Noncompliant behavior of people with mental retardation

Research in Developmental Disabilities. Printed in the USA. All rights reserved.

Vol. 14, pp. 87-105,

1993 Copyright

0891-4222/‘93 $6.00 + .OO 8 1993 Pergamon Press Ltd.

Noncompliant Behavior of People With Mental Retardation G. Rex Walker Southeastern Virginia Training Center

Literature pertaining to noncompliant behavior of people with mental retardation was reviewed. Noncomplianr behavior was considered in terms of antecedents (characteristics of instructions), behaviors (characteristics of tasks being refused). and consequences (environmental results of noncompliance). Literature pertaining to nondisabled “oppositional” children was incorporated along with literature pertaining to persons with mental retardation. Research involving antecedent conditions suggested that noncompliance is more likely when instructions are vague and interrupted with other instructions. It also suggested that a series of high probability requests could enhance compliance to a subsequent low probability request. Research into behavior variables suggested that noncompliance is more likely when task demands are too difficult. Research into consequent conditions indicates that either positive or negative reinforcement may maintain noncompliant behavior. Treatment studies suggested that oppositional children respond poorly to verbal reward alone and somewhat better to tangible rewards and to programs utilizing timeout. By contrast, noncompliance by people with mental retardation appears to respond well to programs utilizing combinations of social and tangible rewards, but results also suggest that results of timeout programs are mixed. Implications for treatment were discussed along with suggestions for future research.

Noncompliant behavior by people with mental retardation is a common and sometimes troublesome habilitation problem. Wehman and McLaughlin (1979) noted that the problem was observed very frequently in people with disabilities. Breiner and Forehand (1982) reported that a sample of developmentally delayed children displayed a greater incidence of noncompliance than a sample of nondisabled children. More recently, Fidura, Lindsey, and Walker (1987) reported that 87% of clients referred for behavRequests for reprints should be sent to G. Rex Walker, Clinical Director, Fioura & Associates, Inc., Boulders II Suite 400,740O Beaufont Springs Drive, Richmond, VA 23225. 87

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ioral treatment in a residential setting had noncompliance identified as one of the referring problems. Schoen (1983) has suggested that noncompliance in response to an instruction could take any of the following three forms: (a) no response is forthcoming, (b) no response is initiated within a prespecified period of time, or(c) some other, nonrequested behavior is performed (p. 483). Inclusion of “nonrequested behaviors” in the definition of noncompliance leads to a blurring of the distinction between noncompliance and other aberrant behaviors. Presumably, anyone who is not complying with an instruction is simultaneously engaging in some other behavior. Accordingly, “noncompliance” is at once both a description of a nonexistent response class and a description of virtually all challenging behaviors. Despite the problem of definition, noncompliance is, in fact, an identifiable behavior disorder and is one that may be amenable to treatment using principles of behavior analysis. As with all challenging behaviors, treatment requires (a) selection of an appropriate operational definition of the problem, (b) analysis of the environmental factors maintaining the problem, and (c) implementation of treatment techniques to remedy the problem. Generating an operational definition of noncompliance requires establishment of procedures for making requests. For example, noncompliance might be defined as failure to begin implementing a request after two verbal prompts that are spaced 1 min apart. Persons making requests would be instructed to make a request one time, walk away for 1 min if there is no response, and then return and repeat the request. If the requested behavior does not begin after the second request, then noncompliance is said to have occurred. A more stringent definition might be inferred from Wruble, Sheeber, Sorensen, Boggs, and Eyberg (1991). In research involving nondisabled children, these authors observed that 85% of children began to comply within 5 s of a request, and thus concluded that a 5-s cutoff is appropriate for coding noncompliance in observational data procedures. Analysis of environmental factors maintaining noncompliance requires the same sort of functional analysis required to analyze any challenging behavior. This typically is accomplished by recording antecedents, behaviors, and consequences (Lennox & Miltenberger, 1989). Implementation of treatment techniques requires that strategies be selected based upon the functional analysis and a review of relevant treatment literature. Portions of the treatment literature pertaining to noncompliance will be described herein. This review will consider treatment of noncompliance from an A-B-C perspective. Specifically, experimental investigations will be reviewed which pertain to the instructions that are refused (antecedents), the types of tasks that are refused (behaviors), and the ramifications of refusal (consequences). Literature is selected from two general sources. The first is

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research dealing with nondisabled “oppositional” children. The second source is research involving people with developmental disabilities. Differences in the results from these two sources will be noted, and implications for habilitative programming will be discussed. RESEARCH

INVOLVING

NONDISABLED

OPPOSITIONAL

CHILDREN

A large amount of research in child behavior therapy has been devoted to the treatment of noncompliance in children. Such children have been described as “oppositional” (Wahler, 1969) or “deviant” (Forehand, 1986). Their behavior ranges from actively refusing to follow parental instructions to “off-task” behavior in school settings. Antecedents

Antecedent conditions pertinent to noncompliant behavior refer to the instructions or requests with which the child fails to comply. Of specific interest is the form in which the requests are given as opposed to the content of the requests. Rex Forehand and his associates have investigated the effects of different types of commands upon response to instructions. Peed, Roberts and Forehand (1977) describe two types of commands: 1. Alpha command: An order, rule, suggestion, or question to which a motoric response is appropriate or feasible. 2. Beta command: A command to which the child has no opportunity to demonstrate compliance. Beta commands include parental commands that are (a) so vague that proper action for compliance cannot be determined, (b) interrupted by further parental verbage before enough time (5 s) has elapsed for the child to comply, or (c) carried out by the parent before the child has an opportunity to comply. (pp. 330-331) A number of studies have suggested that parental use of beta commands is associated with greater levels of child noncompliance. For example, Williams and Forehand (1984) developed a multiple regression analysis of in-home observations of parents and children. They determined that the best predictor of child compliance and noncompliance was the type of command issued by the parent. Alpha commands were shown to predict compliance, whereas beta commands were shown to predict noncompliance. An investigation by Green, Forehand, and McMahon (1979) suggested that when parents were asked to make their children “look compliant” or “look noncompliant,” they did so by means of different types of instructions. Parents were able to elicit noncompliance by using vague (beta)

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commands and could elicit compliance by means of more specific (alpha) commands. Furthermore, Peed, et al. (1977) reported that a program to train parents to use fewer beta commands resulted in decreases in child noncompliance. Dumas and Lechowicz (1989) conducted naturalistic observations of clinic-referred children and their parents to assess when the children complied, failed to comply, or ignored parental commands. Their research supported other research that demonstrated that compliance is more likely when commands are clearly stated. They also found that commands that implied immediate responses elicited more compliance than those requiring delayed responses. Finally, these authors observed that use of physical contact between the parent and child was associated with a decrease in compliance. There also are data to suggest that the number of commands issued is related to the level of compliance. Forehand, King, Peed, and Yoder (1975), for example, found that mothers of children referred to a clinic for noncompliance gave a larger number of commands than a nonreferred control group. Strain, Lambert, Kerr, Stagg, and Lenker (1983) reported that children in a kindergarten who were low-rated in their classroom behavior received a larger number of repeated commands than those who were highly rated in their behavior. The repetition of commands occurred even when the children initially complied with the first issuance of the command. In summary, data suggest that compliance with commands is facilitated when the commands are clear and imply a specific action. Compliance is decreased when commands are vague or are interrupted by repetition of the same command or unrelated speech. Compliance also is decreased when the person issuing the command accompanies the command with deliberate physical contact. The likelihood of compliance is maximized when commands are issued in such a manner that the desired response is clearly described and when ample time is allowed for the individual to respond before the command is repeated or interrupted with criticism or additional commands. Behaviors Behavior variables are characteristics of the task for which the command is issued. When the child fails to perform a task because of some aspect of what he or she is asked to do, then the noncompliance can be said to have resulted from behavior variables. The number of studies investigating behavior variables and noncompliance is quite limited. A few studies have considered the effects of instructional rate upon noncompliance or off-task behavior. Such investigations typically concern classroom settings, where teachers must select a rate of

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presentation that will result in optimal student participation and learning. Camine (1976) utilized an ABABAB design to compare the effects of slow-rate presentation (A) and fast-rate presentation (B) on the frequency of off-task behavior. Subjects in this study were two students from a lowachieving first grade class. Results of this study indicated that the slowrate presentation was associated with higher levels of off-task behavior, whereas fast-rate presentation was associated with much lower levels of off-task behavior. If the definition of noncompliance encompasses “don’t” commands, then disruptive behaviors might be regarded as a form of noncompliance. Accordingly, when parents are busy and unable to interact with children, the children may be said to be noncompliant because they engage in disruptive behavior. Sanders and Dadds (1982) trained parents in a “Planned Activities” procedure involving selection and arrangement of activities along with discussion of rules with the child. Results indicated that the planned activities component was associated with a decrease in disruption. In this case, a lack of situational demands (inactivity) led to an increase in noncompliant disruption, whereas initiation of activities resulted in greater compliance. In summary, few data are found regarding the relationship between task variables and compliance. Those data that exist suggest that classroom tasks should be presented in a fairly rapid format in order to decrease offtask behavior. Moreover, compliance may be enhanced by means of increased structure in the form of planned activities. Consequences

Research into the relationship between consequent conditions and noncompliance is of two types. Studies of etiology attempt to determine the factors in the home or classroom environment that maintain noncompliant behavior. Studies of treatment investigate which sorts of response-contingent interventions are most effective in bringing about a reduction in noncompliant behavior. A few studies have attempted to determine which aspects of the environment are most likely to engender chronic noncompliant behavior. Strain, et al. (1983) observed children in elementary school classrooms. They found that 82% of low-rated (i.e., chronically noncompliant) children never received any positive social consequences for compliant behavior, whereas this was true for only 27% of the high-rated children. Moreover, positive social consequences were more likely to follow noncompliant behavior in low-rated children (14% of the time) than in high-rated children (6% of the time). They concluded that “misplaced contingencies” were associated with the display of noncompliance.

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Patterson (1979) suggested that compliance-related aversive exchanges may be maintained by mutual negative reinforcement. In such an exchange, the parent issues a command and the child responds with an aversive behavior, such as arguing. The parent then withdraws the command and the child ceases arguing. Each member of the dyad thus has negatively reinforced the other and the noncompliant response is strengthened. As an alternative to Patterson’s “compliance hypothesis,” Wahler and Dumas (1986) offer a “predictability hypothesis.” This hypothesis suggests that aberrant child behavior is maintained because it reduces the unpredictability of the parent’s behavior. Specifically, it is believed that parents react inconsistently to children’s appropriate behavior but somewhat more predictably to aversive behavior. The child thus is negatively reinforced for oppositional behavior because doing so makes the parent’s behavior less unpredictable. Results of their study indicated that 90% of aversive interchanges were initiated by children rather than by parents, suggesting that the function of oppositional behavior was not to escape from or avoid compliance with requests but rather served to obtain positive reinforcement in the form of the parent’s response. This is consistent with findings pertaining to punishment in which parents’ aversive reactions to child oppositional behavior actually increased the level of oppositional behavior of children in clinic-referred families. This effect was not observed in nonreferred families (Patterson, 1976). Results of treatment investigations into the effects of differential reinforcement in the treatment of noncompliance have been mixed. Goetz, Holmberg, and LeBlanc (1975) compared a differential reinforcement of other behavior (DRO) procedure with noncontingent reinforcement in the modification of the noncompliant behavior of a 3-year-old girl enrolled in a preschool class. Results indicated that contingent teacher presence (and praise) was superior to noncontingent teacher presence in increasing the percentage of requests with which the child complied. Use of tangible reward systems, such as token economies, has shown somewhat better success. Little and Kelly (1989) utilized a response cost program to decrease noncompliant behavior of three children. Sullivan and O’Leary (1990) found that reward systems involving tokens and response cost systems were equally effective in increasing on-task behavior. However, the response cost procedure produced superior maintenance of on-task behavior following treatment withdrawal. Some have questioned the efficacy of differential social reinforcement procedures alone in the deceleration of child noncompliant behavior. Walle, Hobbs, and Caldwell (1984) reported that contingent parental praise for compliant behavior did not result in a decrease in noncompliance, but they did believe that it might enhance the efficacy of a concurrent timeout procedure. Similar results were reported by Roberts,

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Hatzenbuehler, and Bean (1981) who found that differential attention alone did not alter children’s noncompliance. Roberts (1985) found that young children do value maternal approval but noted that responsiveness to social reinforcers did not predict levels of compliance. The author concluded that noncompliance by children did not appear to be maintained by attention-seeking and speculated that it might be maintained by task avoidance. He further concluded that “praising child compliance appear[s] to be more of a polite ritual than an active therapeutic component for altering noncompliance (p. 611)” Forehand (1986) drew essentially the same conclusion in a review article, but added that inclusion of positive reinforcement in parental programs to decrease noncompliance might improve the acceptability of the interventions to parents. Abramowitz, O’Leary, and Rosen (1987) investigated the relative effects of encouragement and verbal reprimands in decreasing off-task behavior of students in an elementary remedial program. They found that if the teacher made encouraging statements when children were off-task, there was no consistent change in the children’s behavior. By contrast, verbal reprimands contingent upon off-task behavior brought about a decrease in those behaviors. A number of other investigations also have concluded that verbal reprimands can bring about a decrease in off-task behavior (e.g., Rosen, O’Leary, Joyce, Conway, & Pfiffner, 1984; Abramowitz, O’Leary & Futtersak, 1988). Many investigations have demonstrated that contingent timeout can decrease noncompliant behavior. Wahler (1969) found that a program of differential attention and timeout for noncompliance resulted in a decrease in child oppositional behavior. In this study, the timeout procedure involved placement of the child in his or her bedroom for a period of 5 min. Similar results were reported by Forehand and King (1977), who noted that children complied with 77% of maternal commands after a treatment program of contingent praise and timeout (sitting in a chair in the corner). Pretreatment compliance levels had been only 35%. Roberts and Powers (1990) also demonstrated improved compliance following timeout. The general timeout procedure required the child to sit in a chair for a minimum of 2 min with a release criterion of 15 s of sitting quietly. The purpose of the research was to compare different procedures for enforcing timeout. Timeout was enforced by either spanking (spanking the child twice on tbe buttocks), holding (restraining the child in the chair by holding his or her arms), or using a barrier (placing the child in an empty room and holding a plywood barrier over the door). Timeout enforced by barriers and spanking procedures was superior to that of using personal restraint. Moreover, all enforcement procedures produced greater compliance than a procedure in which there was essentially no enforcement.

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Investigations comparing timeout alone with timeout plus contingent praise have suggested no incremental effects when contingent praise is added. Walle, Hobbs, and Caldwell (1984) found that a program of contingent praise with timeout (2 min of sitting in a comer) for noncompliant behavior was no more effective than a program of timeout alone. Similarly, Roberts, et al. (1981) found that programs of contingent attention plus 2 min of timeout and programs of timeout alone were equally effective, and that both were superior to a program of contingent attention alone. In summary, investigations of the consequences of noncompliance by nondisabled children have not resulted in definitive conclusions regarding the factors maintaining noncompliance. Although research by Strain, et al. (1983) suggests that “misplaced social contingencies” are related to noncompliance, attempts to remedy noncompliance by means of verbal praise alone have not been successful. Moreover, although oppositional behavior may be maintained by parental aversive responses (e.g., Wahler & Dumas, 1986), these responses, in the form of verbal reprimands, have been shown to decrease off-task behavior (Abramowitz, et al., 1987). The only consistent finding appears to be the efficacy of contingent timeout and response cost as procedures to decrease noncompliance.

Conclusions From Oppositional Child Research Research attempting to assess the etiology of noncompliant behavior of oppositional children presents a very amorphous picture. One common theme, however, is the relationship between lack of clarity and noncompliance. The work by Forehand and associates suggests that lack of clarity in instructions is common among parents of oppositional children, and that improving clarity can increase compliance. Furthermore, research by Strain, et al. (1983) suggests that lack of clarity in reinforcement contingencies may be related to noncompliant behavior. This lack of clarity may account for the apparent desire for “predictability” noted by Wahler and Dumas (1986). Improving clarity of prompts, expectations, and reinforcers thus may be an appropriate treatment goal when attempting to remedy noncompliance. Drawing conclusions regarding efficacy of treatment procedures is somewhat easier. Use of tangible rewards and token economy systems frequently improve compliance, but procedures involving only verbal praise and extinction are not effective. Addition of timeout as a punishment makes such programs more effective, and there are some data to suggest that timeout procedures alone are as effective as timeout plus contingent praise. There also are data to support the use of response cost and verbal reprimands as interventions to decrease noncompliant behavior.

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RESEARCH INVOLVING PEOPLE WITH MENTAL RETARDATION

Research into noncompliance by people with mental retardation has considered many of the same issues as research into the behavior of oppositional children. One difference between the two is the nature of the noncompliance being investigated. The behavior of oppositional children ranges from failure to implement commands to “active” refusal in which the child becomes disruptive. The noncompliant behavior of people with mental retardation that has been investigated typically consists merely of failure to follow instructions. Antecedents

Research involving nondisabled children (Peed, Roberts, & Forehand, 1977) suggested that noncompliance occurred more often in response to beta (vague or interrupted) commands and less often in response to alpha (clearly stated) commands. Breiner and Forehand (1982) observed parents of developmentally disabled children and found that they issued four times as many beta commands as parents of nondisabled children. The authors concluded that the greater incidence of noncompliance among developmentally disabled children was attributable to the effects of the greater number of beta commands. Breiner and Beck (1984) reviewed treatment literature pertaining to parent training and concluded that parents of children with disabilities should be trained to decrease their use of beta commands. Other investigations of how instructions are presented have come to varying conclusions. Mash and Terdal (1973) trained parents to decrease the number of commands given to mentally retarded children, to decrease the number of questions asked, and to increase their interaction during play. This training brought about a decrease in noncompliant behavior. Burleigh and Marholin (1977) observed that a severely mentally retarded adult male increased his rate of eye-covering and off-task behavior when given the command “look at me.” They were able to decrease his off-task and avoidant behavior by means of a program of reinforcement of appropriate behavior. A few investigations have utilized physical guidance in addition to verbal instructions as a means of improving compliance. Whitman, Zakaras, and Chardos (1971) taught two severely mentally retarded children a series of motor tasks using positive reinforcement, physical guidance, and fading. The children learned to follow instructions, and the “instruction-following” skill generalized to instructions not previously encountered. Striefel and Wetherby (1973) similarly were able to teach responses to specific instructions to a profoundly mentally retarded boy using physical prompting, but found that the instruction-following skill did not generalize.

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Another approach to the use of antecedent conditions to increase compliance has been to alter pretask requests. Singer, Singer, and Homer (1987) increased compliance of four mentally retarded children by asking each child to perform three to five high probability responses before asking them to perform the required task. Instructors initially asked students to perform three to five tasks that they could perform within 3 s and that had a high probability of being followed (e.g., “give me five,” “shake hands”). After the pretask requests were issued, students were asked to complete the target task. Use of these pretask requests brought about an increase in compliance with the requests that followed. In a similar study, Mace et al. (1988) utilized the concept of “behavioral momentum” to develop a procedure to increase compliance with low probability requests. Each low probability command was preceded by a sequence of high probability commands. Here again, the high probability command sequence brought about an increase in compliance with low probability commands. In summary, data regarding antecedents to noncompliant behavior of people with mental retardation are similar to those reported in studies of oppositional children. The issue of clarity of commands appears to be especially important. Mentally retarded individuals might be expected to be less able than nonhandicapped individuals to deal with instructions that are interrupted or ambiguous. Programs that successfully remedy this problem do so by means of clarification of instructions or the addition of physical prompts to verbal commands. Data also suggest that compliance is increased when a task request is preceded by several requests with which the individual is very likely to comply. These data support the notion of behavioral momentum as a means to increase compliance, and also support the use of errorless learning procedures. Behaviors

Data regarding behavior variables and their influence upon compliance by oppositional children were noted previously to be rather scarce. This lack of research also is noted with respect to the influence of these variables upon the behavior of people with mental retardation. Those data that do exist pertain principally to task difficulty and rate of presentation. Plummer, Baer, and LeBlanc (1977) investigated the effects of paced instructions (one instruction every 2 min) on the noncompliant behavior of autistic children. Results indicated that paced instructions alone reduced noncompliant behavior, whereas paced instruction with timeout (i.e., cessation of interaction contingent upon noncompliant disruption) increased noncompliance. The authors suggested that timeout might serve to negatively reinforce noncompliance under these conditions.

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Several investigations of learning disabled children have considered the relationship between level of instructional difficulty and off-task behavior. Krupski (1985) observed a classroom for learning handicapped children (i.e., those who were mildly mentally retarded, learning disabled, or behaviorally disordered) and a control classroom of nondisabled children. She found that nonhandicapped children spent approximately 80% of their time on task, regardless of demand level. By contrast, learning handicapped children varied in level of off-task behavior as a function of task difficulty. Learning handicapped children were off-task most when demands were greatest and off-task least when demands were minimal. Gickling and Armstrong (1978) observed first and second grade classrooms for learning disabled children. They found that off-task behavior was greatest when cognitive demands of tasks were either too high or too low. Off-task behavior was minimized when task demands were at the “instructional” level, defined as “a range of 70% and 85% of known elements of seatwork activity and between 93% and 97% of known elements for reading assignments (p. 34).” Results similar to the above were reported by Weeks and Gaylord-Ross (1981). They measured self-injurious behavior of three severely mentally retarded children in a day treatment center in response to easy and difficult task demands. Data indicated that self-injurious behavior was highest in response to difficult task demands and that self-injury decreased to near zero levels when the environment was demand-free. They concluded that some types of aberrant behavior might be managed by means of changes in curricula. In summary, results of investigations into behavior variables suggest that noncompliance can vary as a function of task demands. Noncompliance seems particularly likely when task demands are too high, possibly because escape from these demands is negatively reinforcing. Accordingly, noncompliance should decrease when modifications are made in the difficulty of tasks themselves or in the manner in which tasks are presented (e.g., paced instructions, which do not negatively reinforce noncompliance). It is also possible, although perhaps less likely, that noncompliance by people with mental retardation could occur when task demands are too easy. Consequences

Data from research involving nondisabled children suggested that verbal praise generally did not increase compliance and that programs of positive reinforcement alone had limited effect upon noncompliance. Use of positive reinforcement alone with people with mental retardation has shown

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somewhat better success. Russo, Cataldo, and Cushing (1981) found that edible and verbal reinforcement of compliant responding by mildly mentally retarded children led to an increase in compliance and a corresponding decrease in correlated behaviors, such as aggression, crying, and selfinjury. Similar results were reported by Parrish, Cataldo, Kolko, Neef, and Egel (1986) and by Cataldo, Ward, Russo, Riordan, and Bennett (1986). Whitman, Zakaras, and Chardos (1971) obtained compliant responding by two severely mentally retarded children using a program of reinforcement of appropriate responses. Results indicated that the children acquired generalized “instruction-following,” meaning that the subjects later complied with instructions not previously encountered. In another study involving a severely mentally retarded individual, Burleigh and Marholin (1977) decreased off-task behavior using a program of reinforcement (edibles and verbal praise) for appropriate responding. Additional research into positive reinforcement effects has demonstrated the efficacy of token reinforcement in increasing compliant responding. Zimmerman, Zimmerman, and Russell (1969) increased the instructionfollowing of mildly and moderately mentally retarded children in a classroom by means of a token economy. Kazdin and Mascitelli (1980) also were able to increase compliance of educably mentally retarded children using a token economy, and found that compliance was further increased if clients were able to earn themselves off of a token system by means of compliant behavior. A final study involving positive reinforcement utilized self- stimulatory behavior as reinforcement for compliant responding. Sugai and White (1986) allowed an autistic boy to self-stimulate by holding a plastic object in his hand so long as he remained on-task. The self-stimulation object was removed as a consequence of off-task behavior. Correct rates of responding for three tasks were increased as a result of this program. Rather few investigations have demonstrated the efficacy of timeout as a treatment of noncompliance of people with mental retardation. Budd, Green, and Baer (1976) demonstrated that placement in a timeout room for 2 min was an effective component of a parent training program to reduce noncompliance of a mentally retarded child. Parrish et al. (1986) were able to bring about a decrease in noncompliant behavior of mildly and moderately mentally retarded children using a contingent observation procedure without concurrent reinforcement of appropriate behavior. The contingent observation procedure involved seating the child in a chair facing the activity for 1 min. Studies reporting poor results from timeout include that of Doleys, Wells, Hobbs, Roberts, and Cartelli (1976), who reported that timeout had virtually no effect upon the noncompliant behavior of mentally retarded children. Their timeout procedure required that the subject be seated away from oth-

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ers for a period of 40 s. Plummer et al. (1977) demonstrated that under conditions of paced instruction, a “walk-away timeout” procedure actually led to an increase in noncompliance. Walk-away timeout consisted of the teacher removing materials and walking away from the student for 1 min. The Doleys et al. (1976) study also assessed the effects of reprimands upon noncompliant behavior. This “social punishment” consisted of a verbal reprimand followed by the trainer glaring at the subject for 40 s. Social punishment was found to be effective in reducing noncompliance, and this treatment also was superior to two other procedures. However, a “nagging” procedure described by Russo, Cataldo, and Cushing (1981), which consisted of repeating a request two to four times contingent upon noncompliance, did not increase the compliance of a mentally retarded 3-year-old boy. Thus data regarding “verbal punishment” are mixed. A few treatment approaches have utilized effort requirements. Most commonly, the individual is physically guided through the requested task if it is not performed upon command. Adubato, Adams, and Budd (1981) trained parents of a 6-year-old severely mentally retarded child in a set of procedures involving physical guidance through a task if the child did not comply within 10 s. The program reduced noncompliance to a low level. Similarly, Doleys et al. (1976) implemented a positive practice procedure as a consequence of noncompliance. Positive practice consisted of manually guiding the individual’s hands through the required activity for 40 s. This was found to reduce noncompliance by some subjects, but the effect was not consistent across subjects. Foxx (1977) utilized an effort requirement in response to noncompliance by three severely mentally retarded children. The program involved giving the prompt “look at me” and, if the child did not respond, implementing “functional movement training” in which the child was physically guided to move his head in one of three directions. The program reportedly produced approximately 90% attention by each of the three children. In summary, investigations of the effects of consequent conditions upon noncompliance by mentally retarded persons produce results that are slightly different from those obtained from investigations of nondisabled oppositional children. While positive reinforcement seems to have limited and somewhat transient effects upon noncompliance by nondisabled children, it appears to have a consistently positive effect upon compliance by people with mental retardation. However, no studies reviewed have shown that verbal reinforcement alone effects a decrease in noncompliance. Timeout has been found to reduce noncompliance by nondisabled children, but investigations of its efficacy with people with mental retardation have shown mixed results. Several studies suggest that physical guidance as a consequence of noncompliance may be a viable treatment option for people with mental retardation. By contrast, research involving nondisabled chil-

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dren suggests that physical contact actually leads to an increase in noncompliance. There also have been some reported successes by programs involving verbal reprimands, but data regarding the efficacy of verbal consequences also are mixed. Conclusions From Mental Retardation Research Differences and similarities are noted between the literature concerning oppositional children and that concerning people with mental retardation. Research into antecedents suggests that vague or interrupted instructions lead to decreased compliance by individuals in both groups. The greater likelihood that parents of mentally retarded children will use vague and interrupted commands seems especially unfortunate, since these children are less able to comprehend what is being said. Data also suggest that establishing compliance by means of “pretask requesting” of high probability responses will increase the likelihood of compliance with future requests. Finally, there is some support for the use of physical support cues as an adjunct to verbal prompts as a means to increase compliance. Some data suggest that negative reinforcement effects (i.e., noncompliance to avoid difficult or otherwise aversive demands) may be more prevalent in people with mental retardation than in nondisabled children. This finding should not be surprising since people with mental retardation typically have higher rates of failure than nondisabled persons. Escape or avoidant behavior becomes more reinforcing as one’s ability to cope with demands decreases. Those episodes of noncompliance that are negatively reinforced would be most amenable to treatment using procedures that prevent task avoidance, and this may be why success with effort requirement programs has been shown only with persons who are mentally retarded. Reinforcement effects are somewhat more straightforward with people who are mentally retarded. Programs of tangible and verbal reinforcement generally have been effective, although the efficacy of social reinforcement alone has not been demonstrated. Timeout from positive reinforcement seems to be a very effective intervention with oppositional children, but seems not to be consistently effective with people with mental retardation. TREATMENT IMPLICATIONS Antecedents The appropriate starting point in attempting to remedy noncompliant behavior is the nature of instructions. There is a good deal of support for the notion that noncompliance is most likely when instructions are pre-

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sented in a vague manner or interrupted by other instructions. Lack of specificity or interfering speech would be expected to create great difficulty for someone with mental retardation, since the disability invariably involves diminished verbal comprehension and verbal memory. It is even possible that a mentally retarded person might refuse to implement a task that he or she does not understand, since saying “I will not” might be less embarrassing than saying “I cannot.” The information value of the request presumably is increased by the addition of support cues (physical prompts), and because of this compliance may be more likely if such cues are added. Another means to increase compliance is to issue a large number of high probability instructions prior to making a task request. In an applied setting, instruction should include a large number of fairly easy, high probability responses coupled with a small number of more difficult responses. Behaviors

Interventions to increase compliance also might consider aspects of the task being requested. Logically one might expect noncompliant behavior to occur simply because the individual does not enjoy doing what is requested. It is therefore both prudent and ethical to consider modification of task demands. Although some research suggests that noncompliance may occur when task demands are too easy, it appears that in most cases noncompliance occurs when task demands are too difficult. However, when difficult demands are unavoidable, programs that arrange instruction so that noncompliance does not result in escape or avoidance also might decrease offtask behavior. However, such a program carries with it the risk that noncompliance might escalate into disruptive behavior. Consequences

In assessing the etiology of noncompliant behavior, two conclusions regarding consequences are possible. Noncompliance might be positively reinforced because it initiates an aversive interchange or gains attention from others, or it might be negatively reinforced because it results in escape or avoidance. Interventions must be selected based upon a determination of which type of consequence is maintaining the behavior. In all cases, positive reinforcement of compliant behavior must be a component of treatment programs. A combination of social and tangible reinforcers appears to be effective in promoting compliance. However, social rewards alone have not yet been shown to be effective in treatment of noncompliance.

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If noncompliant behavior is maintained by positive reinforcement, strategies incorporating timeout from positive reinforcement would seem to be appropriate. The research presented herein suggests that positive reinforcement maintains noncompliance in only the minority of cases, since relatively few successful applications of timeout have been reported. Moreover, there are some reports suggesting that timeout might actually lead to an increase in noncompliance. Use of timeout therefore should be confined to those cases wherein there is clear evidence that positive social reinforcement is maintaining noncompliant behavior. When noncompliance appears to be negatively reinforced by escape or avoidance, alteration of task demands is the most appropriate first step. When this cannot be done, programs that preclude escape or that implement effort requirements might be appropriate. Such programs may be successful if the consequence of noncompliance becomes either maintenance of task demands (escape extinction) or an increase in task demands (effort requirements). The efficacy of using social punishment in the form of verbal reprimands appears questionable. Doleys et al. (1976) suggest that such a program can be quite effective. However, other investigations (Burleigh & Marholin, 1977; Russo et al., 1981) suggest that verbal reprimands or “nagging” may not be very useful. Mace, Page, Ivancic, and O’Brien (1986) suggest that verbal reprimands may lead to an increase in aberrant behavior. DIRECTIONS FOR FUTURE RESEARCH As programs for people with disabilities become more oriented toward teaching, as opposed to merely providing care, developing an understanding of and treatment approaches for noncompliance becomes more important. This investigation of literature pertaining to noncompliance has attempted to summarize what is known. For the purpose of this review, all forms of refusal, off-task behavior, and lack of instruction-following have been considered to be noncompliance. Future research efforts should look more closely at response topographies. One would expect that off-task behavior is functionally very different from refusal in the form of arguing or disruption. Delineation of subtypes of noncompliance by people with mental retardation thus would be very beneficial. Future research also should address mechanisms of etiology. Although consequence variables have been considered in this review, much of this has been based upon inference from the success of treatment efforts. Furthermore, since most studies of treatment have not been based upon a functional assessment, only the most general suggestions regarding the relationship between specific etiologies and intervention techniques have been offered. Future research should assess which treatments are most

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appropriate for varying topographies of noncompliance and different types of individuals. In the author’s own experience, the noncompliant behavior of people with mild or moderate mental retardation has been observed to be much different from that exhibited by persons with severe mental retardation. However, no research was found on this topic. Noncompliance by people with mental retardation continues to present difficulties for clients and those involved in service delivery. Treatment data suggest that noncompliance is amenable to treatment using behavioral interventions. If issues pertaining to noncompliance are sufficiently addressed in the assessment of an individual, one can reasonably expect that compliance will be obtained in the majority of cases. REFERENCES Abramowitz, A. J., O’Leary, S. G., & Futtersak, M. W. (1988). The relative impact of long and short reprimands on children’s off-task behavior in the classroom. Behavior Therapy, 19, 243-241.

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