Main Body Show
Abstract: Consideration is given to the relevant factors involved in making treatment selections based on current research and function of the individual’s challenging behaviors. To put it all together, the design of treatment as reflected in behavior intervention plans is reviewed. Focus Questions:
Treatment choices to decrease an individual’s challenging behavior are based on many factors, such as the function of behavior, empirically-based practices, ethical considerations, likelihood of the desired behavior being supported long-term by others in the natural environment, and the particulars for the case in question (e.g., context, quality of the environment, severity of the problem behavior, people present, resources available, setting, level of functioning, communication skills, etc.) (Spencer, Detrich, & Slocum, 2012). The severity and persistence of the individual’s challenging behavior may influence treatment decisions in terms of number of components in a treatment program, reinforcer magnitude or frequency, and staff/teacher training. A primary factor considered in the design of effective treatments is the function of the challenging behavior (Kurtz et al., 2003; Repp, Felce, & Barton, 1988; Lancioni, Singh, O’Reilly, Sigafoos, & Didden, 2012; Matson, Neal, & Kozlowski, 2012; Mueller, Kosi, & Hine, 2011). Treatments based on the function of behavior, as analyzed from FA data, are more effective than non-function-based approaches to decrease individual’s challenging behavior (Carr & Durand, 1985). Incorrect selection of a treatment or design of a program based on an uninformed or faulty function of behavior may not help the individual learn new desired behaviors and/or may even make the problem worse, in some cases (Iwata, Pace, Cowdery, & Miltenberger, 1994). Thus, an ethical responsibility exists for the professional to make an informed decision based on all available assessment and background information, and a review of empirically-based intervention strategies. Based on over a half century of research conducted since ABA was initiated, many empirically-based interventions have been developed and evaluated. Major treatment components for a well-designed Behavior Intervention Plan (BIP), or a written treatment document to address the individual’s challenging behavior include:
These treatment components should be tailored to the specific function of the individual’s challenging behavior (e.g., tangible positive reinforcement, automatic reinforcement, negative reinforcement, attention positive reinforcement), consider contextual factors (e.g., available assistance, history factors, etc.), and ethical considerations. Specific procedures related to these treatment components will be briefly reviewed below and then more specific functionally-related treatments will be noted. This review only highlights the main treatment possibilities that have received a fairly extensive empirical support and is not exhaustive of the various treatment possibilities available. Also note that to be competent in delivering treatment, additional knowledge and experience is needed (see the Behavior Analyst Certification Board® for more at http://www.bacb.com/). Prevention Efforts or Antecedent-based TreatmentThe individual’s situation can be altered in ways that will eventually reduce the challenging behavior, potentially avoiding the need for reactive strategies. Prevention efforts can entail reducing the individual’s motivation for engaging in the challenging behavior and changing antecedent stimuli in the individual’s natural environment. Noncontingent reinforcement (NCR) is a procedure to reduce the individual’s motivation for engaging in the challenging behaviors whereby the reinforcers for that behavior are provided freely according to a set time (e.g., every 5 min) before the individual engages in that behavior (Marcus & Vollmer, 1996; Vollmer, Marcus, & Ringdahl, 1995). NCR is an empirically validated approach for decreasing challenging behavior (Carr, Severtson, & Lepper, 2009) and may be one of the most frequently used reinforcement-based procedures (Matson et al., 2011). For example, if a student is acting out in the classroom to gain the attention of his classmates then, at the beginning of class before he acts out, give him a classroom job that garners a lot of attention to foster his desirable behavior (e.g., passing out handouts). This approach may reduce the individual’s motivation to engage in the undesired behavior and thereby make it less likely to occur. When using NCR, initially the reinforcer that is controlling the challenging behavior is delivered continuously or more frequently than the average baseline occurrence of the challenging behavior. Once the challenging behavior is reduced, then the frequency of presentation of the reinforcer can be gradually decreased to typically occurring levels (Tucker, Sigafoos, & Bushell, 1998). Table 10: Summary of NCR Procedure
Changing Antecedent Stimuli in the Natural EnvironmentA quick method of preventing the individual’s challenging behavior is to manipulate antecedent stimuli that control behavior (i.e., prompts). Antecedent stimuli include events, objects, or people that are present before the individual’s challenging behavior occurs. Stimuli in the environment that consistently precede the behavior can either be eliminated or changed to affect the likelihood of the behavior (Martin & Pear, 2011). For example, if the individual typically resists doing chores or is noncompliant then providing a choice of a variety of different chores for that person to choose from may be an effective solution (Call, Wacker, Ringdahl, Cooper-Brown, & Boelter, 2004). If the individual is escaping from difficult work or material because the reading level is too difficult (i.e., negative reinforcement), then provide more assistance or better instruction, or make the work easier (Sanford & Horner, 2013). Also for escape-maintained behavior, the demands or requests could be delivered less frequently (e.g., presenting demands once an hour instead of 20 times) and then, as the levels of the challenging behaviors remain low, gradually returned to typical levels (Lalli, Casey, & Kates, 1995). There is research to support the effectiveness of this procedure for decreasing the number of requests, known as demand fading, for escape-maintained challenging behaviors (see Pace, Iwata, Cowdery, Adree, & McIntyre, 1993; Penrod, Gardella, & Fernand, 2012). Another strategy is to add stimuli into the situation in which the challenging behavior occurs to prompt or cue the individual’s desirable behaviors. For example, the likelihood of the desired behavior occurring may be increased by presenting preferred curricular activities (Foster-Johnson, Ferro, & Dunlap, 1994), background music (Desrochers, Oshlag, & Kennelly, 2014), activity choices (Rispoli et al., 2013), or models demonstrating desired behavior (Stokes & Kennedy, 1980). Another method to change the antecedent stimuli involves an overall improvement of the quality of the individual’s environment, known as environmental enrichment (EE). EE entails increasing individuals’ access to preferred activities, people, or objects and providing a variety of choices available in their everyday environment. One of the earliest demonstrations of how EE can decrease problem behavior was conducted by Horner (1980). More recently, in a controlled randomized experiment, it has been shown that increasing sensorimotor experiences can have a beneficial effect on children with autism (Woo & Leon, 2013). Moreover, Ringdahl, Vollmer, Marcus, and Roane (1997) showed how three children with developmental disabilities chose an enriched environment over the opportunity to engage in self-injurious behavior when able to do either. Table 11 below illustrates how antecedent-based treatments can be geared to the function of the individual’s challenging behavior. Table 11: Examples of basing antecedent treatments on the function of the individual’s challenging behavior
Actively increasing or teaching functionally equivalent replacement and other desirable behaviorsA main component of any treatment plan involves reinforcing a desirable behavior that serves the same purpose as the challenging behavior, called functionally equivalent replacement behavior. For instance, an individual’s vocal stereotypy that is maintained by sound may be decreased by encouraging play with auditory toys, a functionally equivalent replacement behavior (Rapp, 2007). An important consideration when selecting the functionally equivalent behavior is to ensure that the individual’s social community will support it or the individual is able to recruit reinforcement from others in his or her natural environment. Functional Communication Training (FCT) is an empirically validated treatment approach (Kurtz, Boelter, Jarmolowicz, Chin, & Hagopian, 2011) that involves teaching the individual to ask for stimuli, events, or people that serve the same function as the problem behavior (Carr & Durand, 1985; Falcomata, Wacker, Ringdahl, Vinquist, & Dutt, 2013). Teaching the individual to request the item that typically was delivered followed his or her challenging behavior in the past can be an effective strategy to decrease that behavior (Kurtz et al.; O’Reilly et al., 2012). The form of the verbal behavior should be tailored to the individual and easy to perform, with possibilities including vocal, sign, picture-card, gesture, or use of assistive technology devices (Mancil & Boman, 2010). For example, the individual may be taught to say “Stop” instead of engaging in self-injury during nonpreferred grooming activities (Steege et al., 1990). More examples of how a communication replacement behavior can be taught can be seen in the Table 12 below.
Consequence-based interventions work to decrease problem behavior by manipulating events and/or stimuli that occur immediately after particular behaviors. Since every treatment program should include positive reinforcement, the procedures used to identify positive reinforcers will be described. Then, commonly used practices schedules to administer reinforcement and extinction procedures to decrease challenging behavior will be reviewed. Identification of Effective ReinforcersThe main ingredient for an effective behavior change program is positive reinforcement. A positive reinforcer is an object or event that increases the behavior it follows. As reviewed in Chapter 1, the principle of positive reinforcement states that when a positive reinforcer is delivered immediately after a behavior, that behavior is more likely to occur in future similar situations (Martin & Pear, 2011). Without consideration of positive reinforcement, the factors responsible for the individual’s challenging behavior may still maintain it, despite efforts to curtail that behavior. Additionally, programming reinforcers to increase the individual’s desirable behavior may result in the challenging behaviors being ‘supplanted’ or over-ridden since increasing one behavior will naturally eliminate the likelihood of engaging in other behaviors that are reinforced less or cannot occur at the same time. Application of a positive reinforcement procedure is not only an effective practice but also an ethically sound step to include in any intervention program. There are several considerations when using a reinforcement procedure, including: (a) incorporating knowledge of the function for the individual’s challenging behavior into treatment design; (b) validating that the consequence is indeed a reinforcer (be-it positive reinforcer or negative reinforcer); and (c) maximizing the individual’s motivation for that reinforcer. It is important to demonstrate that the consequence you believe acts as a reinforcer does indeed do so. The most accurate way to ensure that you have identified an effective positive reinforcer is to conduct a reinforcer test. A reinforcer test involves experimentally comparing levels of the behavior in phases where the item being evaluated is delivered immediately after the behavior to that in another phase where the consequence is provided just according to a set time such as every 5 s or noncontingently (Cooper et al., 2007). This test may entail using an ABAB research design (Martin & Pear, 2011) where the A phase consists of a series of sessions where noncontingent delivery of the item being tested occurs and in B phase consists of a series of sessions where the consequence is provided following each occurrence of that behavior. These phases are alternated in an ABAB fashion to rule out confounding variables or alternative explanations for the findings. If levels of the behavior are higher when the item is delivered contingently (phase B) compared to when it is not (phase A), then that item has been demonstrated to function as a positive reinforcer. See the Table 13 below for an example of how the effectiveness of treatment can be evaluated using an ABAB research design. Table 13: Example of graphed data with an ABAB research design demonstrating that the reinforcer delivered immediately after the behavior during the treatment or B phase increases that behavior as compared to the noncontingent delivery condition or baseline phase.A preference assessment is an efficient method to identify a potential reinforcer by evaluating the individual’s choice for a variety of objects, events, or stimuli (Cooper et al., 2007). One type of preference assessment is a paired-stimulus assessment (Fisher et al., 1992). A paired-stimulus assessment involves identifying the stimulus the individual chooses most when pairs of stimuli are presented across trials (See the Table below for the preference assessment procedure). Table 14: Example of a preference assessment procedure
Reinforcers may vary in their effectiveness in increasing desired behavior depending on whether the individual has had recent access to them (North & Iwata, 2005; McGinnis, Houchins-Juárez, McDaniel, & Kennedy, 2010). Motivating conditions, such as satiation (having too much of something) or deprivation (having too little of something), can alter the probability of behavior that leads to that reinforcer (Michael, 2000). For example, you really liked a particular song when it first came out and used to change the station to locate it, but now that it has been playing on the radio for several weeks, you no longer enjoy listening to it. Instead, you turn to another station to avoid having to listen to it one more time. Likewise, if a child, who typically is disruptive in a certain class to garner the attention of his peers is provided with ample social interaction with peers prior to that class, he may not engage in the disruptive behavior to achieve the same ends. Through use of an FA approach, the reinforcer maintaining the challenging behavior can be identified. Once it is known what that reinforcer is, it can be incorporated into a behavior intervention program to increase desired behavior. However, as Carter (2010) found with an adult male being treated for escape maintained noncompliance, a highly preferred positive reinforcer may also reduce that behavior even without the use of extinction (no longer providing the negative reinforcer). Differential reinforcement procedures can be used to eliminate or decrease the individual’s challenging behavior. This type of reinforcement schedule, or rule when to provide reinforcement, consists of the application of both positive reinforcement and extinction procedures. Extinction refers to the removal of the usual reinforcer following the behavior, which decreases future occurrences of that behavior (Martin & Pear, 2011). Differential reinforcement of zero rates (DRO) involves providing a reinforcer when no instances of the challenging behavior occur during a period of time. For instance, to decrease thumb sucking, every 10 min when the child does not engage in thumb sucking, he gets his favorite toy. Differential reinforcement of incompatible behavior (DRI) involves reinforcing a desired behavior that cannot occur at the same time as the challenging behavior (Martin & Pear, 2011). For instance, the therapist can provide a reinforcer when the person speaks in normal conversation level and does not scream. If a specific incompatible behavior that the individual performs cannot be readily identified, differential reinforcement of alternative behavior (DRA) may be used where a desirable behavior displayed by the individual is reinforced. For example, turning pages of a magazine could be reinforced to decrease the likelihood of an individual engaging in self-injury by hitting her head with her hand. Both turning pages and self-injury could be done at the same time, but that is unlikely to occur. There are also differential reinforcement schedules to reduce, but not necessarily completely eliminate a behavior altogether, that can be used when some amount of behavior is alright. Differential reinforcement of low rates—spaced responding (DRL-spaced responding) entails providing the reinforcer after a period of time when no instances of the challenging behavior have occurred and then the behavior occurs. For instance, to slow down someone’s rate of eating, she could be allowed to take a bite after 3 s of the previous bite of food. Differential reinforcement of low rates—limited (DRL-limited) is when the challenging behavior is less than a specified amount following a set time period (Martin & Pear, 2011). A child in the classroom may excessively raise her hand to ask to use the restroom every half hour where instead, once after two hours of not asking is reinforced. Table 15: A summary of schedules of reinforcement to decrease challenging behaviors
Differential reinforcement has been shown to be a highly useful treatment choice. Differential reinforcement may be just as effective as NCR in decreasing challenging behavior (Allison et al., 2012) and can be applied in the classroom (LeGray, Dufrene, Mercer, Olmi, & Sterling, 2013). Differential reinforcement, in conjunction with other treatments, has been effectively used to decrease a variety of behaviors, such as sensory reinforced eye brow plucking (Nuernberger, Vargo, & Ringdahl, 2013) and pica, or the ingestion of nonedible substances (Hagopian, González, Rivet, Triggs, & Clark, 2011). Differential reinforcement has been shown to be as effective as a punishment procedure (response cost) in reducing tics of children with Tourette syndrome and, as such, would ethically be the preferred treatment (Capriotti, Brandt, Rickftts, Espii, &Woods, 2012). See the Table 16 below for the steps involved in conducting a differential reinforcement procedure.
Reactive procedures or what to do when the challenging behavior occursAn extinction procedure involves no longer providing the reinforcer maintaining the challenging behavior such that the behavior is less likely in future similar situations (Martin & Pear, 2011). The reinforcer maintaining the individual’s challenging behavior must be identified and no longer provided. Thus, when the individual’s challenging behavior is being maintained by attention then attention extinction should be used. For escape-maintained behavior, escape extinction, or not removing the task or demand (and, possibly, using guided assistance for the individual to engage in the task) is employed. An FA to determine what is maintaining the individual’s challenging behavior is essential to be able to accurately remove the reinforcer maintaining the challenging behavior and thereby effectively use an extinction procedure. Iwata, Pace, Cowdery, and Miltenberger (1994) describe how not correctly removing the reinforcer maintaining the individual’s challenging behavior can actually worsen it. A known phenomenon that occurs when implementing an extinction procedure is extinction burst whereby the behavior being extinguished gets “worse before it gets better.” That is, emotional behaviors and aggression, in addition to an increase in severity of the challenging behavior may occur (Martin & Pear, 2011). It is important to inform others about this phenomenon to ensure that they continue implementing the program and do not inadvertently reinforce the individual’s problem behavior and make it worse (i.e., treatment integrity is maintained). An effective and ethical approach is to combine extinction with positive intervention strategies (e.g., differential reinforcement). Out of a sample of 42 cases of treatment for individuals with challenging behavior, Lerman, Iwata, and Wallace (1999) counted the number in which an extinction burst was identified and examined whether positive procedures included in the treatment package lessened the likelihood of extinction bursts. The researchers found substantially fewer cases of extinction burst (i.e., 15%) when positive procedures were incorporated as compared to when only an extinction procedure was used (i.e., 62%). Although there are ethical concerns with using any decelerative procedure, sometimes extinction must be used to effectively decrease the individual’s problem behavior. In a study by Patal et al. (2002) two types of differential reinforcement procedures were not effective until escape extinction was added with three children receiving treatment for feeding disorders. See Table 17 below for methods to increase the effectiveness of an extinction procedure. Table 17: Steps to increase the effectiveness of an extinction procedure
Table 18 summarizes in example format the three main treatment approaches used for each main environmental reason for challenging behavior. Table 18: Summary of treatment strategies based on function of behavior
Generalization & Maintenance of Treatment EffectsGeneralization and maintenance of treatment effects is an essential component to address once: (a) the individual’s desired behavior is occurring at desired levels; (b) the problem has been reduced; and (c) treatment has been removed. There are three important types of generalization or spill-over effects that occur once treatment or training has ended (Martin & Pear, 2011). Stimulus generalization is the extent to which the desired behaviors occur across stimuli, setting, and people. For example, after successfully learning how to ask for help when faced with a difficult task at work, the individual is now able to do likewise when at home. Response generalization is the extent to which behaviors other than the taught behavior occur. For example, after the resident of a group home has been taught to greet visitors with a “Hello” and a handshake (instead of a hug), she also has begun appropriately asking visitors to enter the house and to sit in the living room. Lastly, response maintenance is when the desired behaviors taught occur long after the training has been completed (e.g., weeks, months, or years). Stokes and Baer (1977) wrote their pivotal review of the published research examining generalization and concluded that generalization needs to be planned for during intervention to ensure that it occurs. Although much research on ways to promote generalization of treatment gains has occurred over the years, more remains to be done (Falcomata & Wacker, 2013). A review of methods to promote generalization is beyond the scope of this book. The reader is encouraged to consult other sources such Baer (1981) or Goldstein and Martens (2000) for more information. Evaluation of Treatment EffectivenessA comprehensive evaluation of the effectiveness of treatment for a particular client/student case should include the following:
Designing a Behavior Intervention Plan (BIP)To “put it all together,” it is useful to carefully consider the components of a complete behavior intervention plan. Cautilli, Riley-Tillman, and Thomas (2001) detail the characteristics and content for a well-written, high-quality behavior intervention plan and describe many of the following as essential components:
A best practice when designing a behavior intervention plan to address an individual’s challenging behavior is to use current research-based assessment practices and interventions to guide the approach selected. The Individuals with Disabilities Education Improvement Act (IDEIA, 2004) and ethical practices require that professionals who work with students with disabilities maintain currency with empirically-based assessments and interventions. As the field progresses new and more effective procedures are discovered and revealed to better care for the needs of individuals with developmental disabilities. As one resource to consult, the “What Works Clearinghouse” serves as an online review of evidence-based interventions in education as evaluated by the Institute of Education Science (http://ies.ed.gov/ncee/wwc/news.aspx?sid=8). In this resource, published research concerning common intervention approaches are reviewed according to a standard and report outcomes (e.g., effect size) in relation to the scientific strength of the evidence so that informed selections about treatment practices can be made. Special Education Perspective: Positive Behavioral Support and Response to InterventionPositive Behavior Support (PBS) is generally the first and most appropriate choice at a school-wide level for intervention in schools for children with challenging behaviors. PBS has long been recognized as a prevention approach to undesirable behaviors (Vaughn & Bos, 2009). PBS is often taught in teacher education training programs as the preferred treatment approach in public school classrooms, rather than the use of punishment. Quite simply, PBS is a focus on the desired behavior, rather than focusing on the undesirable or challenging behavior. PBS requires the teacher and other related professionals to systematically look for positive behavior. This is generally accomplished with the use of social, tangible, or verbal reinforcers specific to the desired behavior, such as saying when Mary has her head down and is quietly reading the passage, “Thank you for your attention to the task, Mary.” Teachers in the classroom can use such positive reinforcers to encourage positive behavior and to focus attention on a model of appropriate behavior. As another example, a token economy in the classroom can be employed where children can accumulate points or tickets for desirable behavior that can be turned in for free time, a special lunch with a friend, a free pass on one homework assignment, or other positive reinforcers. Other prevention approaches include teaching children conflict resolution and interpersonal problem solving. Some curricula include aspects of character education and principles for teaching social skills (Vaughn & Bos, 2009). Within recent years, professionals in public school settings have also used an approach called Response to Intervention (RTI). RTI was mandated by federal law (IDEIA, 2004) as a means of not allowing children to fail either behaviorally or academically without access to a variety of research-based interventions individualized for that particular child. RTI requires all professionals to monitor academic and social skills on an ongoing basis, collecting data on performance of every child, and reviewing that data with a team of related professionals. The intent of RTI is to prevent problems or to quickly intervene before a child loses skills. Monitoring occurs at three levels or tiers. Those tiers are: Tier 1: screen for behavior problems, introduce interventions, convey expectations Tier 2: provide supports and feedback for students with similar behavior problems Tier 3: provide more specific and intense interventions for students whose behavior has not improved (Vaughn & Bos, 2009) PBS and RTI work in conjunction with one another and the focus of both approaches is on prevention of problems or preventing the severity of a problem existing without research based responses individualized to the child. Completing an FA will assist in identifying the function of the student’s challenging behavior resulting in the design of the best treatment for that situation. The knowledge gained by implementing an FA will provide the basis for an effective behavior intervention plan which is an essential component of the student’s Individualized Education Program (IEP). The Individualized Education Program (IEP) serves as the foundation of the educational plan for each student with disabilities. The IEP is a strategic planning document that should be far reaching in its educational impact. An IEP identifies a student’s unique strengths and needs and how the school will strategically address those needs (New York State Department of Education, 2010, p.3). It is a legal document, designed and agreed upon by all members of the educational team, including the family of the student with disabilities. The key components of the IEP rest upon the concept of individualization. As stated in the Council for Exceptional Children (CEC) professional standards:
One essential component of the IEP is listing the positive behavioral supports needed by the child. A careful FA analysis is critical to identifying those positive behavioral supports that will help guide the professional to developing the child’s desirable behaviors in the classroom, clinics, in social environments, and at home. SummaryThe design of effective intervention is based on identification of the maintaining variables for the individual’s problem behavior as gathered from a FA. The core of a treatment package should include preventative measures, teaching a replacement behavior that serves the same function as the challenging behavior, reinforcing desirable behavior, and a procedure in place for when that behavior does occur. A behavior intervention plan provides a written form of the treatment for others in the individual’s natural environment to follow to assist the individual with learning desirable behaviors. Discussion Questions
Exercise: Complete the Behavior Intervention Plan (BIP)Instructions: Read the teacher’s referral below and complete a BIP based on the information. You can add details as needed to fully address the components of the BIP. Speculate on the function of Juan’s challenging behavior and design a plausible treatment based on that function. Teacher Referral Report: Juan is a 13-year-old boy with cerebral palsy and intellectual disability. He is in an 8 to 1 classroom. His communication skills are very basic. When he does talk, he whispers. Almost all of his speech repeats what was just said to him (echolalia). Even when he engages in echolalia his intelligibility is poor because he whispers. Occasionally he will kick me or other adults at a table (during groups), but it is lightly and infrequent. He will sometimes also throw things but this has only happened about three times this year. I am most concerned about his lack of any participation in any class activities or conversations. When he is asked to do something he will often just sit there and, less often, he will sometimes rock and hum during the morning meeting when it is his turn to come to the front of the class to review the day, he will come to the front of the classroom, but will then just stand there.
Why are individuals taught to use replacement behaviors in place of problem behavior quizlet?Why are individuals taught to use replacement behaviors in place of problem behavior? Because just suppressing a problem behavior does not provide a way to get an individual's needs met.
How does functional communication training address problem behavior?communication training addresses interfering behaviors by systematically identifying the function of the behavior and providing a replacement behavior in the form of appropriate communication. Functional communication training meets the evidence-based practice criteria with 12 single case design studies.
When should there be replacement behaviors?The replacement behaviors should be easier, more efficient, meet the same function and more socially appropriate than the behaviors of concern. Examples include a student using a more desirable means of gaining access to a tangible, requesting a break and asking for an alternative work assignment.
How can consistency and routine help increase display of a desired behavior?How can consistency & routine help to increase the display of a desired behavior? Predictability that goes along with consistency & routine helps learners focus on what is important. A pivotal skill that helps individuals "learn to learn"? Responding to multiple cues in the environment.
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