Behavior Reduction

Jonathan Tarbox , Courtney Tarbox , in Training Manual for Behavior Technicians Working with Individuals with Autism, 2017

6.4.3 Escape Extinction

Escape extinction consists of no longer allowing an individual to escape or avoid something non-preferred (e.g., task demands) when they engage in challenging behavior. Put more technically, escape extinction is the discontinuation of negative reinforcement for a behavior. There are many ways in which you can implement escape extinction. The important thing to remember is that whatever demands were in place or were going to be placed when the behavior happened, must still be in place after the behavior. For example, if a mother asks her child with ASD to clean his room and the child screams, to implement escape extinction, the mother would need to continue to require him to clean his room until he does it, regardless of screaming. Similarly, if a child had a tantrum to avoid brushing his teeth, escape extinction would involve still having him brush his teeth while having the tantrum.

In some cases, physical guidance or physical prompts are used to prevent a learner from escaping a task. Escape extinction does not require increasing the amount of physical prompting used as a reaction to misbehavior, but rather simply doing the same thing the behavior technician was already doing when the behavior occurred. For example, if the behavior technician was already implementing a prompt hierarchy that included physical prompting, when the learner does not respond to an instructional task, the behavior technician would still implement those same physical prompts. It is important to note that the use of physical prompting and physical guidance has varying degrees of legality and restriction in different settings, for different behaviors, and in different states. In some states, physical guidance is outlawed except in behavioral emergencies (see Section 6.5.1). It is important to note that, if you are not permitted to implement physical guidance to ensure compliance with instructional requests, escape extinction may require some other form of disallowing escape. For example, if you ask a student to complete a worksheet and the student screams, "No!" and you cannot physically guide her complete the worksheet, then you may need to continue to present verbal instructions or just disallow access to any other activity until the worksheet is complete. In this case, the learner is able to escape the task in the short-term by simply refusing. However, if she is not allowed to engage in any other activity until the original task demand is complete, then overall, you are still disallowing escape.

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Common Treatment Packages

Jonathan Tarbox , Taira Lanagan Bermudez , in Treating Feeding Challenges in Autism, 2017

6.2.2 Disadvantages

Just as with other packaged treatments containing escape extinction, there is the potential for unwanted side effects, including the fact that parents and the client may find it nonpreferred. Another variable that is worth considering is the fact that most research that has shown that DRA alone does not work (and they therefore add escape extinction) made little or no attempt to modify positive reinforcement to make it more effective; e.g., increasing the magnitude, duration, or variety of positive reinforcers. In addition, few such studies systematically attempted to vary antecedent components before resorting to escape extinction; e.g., decreasing bite size, etc. For these reasons, we strongly recommend you give a wholehearted effort at optimizing the effectiveness of positive reinforcement for eating before adding escape extinction.

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Treatment Components

Jonathan Tarbox , Taira Lanagan Bermudez , in Treating Feeding Challenges in Autism, 2017

4.2.2 When Escape Extinction is Not Possible

Sometimes, due to practical or safety reasons, full escape extinction is not possible. That is, when the client refuses nonpreferred foods, you may sometimes need to allow them to escape, regardless of what variation of escape extinction you attempt. If this is the case, you may need to overcompensate for your inability to fully do extinction by substantially increasing the amount of reinforcement you are delivering for eating and minimizing, to the greatest extent possible, the escape for food refusal. For example, if you cannot leave the spoon in front of the client's face because of severe behavior, you could give the client a minimal amount of escape from the spoon (e.g., 5 or 10   seconds of escape) when he hits or cries but give him a much larger reinforcer (e.g., 10   minutes of escape from the meal) when he eats a bite of new foods. Or, you could arrange a meal where if the client refuses to eat a new food, he gets a small amount of neutral food, whereas if he accepts a small amount of new food, he gets a large amount of highly preferred foods. Modifications such as these will likely make the treatment process take longer. However, if they work, they may be able to be faded out gradually and they may sometimes be your only options for effective treatment.

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A Behavior-Analytic Approach to the Assessment and Treatment of Pediatric Feeding Disorders

Cathleen C. Piazza , ... Rebecca A. Shalev , in Clinical and Organizational Applications of Applied Behavior Analysis, 2015

Re-presentation

Re-presentation is a consequence-based procedure that is often used in conjunction with the previously described escape extinction procedures. Re-presentation entails scooping up expelled food or liquid and immediately depositing it back into the child's mouth. Conceptually, re-presentation may be understood as a form of escape extinction because it minimizes escape from eating. Alternatively, re-presentation's success may result from the child's increased opportunity to practice the skill of managing and retaining the bolus in the mouth. Sevin, Gulotta, Sierp, Rosica, and Miller (2002) evaluated re-presentation in conjunction with escape extinction when expulsion emerged following the treatment of acceptance and inappropriate mealtime behavior for a 34-month-old girl with a feeding disorder. An evaluation utilizing an ABAB reversal design where the A phase was escape extinction and the B phase was escape extinction plus re-presentation suggested introduction of re-presentation resulted in decreased expulsion. Unfortunately, expulsion for some children may persist despite implementation of re-presentation.

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Challenging Behavior

Suzanne M. Milnes , Cathleen C. Piazza , in International Review of Research in Developmental Disabilities, 2013

4.3.2 Decreasing Expulsion

Some clinicians have used re-presentation (i.e. scooping up expelled food and placing it back into the child's mouth) in addition to the escape extinction procedures described above to decrease expulsion and increase consumption. For example, Sevin et al. (2002) used re-presentation to decrease the percentage of bites expelled when expulsion emerged following the treatment of acceptance and mealtime disruptions. Treatment that involves re-presenting expelled food minimizes escape from eating, potentially decreasing the likelihood that a child will expel in the future. However, expulsions may persist despite introduction of re-presentation. Consequently, clinicians have begun to evaluate supplemental treatment components and alternative techniques for presenting and re-presenting foods.

Patel, Piazza, Santana, and Volkert (2002) conducted a systematic evaluation of food type and texture when a treatment package incorporating re-presenting of expelled foods using a Nuk brush (i.e. a teething/massaging brush with soft, nubby brush tips) failed to result in meaningful changes in expulsion. Patel, Piazza, Santana, et al. found that expulsions per bite were higher with meats relative to other foods. When they reduced the texture of the meats relative to the other foods, they witnessed decreased expulsion and increased gram intake. The authors argued that reducing the texture of meats may have decreased the aversive properties of the food, reducing both the motivation to expel the food and the effort involved in swallowing the food.

Some research suggests that modifying how food is placed in the mouth during presentation and re-presentation may assist in the treatment of expulsion. Girolami, Boscoe, and Roscoe (2007) compared the effectiveness of presenting and re-presenting food with a spoon vs a Nuk brush to decrease expulsions of a 4-year-old child with a complex medical and developmental history who was admitted to an inpatient program for the assessment and treatment of a feeding disorder. In the spoon condition, the feeder deposited the bite into the child's mouth by placing the spoon on the child's tongue until he closed his lip around the spoon and then the spoon was removed. In the Nuk brush condition, the feeder deposited the bite on the center of the tongue by rotating the brush clockwise while sliding the brush out of the mouth. The findings of their analysis demonstrated that presenting and re-presenting food with a Nuk brush was more effective at decreasing expulsions than when bites were presented and/or re-presented using a spoon or when the Nuk was used to only re-present. The authors argued that the decreased expulsions may have been the result of the child attempting to avoid the Nuk and/or the Nuk allowed for better placement of the bite which likely increased the effort necessary to propel food out of the mouth and likewise compensated for possible oral–motor deficits by decreasing the amount of effort necessary to swallow.

Modifying how bites are placed within the mouth may be particularly beneficial when treating expulsion in children with oral–motor deficits. Sharp, Harker, and Jaquess (2010) compared three different bite-presentation methods in the treatment of a 3-year-old girl with cerebral palsy and a complex medical history who had been admitted into an intensive day-treatment program for chronic food refusal and G-tube dependence. Prior to their presentation analysis, the authors reported that the child demonstrated increased acceptance and decreased inappropriate mealtime behavior with the implementation of nonremoval of the spoon (without re-presentation) and noncontingent access to preferred items; however, the child expelled all foods. Rather than evaluating re-presentation of expelled bites, the authors compared the effects of an upright spoon, Nuk brush, and a flipped spoon presentation of bites on expulsion and mouth clean (i.e. a product measure of swallowing). Nuk presentations involved wiping the food off the brush and onto the center of the tongue. Upright spoon presentations involved scraping bites against the child's upper teeth or lip due to a persistent mouth-open posture. Flipped spoon presentations involved placing the spoon into the mouth, flipping it 180°, and depositing the food on the center of the tongue by applying downward pressure and sliding the spoon out of the mouth. Sharp, Harker, et al. observed increased mouth clean and decreased expulsion in both the Nuk and flipped spoon conditions relative to the upright spoon condition. However, the results were not clinically meaningful. Although expulsion decreased and mouth clean increased during the Nuk and flipped spoon conditions, the child was still expelling, on average, over half of her bites and failed to have a mouth clean the vast majority of bites. These findings highlight that although manipulating presentation may have some utility in decreasing expulsion and increasing mouth clean, additional components may be necessary to obtain meaningful treatment outcomes. Sharp, Odom, and Jaquess (2012) extended the work of Sharp, Harker, et al. (2010) by adding re-presentation to two different presentation methods (upright vs flipped spoon) in decreasing expulsion and increasing mouth clean in three children with feeding disorders, complex medical and developmental histories, and oral–motor difficulties relating to retaining food in the mouth (i.e. drooling, tongue protrusion, and limited lip closure). Prior to their analysis, implementation of nonremoval of the spoon consisting of presentation and re-presentation on an upright spoon resulted in frequent expulsions and low levels of mouth clean. Upon incorporation of the flipped spoon during presentation and re-presentation, expulsions decreased and mouth cleans increased to clinically acceptable levels with little to no change in the upright spoon condition. The authors indicated that the placement of the bolus onto the middle of the tongue may have decreased the effort involved in swallowing while increasing the effort involved in expulsion. They further suggested that the placement of food on the center of the tongue may have assisted with bolus formation and propulsion, compensating for oral–motor deficits. Rivas, Piazza, Kadey, Volkert, and Stewart (2011) observed similar increases in mouth clean when feeders presented and re-presented bites using a flipped spoon procedure to increase consumption of a 6-month-old child with a pediatric feeding disorder.

Recently, Wilkins, Piazza, Groff, and Vaz (2011) incorporated a chin prompt on presentation of bites and/or drinks as well as during re-presentation of expelled bites or drinks when re-presentation alone failed to decrease expulsion to clinically acceptable levels for four children with complex medical and developmental histories admitted to an intensive day-treatment program for the treatment of a pediatric feeding disorder. During the chin prompt, the feeder placed his or her forefinger under the child's chin while depositing the bite or drink. After the liquid or solid entered the child's mouth, the feeder placed his or her thumb under the child's lower lip and applied gentle upward pressure on the child's chin (with the forefinger) and lower lip (with the thumb) for 5 s while counting audibly. The addition of the chin prompt to re-presentation produced clinically meaningful and consistent decreases in expulsion. The authors argued that the chin prompt may have been effective because the chin prompt facilitated mouth closure, which thereby may have reduced the likelihood that the bolus could passively pool out of the mouth and make it more difficult for the child to thrust the bolus out of his or her mouth.

Dempsey, Piazza, Groff, and Kozisek (2011) extended the work of Sharp, Harker, et al. (2010) and Wilkins et al. (2011) by evaluating the effects of presenting the bolus on a flipped spoon vs an upright spoon either alone or in combination with a chin prompt when nonremoval of the spoon with representation and NCR failed to result in increased mouth clean. The flipped spoon alone produced small increases in mouth clean (relative to the upright spoon) but the levels were not clinically acceptable. The addition of a chin prompt to the flipped spoon resulted in high levels of mouth clean that did not occur when the chin prompt was combined with the upright spoon.

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Promoting Positive Airway Pressure Adherence in Children Using Escape Extinction within a Multi-Component Behavior Therapy Approach

Keith J. Slifer , in Behavioral Treatments for Sleep Disorders, 2011

Proof of Concept/Supporting Data/Evidence Base

There is extensive evidence from the applied behavior analysis literature that some child behavior problems are maintained by their escape function, and that these behaviors can be reduced using an escape extinction intervention. For example, this approach has been used to successfully treat self-injury [6], food refusal [7], distress during dental procedures [8], and distress during EEG examinations [9].

A 1995 study examining the safety and efficacy of CPAP with children found that when CPAP was not effective, it was because of poor adherence in 92 percent of unsuccessful cases [10]. In that same year, the first article describing successful behavioral intervention to increase compliance with nasal CPAP in children was published [11]. In that study, four children ranging in age from 3 to 12 years of age with diagnosed syndromes (Hunter's, Hurler's, Treacher Collins, Down) involving maxillofacial abnormalities were provided with behavioral intervention to facilitate their compliance with CPAP. Three of the four children had mental retardation (MR), and the youngest child (age 3) had severe MR. The patients and their parents attended training sessions, and the parents learned to coach their children during exposure to and wearing the PAP. The parents participated in a behavioral skills training program using this approach. Subsequently, all four of the children began wearing CPAP during sleep at home, and continued doing so at 3-month follow-up. At 9-month follow-up, three of the four were still successfully using CPAP.

Although other publications have reported use of educational and behavioral interventions to facilitate PAP adherence, these articles lack an adequate description of the intervention procedures that were utilized [12,13].

Two other published studies have described and demonstrated behavioral methods for increasing children's adherence with PAP therapy [1,14]. The first study was a non-experimental case series clinical report of outcome data that supported the utility of behavior analysis and therapy for improving PAP adherence and facilitating effective clinical management of OSA [1]. Although that report included some children with developmental disabilities, the children who achieved the greatest increases in mean hours per night of PAP adherence (i.e., .   5.0 hours/night) were those with higher levels of estimated cognitive functioning. In only one case was a mean increase in adherence of greater than 5 hours per night achieved with a child with mental retardation (MR). For one other child with mild MR and three children with moderate to severe MR, the mean increase in hours of adherence per day ranged from 4.0 to 5.0. However, that study was based on a non-experimental analysis of retrospective clinic data.

Slifer and colleagues [14] conducted a prospective study using repeated measures of cooperation and adherence and single subject experimental design. Their study provides additional preliminary evidence that the "package" of procedures described in this chapter appears to be effective for desensitizing preschool children with developmental delay, behavior problems, and serious health conditions to PAP.

The four children were referred because of their severe behavioral reactions to the PAP mask and airflow during initial attempts to conduct polysomnography or to initiate PAP therapy. The four children were between 3 and 5 years of age, and had a variety of health impairments (obesity, cor pulmonale, diabetes, reactive airway disease, lung hypoplasia, status post-craniopharyngioma resection). Using the same behavior therapy protocol as presented in this chapter, all four children tolerated PAP while sleeping for age-appropriate durations. Home follow-up data were obtained for three of the children that indicated the parents were able to continue the protocol with maintenance of therapeutic benefits.

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Treatment Components

Jonathan Tarbox , Taira Lanagan Bermudez , in Treating Feeding Challenges in Autism, 2017

Abstract

This chapter continues the discussion of treatment components, with an emphasis on antecedent variables. Most published studies have shown that these variables work best when combined with positive reinforcement and escape extinction. Exposure, level of hunger, bite size, demand fading, blending and simultaneous presentation, and texture fading are some of the significant concepts discussed when attempting to design a plan to overcome feeding challenges.

The significant concepts are covered along with some rationale of how they might best be implemented in a course of treatment. For each of the treatment methods, some advantages and disadvantages are provided for consideration.

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Troubleshooting

Jonathan Tarbox , Taira Lanagan Bermudez , in Treating Feeding Challenges in Autism, 2017

9.1.1 Expels

As described in Chapter 3, Preparing for Meals, expels include pushing food or liquid out of the mouth (i.e., past the plane of the lips) after it has been accepted into the mouth (i.e., "spitting" the food out). The consequence you will implement for expels will vary depending on the behavioral feeding treatment you are conducting. For example, differential reinforcement of alternative behavior (DRA) for acceptance involves reinforcement for acceptance of bites and does not include any planned consequences for expelled bites. So, an expelled bite would simply be ignored, although when implementing escape extinction, an expelled bite is most often represented to prevent escape from swallowing the bite.

If your client is engaging in a high rate of expelled bites and this rate is stable or increasing consistently, it is likely time to reexamine your intervention. Occasionally, an antecedent variable may be effective in reducing expels. For example, including stimulus fading or texture fading as a component of your treatment package sometimes decreases expels. For one client we worked with, all that was needed to eliminate expelling of vegetables was to add a nutritionally acceptable amount of salt. You may also want to implement a specific differential reinforcement contingency, such as providing reinforcement for not expelling (i.e., differential reinforcement of other behavior (DRO)), to teach your client not to engage in expelling bites. Don't be afraid to include additional treatment components when troubleshooting, as they can usually be faded over the course of intervention.

If you have tried other options and they have not worked, it may be necessary to implement escape extinction specifically for expels, consisting of representation of expelled bites, if you are not already doing so. To do this, simply scoop-up expelled bites and immediately represent them. If the expelled food falls on the floor or is otherwise not available for representation, present a new bite of the same food immediately. Fig. 9.1 depicts hypothetical data from a feeding intervention that is working to increase acceptance but the client is expelling most of the accepted bites. Adding representation of expelled bites decreases expelling and therefore increases consumption.

Figure 9.1. Sample graph of a feeding intervention that increases food acceptance but that is failing because the client is expelling food. Adding the procedural component of representing expelled bites decreases expelling and therefore increases consumption.

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ABA Applications in the Prevention and Treatment of Medical Problems

Keith D. Allen , Jeffrey F. Hine , in Clinical and Organizational Applications of Applied Behavior Analysis, 2015

Intervention Analysis

Participants in most of the investigations in this line of research were referred for "behavioral consultation" because they were too disruptive to access oral health care without requiring either passive restraint (i.e., a medical stabilization board with Velcro straps) or general anesthesia in an operating room. This included children less than 3 years of age, even though many dentists consider these children to be "precooperative" or unable to be cooperative without sedation or restraint (e.g., Nathan, 1995). The referred children typically required multiple visits for restorative treatment, thus allowing for repeated measurements within and across visits to the dentist.

The original intervention (Allen & Stokes, 1987) was designed to teach children functionally equivalent alternative responses during dental procedures, responses that included remaining quiet and lying very still with hands folded. Gradually longer periods of calm and quiet behaviors were reinforced with repeated but brief (10-15 s) access to periods of escape from ongoing dental treatment. Alternatively, if the child was disruptive, escape was postponed until cooperation was regained. Thus, the treatment involved differential (negative) reinforcement of incompatible behaviors with escape extinction. Researchers delivered the intervention during mock dental treatment in which the children were exposed to many of the sights and sounds of dental treatment, but without actual injections or drilling. Baseline and treatment observations, however, were conducted in situ during actual restorative treatment visits conducted by the dentist, including injections and drilling. In a multiple-baseline across subjects design, five children ages 3-6 with highly disruptive behavior in baseline, including gagging and vomiting, showed marked reductions in disruptive behavior and distress when, and only when, the contingent escape and escape extinction were used. The study was replicated with a similar population and small-n design resulting in comparable outcomes and, in an effort to reach a broader audience, the findings were published in Journal of Dentistry for Children (Allen, Stark, Rigney, Nash, & Stokes, 1988).

Subsequent to these original studies, the referring dentists expressed concern that the delivery of the intervention during analog dental treatment procedures was too time-consuming and impractical for dissemination. Thus, a follow-up study was designed to evaluate the extent to which a dentist could deliver the intervention in situ (Allen, Loiben, Allen, & Stanley, 1992). In addition, the participating dentists expressed concern that the escape extinction component would have poor social acceptability with parents and also potentially expose the dentist to increased liability risks; thus, the escape extinction component was removed. A participating dentist was then trained to deliver escape contingently when the dentist observed the patient lying still and quiet for anywhere from 5 to 15   s. The dentist was trained to notice and deliver escape during at least 80% of these opportunities during treatment.

In a multiple-baseline design across four participants ages 3-7, we found that the contingent escape alone, without the escape extinction component, was effective in reducing child disruptive behavior in a relatively short amount of time (see Figure 5.4). The results also showed a strong correspondence between treatment fidelity and response to treatment. In Beth's second treatment visit (fourth visit overall), the dentist did not meet the criterion for treatment fidelity and disruptive behavior increased to near baseline levels, serving as an unintentional treatment reversal. In addition, Ray's second visit was intended to be a treatment visit; however, the dentist delivered the contingent escape procedure only 25% of the time. This resulted in continued high rates of disruptive behavior, thus confirming the importance of measuring treatment fidelity. Finally, we found that on average the dentist did not spend any more time using behavior management during implementation of the contingent escape procedure than during baseline sessions. This was considered critical for dissemination and broader adoption by general practitioners.

Figure 5.4. Percentage of 15   s intervals with disruptive behavior. Asterisks by visit number indicate treatment integrity below criterion.

Although the contingent escape procedure was effective, the participating dentist expressed concern that maintaining treatment fidelity required a high response effort related to noticing cooperative behavior, thereby distracting him from attending to the delivery of quality dental treatment. Thus, we began discussions about how to modify the procedure to accommodate the needs of the dentist to attend more fully to dental treatment. The discussions centered on the possibility of making access to escape noncontingent and based on time rather than behavior. The result would be a fixed-time (FT) schedule of negative reinforcement (see Carr, Severtson, & Lepper, 2009).

The noncontingent reinforcement (NCR) procedure required the dentist to wear an electronic prompter (MotivAider®) that signaled to the dentist the FT schedule under which he was to deliver access to 10   s of escape from treatment. The dentist initially began by following an FT 15-s schedule. Then, over time, the dentist lengthened the time between reinforcement deliveries based on fewer occurrences of disruptive behavior. The treatment was delivered sequentially across five highly disruptive young children, four of whom required physical restraint to prevent injury to self and others and to complete dental procedures. Using a multiple-baseline design across participants, results showed marked reductions in disruptive behavior (O'Callaghan, Allen, Powell, & Salama, 2006). The procedure also nearly eliminated the need for restraint. Again, the procedure took virtually the same amount of time to deliver as did typical behavior management used by the dentist in baseline conditions.

The final study in this line of research involved a federally funded, randomized, controlled trial. The impetus for this study centered on extending the research to a broad population of typical children commonly seen in general pediatric dental clinics. The previous series of small-n experimental-design studies had verified and replicated a functional relationship between escape and child behavior during dental treatment. Randomized controlled trials can add important scientific value for behavior analysts by showing external validity and generality of procedures (Smith, 2013), and they are also experimental designs that are widely respected and valued in nonbehavioral communities, perhaps enhancing the potential for acceptance and dissemination.

The study was conducted across two locations: an urban university-based dental clinic and a suburban children's hospital-based clinic. Rather than using a referred sample of the most difficult children, this study focused on a convenience sample of 151 typical children, ages 2-9 years who were visiting the dentist (Allen & Wallace, 2013). In the randomized, controlled trial, participants were exposed to either usual behavior management used by the dentists or the FT schedule of breaks from treatment. The dental treatment and behavioral observation methods matched those of the previous studies, including direct observations of distress behavior, observer training, and measures of reliability, close scrutiny of treatment implementation integrity, and treatment acceptability. Results showed that the routine delivery of scheduled breaks from treatment significantly reduced disruptive behavior. A cumulative record of the rate of disruptive behavior shows that the differences between the two groups increased over time (see Figure 5.5). This increasing difference between the two groups makes sense if one views access to noncontingent escape as a process that takes some time to exert its influence; either by reducing the effectiveness of escape as a reinforcer or by disrupting the contingency that maintained disruptive behavior in the first place. Finally, consistent with all previous studies, results showed that the children exposed to the NCR procedure required significantly less restraint to manage their behavior and that the NCR procedure did not significantly increase the time spent on behavior management by dentists.

Figure 5.5. Cumulative intervals of disruptive behavior across minutes within each dental visit.

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Sleep, Elimination, and Noncompliance in Children

Aurelia Ribeiro , ... Michael E. Kelley , in Clinical and Organizational Applications of Applied Behavior Analysis, 2015

Treatment

According to Wilder et al. (2012), interventions to increase compliance may be classified as antecedent- or consequence-based. Antecedent-based interventions include the manipulation of environmental variables that are present before the opportunity to comply. This type of intervention may include interruption of child's play before presenting the instruction, teacher's distance from the child, advance notice or warning (i.e., a warning given to the child that anticipates what she will be instructed to do within a given period of time), rationales (i.e., reasons why the child should comply with the instruction), high-probability instructional sequence (i.e., presentation of instructions with a high probability of compliance before presenting the target instruction).

Antecedent-based interventions have not been consistently effective at increasing compliance. In many cases, additional consequence components are necessary (e.g., Wilder, Nicholson, & Allison, 2010; Wilder, Zonneveld, et al., 2007). For instance, Wilder, Zonneveld, et al., (2007) first attempted to increase compliance by systematically implementing noncontingent reinforcement, a warning, and a high-probability sequence. The results suggested that for all three participants, noncontingent reinforcement and the use of the warning were each ineffective at increasing compliance. Furthermore, the high-probability sequence was effective for only one participant. For the other two participants, the authors implemented extinction, resulting in compliance.

While antecedent-based interventions have not been reliably successful in the treatment of noncompliance, consequence-based interventions have been demonstrated as an effective alternative for treatment. In this type of intervention, compliance (or noncompliance) is followed by the delivery or removal of a stimulus (Wilder et al., 2012). For example, Wilder, Allison, Nicholson, Abellon, and Saulnier (2010) increased levels of compliance by providing access to preferred edible items contingent on compliance. Other examples of consequence-based interventions include time-out from positive reinforcement (i.e., removing access to positive reinforcement for a brief period of time contingent on noncompliance) and escape extinction (i.e., contingent on noncompliance, physical guidance is provided to assist the child in completing the task).

Although most interventions for noncompliance clearly fall into one of the two previously described categories, some interventions may include aspects of both. One example of such an intervention is guided compliance, which was first described by Horner and Keilitz (1975). Typically, this procedure starts with a vocal prompt to perform an action (e.g., "Clean up your toys"). In the absence of a response (i.e., noncompliance), the caregiver models the correct response while repeating the vocal prompt. If the child does not comply with the model prompt, the caregiver repeats the vocal prompt while physically guiding the child to perform the required action. Usually, compliance is scored if the participant performs the required action after the first or second prompt (i.e., vocal and model, respectively). According to Wilder and Atwell (2006), decreased levels of noncompliance that result from guided compliance may be related to behavioral mechanisms such as escape extinction (i.e., noncompliance does not result in removal of the request, but rather the presentation of prompts until the child ultimately engages in the response) and punishment (e.g., the physical guidance may be aversive for some children). Alternatively, it is possible that the vocal and modal prompts evoke compliance because they either signal the availability of reinforcement for compliance or allows the child to avoid punishment (i.e., compliance to the vocal or model prompt avoids the physical prompt).

In a recent study on guided compliance, Wilder et al. (2012) implemented two modified versions of the procedure with four typically developing children after implementing the three-step-guided compliance. In the first modification, the two-step-guided compliance, the authors eliminated the model prompt (i.e., noncompliance to the vocal prompt within 10   s was followed by physical prompt). The authors argued that keeping the model prompt would simply prolong the time between the first vocal prompt and compliance, with consequent prolonged access to the reinforcing stimulation for noncompliance. Furthermore, the model prompt might be unnecessary for children with appropriate listener repertoires. In the second modification of the three-step guidance, besides the elimination of the model prompt, the authors reduced the time required for compliance from 10 to 5   s. This modification resulted in further reduction of the interval between the first vocal prompt and compliance. The authors found that for all four participants, the three-step-guided compliance produced elevated but variable levels of compliance. However, each modification of this procedure was effective for one participant. For the remaining two participants, differential reinforcement was necessary to increase compliance. Thus, this study demonstrated that, for some children, three-step-guided compliance might be modified to enhance treatment effects.

Because noncompliance levels vary across different ages, the goal of treatments intended to increase compliance should take into consideration compliance levels of similar-age peers. For instance, increasing compliance to 100% may not be a reasonable treatment goal. Using a standardized assessment, Stephenson and Hanley (2010) were able to measure noncompliance of 15 preschoolers in comparison to same-age peers and identify those who consistently demonstrated lower compliance levels compared to their peers. Following assessment, the authors selected for treatment four children who displayed low levels of compliance. Two of these children were exposed to two conditions in a reversal design. During baseline sessions, the teacher stood at least 1 m away from the child, did not make eye contact or interact with the child except to deliver the instruction. Then, the teacher stated the child's name, delivered the instruction (i.e., one-step instruction), and waited 6   s for a response. Compliance resulted in praise from the teacher, however, there were no programmed consequences for either noncompliance or incorrect response. The intervention consisted of sequentially adding six antecedent variables (i.e., one variable was added in each session). The antecedent variables were added in the following order: the teacher was within 0.3 m of the child; the teacher crouched next to the child; the teacher gently touched the child's shoulder; the teacher delivered 5   s of vocal attention in the form of comments; teacher attempted to make eye contact with the child; and the teacher interrupted the child's play prior to and while delivering the instruction. For both participants, manipulation of antecedent variables resulted in increased levels of compliance, especially when six elements were in place.

The remaining two participants selected for the second phase during Stephenson and Hanley (2010) were initially exposed to the same conditions previously described (i.e., baseline and additive antecedent intervention or AAI). However, because antecedent manipulation did not result in increased compliance, the authors implemented noncompliance intervention, which consisted of a three-step prompting to promote compliance to instructions. Correct responses at any prompt level were followed by descriptive praise and incorrect responses were ignored. This intervention resulted in increased compliance levels for one participant but had no effect on the other. The authors then exposed these participants to the full antecedent plus noncompliance intervention, in which both antecedent variables and consequences were in place (i.e., this condition was a combination of the two previous conditions). This package resulted in increased levels of compliance for both participants. This study demonstrated the effectiveness of antecedent-based interventions for two of the four participants. In addition, for the other two participants, the most effective intervention consisted of a combination of antecedent variables and consequences for noncompliance.

In summary, noncompliance is a problem of great impact and needs to be addressed early. Usually, treatments are designed to increase compliance and may be more effective if they are based on assessment of the functional relation between environmental variables and noncompliance. Treatment outcomes may vary according to a child's age, the difficulty level of the tasks, and other variables. However, in general, guided compliance and consequence-based interventions have been more effective in the treatment of noncompliance. These interventions may be combined to further enhance treatment outcomes.

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