http://dx.doi.org/10.24016/2024.v10.430
ORIGINAL ARTICLE
Effectiveness of functional
communication training in the regulation of self-injurious behavior in children
and adolescents diagnosed with autism spectrum disorder: an empty systematic
review
Efectividad del entrenamiento en comunicación funcional en la regulación
de la conducta autolesiva en niños y adolescentes diagnosticados de trastorno
del espectro autista: una revisión sistemática vacía
Franco Tejada-Flores1,
Yscenia Paredes-Gonzales 2
1 Valencian
International University, Valencia, Spain.
2 Instituto
Peruano de Orientación Psicológica, Lima, Peru.
*
Correspondence: yosoyfrancops@gmail.com
Received: September 15, 2024 |
Revised: October 15, 2024 | Accepted: October 18, 2024
| Published Online: October 23, 2024
CITE IT AS:
Tejada-Flores,
F., Paredes-Gonzales, Y. (2024). Effectiveness of functional communication
training in the regulation of self-injurious behavior in children and
adolescents diagnosed with autism spectrum disorder: an empty systematic review.
Interacciones, 10, e430. http://dx.doi.org/10.24016/2024.v10.430
ABSTRACT
Background: Self-injurious behaviors are highly prevalent in
individuals with autism spectrum disorder (ASD), occurring frequently in those
with associated intellectual disabilities as well as in those without
intellectual impairment. Single-case studies have found that functional
communication training helps regulate self-injurious behaviors and repetitive
behaviors, particularly in children with ASD. However, no review identifies
whether there is experimental evidence to support the use of this treatment. Objective: Our review aims to determine
the efficacy of functional communication training for regulating self-injurious
behavior in children and adolescents diagnosed with ASD. Methods: A systematic review was conducted.PubMed, Scopus, Web of Science, and Embase
were searched for single-case experimental studies and randomized clinical
trials. Results: A total of 67
studies were initially identified, of which 16 remained eligible after
duplicate elimination and selection based on title and abstract. However, a
thorough review of each text revealed that some needed to meet the inclusion
criteria or had exclusionary elements. Therefore, they did not qualify for the
next stage of the process. As a result, no publications were found that
provided robust evidence to support the efficacy of functional communication
training in regulating self-injurious behaviors in children and adolescents
diagnosed with ASD. However, four publications met the secondary objective of
identifying relationships between the proposed variables and presenting
variations of the proposed intervention prototype. The quality of these
publications was assessed and discussed according to the transparency
recommendations of the Cochrane Effective Practice and Organization of Care
guideline for reporting reviews without eligible or empty studies and the
PRISMA 2020 guidelines. Conclusions: There
is an urgent need for more research in this area, given the harmfulness
and self-injurious behaviors, in addition to their high incidence in
individuals diagnosed with ASD. This study's results help identify existing
knowledge gaps and suggest new directions for research in this area.
Keywords: autism spectrum disorder; self-injurious
behaviors; functional communication training; children; girls; adolescents;
systematic review.
RESUMEN
Introducción: Las conductas autolesivas son altamente prevalentes en individuos con
trastorno del espectro autista (TEA), ocurriendo con frecuencia tanto en
aquellos con discapacidad intelectual asociada como en aquellos sin
discapacidad intelectual. Los estudios de casos individuales han encontrado que
el entrenamiento en comunicación funcional ayuda a regular las conductas
autolesivas y las conductas repetitivas, particularmente en niños con TEA. Sin
embargo, no hay ninguna revisión que identifique si existen pruebas
experimentales que apoyen el uso de este tratamiento. Objetivo: Nuestra revisión busca determinar la eficacia del
entrenamiento en comunicación funcional para la regulación de la conducta
autolesiva en niños, niñas y adolescentes diagnosticados con TEA. Método: Se realizó una revisión
sistemática. Se realizó la búsqueda de estudios experimentales de caso único y
ensayos clínicos aleatorizados en PubMed, Scopus, Web
of Science y Embase. Resultados: Inicialmente,
se encontraron un total de 67 investigaciones, de las cuales, tras la
eliminación de duplicados y la selección basada en el título y el resumen,
quedaron 16 artículos elegibles. Sin embargo, durante la revisión exhaustiva de
cada texto, se descubrió que algunos no cumplían con los criterios de inclusión
o presentaban elementos excluyentes, por lo que no calificaron para la
siguiente etapa del proceso. En consecuencia, no se encontraron publicaciones
que brinden evidencia robusta para comprobar la eficacia del entrenamiento en
comunicación funcional para regular las conductas autolesivas en niños, niñas y
adolescentes diagnosticados con TEA. No obstante, cuatro publicaciones lograron
cumplir el objetivo secundario de identificar relaciones entre las variables
propuestas y presentar variaciones al prototipo de intervención planificada.
Estas publicaciones fueron evaluadas en calidad y discutidas siguiendo las recomendaciones
de transparencia de la guía de Cochrane Effective Practice and Organisation of Care para informar revisiones sin estudios elegibles o
vacías y los lineamientos de PRISMA 2020. Conclusiones:
Existe una necesidad imperante de más investigación en este campo dada la
nocividad y facilidad de cronificación de las conductas autolesivas, además de
su alta incidencia en personas diagnosticadas con TEA. Los hallazgos de este
estudio ayudan a identificar las brechas de conocimiento existentes y sugiere
nuevas direcciones para la investigación en este campo.
Palabras claves: trastorno del espectro autista; conductas autolesivas;
entrenamiento en comunicación funcional; niños; niñas; adolescentes; revisión
sistemática.
Self-injurious
behaviors represent highly harmful clinical phenomena, with the potential for
chronicity and a significant negative impact on individuals' health and
well-being. In the context of neurodevelopmental disorders, self-injurious
behavior is defined as behavior in which an individual unintentionally causes
harm to themselves, excluding suicidal intent (Iwata et al., 1994). Like
others with an operant component, these behaviors are governed by environmental
consequences that increase the likelihood of their repetition in similar
contexts. On the other hand, the DSM-5 also defines self-injury in the context
of neurodevelopmental disorders, noting that it can occur without suicidal
intent and is associated with deficiencies in impulse control, communication
difficulties, and atypical sensory responses. These factors interact to
increase the likelihood of self-injurious behaviors, which, in these cases,
have repetitive and persistent characteristics as part of the behavioral
profile of neurodevelopmental disorders (American Psychiatric Association,
2013). In other words, self-injurious behaviors are reinforced by the effects they
produce and will persist as long as they continue to yield the same outcomes in
similar situations (Hanley et al., 2003). These behaviors are particularly
prevalent in individuals with neurodevelopmental disorders, such as Autistic
Spectrum Disorder (ASD) (Maenner et al., 2023). They can affect various
areas of their functioning and quality of life (Waizbard-Bartov
et al., 2023). Therefore, it is imperative to have effective and timely
treatments to address these behaviors and reduce the associated disability
The prevalence
of autism in infants has shown a sustained increase in recent years (Alrehaili et al., 2023). Various studies have
supported this trend, demonstrating an increasing proportion of individuals
with ASD compared to the general population, ranging from 1 in 36 (Maenner
et al., 2023), 1 in 59 (Iyama-Kurtycz, 2020),
and 1 in 100 (Zeidan et al., 2022). In the latter study, a male-to-female
ratio of 4:1 was found, with 30% of cases also presenting comorbid intellectual
disability. This rise in prevalence, along with the significant impact on the
autonomy of individuals with ASD whose specific needs are not addressed
promptly, makes this condition a substantial focus for public health research.
Self-injurious
behaviors are highly prevalent in individuals with ASD (Maenner et al.,
2023), occurring frequently in those with associated intellectual disabilities
as well as in those without intellectual impairment (Soke et al., 2017; Rydzewska
et al., 2019). The function of these behaviors can vary over time and
throughout the development of the individual with ASD (Furniss and Biswas,
2020). Furthermore, they are linked to neurobiological mechanisms related to
self-regulation and coping with stress and anxiety (Rothbart, 2007).
The risk
factors for self-injurious behaviors in individuals with ASD vary depending on
the presence or absence of intellectual disability (Furniss and Biswas, 2020).
In individuals with ASD and intellectual disability, risk factors include
atypical sensory processing, insistence on sameness, deficits in social and
communicative functioning, and high levels of anxiety (Dempsey et al.,
2016; Duerden et al., 2012; Soke et al., 2017). In individuals with
ASD without associated intellectual disability, the risk factors are limited to
atypical sensory processing, insistence on sameness, and deficits in social and
communicative functioning (Black et al., 2017; Rattaz
et al., 2015; Rodgers et al., 2012). Additionally, Paula (2018)
highlights that genetic vulnerability is a critical factor in the development
of self-injurious behaviors in this population, noting that this genetic
predisposition can interact with specific environments to intensify the manifestation
of these behaviors. According to Paula (2018), certain environmental and
contextual factors can act as triggers in individuals with a genetic
predisposition, increasing the likelihood of self-injurious behaviors.
Functional
communication training is an evidence-based intervention that has shown
positive results in reducing the frequency and intensity of excessive
behaviors, including self-injurious ones (Ghaemmaghami et al., 2021; Tiger
et al., 2008). Functional communication training is based on the
differential reinforcement of other behaviors, a behavioral modification
technique that proposes an alternative, topographically different but
functionally equivalent, to a behavior identified as problematic (Carr &
Durand, 1985). The aim of replacing the problematic behavior is to reinforce
the continued occurrence of the alternative behavior. Simultaneously, the
extinction of the interfering or problematic behavior is sought, eventually
establishing a new behavioral repertoire that maintains the same functionality
but varies in its presentation mode, helping the individual develop socially
relevant behaviors (Vollmer et al., 2020). In the context of this
research, this refers to behaviors related to the communication of needs and
the establishment of bidirectional relationships based on verbal behavior (Durand,
1990).
Single-case
studies have found that functional communication training helps regulate
self-injurious and repetitive behaviors, particularly in children with ASD (Carr
& Durand, 1985; Ghaemmaghami et al., 2021; Tiger et al., 2008).
However, a comprehensive literature synthesis that systematically evaluates its
impact on regulating these behaviors in the population above has not yet been
conducted. This gap in the available evidence poses a barrier to identifying
effective and efficient interventions for various self-injurious behavior
topographies, hindering the development of optimal treatment solutions for this
issue.
Our study
aimed to conduct a systematic review of the literature to determine whether
functional communication training is efficacious in improving the regulation of
self-injurious behaviors in children and adolescents diagnosed with ASD.
METHODS
Design and protocol
We used the
criteria proposed in the PRISMA 2020 statement for systematic reviews and meta-analyses
(Page et al., 2021) (see supplementary material 1). Our protocol was registered
in PROSPERO (CRD4202424540914).
Eligibility criteria
The present
systematic review was based on the PICOS strategy (P: participants, I:
intervention, C: comparison, O: outcomes, and S: study design) (Amir-Behghadami & Janati, 2020),
which allowed structuring the research question of this study: is functional
communication training significantly effective in regulating self-injurious
behaviors in children and adolescents diagnosed with ASD?
In this sense,
the present research proposes the following inclusion criteria for review
studies.
Participants:
Children and adolescents under the age of 18 are diagnosed with ASD. Reviews
that include research in which the family or primary
caregivers of this population receive the intervention will also be considered,
as long as they are the indirect applicators of the
intervention.
Intervention:
Functional communication training is derived from the differential
reinforcement process (hence it is found under both names) of Applied
Functional Analysis (ABA).
Comparison: it
is not necessary to compare it with other treatments.
Outcome:
Regulation of self-injurious behavior, understood as a quantitative reduction
in the frequency, intensity, or duration of such behavior as measured by direct
or indirect behavioral observation scales.
Studies (types
of studies): randomized clinical trials and single-case experimental studies
conducted from 1985 (date of proposal of the functional communication training
protocol) to the date of the search: May 04, 2024.
It is worth
mentioning that the following exclusion criteria were considered: systematic
reviews, meta-analyses, case studies, studies focusing on a diagnosis other
than autism, quasi-experimental studies, studies conducted in adult
populations, letters to editors or other non-peer-reviewed articles (books,
chapters, book reviews, dissertations, etc.).
Finally, it is
pertinent to mention that the (Cochrane Effective Practice and Organisation of Care (EPOC), 2017) recommends making
explicit the reason for including certain types of studies; in the case of the
present research, we seek to extrapolate and generalize the data found to
obtain robust information about the effectiveness of functional communication
training for the regulation of self-injurious behaviors in children and
adolescents with ASD. This aspect can be achieved when there are experimental
conditions such as randomization in the assignment of variables, the
establishment of control groups, and the guarantee of replicability.
Information sources
The search was
carried out in the main databases of international prestige in psychology,
neuropsychology, and other health sciences. Four reference sources were
selected: PubMed, Scopus, Web of Science (WOS), and Embase.
Search Strategy
Key terms
derived from the PICOS proposal were identified: autism, children and
adolescents, functional communication training, self-injurious behavior,
randomized clinical trials, and single-case experimental studies. The search
was carried out by translating these terms into English, as this is the
language in which most of the scientific production exists. Once translated, we
searched for mesh terms (medical subject headings) from the National Library of
Medicine of the United States. This allowed us to homologate other terms that
allude to the same concept. These terms were combined using the Boolean
connectors "AND" and "OR" (see supplementary material 2).
It should be
noted that depending on the database used, some codes or ways of designing the
search strategy may change: In PubMed, the [mesh] specifier is used for
homologous terms, in addition to the [tiab] search
engine, so that key terms are searched both in the title and the abstract or
summary; in SCOPUS, the "TITLE-ABS-KEY" specifier is used so that
terms are searched in the title, abstract and keywords by their English names;
in WOS, "TS" is used to search for the terms of the subject in the
title, abstract and keywords; in EMBASE, the "/exp" terminator is
used to search not only for the term but also for other related terms, in
addition to "ti,ab,kw" to search for the
terms in the title, abstract and keywords, thus allowing a more detailed and
complete exploration of the information.
The Appendix
section details the selected concepts, results, and search strategies designed
for each database: PubMed, Scopus, Web of Science, and Embase, whose searches
were conducted on May 4, 2024. The recording of this information contributes to
the transparency of scientific work, as it allows any other researcher to
verify the accuracy of the recorded data at any time (Cochrane Effective
Practice and Organisation of Care (EPOC), 2017).
Selection process
During the
search process, all identified records were downloaded in RIS format and
consolidated into a Zotero file that served as a repository for all retrieved
records. However, this file may have contained duplicate records removed using
both automated and manual methods. The list of unique records was then exported
from Zotero to Rayyan, a web tool designed explicitly for systematic reviews (Ouzzani et al., 2016). The review of titles,
abstracts, and full texts was performed independently by two investigators. To resolve discrepancies in evaluating these sections, two
reviewers discussed each point in meetings organized for this purpose. A third
reviewer was called upon to make the final decision if an agreement could not
be reached. It is worth noting.
Data extraction process
Two authors
collected information from the included studies using a data extraction form
previously designed in a Microsoft Excel spreadsheet. The extraction form was
assessed: a) general information (authors, year of publication, title, country,
and language); b) characteristics of the participants (age range, percentage of
females, total number of participants, prevalence of diagnosis, and level of
impairment associated with the diagnosis of ASD); c) characteristics of the
interventions (duration, frequency and brief description of the intervention);
d) information on passive comparators (i.e., nothing, waiting list and
treatment as usual) or active comparators (i.e., sensory therapy as usual) or
active comparators (i.e., sensory therapy as usual). e.g., nothing, wait-list,
and treatment as usual) or active comparators (e.g., sensory therapy,
pharmacological therapy, psychological therapies, and other ABA-based
therapies)*; e) main outcomes (means, standard deviations, and numbers of
participants before and after the intervention, effect size of the control and
intervention groups); f) other relevant information such as conflicts of
interest, funding, and number of study arms.
Analysis plan
Our protocol originally proposed a meta-analysis.
However, we did not perform such an analysis because our review did not find
any clinical trials or single-case experimental studies (as will be presented
later). Cochrane's recommendation for empty reviews
suggests reporting studies that partially meet the inclusion criteria.
Therefore, a descriptive sub-analysis of these studies was conducted, in which
each one was individually described.
Originally, a
meta-analysis and a risk of bias assessment using the RoB2 tool were planned.
However, since the review yielded no results, these analyses could not be
conducted.
RESULTS
Study selection
Our study identified 67 records in the different databases. Duplicate records were excluded (n=23), and 44 records were reviewed by title and abstract. Subsequently, only 16 records were reviewed for full text. However, all records were excluded as none met our inclusion criteria (see Figure 1). The 16 records examined in full text are listed in supplementary material 3, along with the reasons for each record's exclusion. Therefore, the present systematic review is declared empty.
Figure 1. Flowchart.
Finding an empty systematic review should not be interpreted as a
negative assessment of the study, but rather as an opportunity to identify
areas of science that need further attention and research (Yaffe et al.,
2012). The Cochrane Network provides specific guidelines for reporting
systematic reviews in which no eligible studies are found that meet the
established inclusion criteria (Cochrane Effective Practice and Organisation of Care (EPOC), 2017). These guidelines
emphasize the importance of transparency in explaining the absence of eligible
studies to avoid the inclusion of untrue data, which was rigorously followed in
this study.
Secondary
analysis of excluded records
In the case of empty systematic reviews, the Cochrane Network suggests
considering research that does not meet all inclusion criteria or has some
exclusion criteria. However, it may still be helpful for secondary analyses (Cochrane
Effective Practice and Organisation of Care (EPOC),
2017). These studies may contain relevant data related to the research
objectives or serve as a guide for future research. Following this
recommendation, we analyzed four articles that, although initially excluded,
were considered beneficial to answer our research question partially.
Bienstein and Nussbeck (2009)
This study details an individual intervention conducted with a
10-year-old female patient diagnosed with ASD and a possible associated
intellectual disability. A descriptive (non-experimental) case study design was
used to document the intervention's assessment, planning, and implementation,
which focused on functional communication training. A reduction in self-injurious and other diagnosis-related problem behaviors was
observed, however, hypothesis tests were not used because it cannot be
determined that there would have been a significant reduction. Although the
study provides evidence for the effectiveness of this intervention in reducing
self-injurious behaviors, it is essential to note that, due to the
non-randomized nature of the research and the lack of a control group, the
results are not generalizable to other populations.
Muharib et al.
(2019)
This study describes the design, implementation, and evaluation of a
functional communication training intervention for two children diagnosed with
autism, ages five and six. Using a non-experimental case study approach, it was
found that only one of the children exhibited self-injurious behaviors, such as
violent head shaking. Both children were preverbal, meaning they did not
functionally use oral language. The intervention used an electronic device to
facilitate communication by exchanging pictures. Results indicated improvements
in regulating both children's behaviors; however, hypothesis testing was not
conducted to determine a statistically significant reduction in these
behaviors.
Hall et al.
(2022)
This study examines the efficacy and long-term sustainability of a
previous intervention (follow-up) to reduce challenging behaviors in children
with Fragile X syndrome delivered via telemedicine. The goal was to evaluate
the effectiveness of an intervention that persists when subjects return to
their natural environments. The results indicate that children who received
functional communication training showed a reduced tendency to exhibit
challenging behaviors.
It is important to note that although the study focuses on fragile X
syndrome and not autism spectrum disorders (ASD), the behavioral manifestations
may be similar. Previously, conditions such as Rett syndrome and childhood
disintegrative disorder were classified within the autism spectrum according to
the fourth edition of the Diagnostic and Statistical Manual of Mental Disorders
(Rosen et al., 2021). In addition, telehealth training requires parents
and caregivers to be trained to perform the activities guided, suggesting a
promising approach for future functional communication interventions. This
study highlights the importance of investigating the sustainability of outcomes
after the intervention ends, a critical but understudied aspect in the
management of self-injurious behaviors (Ghaemmaghami et al., 2021).
Casey and Merical
(2006)
This study evaluates the use of functional communication training with
individuals with ASD who exhibit self-injurious behaviors, as part of the
procedure involves extinction, which in some cases may reinforce the target
behavior. This single-case (non-experimental) design study describes the case
of an 11-year-old patient who underwent a functional communication training
intervention to reduce self-injurious behaviors. The researchers highlight the
success of intervention without resorting to techniques such as extinction or
positive punishment and point out that the use of differential reinforcement in
different situations, contingent and non-contingent, produced similar results.
In addition, it is emphasized that the intervention was followed up for up to
two years, showing that the benefits obtained were maintained to some extent
over time. This aspect underscores the importance of including long-term
evaluation procedures in research reports of this type of intervention (Ghaemmaghami
et al., 2021).
DISCUSSION
The central contribution of the present review is to identify that there
is no experimental evidence to support the efficacy of functional communication
training in regulating self-injurious behaviors in children and adolescents
with ASD.
The lack of evidence may be because our review's two main search terms
have highly variable definitions, such as ASD and self-injurious behaviors.
This highlights the need for greater conceptual precision in future research.
On the one hand, about self-injurious behaviors, it has been observed
that this term shares its semantic field with other terms that require greater
precision and operationalization, such as non-suicidal self-injury, which still
needs to be the subject of further research for its precise definition (American
Psychiatric Association, 2023). Another example is the dichotomy of terms such
as self-harm and self-injury. The literature suggests that the difference
between them is that the former implies an intention to harm, whereas the
latter does not. Paula (2018) explained that the difficulty here lies in the
fact that intentionality may be required in some instances, such as those with
ASD, intellectual disabilities, and the absence of functional oral language,
which makes it challenging to identify the person's purpose in self-harming and
therefore to determine which term to apply to their activity. Furthermore, the
concept of "challenging behavior" is presented as a broad term
encompassing the destruction or damage of the environment or the person himself,
implicitly including self-harm (Muharib et al., 2019). In this sense, it
is essential to note that when reviewing studies dealing with self-injurious
behavior, it is valid to ask whether the exact definition of such behavior is
being used, highlighting the need for greater precision and uniformity in the concept
(Paula, 2018). Similarly, in the proposal of Furniss and Biswas (2020),
self-injurious behaviors are described as those that develop in stages,
starting with behaviors controlled by responsive and operant conditioning
processes and progressing to a compulsive stage. It is noted that the
functional communication training procedure may be more effective in one of
these stages and less effective in others, suggesting the need for segmentation
or diversification to achieve greater precision in selecting the specific
population to be studied.
On the other hand, regarding the definition of ASD, Rosen et al. (2021)
note that in previous editions of the DSM-IV manual, it was mentioned that this
diagnostic label included other clinical conditions such as fragile X syndrome,
Rett syndrome, and childhood disintegrative disorder, among others. This leads
us to consider the possibility that these terms and other conditions related to
neurodevelopmental impairments and a behavioral phenotype like ASD could be
included as inclusion criteria in future research. In addition, there is
evidence that functional communication training is practical in regulating
behavioral excesses, particularly those related to the social initiative and
functional communication deficits, in individuals with ASD and intellectual
disability, both boys and girls (Bienstein & Nussbeck, 2009; Casey & Merical, 2006; Muharib
et al., 2019). However, it remains to be determined whether self-injurious
behaviors developed in other subgroups, such as ASD without intellectual
disability, can also be addressed by this type of training, given that there
are anatomical and functional differences that suggest that the same
self-injurious behaviors may have different causes depending on the ASD
subgroup investigated, as pointed out by Uljarević
et al. (2017) and Traynor et al. (2018).
In line with the above, it is essential to mention that basic
communication intervention programs for children with ASD with intellectual
disabilities are effective in reducing a wide range of overreaching behaviors (Brignell
et al., 2018). However, many of these behaviorally oriented programs need
to explicitly incorporate terms such as functional communication training or
differential reinforcement into their theoretical frame of reference, making it
difficult to identify using the search strategy used in the present study.
Therefore, a review of this concept is necessary.
As noted above, functional communication training is based on
differential reinforcement; both techniques are derived from applied
behavior analysis, a technological branch of behavior analysis. Traditionally,
applied behavior analysis has been studied using single case studies in which
standardization of the individual's pre-intervention baseline conditions served
as the control variable. This approach allowed for the accumulation of evidence
to strengthen the efficacy of interventions for social functioning and
communication difficulties. However, the lack of randomization in the results
and the use of control cases limits the generalizability of the results. As Smith
(2012) points out, this is one of the aspects in which branches such as
neuropsychology and behavior analysis are expected to make progress, since they
have traditionally opted for case studies, especially in people with injuries
or neurodevelopmental disorders, which, although they provide information about
the interventions under consideration, do not allow for the generalization of
their results and, therefore, for the acquisition of solid evidence to
establish it as a proven effective intervention. The latter aspect has been
historically pending for the discipline of behavior analysis.
Although positive effects have been observed with functional
communication training, these results cannot yet be generalized to application
in large groups or large-scale interventions in the ASD population. As noted
above, the lack of randomized clinical trials precludes the availability of
robust evidence to support the applicability of this technique in large
populations.
As a result, information about the potential benefits of this
intervention is fragmented and incomplete, making it difficult for broad
segments of the population to access and benefit from this intervention. In
addition, the lack of sufficient evidence reduces the likelihood that these
proposals, although promising, will be considered in public policies designed
to address self-injury in people with ASD, which mainly affects those with
lower socioeconomic resources (Talantseva
et al., 2023). This may result in a lack of early and timely intervention,
increasing the risk of self-harm becoming chronic over time, demonstrating an
urgent and real need for attention.
Strengths and
limitations
The main strength
of our study is that a comprehensive review of major scientific article
databases was conducted, ensuring a broad understanding of the available
evidence. This makes it unlikely that randomized clinical trials or single-case
experimental studies focusing on functional communication training to regulate
self-injurious behaviors in children and adolescents under 18 years of age
diagnosed with ASD were omitted.
However, our
research also has certain limitations. First, key terms such as ASD,
self-injury, and functional communication training have been conceptualized
differently, broadening possible interpretations and making it difficult to
identify the most relevant research systematically. Second, although our study
focuses exclusively on the effectiveness of functional communication training
in reducing self-injurious behaviors in children and adolescents with ASD, it
is limited by not including other types of designs, such as nonexperimental and
single-case studies with control conditions, which could have increased the
number of studies considered. Third, the study excludes preprints, which
implies the possible omission of relevant research in the publication process. Finally, excluding the PsycINFO database represents a
limitation, as it may have led to the absence of additional studies relevant to
our research question.
Future research
lines
Future systematic reviews should include quasi-experimental studies to
strengthen the evidence, although this may compromise the replicability and
generalizability offered by control group clinical trials. Quasi-experimental
studies can serve as a starting point to encourage more randomized clinical
trials in this area.
In addition, it is critical to establish a clear delineation of ASD
subtypes or a classification that includes phenotypic manifestations shared
with other diagnoses to broaden the population sample in research. In addition,
it is recommended that an "umbrella term" be developed to encompass
the functional communication training and differential reinforcement implicit
in programs designed to improve communication and socialization skills in
individuals with ASD. A conceptual systematic review could be developed to
define such an umbrella term.
Finally, based on the secondary analysis, a telehealth intervention
focused on training the family, so that the indirect beneficiaries are the
children and adolescents with ASD, emerges as a promising proposal. This trend
of remote interventions has gained momentum in recent years and may offer
effective solutions.
Conclusion
Our study found that, at the time of the search, no randomized clinical
trials or single-case experimental studies had been published evaluating the
effect of functional communication training in regulating self-injurious
behaviors in children and adolescents under 18 diagnosed with ASD. As a result,
the effectiveness of functional communication training in regulating
self-injurious behaviors in this population is unknown based on the evidence
reported in academic databases. However, uncontrolled and quasi-experimental
studies suggest positive effects of this intervention in their functioning and
foundation that justifies the need for controlled and randomized studies to
assess its effectiveness in this population rigorously. The results of the
present systematic review demonstrate the need for further research in this
area, mainly focused on controlled studies that allow causal inference of the
actual effect of functional communication training in regulating self-injurious
behaviors in the ASD population.
ORCID
Franco Tejada-Flores https://orcid.org/0000-0002-9017-1545
Yscenia Paredes-Gonzales https://orcid.org/0009-0001-7588-4977
AUTHORS’
CONTRIBUTION
Franco Tejada-Flores: Conceptualization,
Methodology, Validation, Formal analysis, Investigation, Data Curation, Writing
- Original Draft, Visualization.
Yscenia Paredes-Gonzales: Methodology,
Validation, Formal analysis, Investigation, Data Curation, Writing - Original
Draft.
FUNDING SOURCE
This study has not been funded by any institution.
CONFLICT OF INTEREST
The authors declare no conflicts of interest in
collecting data, analyzing information, or writing the manuscript.
ACKNOWLEDGMENTS
Not applicable.
REVIEW PROCESS
This study has been reviewed by external peers in double-blind mode by Giuliana
Salazar, Christian Canales, and another reviewer. The editor in charge was Renzo
Rivera. The review process is included as supplementary material 4.
DATA AVAILABILITY STATEMENT
Not applicable.
DISCLAIMER
The authors are responsible for all statements made in
this article.
REFERENCES
Alrehaili, R. A., ElKady, R. M., Alrehaili, J. A.,
& Alreefi, R. M. (2023). Exploring Early
Childhood Autism Spectrum Disorders: A Comprehensive Review of Diagnostic
Approaches in Young Children. Cureus, 15(12),
e50111. https://doi.org/10.7759/cureus.50111
American
Psychiatric Association. (2023). Diagnostic
and Statistical Manual of Mental Disorders | Psychiatry Online. DSM
Library. https://psychiatryonline.org/doi/book/10.1176/appi.books.9780890425787
Amir-Behghadami, M., & Janati, A.
(2020). Population, Intervention, Comparison, Outcomes and Study (PICOS) design
as a framework to formulate eligibility criteria in systematic reviews. Emergency Medicine Journal: EMJ, 37(6), 387.
https://doi.org/10.1136/emermed-2020-209567
Bienstein, P., & Nussbeck, S. (2009). [Reducing
self-injurious behaviour through functional
communication training—A single case study]. Zeitschrift Fur Kinder- Und Jugendpsychiatrie Und Psychotherapie, 37(6),
559-568. https://doi.org/10.1024/1422-4917.37.6.559
Black, K. R.,
Stevenson, R. A., Segers, M., Ncube, B. L., Sun, S. Z., Philipp-Muller, A.,
Bebko, J. M., Barense, M. D., & Ferber, S.
(2017). Linking Anxiety and Insistence on Sameness in Autistic Children: The
Role of Sensory Hypersensitivity. Journal
of Autism and Developmental Disorders, 47(8),
2459-2470. https://doi.org/10.1007/s10803-017-3161-x
Brignell, A., Chenausky, K. V., Song, H., Zhu, J., Suo, C., & Morgan,
A. T. (2018). Communication interventions for autism spectrum disorder in
minimally verbal children. The Cochrane
Database of Systematic Reviews, 11(11),
CD012324. https://doi.org/10.1002/14651858.CD012324.pub2
Carr, E. G., & Durand, V. M. (1985). Reducing behavior
problems through functional communication training. Journal of Applied Behavior Analysis, 18(2), 111-126. https://doi.org/10.1901/jaba.1985.18-111
Casey, S. D.,
& Merical, C. L. (2006). The Use of Functional Communication Training
without Additional Treatment Procedures in an Inclusive School Setting. Behavioral Disorders, 32(1), 46-54.
https://doi.org/10.1177/019874290603200102
Cochrane
Effective Practice and Organisation of Care (EPOC).
(2017). Reporting empty reviews and
results from excluded studies. EPOC Resources for review authors.
epoc.cochrane.org/resources/epocresources-review-authors
Dempsey, J.,
Dempsey, A. G., Guffey, D., Minard, C. G., & Goin-Kochel, R. P. (2016).
Brief Report: Further Examination of Self-Injurious Behaviors in Children and
Adolescents with Autism Spectrum Disorders. Journal
of Autism and Developmental Disorders, 46(5),
1872-1879. https://doi.org/10.1007/s10803-016-2704-x
Duerden, E. G.,
Oatley, H. K., Mak-Fan, K. M., McGrath, P. A., Taylor, M. J., Szatmari, P.,
& Roberts, S. W. (2012). Risk factors associated with self-injurious
behaviors in children and adolescents with autism spectrum disorders. Journal of Autism and Developmental
Disorders, 42(11), 2460-2470.
https://doi.org/10.1007/s10803-012-1497-9
Durand, V. M.
(1990). Severe Behavior Problems: A
Functional Communication Training Approach. Guilford Press.
Furniss and
Biswas. (2020). Self-Injurious Behavior
in Individuals with Neurodevelopmental Conditions. Springer.
Ghaemmaghami, M.,
Hanley, G. P., & Jessel, J. (2021). Functional communication training: From
efficacy to effectiveness. Journal of
Applied Behavior Analysis, 54(1),
122-143. https://doi.org/10.1002/jaba.762
Hanley, G. P.,
Iwata, B. A., & McCord, B. E. (2003). Functional analysis of problem
behavior: A review. Journal of Applied
Behavior Analysis, 36(2),
147-185. https://doi.org/10.1901/jaba.2003.36-147
Iwata, B. A.,
Dorsey, M. F., Slifer, K. J., Bauman, K. E., & Richman, G. S. (1994).
Toward a functional analysis of self-injury. Journal of Applied Behavior Analysis, 27(2), 197-209. https://doi.org/10.1901/jaba.1994.27-197
Iyama-Kurtycz, T. (2020). Diagnosing and Caring
for the Child with Autism Spectrum Disorder. Springer.
Maenner, M. J.,
Warren, Z., Williams, A. R., Amoakohene, E., Bakian, A. V., Bilder, D. A., Durkin, M. S., Fitzgerald, R.
T., Furnier, S. M., Hughes, M. M., Ladd-Acosta, C. M., McArthur, D., Pas, E.
T., Salinas, A., Vehorn, A., Williams, S., Esler, A., Grzybowski, A.,
Hall-Lande, J., … Shaw, K. A. (2023). Prevalence and Characteristics of Autism
Spectrum Disorder Among Children Aged 8 Years—Autism and Developmental
Disabilities Monitoring Network, 11 Sites, United States, 2020. Morbidity and Mortality Weekly Report.
Surveillance Summaries (Washington, D.C.: 2002), 72(2), 1-14. https://doi.org/10.15585/mmwr.ss7202a1
Muharib, R.,
Correa, V. I., Wood, C. L., & Haughney, K. L. (2019). Effects of Functional
Communication Training Using GoTalk NowTM iPad® Application on Challenging Behavior of Children
With Autism Spectrum Disorder. Journal of Special Education Technology, 34(2), 71-79. https://doi.org/10.1177/0162643418783479
Ouzzani, M., Hammady, H., Fedorowicz, Z., & Elmagarmid,
A. (2016). Rayyan—A web and mobile app for systematic reviews. Systematic Reviews, 5(1), 210. https://doi.org/10.1186/s13643-016-0384-4
Paula, I. (2018). La autolesión en el autismo. ¿Búsqueda del dolor o liberación del mismo? Alianza.
Rattaz, C., Michelon, C., & Baghdadli, A.
(2015). Symptom severity as a risk factor for self-injurious behaviours in adolescents with autism spectrum disorders. Journal of Intellectual Disability Research:
JIDR, 59(8), 730-740.
https://doi.org/10.1111/jir.12177
Rodgers, J.,
Glod, M., Connolly, B., & McConachie, H. (2012). The relationship between
anxiety and repetitive behaviours in autism spectrum
disorder. Journal of Autism and
Developmental Disorders, 42(11),
2404-2409. https://doi.org/10.1007/s10803-012-1531-y
Rosen, N. E.,
Lord, C., & Volkmar, F. R. (2021). The Diagnosis of Autism: From Kanner to
DSM-III to DSM-5 and Beyond. Journal of Autism and Developmental Disorders, 51(12), 4253-4270. https://doi.org/10.1007/s10803-021-04904-1
Rothbart, M. K.
(2007). Temperament, Development, and
Personality. 16.
https://journals.sagepub.com/doi/10.1111/j.1467-8721.2007.00505.x
Rydzewska, E.,
Hughes-McCormack, L. A., Gillberg, C., Henderson, A.,
MacIntyre, C., Rintoul, J., & Cooper, S.-A.
(2019). Prevalence of sensory impairments, physical and intellectual
disabilities, and mental health in children and young people with
self/proxy-reported autism: Observational study of a whole country
population. Autism: The International
Journal of Research and Practice, 23(5),
1201-1209. https://doi.org/10.1177/1362361318791279
Smith, T. (2012).
Evolution of research on interventions for individuals with autism spectrum
disorder: Implications for behavior analysts. The Behavior Analyst, 35(1),
101-113. https://doi.org/10.1007/BF03392269
Soke, G. N.,
Rosenberg, S. A., Hamman, R. F., Fingerlin, T.,
Rosenberg, C. R., Carpenter, L., Lee, L. C., Giarelli,
E., Wiggins, L. D., Durkin, M. S., Reynolds, A., & DiGuiseppi, C. (2017).
Factors Associated with Self-Injurious Behaviors in Children with Autism
Spectrum Disorder: Findings from Two Large National Samples. Journal of Autism and Developmental
Disorders, 47(2), 285-296.
https://doi.org/10.1007/s10803-016-2951-x
Talantseva, O. I., Romanova,
R. S., Shurdova, E. M., Dolgorukova,
T. A., Sologub, P. S., Titova,
O. S., Kleeva, D. F., & Grigorenko,
E. L. (2023). The global prevalence of autism spectrum disorder: A three-level
meta-analysis. Frontiers in Psychiatry,
14, 1071181.
https://doi.org/10.3389/fpsyt.2023.1071181
Tiger, J. H.,
Hanley, G. P., & Bruzek, J. (2008). Functional communication training: A
review and practical guide. Behavior
Analysis in Practice, 1(1),
16-23. https://doi.org/10.1007/BF03391716
Traynor, J. M.,
Doyle-Thomas, K. a. R., Hanford, L. C., Foster, N. E., Tryfon, A., Hyde, K. L.,
Anagnostou, E., Evans, A. C., Zwaigenbaum, L., Hall,
G. B. C., & NeuroDevNet ASD Imaging Group.
(2018). Indices of repetitive behaviour are
correlated with patterns of intrinsic functional connectivity in youth with
autism spectrum disorder. Brain Research,
1685, 79-90.
https://doi.org/10.1016/j.brainres.2018.02.009
Uljarević, M., Arnott, B., Carrington, S. J., Meins, E., Fernyhough, C.,
McConachie, H., Le Couteur, A., & Leekam, S. R. (2017). Development of restricted and
repetitive behaviors from 15 to 77 months: Stability of two distinct subtypes? Developmental Psychology, 53(10), 1859-1868.
https://doi.org/10.1037/dev0000324
Vollmer, T. R.,
Peters, K. P., Kronfli, F. R., Lloveras,
L. A., & Ibañez, V. F. (2020). On the definition of differential
reinforcement of alternative behavior. Journal
of Applied Behavior Analysis, 53(3),
1299-1303. https://doi.org/10.1002/jaba.701
Waizbard-Bartov, E., Fein, D., Lord, C., & Amaral, D. G. (2023). Autism
severity and its relationship to disability. Autism Research: Official Journal of the International Society for
Autism Research, 16(4), 685-696.
https://doi.org/10.1002/aur.2898
Yaffe, J.,
Montgomery, P., Hopewell, S., & Shepard, L. D. (2012). Empty reviews: A
description and consideration of Cochrane systematic reviews with no included
studies. PloS One, 7(5), e36626. https://doi.org/10.1371/journal.pone.0036626
Zeidan, J., Fombonne, E., Scorah, J.,
Ibrahim, A., Durkin, M. S., Saxena, S., Yusuf, A., Shih, A., & Elsabbagh, M. (2022). Global prevalence of autism: A
systematic review update. Autism
Research: Official Journal of the International Society for Autism Research,
15(5), 778-790.
https://doi.org/10.1002/aur.2696