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The reductive effects of reinforcement procedures on the genital stimulation and stereotypy of a mentally retarded adolescent male
Analysis and Intervention in Developmental Disabilities, Vol. 6, pp. 239-248, 1986 0270-4684/86 $3.00+ .00 Printed in the USA. All rights reserved. Copyright © 1986 Pergamon Journals Ltd.
The Reductive Effects of Reinforcement Procedures on the Genital Stimulation and Stereotypy of a Mentally Retarded Adolescent Male R. M. Foxx, Martin J. McMorrow, Sarah Fenlon, and Ron G. Bittle Anna Mental Health and Developmental Center
This study evaluated the effects o f access to opportunities to earn edibles for performing a high probability stereotypic behavior on the public genital stimulation and stereotypy o f a severely retarded male in a special education class. The treatment involved the use o f a series o f increasing DRO lengths in which the absence o f genital stimulation was reinforced with edibles and a stereotypic behavior. Later, we attempted to reduce the rate o f stereotypy by withdrawing the edibles that had been provided for it during the reinforcement period. The results indicated that (a) genital stimulation was nearly eliminated with the graduated DRO procedure; (b) withholding the edibles had little effect in reducing the stereotypic behavior; and (c) edibles alone were enough to maintain the reductions in genital stimulation. These findings suggest that public genital stimulation is amenable to treatment with a positive treatment procedure, but more research with the reinforcer displacement technique is needed before any firm conclusions can be drawn about its effectivness in an applied setting.
The treatment o f the inappropriate sexual behavior o f mentally retarded persons has received little attention (Foxx, Bittle, Bechtel, & Livesay, in press) even though it frequently interferes with programming efforts and community placement. One o f the most c o m m o n o f these behaviors is public masturbation (see Mulhern, 1975).
We thank Leon Rendleman, Laura Davis, Allen Lanter, and the staff of the Tri-County School for their assistance with this project. Reprint requests should be addressed to Richard M. Foxx, Anna Mental Health and Developmental Center, 1000 N. Main, Anna, IL 62906. 239
240
R. M. Foxx, Martin J. McMorrow, Sarah Fenlon, and Ron G. Bittle
Even so, the successful treatment of public masturbation has been reported in only four case studies and it is questionable whether the procedures used would be employed in many settings. There are some reasons why. First, all of these studies used punishment procedures such as contingent lemon juice (Cook, Altman, Shaw, & Blaylock, 1979), social restitution (Polvinale & Lutzker, 1980), facial screening (Barmann & Murray, 1981), and overcorrection (Luiselli, Helfen, Pemberton, & Reisman, 1977). Second, the studies that have tried less intrusive procedures (e.g., DRO, DRA) have lacked the procedural specificity that would permit replication. For example, Polvinale and Lutzker (1980) used praise to reinforce the absence of masturbation, but provided no details on the length of the DRO intervals, how they were extended, or what type of praise was used. Finally, a good deal of behavioral expertise would be required to use some of the successful procedures. For example, Luiselli et al. (1977) did not encourage their subject's parents to try overcorrection at home because it would be difficult for them to implement and maintain. The present study attempted to address these problems while treating an adolescent male's genital stimulation in a classroom setting. The general plan was to treat the boy's genital touching with a series of graduated DRO lengths that would not only increase the time between occurrences, but decrease the number of teacher/trainer interventions. In addition, the program included a somewhat novel reinforcement strategy. Our plan at the start of the program was to reinforce the absence of genital touching by allowing the boy opportunities to earn edibles for engaging in a highly preferred stereotypy that was incompatible with genital touching. Later, we planned to reduce the frequency of the stereotypy by withdrawing the edibles. To our knowledge, this strategy has never been evaluated in an applied setting; yet, there were several reasons why we expected it would work. For example, several studies have shown that stereotypy can be an effective reinforcer for appropriate or adaptive behavior (Hung, 1978; Wolery, 1978; Wolery, Kirk, & Gast, 1985). Thus, we expected that the opportunity to engage in a preferred stereotypy could be used to reinforce the absence of genital touching. However, stereotypies traditionally have been targeted for reduction since they interfere with the acquisition of adaptive behaviors (Foxx & Azrin, 1973). Hence, contingencies were included in an attempt to reduce the stereotypy after it was successfully reinforcing the absence of masturbation. This was done via a reinforcer displacement procedure (Foxx & McMorrow, 1983; Neisworth, Hunt, Gallop, & Madle, 1985). Reinforcer displacement is a reductive procedure in which known reinforcers are (a) delivered on a per response basis (CRF) for a behavior that is already occurring at a given rate, and then (b) abruptly removed at some arbitrary point in an attempt to decrease the frequency of responding. The procedure is based on the rationale that adding reinforcing consequences to
Genital Stimulation
241
ongoing behavior may decrease responding when the added consequences are subsequently withdrawn. Although this procedure has produced reductions in stereotyped behaviors in tightly controlled experimental conditions, it has not been evaluated in an applied setting or as a part of a DRO procedure.
METHOD
Subject The principal of an institution-based school was asked to refer students who masturbated or touched their genitals in the classroom. Zeke, a 16-yearold severely retarded male (IQ 21), who had a long history of rubbing his crotch in public, was selected for treatment because he also engaged in a high probability stereotypy that was incompatible with genital stimulation. His genital touching previously had been treated by teacher reprimands, scolding, and reinforcement of appropriate or incompatible behavior (e.g., reinforcement of hands on table). All were ineffective in reducing his genital touching.
Experimental Design and Setth~g A multiple baseline design across morning and afternoon classes was used to assess the effects of the procedures. The morning (a.m.) session was generally conducted in a classroom that contained nine severely or profoundly mentally handicapped adolescents. The class met each day from 9:30 to 11 a.m. Twice a week the students attended a home economics class in a different room. There also were days when the class traveled to the community for various types of training (e.g., grocery shopping). In the afternoon (p.m.) session, the class attended a woodshop from 12:45 to 1:30 p.m. and then a pre-vocational workshop until 2:15 p.m.
Target Behaviors Genital stimulation was defined as finger or hand movement on the crotch area. Zeke's hand stereotypy occurred whenever he found or was given small objects. It consisted of either repeatedly picking up and dropping the objects into one hand or switching objects from one hand to the other. Pretreatment observations revealed that when small objects were available, Zeke did not stimulate his genitals. Of the items that were assessed prior to treatment, uncooked rice was selected because Zeke's rate of stereotypy with it was higher than with other objects (e.g., noodles, pieces of styrofoam) and he consistently chose the rice when given free access to all of the items.
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R. M. Fox.x, Martin J. McMorrow, Sarah Fenlon, and Ron G. Bittle
Recording and Reliability Each session was divided into continuous 30 sec intervals and the occurrence or non-occurrence of genital touching was recorded in each interval by the third author. Zeke was observed in all settings except the bathroom. Reliability was assessed by a second observer on randomly selected days in each condition. The second observer was naive as to the purpose of the study. Percent agreement was calculated for occurrences by dividing the number of agreements by the number of agreements plus disagreements, times 100. Stereotyped behavior was measured by simply counting the number of rice drops that occurred during each reinforcement period. Reliability was assessed by having the second observer independently record the number of rice-drops. Agreement was determined by dividing the lower frequency by the higher frequency, times 100. Reliability checks on both behaviors were conducted in approximately 20°70 of the sessions.
Procedure Baseline. The trainer sat approximately 5 ft from Zeke and did not interact with him. The teacher was instructed to deal with genital touching as he normally would. Although the teacher ignored most occurrences, he occasionaily used verbal reprimands (e.g., "no," or "stop that"). Noncontingent stereotypy. After 11 baseline sessions a noncontingent hand stereotypy condition was implemented during the morning session only. This condition served as a control for the contingent reinforcement of stereotypy condition that was to follow. It also permitted the determination of whether opportunity to engage in stereotypy would affect Zeke's genital stimulation. Zeke was given the opportunity to engage in rice play (i.e., rice dropping) every 3 minutes for 30 sec. The 3 minute interval was chosen because it represented the average interresponse-time (IRT) between genital touches in the preceding a.m. and p.m. baseline sessions. Every 3 minutes the observer signaled Zeke to leave his seat and come sit in a chair approximately 2 ft from her. Once he was seated, she placed approximately one tablespoon of the rice from a small jar into one of his hands and then recorded the number of times he dropped the rice. She ignored him during the rice play period. After 30 sec, Zeke was instructed to return the rice to the jar and return to his classroom seat. No edibles were provided for stereotypy. This condition was not implemented in the afternoon since genital touching in the morning increased (see Figure 1). DRO: Reinforcing the absence o f genital stimulation with stereotypy and edibles. This condition began on day 15 in the morning and day 18 in the afternoon. Initially, Zeke was allowed to engage in 30 sec of rice play whenever 3 min elapsed in which he did not touch his genital area. Prior to each session,
Genital Stimulation BASELINE
NCE~ $
DRO ( M I N U T E 8 ) • 16 Sl 80
II
243 45
REINFORCER DI8PLACEMENT
0
g uJ
nO
o
:E
t-
10
16
20
26
~0
86
40
46
DAYS
FIGURE 1. Percent intervals of genital stimulation and mean frequency of stereotypy (rice drops) in morning and afternoon school sessions.
the observer told Zeke that he would be allowed to play with the rice if he did not touch himself. She then showed him the jar of rice, poured a small portion into his hand, and permitted him to play with it for approximately 30 sec. This was done at the start of each session in order to permit reinforcer sampling and enhance the saliency of the instructions. A stopwatch was used to time the 3 rain DRO intervals and 30 sec reinforcement periods (i.e., rice play). Whenever Zeke met the 3 min DRO criterion, the observer instructed .him to come sit beside her. She then briefly
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R. M. Foxx, Martin J. McMorrow, Sarah Fenlon, and Ron G. Bittle
praised him, "Good Zeke, you didn't touch yourself, you get to play with the rice," and gave him the rice. Each time Zeke dropped the rice, the observer dropped a Cocoa P u f f into a transparent cup that was within his view. The Cocoa Puffs were used (a) to reinforce rice play, (b) as an additional consequence for the absence of genital touching, and (c) because they were one o f Zeke's preferred foods. At the end of the 30 sec reinforcement period, Zeke was praised for playing with the rice and instructed to return it to the jar. The observer then gave him the cup o f Cocoa Puffs and said, "These are for playing with the rice." Zeke returned to his seat as soon as he had eaten the Cocoa Puffs and then another 3 min DRO interval was begun. If Zeke stimulated his genitals at any time during the 3 min DRO interval he was interrupted and told, "No, Zeke, you touched yourself, you'll have to wait to play with the rice." If genital touching occurred during the rice play period, the period was discontinued and Zeke was returned to his seat. As specified in Table 1, the DRO interval was gradually lengthened to a maximum of 45 min as Zeke's rate of touching decreased. The criterion for switching to a longer DRO interval was that Zeke's percent of touching in a given session had to be equal to or lower than the previous day's session in that setting. Table 1 shows that the reinforcement period also was increased each time the DRO interval was increased such that Zeke was allowed 30 sec of rice play for every 3 min of no genital stimulation. The DRO condition lasted 22 days in both settings. Reinforcer displacement. In this condition, the DRO interval remained at 45 min and the absence of genital stimulation during the interval was followed by 7.5 min of rice play. However, no Cocoa Puffs were given for rice dropping. Instead, the empty cup and Cocoa Puffs were placed where Zeke could see them and the observer simply ignored him during his rice play. At the end of the period, Zeke was told to put away the rice and remain where he was for 30 sec (i.e., this was the amount o f time it normally took him to eat the Cocoa Puffs) before returning to his classroom seat.
TABLE 1. Reinforcement Period (Rice Play) and DRO Interval Lengths (Minutes and Seconds)
Reinforcement Period (Rice Play)
DRO Interval
:30 1:00
3:00 6:00 9:00 15:00 21:00 30:00 45:00
1:30
2:30 3:30 5:00 7:30
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245
Program transfer and maintenance. The program was transferred to the classroom personnel over a period o f several days beginning on day 28 and continuing throughout the remainder of the treatment, displacement, and maintenance conditions. In the last treatment sessions and in the displacement condition they were responsible for all facets of the program except that the primary observer continued to conduct the recordings and monitor the reinforcement periods. Maintenance sessions began two weeks following the last reinforcer displacement session. This 2 week period represented a holiday break between school semesters. The two 45-min DRO intervals remained in effect in both the a.m. and p.m. settings since both classes lasted 1 ½ hours. During this phase, classroom staff conducted the entire program and simply recorded the occurrence and time of genital stimulation since it occurred very infrequently. In addition, the rice play periods were discontinued. Instead, Zeke was simply given a small number of Cocoa Puffs whenever 45 min elapsed in which genital stimulation did not occur. This was done to determine if Cocoa Puffs alone would be effective in maintaining the absence of genital stimulation and because simply delivering Cocoa Puffs would (a) take less of the teacher's time than the rice play periods, and (b) allow Zeke to spend virtually all of his time in classroom activities. Also, the Cocoa Puffs constituted a more "normal" classroom reinforcer. RESULTS Genital Stimulation Nineteen interobserver reliability checks were conducted; 9 in the morning and 10 in the afternoon. Mean agreement was 89°7o (range 83.3-100°7o) in the a.m. and 90.2% (range 83.3-100O7o) in the p.m. Figure 1 shows that during the a.m. baseline, genital stimulation occurred in an average of 13.2°7o of the intervals and ranged between 5.4-23.3%, whereas it averaged 17.1°7o and ranged between 4.8-36.7°7o during the p.m. baseline. There was an increase in genital stimulation in the a.m. noncontingent stereotypy condition to an average of 15.8°7o (range 7.2-24.2%). Genital stimulation decreased rapidly in both the a.m. and p.m. settings when the 3 min DRO contingency was introduced. It decreased to an average of 4.1 °7o (range 1.9-6.7°7o) in the a.m. and 3.9O7oin the p.m. (range .7-6.3O7o). In addition, genital stimulation continued to decrease as the DRO intervals were lengthened and by the 45 min DRO it had decreased to a mean of .6°7o (range 0-1.7°7o) in the a.m. and .507o (range 0-1.7°70) in the p.m. After the 9th day of treatment in the a.m. (9 min DRO, Day 23), genital stimulation never exceeded three occurrences per session except on one occasion. This was also
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R. M. Fox.x, Martin J. McMorrow, Sarah Fenlon, and Ron G. BRtle
the case after the p.m. 15 min DRO session (Day 27). More importantly, there were 13 a.m. days and 10 p.m. days in which no genital stimulation occurred. Zeke's genital touching was recorded by the school personnel in both a.m. and p.m. settings daily for one month in the maintenance condition. Except for one afternoon session in which five instances were recorded, Zeke never stimulated his genitals more than twice in a session, and none occurred during 6407o of the sessions. Stereotypy: Rice Play
There were 8 reliability checks in the a.m. and 6 in the p.m. During the a.m. sessions interobserver agreement on the frequency of rice drops averaged 95.3070 (range 92.1-98.3070) whereas it averaged 95.4070 (range 92.4-97.60/0) in the p.m. Figure 1 shows that in the a.m. noncontingent stereotypy condition, Zeke dropped rice an average of 5.69 times per 30 sec (range 4.89-6.59). During the entire a.m. DRO condition, he averaged 5.16 drops per 30 sec (range 3.7-7.0) when a Cocoa Puff was given for each rice drop. The average number of rice drops declined by 2007o to 4.17 (range 3.6-4.7) during the a.m. reinforcer displacement condition when the Cocoa Puffs were withdrawn. During the p.m. DRO condition Zeke averaged 5.28 rice drops (range 3.9-7) while his average was 9070 lower, 4.83 (range 3.5-5.4) during the reinforcer displacement condition. Anecdotal Results
Zeke usually appeared excited when he received the rice and frequently smiled and laughed when the Cocoa Puffs were dropped into the cup. However, during the second session of the a.m. reinforcer displacement condition (Day 38), Zeke became physically aggressive when he did not receive the Cocoa Puffs. In this instance, he reached for the Cocoa Puffs 3 times following the rice play period and was told "No" each time. On the third attempt, he began to bite himself, slap his head with his hand, and briefly attempted to choke and scratch the observer. DISCUSSION The present study demonstrated that opportunities to earn edibles for engaging in a preferred stereotypy nearly eliminated public genital stimulation when they were used as part of a systematic DRO treatment. The program reduced genital stimulation to near zero levels in both morning and afternoon school sessions and these effects were maintained (a) as the DRO intervals were extended; (b) when school personnel conducted the program, and (c)
Genital Stimulation
247
when either stereotypy alone or edibles alone were used as reinforcers for the absence of the behavior. At the end of the study, Zeke's teachers were able to maintain the treatment effects by simply correcting him if genital stimulation occurred and delivering edibles once per 45 min when it did not. The effects of the DRO treatment on genital stimulation were particularly encouraging since two previous studies have found it to be ineffective (Luiselli et al., 1977; Polvinale & Lutzker, 1980) and all previously successful treatments have included punishment. Hence, this study not only suggests that punishment procedures may not always be necessary in the treatment of genital stimulation, but raises questions as to why the present DRO strategy was effective. There appear to be several possible answers. First, the present study employed several potentially reinforcing consequences for the absence of genital stimulation (i.e., praise, edibles, and stereotypy) and one of them, stereotypy, was a higher probability behavior than genital stimulation in a free operant setting. This reasoning is supported by previous research that has shown that contingent access to high probability behaviors (e.g., even relatively common ones) may be used to reinforce lower probability behaviors (e.g., Lattal, 1969; McMorrow, Cullinan, & Epstein, 1978; Osborne, 1969). Second, the initial DRO interval (i.e., 3 min) was empirically determined on the basis of Zeke's frequency of genital stimulation during the baseline observations (see Foxx, 1982). Third, the DRO intervals were systematically lengthened to help insure that the initial reductions would be maintained or perhaps enhanced. Although the effects of the DRO procedure on genital stimulation were quite encouraging, the effects of the reinforcer displacement contingency on stereotypy were not. In fact, the removal of the edibles that had been provided for each rice drop during the reinforcement periods in the DRO condition had almost no effect on Zeke's rice dropping. Thus, while the anecdotal results suggested that something akin to extinction was possibly taking place (i.e., Zeke's SIB and aggression in the reinforcer displacement condition), the target behavior did not display an extinction effect. To us, this lack of effects may have been due to the delay between a rice drop and consumption of the edible. Recall that although a Cocoa Puff was placed in the cup after each rice drop, Zeke was not allowed to consume the Cocoa Puffs until the end of the reinforcement period which in some phases lasted 7.5 min. Nevertheless, the displacement condition was useful for other reasons. Most importantly, it demonstrated that the reductions in genital stimulation could be maintained by simply providing access to the stereotypy. This, of course, also suggested that the reduction might be maintained by simply providing the edibles. Use of the edible reinforcers alone in the DRO program after the displacement contingency had failed to reduce stereotypy seemed important because providing continued opportunities to engage in the stereotypy might be viewed as encouraging maladaptive behavior whereas simply
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R. M. Foxx, Martin J. McMorrow, Sarah Fenlon, and Ron G. Bittle
p r o v i d i n g edibles w o u l d b e less t i m e - c o n s u m i n g a n d m o r e n a t u r a l in a n e d u cational environment. I n s u m m a r y , t h e p r e s e n t s t u d y d e m o n s t r a t e d t h a t g e n i t a l s t i m u l a t i o n was r e d u c e d w i t h a series o f g r a d u a t e d D R O intervals t h a t w e r e f o l l o w e d b y access to o p p o r t u n i t i e s to e a r n r e i n f o r c e r s f o r h i g h p r o b a b i l i t y b e h a v i o r s . V a r i a t i o n s o f this d u a l t r e a t m e n t s t r a t e g y m a y n o t o n l y b e u s e f u l in f u t u r e t r e a t m e n t s o f g e n i t a l s t i m u l a t i o n , b u t f o r o t h e r b e h a v i o r p r o b l e m s as well. F i n a l l y , m o r e r e s e a r c h o n r e i n f o r c e r d i s p l a c e m e n t is n e e d e d t o d e t e r m i n e i f o r h o w it s h o u l d b e u s e d in a p p l i e d s e t t i n g s .
REFERENCES Barmann, B. C., & Murray, W. J. (1981). Suppression of inappropriate sexual behavior by facial screening. Behavior Therapy, 12, 730-735. Cook, J. W., Altman, K., Shaw, J., & Blaylock, M. (1978). Use of contingent lemon juice to eliminate public masturbation by a severely retarded boy. Behaviour Research and Therapy, 16, 131-134. Foxx, R. M. (1982). Decreasing behaviors of severely retarded and autisticpersons. Champaign, IL: Research Press. Foxx, R. M., & Azrin, N. H. (1973). The elimination of autistic self-stimulatory behavior by overcorrection. Journal of Applied Behavior Analysis, 6, 1-14. Foxx, R. M., Bittle, R. G., Bechtel, D. R., & Livesay, J. R. (in press). Behavioral treatment of the sexually deviant behavior of mentally retarded individuals. In N. R. Ellis (Ed.), International review of research in mental retardation. New York, NY: Academic Press. Foxx, R. M., & McMorrow, M. J. (1983). The effects of continuous and fixed ratio schedules of external consequences on the performance and extinction of human stereotyped behavior. Behaviour Analysis Letters, 3, 371-379. Hung, D. W. (1978). Using self-stimulation as reinforcement for autistic children. Journal of Autism and Childhood Schizophrenia, 8, 355-366. Lattal, K. A. (1969). Contingency management of toothbrushing behavior in a summer camp for children. Journal of Applied Behavior Analysis, 2, 195-198. Luiselli, J. K., Helfen, C. S., Pemberton, B. W., & Reisman, J. (1977). The elimination of a child's in-class masturbation by overcorrection and reinforcement. Journal of Behavior Therapy and Experimental Psychiatry, 8, 201-224. McMorrow, M. J., Cullinan, D., & Epstein, M. H. (1978). The use of the Premack Principle to motivate patient activity attendance. Perspectives in Psychiatric Care, 16, 14-18. Mulhern, T. J. (1975). Survey of reported sexual behavior and policies characterizing residential facilities for retarded citizens. American Journal of Mental Deficiency, 79, 670-673. Neisworth, J. T., Moosbrugger Hunt, F., Gallop, H. R., & Madle, R. A. (1985). Reinforcer Displacement: A preliminary study of the clinical application of the CRF/EXT effect. Behavior Modification, 9, 103-115. Osborne, J. G. (1969). Free-time as a reinforcer in the management of classroom behavior. Journal of Applied Behavior Analysis, 2, 113-118. Polvinale, R. A., & Lutzker, J. R. (1980). Elimination of assaultive and inappropriate sexual behavior by reinforcement and social-restitution. Mental Retardation, 18, 27-30. Wolery, M. (1978). Self-stimulatory behavior as a basis for devising reinforcers. AAESPHReview, 3, 23-29. Wolery, M., Kirk, K., & Gast, D. L. (1985). Stereotypic behavior as a reinforcer: Effects and side-effects. Journal of Autism and Developmental Disorders, 15, 149-161.
The Reductive Effects of Reinforcement Procedures on the Genital Stimulation and Stereotypy of a Mentally Retarded Adolescent Male R. M. Foxx, Martin J. McMorrow, Sarah Fenlon, and Ron G. Bittle Anna Mental Health and Developmental Center
This study evaluated the effects o f access to opportunities to earn edibles for performing a high probability stereotypic behavior on the public genital stimulation and stereotypy o f a severely retarded male in a special education class. The treatment involved the use o f a series o f increasing DRO lengths in which the absence o f genital stimulation was reinforced with edibles and a stereotypic behavior. Later, we attempted to reduce the rate o f stereotypy by withdrawing the edibles that had been provided for it during the reinforcement period. The results indicated that (a) genital stimulation was nearly eliminated with the graduated DRO procedure; (b) withholding the edibles had little effect in reducing the stereotypic behavior; and (c) edibles alone were enough to maintain the reductions in genital stimulation. These findings suggest that public genital stimulation is amenable to treatment with a positive treatment procedure, but more research with the reinforcer displacement technique is needed before any firm conclusions can be drawn about its effectivness in an applied setting.
The treatment o f the inappropriate sexual behavior o f mentally retarded persons has received little attention (Foxx, Bittle, Bechtel, & Livesay, in press) even though it frequently interferes with programming efforts and community placement. One o f the most c o m m o n o f these behaviors is public masturbation (see Mulhern, 1975).
We thank Leon Rendleman, Laura Davis, Allen Lanter, and the staff of the Tri-County School for their assistance with this project. Reprint requests should be addressed to Richard M. Foxx, Anna Mental Health and Developmental Center, 1000 N. Main, Anna, IL 62906. 239
240
R. M. Foxx, Martin J. McMorrow, Sarah Fenlon, and Ron G. Bittle
Even so, the successful treatment of public masturbation has been reported in only four case studies and it is questionable whether the procedures used would be employed in many settings. There are some reasons why. First, all of these studies used punishment procedures such as contingent lemon juice (Cook, Altman, Shaw, & Blaylock, 1979), social restitution (Polvinale & Lutzker, 1980), facial screening (Barmann & Murray, 1981), and overcorrection (Luiselli, Helfen, Pemberton, & Reisman, 1977). Second, the studies that have tried less intrusive procedures (e.g., DRO, DRA) have lacked the procedural specificity that would permit replication. For example, Polvinale and Lutzker (1980) used praise to reinforce the absence of masturbation, but provided no details on the length of the DRO intervals, how they were extended, or what type of praise was used. Finally, a good deal of behavioral expertise would be required to use some of the successful procedures. For example, Luiselli et al. (1977) did not encourage their subject's parents to try overcorrection at home because it would be difficult for them to implement and maintain. The present study attempted to address these problems while treating an adolescent male's genital stimulation in a classroom setting. The general plan was to treat the boy's genital touching with a series of graduated DRO lengths that would not only increase the time between occurrences, but decrease the number of teacher/trainer interventions. In addition, the program included a somewhat novel reinforcement strategy. Our plan at the start of the program was to reinforce the absence of genital touching by allowing the boy opportunities to earn edibles for engaging in a highly preferred stereotypy that was incompatible with genital touching. Later, we planned to reduce the frequency of the stereotypy by withdrawing the edibles. To our knowledge, this strategy has never been evaluated in an applied setting; yet, there were several reasons why we expected it would work. For example, several studies have shown that stereotypy can be an effective reinforcer for appropriate or adaptive behavior (Hung, 1978; Wolery, 1978; Wolery, Kirk, & Gast, 1985). Thus, we expected that the opportunity to engage in a preferred stereotypy could be used to reinforce the absence of genital touching. However, stereotypies traditionally have been targeted for reduction since they interfere with the acquisition of adaptive behaviors (Foxx & Azrin, 1973). Hence, contingencies were included in an attempt to reduce the stereotypy after it was successfully reinforcing the absence of masturbation. This was done via a reinforcer displacement procedure (Foxx & McMorrow, 1983; Neisworth, Hunt, Gallop, & Madle, 1985). Reinforcer displacement is a reductive procedure in which known reinforcers are (a) delivered on a per response basis (CRF) for a behavior that is already occurring at a given rate, and then (b) abruptly removed at some arbitrary point in an attempt to decrease the frequency of responding. The procedure is based on the rationale that adding reinforcing consequences to
Genital Stimulation
241
ongoing behavior may decrease responding when the added consequences are subsequently withdrawn. Although this procedure has produced reductions in stereotyped behaviors in tightly controlled experimental conditions, it has not been evaluated in an applied setting or as a part of a DRO procedure.
METHOD
Subject The principal of an institution-based school was asked to refer students who masturbated or touched their genitals in the classroom. Zeke, a 16-yearold severely retarded male (IQ 21), who had a long history of rubbing his crotch in public, was selected for treatment because he also engaged in a high probability stereotypy that was incompatible with genital stimulation. His genital touching previously had been treated by teacher reprimands, scolding, and reinforcement of appropriate or incompatible behavior (e.g., reinforcement of hands on table). All were ineffective in reducing his genital touching.
Experimental Design and Setth~g A multiple baseline design across morning and afternoon classes was used to assess the effects of the procedures. The morning (a.m.) session was generally conducted in a classroom that contained nine severely or profoundly mentally handicapped adolescents. The class met each day from 9:30 to 11 a.m. Twice a week the students attended a home economics class in a different room. There also were days when the class traveled to the community for various types of training (e.g., grocery shopping). In the afternoon (p.m.) session, the class attended a woodshop from 12:45 to 1:30 p.m. and then a pre-vocational workshop until 2:15 p.m.
Target Behaviors Genital stimulation was defined as finger or hand movement on the crotch area. Zeke's hand stereotypy occurred whenever he found or was given small objects. It consisted of either repeatedly picking up and dropping the objects into one hand or switching objects from one hand to the other. Pretreatment observations revealed that when small objects were available, Zeke did not stimulate his genitals. Of the items that were assessed prior to treatment, uncooked rice was selected because Zeke's rate of stereotypy with it was higher than with other objects (e.g., noodles, pieces of styrofoam) and he consistently chose the rice when given free access to all of the items.
242
R. M. Fox.x, Martin J. McMorrow, Sarah Fenlon, and Ron G. Bittle
Recording and Reliability Each session was divided into continuous 30 sec intervals and the occurrence or non-occurrence of genital touching was recorded in each interval by the third author. Zeke was observed in all settings except the bathroom. Reliability was assessed by a second observer on randomly selected days in each condition. The second observer was naive as to the purpose of the study. Percent agreement was calculated for occurrences by dividing the number of agreements by the number of agreements plus disagreements, times 100. Stereotyped behavior was measured by simply counting the number of rice drops that occurred during each reinforcement period. Reliability was assessed by having the second observer independently record the number of rice-drops. Agreement was determined by dividing the lower frequency by the higher frequency, times 100. Reliability checks on both behaviors were conducted in approximately 20°70 of the sessions.
Procedure Baseline. The trainer sat approximately 5 ft from Zeke and did not interact with him. The teacher was instructed to deal with genital touching as he normally would. Although the teacher ignored most occurrences, he occasionaily used verbal reprimands (e.g., "no," or "stop that"). Noncontingent stereotypy. After 11 baseline sessions a noncontingent hand stereotypy condition was implemented during the morning session only. This condition served as a control for the contingent reinforcement of stereotypy condition that was to follow. It also permitted the determination of whether opportunity to engage in stereotypy would affect Zeke's genital stimulation. Zeke was given the opportunity to engage in rice play (i.e., rice dropping) every 3 minutes for 30 sec. The 3 minute interval was chosen because it represented the average interresponse-time (IRT) between genital touches in the preceding a.m. and p.m. baseline sessions. Every 3 minutes the observer signaled Zeke to leave his seat and come sit in a chair approximately 2 ft from her. Once he was seated, she placed approximately one tablespoon of the rice from a small jar into one of his hands and then recorded the number of times he dropped the rice. She ignored him during the rice play period. After 30 sec, Zeke was instructed to return the rice to the jar and return to his classroom seat. No edibles were provided for stereotypy. This condition was not implemented in the afternoon since genital touching in the morning increased (see Figure 1). DRO: Reinforcing the absence o f genital stimulation with stereotypy and edibles. This condition began on day 15 in the morning and day 18 in the afternoon. Initially, Zeke was allowed to engage in 30 sec of rice play whenever 3 min elapsed in which he did not touch his genital area. Prior to each session,
Genital Stimulation BASELINE
NCE~ $
DRO ( M I N U T E 8 ) • 16 Sl 80
II
243 45
REINFORCER DI8PLACEMENT
0
g uJ
nO
o
:E
t-
10
16
20
26
~0
86
40
46
DAYS
FIGURE 1. Percent intervals of genital stimulation and mean frequency of stereotypy (rice drops) in morning and afternoon school sessions.
the observer told Zeke that he would be allowed to play with the rice if he did not touch himself. She then showed him the jar of rice, poured a small portion into his hand, and permitted him to play with it for approximately 30 sec. This was done at the start of each session in order to permit reinforcer sampling and enhance the saliency of the instructions. A stopwatch was used to time the 3 rain DRO intervals and 30 sec reinforcement periods (i.e., rice play). Whenever Zeke met the 3 min DRO criterion, the observer instructed .him to come sit beside her. She then briefly
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R. M. Foxx, Martin J. McMorrow, Sarah Fenlon, and Ron G. Bittle
praised him, "Good Zeke, you didn't touch yourself, you get to play with the rice," and gave him the rice. Each time Zeke dropped the rice, the observer dropped a Cocoa P u f f into a transparent cup that was within his view. The Cocoa Puffs were used (a) to reinforce rice play, (b) as an additional consequence for the absence of genital touching, and (c) because they were one o f Zeke's preferred foods. At the end of the 30 sec reinforcement period, Zeke was praised for playing with the rice and instructed to return it to the jar. The observer then gave him the cup o f Cocoa Puffs and said, "These are for playing with the rice." Zeke returned to his seat as soon as he had eaten the Cocoa Puffs and then another 3 min DRO interval was begun. If Zeke stimulated his genitals at any time during the 3 min DRO interval he was interrupted and told, "No, Zeke, you touched yourself, you'll have to wait to play with the rice." If genital touching occurred during the rice play period, the period was discontinued and Zeke was returned to his seat. As specified in Table 1, the DRO interval was gradually lengthened to a maximum of 45 min as Zeke's rate of touching decreased. The criterion for switching to a longer DRO interval was that Zeke's percent of touching in a given session had to be equal to or lower than the previous day's session in that setting. Table 1 shows that the reinforcement period also was increased each time the DRO interval was increased such that Zeke was allowed 30 sec of rice play for every 3 min of no genital stimulation. The DRO condition lasted 22 days in both settings. Reinforcer displacement. In this condition, the DRO interval remained at 45 min and the absence of genital stimulation during the interval was followed by 7.5 min of rice play. However, no Cocoa Puffs were given for rice dropping. Instead, the empty cup and Cocoa Puffs were placed where Zeke could see them and the observer simply ignored him during his rice play. At the end of the period, Zeke was told to put away the rice and remain where he was for 30 sec (i.e., this was the amount o f time it normally took him to eat the Cocoa Puffs) before returning to his classroom seat.
TABLE 1. Reinforcement Period (Rice Play) and DRO Interval Lengths (Minutes and Seconds)
Reinforcement Period (Rice Play)
DRO Interval
:30 1:00
3:00 6:00 9:00 15:00 21:00 30:00 45:00
1:30
2:30 3:30 5:00 7:30
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Program transfer and maintenance. The program was transferred to the classroom personnel over a period o f several days beginning on day 28 and continuing throughout the remainder of the treatment, displacement, and maintenance conditions. In the last treatment sessions and in the displacement condition they were responsible for all facets of the program except that the primary observer continued to conduct the recordings and monitor the reinforcement periods. Maintenance sessions began two weeks following the last reinforcer displacement session. This 2 week period represented a holiday break between school semesters. The two 45-min DRO intervals remained in effect in both the a.m. and p.m. settings since both classes lasted 1 ½ hours. During this phase, classroom staff conducted the entire program and simply recorded the occurrence and time of genital stimulation since it occurred very infrequently. In addition, the rice play periods were discontinued. Instead, Zeke was simply given a small number of Cocoa Puffs whenever 45 min elapsed in which genital stimulation did not occur. This was done to determine if Cocoa Puffs alone would be effective in maintaining the absence of genital stimulation and because simply delivering Cocoa Puffs would (a) take less of the teacher's time than the rice play periods, and (b) allow Zeke to spend virtually all of his time in classroom activities. Also, the Cocoa Puffs constituted a more "normal" classroom reinforcer. RESULTS Genital Stimulation Nineteen interobserver reliability checks were conducted; 9 in the morning and 10 in the afternoon. Mean agreement was 89°7o (range 83.3-100°7o) in the a.m. and 90.2% (range 83.3-100O7o) in the p.m. Figure 1 shows that during the a.m. baseline, genital stimulation occurred in an average of 13.2°7o of the intervals and ranged between 5.4-23.3%, whereas it averaged 17.1°7o and ranged between 4.8-36.7°7o during the p.m. baseline. There was an increase in genital stimulation in the a.m. noncontingent stereotypy condition to an average of 15.8°7o (range 7.2-24.2%). Genital stimulation decreased rapidly in both the a.m. and p.m. settings when the 3 min DRO contingency was introduced. It decreased to an average of 4.1 °7o (range 1.9-6.7°7o) in the a.m. and 3.9O7oin the p.m. (range .7-6.3O7o). In addition, genital stimulation continued to decrease as the DRO intervals were lengthened and by the 45 min DRO it had decreased to a mean of .6°7o (range 0-1.7°7o) in the a.m. and .507o (range 0-1.7°70) in the p.m. After the 9th day of treatment in the a.m. (9 min DRO, Day 23), genital stimulation never exceeded three occurrences per session except on one occasion. This was also
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R. M. Fox.x, Martin J. McMorrow, Sarah Fenlon, and Ron G. BRtle
the case after the p.m. 15 min DRO session (Day 27). More importantly, there were 13 a.m. days and 10 p.m. days in which no genital stimulation occurred. Zeke's genital touching was recorded by the school personnel in both a.m. and p.m. settings daily for one month in the maintenance condition. Except for one afternoon session in which five instances were recorded, Zeke never stimulated his genitals more than twice in a session, and none occurred during 6407o of the sessions. Stereotypy: Rice Play
There were 8 reliability checks in the a.m. and 6 in the p.m. During the a.m. sessions interobserver agreement on the frequency of rice drops averaged 95.3070 (range 92.1-98.3070) whereas it averaged 95.4070 (range 92.4-97.60/0) in the p.m. Figure 1 shows that in the a.m. noncontingent stereotypy condition, Zeke dropped rice an average of 5.69 times per 30 sec (range 4.89-6.59). During the entire a.m. DRO condition, he averaged 5.16 drops per 30 sec (range 3.7-7.0) when a Cocoa Puff was given for each rice drop. The average number of rice drops declined by 2007o to 4.17 (range 3.6-4.7) during the a.m. reinforcer displacement condition when the Cocoa Puffs were withdrawn. During the p.m. DRO condition Zeke averaged 5.28 rice drops (range 3.9-7) while his average was 9070 lower, 4.83 (range 3.5-5.4) during the reinforcer displacement condition. Anecdotal Results
Zeke usually appeared excited when he received the rice and frequently smiled and laughed when the Cocoa Puffs were dropped into the cup. However, during the second session of the a.m. reinforcer displacement condition (Day 38), Zeke became physically aggressive when he did not receive the Cocoa Puffs. In this instance, he reached for the Cocoa Puffs 3 times following the rice play period and was told "No" each time. On the third attempt, he began to bite himself, slap his head with his hand, and briefly attempted to choke and scratch the observer. DISCUSSION The present study demonstrated that opportunities to earn edibles for engaging in a preferred stereotypy nearly eliminated public genital stimulation when they were used as part of a systematic DRO treatment. The program reduced genital stimulation to near zero levels in both morning and afternoon school sessions and these effects were maintained (a) as the DRO intervals were extended; (b) when school personnel conducted the program, and (c)
Genital Stimulation
247
when either stereotypy alone or edibles alone were used as reinforcers for the absence of the behavior. At the end of the study, Zeke's teachers were able to maintain the treatment effects by simply correcting him if genital stimulation occurred and delivering edibles once per 45 min when it did not. The effects of the DRO treatment on genital stimulation were particularly encouraging since two previous studies have found it to be ineffective (Luiselli et al., 1977; Polvinale & Lutzker, 1980) and all previously successful treatments have included punishment. Hence, this study not only suggests that punishment procedures may not always be necessary in the treatment of genital stimulation, but raises questions as to why the present DRO strategy was effective. There appear to be several possible answers. First, the present study employed several potentially reinforcing consequences for the absence of genital stimulation (i.e., praise, edibles, and stereotypy) and one of them, stereotypy, was a higher probability behavior than genital stimulation in a free operant setting. This reasoning is supported by previous research that has shown that contingent access to high probability behaviors (e.g., even relatively common ones) may be used to reinforce lower probability behaviors (e.g., Lattal, 1969; McMorrow, Cullinan, & Epstein, 1978; Osborne, 1969). Second, the initial DRO interval (i.e., 3 min) was empirically determined on the basis of Zeke's frequency of genital stimulation during the baseline observations (see Foxx, 1982). Third, the DRO intervals were systematically lengthened to help insure that the initial reductions would be maintained or perhaps enhanced. Although the effects of the DRO procedure on genital stimulation were quite encouraging, the effects of the reinforcer displacement contingency on stereotypy were not. In fact, the removal of the edibles that had been provided for each rice drop during the reinforcement periods in the DRO condition had almost no effect on Zeke's rice dropping. Thus, while the anecdotal results suggested that something akin to extinction was possibly taking place (i.e., Zeke's SIB and aggression in the reinforcer displacement condition), the target behavior did not display an extinction effect. To us, this lack of effects may have been due to the delay between a rice drop and consumption of the edible. Recall that although a Cocoa Puff was placed in the cup after each rice drop, Zeke was not allowed to consume the Cocoa Puffs until the end of the reinforcement period which in some phases lasted 7.5 min. Nevertheless, the displacement condition was useful for other reasons. Most importantly, it demonstrated that the reductions in genital stimulation could be maintained by simply providing access to the stereotypy. This, of course, also suggested that the reduction might be maintained by simply providing the edibles. Use of the edible reinforcers alone in the DRO program after the displacement contingency had failed to reduce stereotypy seemed important because providing continued opportunities to engage in the stereotypy might be viewed as encouraging maladaptive behavior whereas simply
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R. M. Foxx, Martin J. McMorrow, Sarah Fenlon, and Ron G. Bittle
p r o v i d i n g edibles w o u l d b e less t i m e - c o n s u m i n g a n d m o r e n a t u r a l in a n e d u cational environment. I n s u m m a r y , t h e p r e s e n t s t u d y d e m o n s t r a t e d t h a t g e n i t a l s t i m u l a t i o n was r e d u c e d w i t h a series o f g r a d u a t e d D R O intervals t h a t w e r e f o l l o w e d b y access to o p p o r t u n i t i e s to e a r n r e i n f o r c e r s f o r h i g h p r o b a b i l i t y b e h a v i o r s . V a r i a t i o n s o f this d u a l t r e a t m e n t s t r a t e g y m a y n o t o n l y b e u s e f u l in f u t u r e t r e a t m e n t s o f g e n i t a l s t i m u l a t i o n , b u t f o r o t h e r b e h a v i o r p r o b l e m s as well. F i n a l l y , m o r e r e s e a r c h o n r e i n f o r c e r d i s p l a c e m e n t is n e e d e d t o d e t e r m i n e i f o r h o w it s h o u l d b e u s e d in a p p l i e d s e t t i n g s .
REFERENCES Barmann, B. C., & Murray, W. J. (1981). Suppression of inappropriate sexual behavior by facial screening. Behavior Therapy, 12, 730-735. Cook, J. W., Altman, K., Shaw, J., & Blaylock, M. (1978). Use of contingent lemon juice to eliminate public masturbation by a severely retarded boy. Behaviour Research and Therapy, 16, 131-134. Foxx, R. M. (1982). Decreasing behaviors of severely retarded and autisticpersons. Champaign, IL: Research Press. Foxx, R. M., & Azrin, N. H. (1973). The elimination of autistic self-stimulatory behavior by overcorrection. Journal of Applied Behavior Analysis, 6, 1-14. Foxx, R. M., Bittle, R. G., Bechtel, D. R., & Livesay, J. R. (in press). Behavioral treatment of the sexually deviant behavior of mentally retarded individuals. In N. R. Ellis (Ed.), International review of research in mental retardation. New York, NY: Academic Press. Foxx, R. M., & McMorrow, M. J. (1983). The effects of continuous and fixed ratio schedules of external consequences on the performance and extinction of human stereotyped behavior. Behaviour Analysis Letters, 3, 371-379. Hung, D. W. (1978). Using self-stimulation as reinforcement for autistic children. Journal of Autism and Childhood Schizophrenia, 8, 355-366. Lattal, K. A. (1969). Contingency management of toothbrushing behavior in a summer camp for children. Journal of Applied Behavior Analysis, 2, 195-198. Luiselli, J. K., Helfen, C. S., Pemberton, B. W., & Reisman, J. (1977). The elimination of a child's in-class masturbation by overcorrection and reinforcement. Journal of Behavior Therapy and Experimental Psychiatry, 8, 201-224. McMorrow, M. J., Cullinan, D., & Epstein, M. H. (1978). The use of the Premack Principle to motivate patient activity attendance. Perspectives in Psychiatric Care, 16, 14-18. Mulhern, T. J. (1975). Survey of reported sexual behavior and policies characterizing residential facilities for retarded citizens. American Journal of Mental Deficiency, 79, 670-673. Neisworth, J. T., Moosbrugger Hunt, F., Gallop, H. R., & Madle, R. A. (1985). Reinforcer Displacement: A preliminary study of the clinical application of the CRF/EXT effect. Behavior Modification, 9, 103-115. Osborne, J. G. (1969). Free-time as a reinforcer in the management of classroom behavior. Journal of Applied Behavior Analysis, 2, 113-118. Polvinale, R. A., & Lutzker, J. R. (1980). Elimination of assaultive and inappropriate sexual behavior by reinforcement and social-restitution. Mental Retardation, 18, 27-30. Wolery, M. (1978). Self-stimulatory behavior as a basis for devising reinforcers. AAESPHReview, 3, 23-29. Wolery, M., Kirk, K., & Gast, D. L. (1985). Stereotypic behavior as a reinforcer: Effects and side-effects. Journal of Autism and Developmental Disorders, 15, 149-161.