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Management of a hyperactive-conduct disordered child through correspondence training: A preliminary study
1. Behm. Ther. & fip. Psychid. Printed in Great Britain.
Vol. 21. No.
1. pp. 63418.
1990. 0
OOOS-7916/90 S3.00+0.00 1990 Pergamon Press ptc.
MANAGEMENT OF A HYPERACTIVE-CONDUCT DISORDERED CHILD THROUGH CORRESPONDENCE TRAINING: A PRELIMINARY STUDY FREDDY
A. PANIAGUA,
PATRICIA
B. MORRISON,
and SANDRA A. BLACK
University of Texas Medical Branch study examined the clinical effects of correspondence training procedures in of a hyperactive-conduct disordered boy. During the reinforcemenr of promise-do correspondence procedure. a toy (reinforcer) was given contingent upon the presence of a promise to inhibit target behaviors (e.g., inattention, overactivity, aggression) and the actual inhibition of such behaviors. This intervention was programmed in a multiple baseline design across settings. Consistently Lower Levels of hyperactivity and conduct disorders were noted during treatment, relative to baseline. A demonstration of the indirect effects of the procedures upon the child’s academic performance was also seen. Summary-This
the management
is unique in that it reports preliminary results involving the clinical utility of correspondence training in the management of a child with both diagnoses of A-DHD and conduct disorder (DSM-III-R).
Three traditional approaches in the management of hyperactive children include drug therapy, behavior therapy, and cognitivebehavioral training (Barkley, 1981, 1989). Correspondence training is a non-traditional approach suggested by Abikoff and Gittelman (1985) for the management of these children. A relationship between what a person says he/ she will do and what he/she then does, or between what he/she does and later says that he/she has done is termed correspondence between verbal and nonverbal behavior (Israel, 1978). The effects of this training in establishing, decreasing, maintaining, and/or extinguishing behavior have been documented in both basic research (Israel & Brown, 1977; Paniagua & Baer, 1982; Risley & Hart, 1968) and clinical research studies (Paniagua, 1985). Recently, Paniagua and his associates 1987; Paniagua, Pumariega, & (Paniagua, Black, 1988) used the correspondence training approach with children fulfilling DSM-III-R (1987) criteria for Attention-Deficit Hyperactive Disorder (A-DHD). The present study
Method Subject. A boy, seven years old, admitted in the Division of Child and Adolescent Psychiatry of the University of Texas Medical Branch, was the participant. Selection criteria included: (1) IQ greater than 70 on the WISC-R (Subject’s IQ= 101); (2) an average cutoff point of 1.5 on the Abbreviated Teacher Rating Scale (ATRS, Conners, 1973); (3) DSM-III-R criteria for Attention-Deficit Hyperactive Disorder and Conduct Disorder; (4) not currently taking medication for ADHD; (5) no peripheral sensory loss, psychosis, epilepsis, cerebral palsy, or unequivocal brain damage; and (6) consent from both the patient and authorized representatives to participate in this study.
Authors’ Nore: This research was supported in part by a grant from the Hogg Foundation for Mental Health given to the
first author. A Portion of this paper was presented in the Second Annual Rivendell Conference, Memphis, TN. Reprint requests should be addressed to: Freddy A. Paniagua, Ph.D., Division of Child and Adolescent Psychiatry, University of Texas Medical Branch, Galveston, TX 77550. 63
64
FREDDY
Target
A. PANIAGUA,
PATRICIA
Behaviors.
The target behaviors included the child’s promise in not manifesting the target (nonverbal) maladaptive behaviors, inattention to a specific task, overactivity, conduct disorders (e.g., aggressiveness), and the child’s academic performance. Promises were defined as verbal responses about the inhibition of hyperactivity (e.g., “I’ll sit still”) and conduct disorders (e.g., “I’ll not hit people in this room”) following the question, “Are you going to (e.g., sit still in your chair)?” and “Will you (e.g., hit people or make noise in this room)?” Promises about the completion of academic tasks were not collected. Hyperactivity was defined in terms of two classes of behavior: (1) Inattention and Conduct Disorder was (2) Overactivity. defined in terms of three classes of behaviors: (1) Aggressiveness, (2) Destructiveness, and (3) Noise. Table 1 summarizes the behavioral definition of the responses within each class of behavior. Academic performance was defined (and recorded) in terms of the number of math/spelling problems completed correctly (correct doing) and incorrectly (incorrect doing).
B. MORRISON
and SANDRA
Table 1 The Definition of Hyperactivity and Conduct Disorders in Terms of Several Classes of Behavio? Hyperactivity Class I: Inattention (A) Off-Task Behavior
(B) Activity
Change
Class II: Overactivity (A) Fidgeting
Recording
Techniques
and
Reliability.
Promises were recorded verbatim during a verbalization period of (approximately) five
Eyes not oriented toward task materials. teacher, or trainer for at least 1.5 second duration during any 30 second interval. Physical contact with a new toy, group of toys, or task materials. New is defined as any toy, group of toys, or task materials which the child is not engaged with at the start of the interval. Moving the hands. legs, torso, head without apparent purpose.
(B) Grid-Marked Changes
Crossing a gridline under own power; both feet must be completely in new quadrant to be scored as grid changes.
(C) Out-of-Seat Behavior
Any situation where normal seating surface of neither buttocks is applied to the child’s seat.
Class I: Aggressiveness
Settings. Observations were conducted in three settings: a classroom, a simulated classroom, and a treatment room located in the Division of Child and Adolescent Psychiatry. In general, five to nine children constituted the maximum number of children in the classroom. The simulated classroom was adjacent to the regular classroom and it included the target subject and two therapists. The treatment room was adjacent to the inpatient unit and its for videotaping contained two cameras purposes and an adjacent room for observation through a one-way mirror. In the treatment room only the target subject was present during the 10 minute obse-rvation period.
A. BLACK
Conduct Disorders Kicking others. hitting pushing others
Class II: Destructiveness
Breaking materials property.
objects/task or another
Class III: Noise
Clapping pencils
hands,
others,
person’s
tapping
minutes. Hyperactivity and conduct disorder were recorded with the partial-interval timesampling recording system (Sulzer-Azaroff & Mayer, 1977). Each session lasted 10 minutes and was divided into 20 thirty-second intervals for recording. One session per day in each setting was scheduled throughout the completion of the study. Observations were scheduled from Monday through Friday in each setting. Each day, the child was first observed in the classroom, which was immediately followed by another observational period in the
Management of Hyperactivity-Conduci
simulated classroom, and a third observation in the treatment room immediately after completion of the observation in the simulated classroom. The last observational period was scheduled to assess the generalized effects of interventions in the treatment room. Each 10 minute observation (and use of the correspondence training techniques) was conducted by the same therapists. It should be noted that although ten minutes of observation per session seems quite brief, in the present area of research that period is often a sufficient timeframe for the evaluation of treatment effects (see Barkley, 1981, pp. 158-159). The reliability of recording target behaviors was calculated with the formula: Number of agreements divided by the number of agreements plus disagreements x 100. Reliabilty for recording promises and academic performance was 100%. The reliability for recording the hyperactivity and conduct disorder ranged from 75 to 100% with an overall mean of 97%. Experimental Designs. The basic design was a multiple baseline design (MBD) across settings (Kratochwill, Mott, & Dodson, 1984). The original plan was to program the intervention across the classroom, simulated room, and treatment room settings. However, the generalization of intervention effects in the third setting (treatment room) did not permit the programming of intervention in that setting using the MBD. During the delivery of the reinforcer contingent upon promise-do correspondence, three clinical criteria were established based on a specific number of intervals (within the 20 thirty-second observational period) during which promise-do correspondence were required for the actual delivery of the reinforcer: Criteria 1 = eight consecutive intervals (or 40% of total intervals, in Figure 1 and 2); Criterion 2= 15 consecutive intervals (or 75%), and Criterion 3=20 consecutive intervals (or 100%). The reason for these clinical criteria was to prevent the child from holding his inappropriate behaviors during few intervals (e.g., first interval in a total of 20 thirty
Disorder
65
second intervals) and then to continue behaving inappropriately during subsequent intervals (e.g., next 19 thirty second intervals). Procedures Baseline. Promises were evoked before the recording of hyperactive and conduct disorders in a given setting. The child received his academic task and remained in the particular setting until the end of the observational period. No consequences were programmed during this phase. Reinforcement of Promise-Do Correspondence. The child’s promise about the inhibition
of hyperactivity and conduct disorders was obtained and, immediately after that observational period, a tangible reinforcer (e.g., small toys) was delivered contingent upon the presence of the promise (evoked earlier), fulfillment of the promise (e.g., the absence of target maladaptive behaviors), and fulfillment of the particular clinical criterion (e.g., maladaptive behaviors not present across eight consecutive intervals or 40% of total intervals). Three verbal feedbacks were presented: (1) “This page [i.e., the data collection form] shows you did (e.g., not hit people and sit still in your chair) for a long period of time [i.e., fulfillment of the criterion level]. You also worked on your task. Here is your toy for today”; (2) “This page shows that you (e.g., did hit people and did not sit still) for a long period of time [i.e., criterion level was not fulfilled]. Also, you did not work on your task. I cannot give you this toy today”; and (3) “This page shows that you (e.g., did not hit people and sit still) but only for a brief period of time [i.e., criterion level was partially fulfilled]. Also, you did little work on your tasks. I cannot give you this toy today.” It should be noted that academic work was scheduled during the session and scored immediately after the completion of the 20 thirty second intervals. At the end of the session, the experimenter scored the number of tasks completed correctly or incorrectly and provided
FREDDY A. PANIAGUA,
66
PATRICIA
no consequences (i.e., the correspondence training technique and feedbacks were not programmed upon the child’s academic performance).
B. MORRISON and SANDRA A. BLACK
BASELINE. S’PROMISE-DO
X GIIWI..,
CLASSROOM a
. . .._.
,.
-.....
Results and Discussion Figure 1 shows that the application of correspondence training procedures decreased inattention and overactivity markedly, relative to baseline. When the training was in effect in the classroom and simulated classroom settings, target behaviors decreased in the third setting (treatment room) in the absence of training. This change in target behaviors in the third setting could be explained in terms of the process of training of sujjkient exemplars proposed by Stokes and Baer (1977) in the promotion of generalization of treatment effects.
SIMULATED CLASSRODM
SESSIONS
CLASSW
XGNdNl 44 I
,5 0
cl
5
;
Figure 2. Daily percentages of aggressiveness, destructiveness, noise, and promises during baseline and reinforcement of promise-do correspondence across two settings (classroom and simulated classroom). In the third setting (treatment room), a decrease in target behavior is noted in the absence of training.
_I..
Figure 1. Daily percentages of inattention, overactivity. and promises during baseline and reinforcement of promise-do correspondence across a classroom and a simulated classroom setting. In the third setting (treatment room), a decrease in target behaviors is noted in the absence of training.
That is, the introduction of training in the classroom and simulated room settings (the first two exemplars in the design) was, probably, a sufficient condition for changes in target maladaptive behaviors in the unmanipulated exemplars (i.e., the treatment room). If so, such results could be considered as an example of the promotion of generalization of training effects in a condition of training of sufficient exemplars. Figure 2 displays the data for conduct disorders. In general, aggressiveness and destructiveness were not major problems across settings; noise constituted the most common form of conduct disorders across settings. Figure 2 shows a substantial decrease in the level of noise during treatment, in comparison with baseline observations. The level of noise also decresed markedly in the treatment room
Management of Hyperactivity-Conduct ACADEMIC 1
3
PERFORMANCE
n
CLASSROOM
Figure 3. Daily percentages of correct and incorrect academic tasks across target settings. These results represent an index of the child’s academic performance during the application of correspondence training contingent upon the absence of maladaptive behaviors in the classroom and simulated classroom settings (Figures 1 and 2).
the training was introduced in the classroom and simulated classroom settings. These results again suggest that training in two exemplars facilitated the management of noise in the third exemplar (treatment room). Figure 3 shows the child’s academic performance across settings. Figure 3 shows that when the reinforcement of promise-do correspondence procedure was programmed in the classroom (during the management of hyperactivity and conduct disorder), the percentages of correct doing increased and percentages of incorrect doing decreased substantially from sessions five to nine; in session lo-11 the level for each academic performance increased. However, the percentage of incorrect doing remained at zero levels across intervention when
Disorder
67
sessions suggesting that each time the child completed the particular task he did so correctly. Overall, these results suggest that when correspondence training is directly programmed upon the maladaptive behaviors of hyperactive children indirect control (improvement) of academic performance among such children could also be achieved. The present results correlated with the Teacher Rating scores. In that scale, scores of 1.5 or higher indicate high level of hyperactivity. The ATRS mean score in baseline was 2.65; during the introduction of correspondence training the score was 1.40. There are some limitations in this study. In the case of decreasing hyperactivity and conduct disorder in the third setting (the third exemplar) that decrease was clearly noted only during a short period of observation. Thus, future research is needed to investigate the generalized effect of correspondence training during a longer period of time. Second, in the treatment room only the subject was present; in the classroom setting, the subject was intervened in the presence of other children and therapists, and in the simulated classroom setting only therapists and the subject were present. These factors (e.g., peers + therapists + subject, in the classroom) could also explain the generalization of training in the third setting, and not simply the training of sulyicient exemplars process. Another limitation is that the present results represent the clinical utility of correspondence training in the management of only one subject with both diagnoses of A-DAH and conduct disorder. (Currently, a large number of subjects meeting both diagnoses are being treated in the Division using various forms of correspondence training.) However, it should be noted that in this study noise was the only conduct-disorder behavior present in the subject. Therefore, future research is needed to demonstrate the clinical utility of correspondence training in the management of aggressiveness, destructiveness, and other instances of conduct-disorder behaviors.
FREDDY A. PANIAGUA,
68
PATRICIA B. MORRISON and SANDRA A. BLACK
However, despite these limitations the results suggest that correspondence training could be a practical alternative in current management programs for A-DHD and conduct disordered children in classroom and home settings. For example, correspondence training would be the appropriate and practical alternative in those cases when teachers, parents, and therapists do not have the time to program other time-consuming procedures (e.g., timeout from positive reinforcement) in the management of hyperactive children (Paniagua, 1989). In addition, most traditional interventions for A-DHD and conduct disorder (e.g., token programs) emphasize direct control of target (maladaptive-nonverbal) behavior. This means that in such interventions the inappropriate behavior (e.g., aggression noise, and inattention) has to be present before the treatment is actually employed. In correspondence training the emphasis is placed upon the management of the maladaptive behavior before the target behavior is actually emitted. Thus, correspondence training can be used in treatment programs specifically designed to change behavior (e.g., present study) and in prevention programs designed to prevent the development of maladaptive behaviors (Paniagua, 1989). References
Barkley, R. A. (1981). Hyperactive children. New York: Guilford. Barkley, R. A. (1989). Attention deficit-hyperactive disorder. In E. J. Mash & R. A. Barkley (Eds.,), Childhood d&orders (pp. 39-72). New York: Guilford Press. Conners, C. K. (1973). Rating scales for use in drug studies with children. Psychopharmacological Bulletin (Special Issue-Pharmacotherapy with children), 24-84. Israel, A. C. (1978). Some thoughts on correspondence between saying and doing. Journal of Applied Behavior Analysts,
Applied
Psychiatry,
42,953-961.
American Psychiatry Association.
(1987). Diagnostic and statistical manual: DSM-DIR. Washington, D.C.: American Psychiatry Association.
Behavior
Analysis,
JO, 333-338.
Kratochwill, T. R., Mott, S. E., & Dodson, C. L. (1984). Case study and single-case research in clinical and applied psychology. In A. S. Bellack & M. Hersen (Eds.), Research methods in clinical psychology pp. 5599. New York: Pergamon Press. Paniagua, F. A. (1985). Development of self-care skills and helping behaviors of adolescents in a group home through correspondence training. Journal of Behavior Therapy and Experimental
Psychiatry,
16, 237-244.
Paniagua, F. A. (1987). Management of hyperactive children through correspondence training procedures: A preliminary study. Behavior Residential Treatment, 2, l-23.
Panaigua, F. A. (1989). Lying by children: Why children say one thing, do another? Psychological Reports, 64, 971-984.
Paniagua, F. A., & Baer, D. M. (1982). The analysis of correspondence training as a chain reinforceable at any point.‘Child Developm&t, 53, 786-798. Paniaeua. F. A.. Pumarieea. A. J.. & Black. S. A. (1988). Cl&al effects of correspondence training in the management of hyperactive children. Behavioral Residential Treatment,
3, 19-40.
Risley, T. R., & Hart, B. (1968). Developing correspondence between the nonverbal and verbal behavior of preschool children. Journal of Applied Behavior Analysis,
Abikoff, G., & Gittelman, R. (1985). Hyperactive children treated with stimulants. Archives of General
11, 271-273.
Israel, A. C., & Brown, M. S. (1977). Correspondence training prior verbal training and control of nonverbal behavior via control of verbal behavior. Journal of
I, 267-281,
Stokes, T. F., & Baer, D. M. (1977). An implicit technology of generalization. Journal of Applied Behavior Analysis,
IO, 349-367.
Sulzer-Azaroff,
B., & Mayer, G. R. (1977). Applying
behavior-analysis procedures New York: Holt.
with children
and youth.
Vol. 21. No.
1. pp. 63418.
1990. 0
OOOS-7916/90 S3.00+0.00 1990 Pergamon Press ptc.
MANAGEMENT OF A HYPERACTIVE-CONDUCT DISORDERED CHILD THROUGH CORRESPONDENCE TRAINING: A PRELIMINARY STUDY FREDDY
A. PANIAGUA,
PATRICIA
B. MORRISON,
and SANDRA A. BLACK
University of Texas Medical Branch study examined the clinical effects of correspondence training procedures in of a hyperactive-conduct disordered boy. During the reinforcemenr of promise-do correspondence procedure. a toy (reinforcer) was given contingent upon the presence of a promise to inhibit target behaviors (e.g., inattention, overactivity, aggression) and the actual inhibition of such behaviors. This intervention was programmed in a multiple baseline design across settings. Consistently Lower Levels of hyperactivity and conduct disorders were noted during treatment, relative to baseline. A demonstration of the indirect effects of the procedures upon the child’s academic performance was also seen. Summary-This
the management
is unique in that it reports preliminary results involving the clinical utility of correspondence training in the management of a child with both diagnoses of A-DHD and conduct disorder (DSM-III-R).
Three traditional approaches in the management of hyperactive children include drug therapy, behavior therapy, and cognitivebehavioral training (Barkley, 1981, 1989). Correspondence training is a non-traditional approach suggested by Abikoff and Gittelman (1985) for the management of these children. A relationship between what a person says he/ she will do and what he/she then does, or between what he/she does and later says that he/she has done is termed correspondence between verbal and nonverbal behavior (Israel, 1978). The effects of this training in establishing, decreasing, maintaining, and/or extinguishing behavior have been documented in both basic research (Israel & Brown, 1977; Paniagua & Baer, 1982; Risley & Hart, 1968) and clinical research studies (Paniagua, 1985). Recently, Paniagua and his associates 1987; Paniagua, Pumariega, & (Paniagua, Black, 1988) used the correspondence training approach with children fulfilling DSM-III-R (1987) criteria for Attention-Deficit Hyperactive Disorder (A-DHD). The present study
Method Subject. A boy, seven years old, admitted in the Division of Child and Adolescent Psychiatry of the University of Texas Medical Branch, was the participant. Selection criteria included: (1) IQ greater than 70 on the WISC-R (Subject’s IQ= 101); (2) an average cutoff point of 1.5 on the Abbreviated Teacher Rating Scale (ATRS, Conners, 1973); (3) DSM-III-R criteria for Attention-Deficit Hyperactive Disorder and Conduct Disorder; (4) not currently taking medication for ADHD; (5) no peripheral sensory loss, psychosis, epilepsis, cerebral palsy, or unequivocal brain damage; and (6) consent from both the patient and authorized representatives to participate in this study.
Authors’ Nore: This research was supported in part by a grant from the Hogg Foundation for Mental Health given to the
first author. A Portion of this paper was presented in the Second Annual Rivendell Conference, Memphis, TN. Reprint requests should be addressed to: Freddy A. Paniagua, Ph.D., Division of Child and Adolescent Psychiatry, University of Texas Medical Branch, Galveston, TX 77550. 63
64
FREDDY
Target
A. PANIAGUA,
PATRICIA
Behaviors.
The target behaviors included the child’s promise in not manifesting the target (nonverbal) maladaptive behaviors, inattention to a specific task, overactivity, conduct disorders (e.g., aggressiveness), and the child’s academic performance. Promises were defined as verbal responses about the inhibition of hyperactivity (e.g., “I’ll sit still”) and conduct disorders (e.g., “I’ll not hit people in this room”) following the question, “Are you going to (e.g., sit still in your chair)?” and “Will you (e.g., hit people or make noise in this room)?” Promises about the completion of academic tasks were not collected. Hyperactivity was defined in terms of two classes of behavior: (1) Inattention and Conduct Disorder was (2) Overactivity. defined in terms of three classes of behaviors: (1) Aggressiveness, (2) Destructiveness, and (3) Noise. Table 1 summarizes the behavioral definition of the responses within each class of behavior. Academic performance was defined (and recorded) in terms of the number of math/spelling problems completed correctly (correct doing) and incorrectly (incorrect doing).
B. MORRISON
and SANDRA
Table 1 The Definition of Hyperactivity and Conduct Disorders in Terms of Several Classes of Behavio? Hyperactivity Class I: Inattention (A) Off-Task Behavior
(B) Activity
Change
Class II: Overactivity (A) Fidgeting
Recording
Techniques
and
Reliability.
Promises were recorded verbatim during a verbalization period of (approximately) five
Eyes not oriented toward task materials. teacher, or trainer for at least 1.5 second duration during any 30 second interval. Physical contact with a new toy, group of toys, or task materials. New is defined as any toy, group of toys, or task materials which the child is not engaged with at the start of the interval. Moving the hands. legs, torso, head without apparent purpose.
(B) Grid-Marked Changes
Crossing a gridline under own power; both feet must be completely in new quadrant to be scored as grid changes.
(C) Out-of-Seat Behavior
Any situation where normal seating surface of neither buttocks is applied to the child’s seat.
Class I: Aggressiveness
Settings. Observations were conducted in three settings: a classroom, a simulated classroom, and a treatment room located in the Division of Child and Adolescent Psychiatry. In general, five to nine children constituted the maximum number of children in the classroom. The simulated classroom was adjacent to the regular classroom and it included the target subject and two therapists. The treatment room was adjacent to the inpatient unit and its for videotaping contained two cameras purposes and an adjacent room for observation through a one-way mirror. In the treatment room only the target subject was present during the 10 minute obse-rvation period.
A. BLACK
Conduct Disorders Kicking others. hitting pushing others
Class II: Destructiveness
Breaking materials property.
objects/task or another
Class III: Noise
Clapping pencils
hands,
others,
person’s
tapping
minutes. Hyperactivity and conduct disorder were recorded with the partial-interval timesampling recording system (Sulzer-Azaroff & Mayer, 1977). Each session lasted 10 minutes and was divided into 20 thirty-second intervals for recording. One session per day in each setting was scheduled throughout the completion of the study. Observations were scheduled from Monday through Friday in each setting. Each day, the child was first observed in the classroom, which was immediately followed by another observational period in the
Management of Hyperactivity-Conduci
simulated classroom, and a third observation in the treatment room immediately after completion of the observation in the simulated classroom. The last observational period was scheduled to assess the generalized effects of interventions in the treatment room. Each 10 minute observation (and use of the correspondence training techniques) was conducted by the same therapists. It should be noted that although ten minutes of observation per session seems quite brief, in the present area of research that period is often a sufficient timeframe for the evaluation of treatment effects (see Barkley, 1981, pp. 158-159). The reliability of recording target behaviors was calculated with the formula: Number of agreements divided by the number of agreements plus disagreements x 100. Reliabilty for recording promises and academic performance was 100%. The reliability for recording the hyperactivity and conduct disorder ranged from 75 to 100% with an overall mean of 97%. Experimental Designs. The basic design was a multiple baseline design (MBD) across settings (Kratochwill, Mott, & Dodson, 1984). The original plan was to program the intervention across the classroom, simulated room, and treatment room settings. However, the generalization of intervention effects in the third setting (treatment room) did not permit the programming of intervention in that setting using the MBD. During the delivery of the reinforcer contingent upon promise-do correspondence, three clinical criteria were established based on a specific number of intervals (within the 20 thirty-second observational period) during which promise-do correspondence were required for the actual delivery of the reinforcer: Criteria 1 = eight consecutive intervals (or 40% of total intervals, in Figure 1 and 2); Criterion 2= 15 consecutive intervals (or 75%), and Criterion 3=20 consecutive intervals (or 100%). The reason for these clinical criteria was to prevent the child from holding his inappropriate behaviors during few intervals (e.g., first interval in a total of 20 thirty
Disorder
65
second intervals) and then to continue behaving inappropriately during subsequent intervals (e.g., next 19 thirty second intervals). Procedures Baseline. Promises were evoked before the recording of hyperactive and conduct disorders in a given setting. The child received his academic task and remained in the particular setting until the end of the observational period. No consequences were programmed during this phase. Reinforcement of Promise-Do Correspondence. The child’s promise about the inhibition
of hyperactivity and conduct disorders was obtained and, immediately after that observational period, a tangible reinforcer (e.g., small toys) was delivered contingent upon the presence of the promise (evoked earlier), fulfillment of the promise (e.g., the absence of target maladaptive behaviors), and fulfillment of the particular clinical criterion (e.g., maladaptive behaviors not present across eight consecutive intervals or 40% of total intervals). Three verbal feedbacks were presented: (1) “This page [i.e., the data collection form] shows you did (e.g., not hit people and sit still in your chair) for a long period of time [i.e., fulfillment of the criterion level]. You also worked on your task. Here is your toy for today”; (2) “This page shows that you (e.g., did hit people and did not sit still) for a long period of time [i.e., criterion level was not fulfilled]. Also, you did not work on your task. I cannot give you this toy today”; and (3) “This page shows that you (e.g., did not hit people and sit still) but only for a brief period of time [i.e., criterion level was partially fulfilled]. Also, you did little work on your tasks. I cannot give you this toy today.” It should be noted that academic work was scheduled during the session and scored immediately after the completion of the 20 thirty second intervals. At the end of the session, the experimenter scored the number of tasks completed correctly or incorrectly and provided
FREDDY A. PANIAGUA,
66
PATRICIA
no consequences (i.e., the correspondence training technique and feedbacks were not programmed upon the child’s academic performance).
B. MORRISON and SANDRA A. BLACK
BASELINE. S’PROMISE-DO
X GIIWI..,
CLASSROOM a
. . .._.
,.
-.....
Results and Discussion Figure 1 shows that the application of correspondence training procedures decreased inattention and overactivity markedly, relative to baseline. When the training was in effect in the classroom and simulated classroom settings, target behaviors decreased in the third setting (treatment room) in the absence of training. This change in target behaviors in the third setting could be explained in terms of the process of training of sujjkient exemplars proposed by Stokes and Baer (1977) in the promotion of generalization of treatment effects.
SIMULATED CLASSRODM
SESSIONS
CLASSW
XGNdNl 44 I
,5 0
cl
5
;
Figure 2. Daily percentages of aggressiveness, destructiveness, noise, and promises during baseline and reinforcement of promise-do correspondence across two settings (classroom and simulated classroom). In the third setting (treatment room), a decrease in target behavior is noted in the absence of training.
_I..
Figure 1. Daily percentages of inattention, overactivity. and promises during baseline and reinforcement of promise-do correspondence across a classroom and a simulated classroom setting. In the third setting (treatment room), a decrease in target behaviors is noted in the absence of training.
That is, the introduction of training in the classroom and simulated room settings (the first two exemplars in the design) was, probably, a sufficient condition for changes in target maladaptive behaviors in the unmanipulated exemplars (i.e., the treatment room). If so, such results could be considered as an example of the promotion of generalization of training effects in a condition of training of sufficient exemplars. Figure 2 displays the data for conduct disorders. In general, aggressiveness and destructiveness were not major problems across settings; noise constituted the most common form of conduct disorders across settings. Figure 2 shows a substantial decrease in the level of noise during treatment, in comparison with baseline observations. The level of noise also decresed markedly in the treatment room
Management of Hyperactivity-Conduct ACADEMIC 1
3
PERFORMANCE
n
CLASSROOM
Figure 3. Daily percentages of correct and incorrect academic tasks across target settings. These results represent an index of the child’s academic performance during the application of correspondence training contingent upon the absence of maladaptive behaviors in the classroom and simulated classroom settings (Figures 1 and 2).
the training was introduced in the classroom and simulated classroom settings. These results again suggest that training in two exemplars facilitated the management of noise in the third exemplar (treatment room). Figure 3 shows the child’s academic performance across settings. Figure 3 shows that when the reinforcement of promise-do correspondence procedure was programmed in the classroom (during the management of hyperactivity and conduct disorder), the percentages of correct doing increased and percentages of incorrect doing decreased substantially from sessions five to nine; in session lo-11 the level for each academic performance increased. However, the percentage of incorrect doing remained at zero levels across intervention when
Disorder
67
sessions suggesting that each time the child completed the particular task he did so correctly. Overall, these results suggest that when correspondence training is directly programmed upon the maladaptive behaviors of hyperactive children indirect control (improvement) of academic performance among such children could also be achieved. The present results correlated with the Teacher Rating scores. In that scale, scores of 1.5 or higher indicate high level of hyperactivity. The ATRS mean score in baseline was 2.65; during the introduction of correspondence training the score was 1.40. There are some limitations in this study. In the case of decreasing hyperactivity and conduct disorder in the third setting (the third exemplar) that decrease was clearly noted only during a short period of observation. Thus, future research is needed to investigate the generalized effect of correspondence training during a longer period of time. Second, in the treatment room only the subject was present; in the classroom setting, the subject was intervened in the presence of other children and therapists, and in the simulated classroom setting only therapists and the subject were present. These factors (e.g., peers + therapists + subject, in the classroom) could also explain the generalization of training in the third setting, and not simply the training of sulyicient exemplars process. Another limitation is that the present results represent the clinical utility of correspondence training in the management of only one subject with both diagnoses of A-DAH and conduct disorder. (Currently, a large number of subjects meeting both diagnoses are being treated in the Division using various forms of correspondence training.) However, it should be noted that in this study noise was the only conduct-disorder behavior present in the subject. Therefore, future research is needed to demonstrate the clinical utility of correspondence training in the management of aggressiveness, destructiveness, and other instances of conduct-disorder behaviors.
FREDDY A. PANIAGUA,
68
PATRICIA B. MORRISON and SANDRA A. BLACK
However, despite these limitations the results suggest that correspondence training could be a practical alternative in current management programs for A-DHD and conduct disordered children in classroom and home settings. For example, correspondence training would be the appropriate and practical alternative in those cases when teachers, parents, and therapists do not have the time to program other time-consuming procedures (e.g., timeout from positive reinforcement) in the management of hyperactive children (Paniagua, 1989). In addition, most traditional interventions for A-DHD and conduct disorder (e.g., token programs) emphasize direct control of target (maladaptive-nonverbal) behavior. This means that in such interventions the inappropriate behavior (e.g., aggression noise, and inattention) has to be present before the treatment is actually employed. In correspondence training the emphasis is placed upon the management of the maladaptive behavior before the target behavior is actually emitted. Thus, correspondence training can be used in treatment programs specifically designed to change behavior (e.g., present study) and in prevention programs designed to prevent the development of maladaptive behaviors (Paniagua, 1989). References
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