., 1996). Recent case study, 9 children with autism (6 to 12 years reports have suggested that selective serotonin old) received 25- to 50-mg daily doses of reuptake inhibitors (SSRIs), which have been sertraline for the treatment of anxiety and prescribed for individuals with obsessive com- agitation (Steingard, Zimnitzky, DeMaso, Bau- pulsive disorder, may also serve to reduce man, & Bucci, 1997). The authors reported repetitive behaviors displayed by individuals that 8 of 9 participants showed improvement with autism. Sertraline (Zoloft), which has based solely on uncontrolled clinical observa- dopamine uptake-blocking properties, has been tions. Despite limited data on its effectiveness evaluated as a treatment for repetitive behavior for reducing repetitive behaviors, sertraline (and in individuals with autism in three open-label other SSRI medications) has been frequently studies. Results from one study conducted with prescribed for children with autism (Soorya, 42 adults with pervasive developmental disorder suggested that 50 to 200 mg of sertraline per Applied behavior-analytic procedures are an day resulted in improvement on measures of alternative to SSRIs that have been researched repetitive thoughts and aggression (McDougle and effectively used to reduce both motor and et al., 1998). Another study suggested that after vocal stereotypy (e.g., Ahearn, Clark, Mac- 28 days of treatment, 8 of 9 adults diagnosed Donald, & Chung, 2007; Piazza, Adelinis, with mental retardation, 5 of whom had autism, Hanley, Goh, & Delia, 2000). Most recently,Ahearn et al. evaluated the effectiveness of We thank Rebecca McDonald and the staff in the response interruption and redirection (RIRD) Intensive Instruction Program at NECC for their on-sitesupport, as well as Linda Copeland, Danielle LaFrance, on automatically maintained vocal stereotypy in and Becky Penrod for their comments on a previous 4 children (7 to 11 years old) diagnosed with version of this manuscript. Lisa Tereshko is now at Area autism. The procedure involved interrupting Address correspondence to Caio Miguel, who is now at vocal stereotypy and redirecting it to appropri- the Department of Psychology, California State Univer- ate vocalizations. An ABAB design was used to sity, Sacramento, 6000 J St., Sacramento, California determine the effectiveness of RIRD on vocal stereotypy. Vocal demands (e.g., social ques- tions) were presented following the occurrence toys that presumably did not match the sensory of vocal stereotypy and were continuously consequence that maintained the stereotypic presented until the child complied with three behavior. Moderately preferred toys were se- consecutively issued demands without stereoty- lected and were present during sessions.
py. In addition, if participants independentlyvocalized appropriately (e.g., asked for an item), Response Measurement, Experimental Design, and the teacher delivered praise and the requested item (if applicable). For each child, RIRD Vocal stereotypy was defined as any instance of decreased rates of vocal stereotypy substantially noncontextual or nonfunctional speech and more than those observed in baseline. For 3 of included sustained vowel sounds, varying pitch- the children, an increase in appropriate com- es of a sound, and spit swooshing at an audible munication (e.g., mands and tacts) was also level. Examples included ‘‘ee, ee, ee, ee’’ outside the context of a vocal imitation task. Non- examples included repeating a sound immedi- effects of RIRD with and without sertraline in ately after the experimenter, making a request, the treatment of automatically reinforced vocal or labeling items. An appropriate vocalization stereotypy displayed by a young child diagnosed was defined as the emission of a verbal utterance known to function as a mand or a tact (e.g., ‘‘alldone,’’ ‘‘toy’’).
vocalizations were collected using a data sheet with continuous 1-s intervals. Vocal stereotypy James was a 4-year-old child with autism and is reported as percentage of intervals, and communication delay. He was enrolled in an appropriate vocalizations are reported as a intensive applied behavior-analytic preschool frequency measure because they were discrete program during the course of the study. He had and varied little in duration. Observers recorded sertraline for his vocal and motor stereotypy implementations. Observers did not record data for 3 months prior to the beginning of the on vocal stereotypy or appropriate vocalizations study. Stereotypic behavior was reported by his when the experimenter implemented RIRD.
clinical team and parents to occur at unaccept- Furthermore, the experimenter stopped the able levels despite the medication. This high session clock each time he or she implemented level of stereotypy was not only interfering with the procedure and restarted it following delivery his learning, but it also prevented James from of social praise to ensure that time spent participating in a variety of activities with his implementing RIRD was taken out of the 5- peers. Although response blocking was being used to redirect motor stereotypy, no treatment The effects of RIRD and sertraline removal other than medication was in place for vocal were evaluated using an ABABC reversal design in which A was sertraline only, B was RIRD Experimental sessions were conducted once plus sertraline, and C was RIRD only.
per day in a room in James’ school (1.5 m by Interobserver agreement data were collected by 3 m) equipped with a wide-angle video camera, an independent rater during approximately 31% microphone, video recording equipment, mate- of treatment sessions across conditions. Mean rials for the session, and a table with two chairs.
interobserver agreement was 99% (range, 98% to A paired-stimulus preference assessment (Fisher 100%) for vocal stereotypy and 91% (range, 75% et al., 1992) was conducted with a variety of to 100%) for appropriate vocalizations.
A functional analysis of vocal stereotypy was Figure 1 (middle) depicts the percentage of conducted as described by Ahearn et al. (2007).
vocal stereotypy and frequency of appropriate Vocal stereotypy occurred across all conditions vocalizations across all conditions. During the of the functional analysis and most frequently sertraline-only phase, mean percentage of during the alone condition, suggesting that intervals with vocal stereotypy was 49%, and vocal stereotypy was maintained by automatic the mean number of appropriate vocalizations was 6.3 per session. When the experimenterimplemented RIRD, the mean percentage of intervals with vocal stereotypy decreased to Sertraline. The experimenter was present, and moderately preferred toys were in sight but (M 5 11.6% across the last 12 sessions). The out of reach. The experimenter interrupted total number of appropriate vocalizations per every instance of vocal stereotypy by removing any item with which James was engaged.
condition (M 5 22.4). During the reversal Mands were followed by social praise and the item. James took a daily dose of 10 mg of vocalizations returned to original levels. When RIRD plus sertraline. This condition was the the experimenter reintroduced RIRD, there same as the sertraline-only condition except was an immediate decrease in vocal stereotypy that the experimenter interrupted every in- (M 5 8.8%) and an increase in appropriate stance of vocal stereotypy by removing any vocalizations (M 5 15.8).When sertraline was item and presenting vocal demands, consisting of a series of vocal imitation tasks involving sounds that James had already mastered (e.g., percentage of vocal stereotypy or frequency ‘‘ah,’’ ‘‘ma,’’ ‘‘mo,’’ ‘‘ee,’’ ‘‘oh,’’ and ‘‘bee’’).
None of his appropriate vocalizations were Figure 1 (bottom) depicts the length of time experimenter presented vocal demands until implementing RIRD and frequency of imple- James responded correctly three times in the mentations across treatment sessions. When absence of vocal stereotypy. Social praise the experimenter first introduced RIRD, the followed correct responses. Appropriate mands time spent implementing the procedure de- again resulted in delivery of social praise and (Session 18), 35 and 20 implementations per session, respectively. During the second intro- faded across 5 days while RIRD continued to duction of RIRD, the time spent implement- be implemented. The fading dosages of 6 mg, ing the procedure decreased from 156 s to 33 s (Session 37), 31 and 10 implementations per developmental pediatrician who had originally These results replicate those of Ahearn et al.
Follow-up. Follow-up sessions were conduct- (2007) in that vocal stereotypy decreased with the introduction of RIRD, while appropriate sertraline to no longer be physiologically vocalizations (mands) increased. In addition, when sertraline was removed, the participant’s Percentage of intervals with vocal stereotypy for James during functional analysis sessions (top). Percentage of intervals with vocal stereotypy (left axis) and total number of appropriate vocalizations (right axis) during responseinterruption and redirection intervention (RIRD) with and without sertraline (middle). Length of time (seconds) spentimplementing RIRD (left axis) and frequency of RIRD implementations across treatment sessions (right axis) across allconditions (bottom).
reducing repetitive behaviors in children with autism to assist in providing that empirical evidence necessary to develop dosage guide- Of note, the results of the current study were collected during school hours suggested that relevant only to the participant evaluated.
the procedure was initially being implemented However, the procedures employed could be as often as 100 times per day. Future research expanded for the study of other individuals should evaluate the effectiveness and feasibility receiving similar interventions and with similar of an RIRD-based procedure conducted across topographies of behavior. We believe that the the entire day under naturalistic conditions.
current investigation provides a practical meth- The current study is the first to evaluate od for determining the effects of specific medications on problem behaviors in clinical combination with a behavioral intervention settings. Single-subject research designs can be in the treatment of vocal stereotypy displayed used to monitor the effects of medications on by an individual with autism. Although no problem behaviors in the same manner that decreases in motor stereotypy were observed these designs are used to evaluate behavioral as a function of this intervention, future interventions. The evaluation of drug–behavior research should evaluate the effects of sertra- interactions in the clinical setting is an area in which behavior analysts have much to contrib- Although these results support the effective- ness of RIRD, it suggests that sertraline was not effective in treating vocal stereotypy Ahearn, W. H., Clark, K. M., MacDonald, R. P. F., & displayed by this participant. Had sertraline Chung, B. I. (2007). Assessing and treating vocal been exerting suppressive effects on the target stereotypy in children with autism. Journal of Applied behavior, its removal should have resulted in Fisher, W., Piazza, C. C., Bowman, L. G., Hagopian, an increase in vocal stereotypy. An important L. P., Owens, J. C., & Slevin, I. (1992). A limitation of the study is that sertraline comparison of two approaches for identifying reinforcers for persons with severe and profounddisabilities. Journal of Applied Behavior Analysis, reversal design to demonstrate experimental Hellings, J. A., Kelley, L. A., Gabrielli, W. F., Kilgore, E., vocal stereotypy remained low, James’ family & Shah, P. (1996). Sertraline response in adults with did not want to reintroduce it. Future studies mental retardation and autistic disorder. Journal ofClinical Psychiatry, 57, 333–336.
should attempt to alternate introduction and Martin, A., Scahill, L., Charney, D. S., & Leckman, removal of medications systematically using J. F. (2003). Pediatric psychopharmacology: Princi- reversal or crossover designs. Another possible ples and practice. New York: Oxford UniversityPress.
limitation is that the 10-mg dose may have McDougle, C. J., Brodkin, E. S., Naylor, S. T., Carlson, D. C., Cohen, D. J., & Price, L. H. (1998). Sertraline effect. There are currently no objective dosage in adults with pervasive developmental disorders: Aprospective open-label investigation. Journal of Clin- guidelines for the use of psychotropic medi- ical Psychopharmacology, 18, 62–66.
cations in children, especially those with McDougle, C. J., Naylor, S. T., Cohen, D. J., Volkmar, F.
autism (Martin, Scahill, Charney, & Leckman, R., Heninger, G. R., & Price, L. H. (1996). A double-blind, placebo-controlled study of fluvoxa-mine in adults with autistic disorder. Archives of effectiveness of different doses of sertraline in General Psychiatry, 53, 1001–1008.
Piazza, C. C., Adelinis, J. D., Hanley, G. P., Goh, H., & Steingard, R. J., Zimnitzky, B., DeMaso, D. R., Bauman, Delia, M. D. (2000). An evaluation of the effects of M. L., & Bucci, J. P. (1997). Sertraline treatment of matched stimuli on behaviors maintained by auto- transition-associated anxiety and agitation in children matic reinforcement. Journal of Applied Behavior with autistic disorder. Journal of Child and Adolescent Soorya, L., Kiarashi, J., & Hollander, E. (2008). Psycho- pharmacologic interventions for repetitive behaviors in autism spectrum disorders. Child and Adolescent Psychiatric Clinics of North America, 17, 753–771.


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