Treatment of Severe Behavior Disorders

CHAPTER 3

Treatment of Severe Behavior Disorders Timothy R. Vollmer, Kerri P. Peters, Sarah K. Slocum Psychology Department, University of Florida, Gainesville, Florida, USA

OVERVIEW: BEHAVIOR DISORDERS AS OPERANT BEHAVIOR One overall aim of this book is to demonstrate that applied behavior analysis is an effective approach in a wide range of socially relevant domains. An argument could be made that the field has had its greatest influence in the assessment and treatment of behavior disorders displayed by individuals with autism spectrum disorder and intellectual disabilities. Indeed, behavior-analytic research and the principles derived from such research have influenced public policy (e.g., IDEA, 2004; NIH, 1989), scientific best practices (e.g., Odom et al., 2003), and educational standards (Sugai et al., 2000) in relation to the treatment of individuals who display severe behavior disorders. For educators, care providers, family members, and the individuals themselves, severe behavior disorders can be, at a minimum, life inhibiting and, at the extremes, life threatening. Some general categories of behavior disorders include self-injurious behavior (SIB), aggression, property destruction, pica (eating inedible items), rumination (regurgitation and reswallowing previously consumed food), tantrums, and extreme stereotypy (highly repetitive and inflexible behavior), among others. Clearly, behavior that causes harm to one’s self or others, or causes damage to property, is of great concern. A major breakthrough in understanding behavior disorders occurred in 1982 when Iwata, Dorsey, Slifer, Bauman, and Richman published a paper demonstrating an experimental approach to the assessment of SIB. Iwata, Dorsey, Slifer, Bauman, and Richman’s (1982/1994) study synthesized prior research suggesting that SIB and related disorders might be learned, operant forms of behavior. In a series of 15-min sessions, Iwata et al. tested possible sources of reinforcement for SIB including adult attention in the form of social reprimands (i.e., positive reinforcement), escape from instructional demands (i.e., negative reinforcement), and reinforcement produced by the behavior itself without social mediation (i.e., automatic positive or negative Clinical and Organizational Applications of Applied Behavior Analysis http://dx.doi.org/10.1016/B978-0-12-420249-8.00003-4

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reinforcement). In Iwata et al. and hundreds of subsequent studies, such assessments, known as functional analyses, have shown that severe behavior disorders are sensitive to one or more of the aforementioned consequences as reinforcement (Hanley, Iwata, & McCord, 2003). The experimental approach to behavioral assessment is important for at least three general reasons. (1) It has laid the groundwork for a vast literature base, clarifying through parsimonious logic why such seemingly counterintuitive behavior would persist. In short, the behavior continues to occur because it produces favorable consequences, at least in the short term, for the individual engaging in the behavior. (2) It has provided a screening method by which to identify appropriate subjects to address specific research questions. For example, it was previously not possible to investigate interventions for behavior maintained by negative reinforcement because, without a functional analysis, the operant function of behavior was unknown. To date, hundreds of studies have used particular functional-analysis outcomes as inclusion criteria to address specific research questions. (3) It has provided a method of clinical assessment that directly prescribes a treatment for the behavior disorder. For example, if a functional analysis shows that SIB is reinforced by adult attention, SIB could be placed on extinction (i.e., it would no longer produce attention) and some alternative behavior could be taught or strengthened via reinforcement in the form of attention. This chapter, then, is based on the premise, supported by decades of research, that behavior disorders are learned forms of operant behavior. Many other chapters and reviews have covered the most basic forms of intervention derived from a functional analysis of behavior, including extinction, differential reinforcement, and noncontingent reinforcement (NCR). We will cover those treatments in this chapter as well, but we will also focus on some particularly challenging issues surrounding behavioral treatments in contemporary research and clinical application. For example, it is widely known that behavioral treatments work best when they include an extinction component (Fisher et al., 1993; Hagopian, Fisher, Sullivan, Acquisto, & LeBlanc, 1998; Patel, Piazza, Martinez, Volkert, & Christine, 2002; Shirley, Iwata, Kahng, Mazaleski, & Lerman, 1997). But, what if extinction is not possible for practical, legal, or ethical reasons (e.g., when blocking is required for attention-maintained behavior)? As another example, it is widely known that behavioral treatments involving reinforcement of alternative behavior using the reinforcer maintaining problem behavior will be effective in the long-term if the treatment is conducted with reasonable integrity (Vollmer & Iwata, 1992; Vollmer, Roane, Ringdahl, & Marcus,

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1999). But, what if the behavior is so severe that it must be stopped immediately? What if the reinforcer for problem behavior is itself undesirable from the teacher’s or caregiver’s perspective, such as leaving school for the day or leaving classwork to watch videos on a computer? As a final example, it is widely known that behavioral treatments based on a functional analysis are highly effective for behavior maintained by socially mediated reinforcement. But, what if the behavior produces its own source of reinforcement (i.e., automatic reinforcement)? Behavioral treatments are known to have some influence on behavior maintained by automatic reinforcement, but there is also evidence that such behavior remains a major challenge in intervention research and practice (Rapp & Vollmer, 2005). In the process of describing commonly used behavioral treatments for severe behavior disorders, we will highlight several of these unique predicaments that emerge in the prescription of treatments based on a functional analysis.

TREATMENT OF SOCIALLY REINFORCED BEHAVIOR DISORDERS Generally speaking, problem behavior maintained by social reinforcement is relatively easier to treat compared to problem behavior maintained by automatic reinforcement. The reason for this is that, once identified via a functional analysis, the socially mediated reinforcer(s) can be withheld, delivered contingent upon some alternative or other behavior, delivered independent of the problem behavior, or some combination.

Extinction As treatment for problem behavior, extinction involves withholding the reinforcer that previously maintained problem behavior. For example, if problem behavior is maintained by attention, extinction would involve withholding any sort of attention following instances of problem behavior (Iwata, Pace, Cowdery, & Miltenberger, 1994). If problem behavior is maintained by other sorts of socially mediated positive reinforcement, extinction would involve withholding the specific item(s) maintaining the problem behavior. For example, if a child engages in severe tantrums because in the past such tantrums have produced access to preferred toys, extinction would involve withholding those toys when tantrums occur. Extinction of problem behavior maintained by socially mediated negative reinforcement takes a different form. If problem behavior is reinforced by escape from an instructional activity, extinction involves continuation of the instructional activity following instances of problem behavior (Iwata,

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Pace, Kalsher, Cowdery, & Cataldo, 1990). This typically involves physical hand-over-hand guidance to complete an instruction. At times, extinction presented in isolation (i.e., without an accompanying reinforcement procedure) can produce negative side effects. Although there is evidence that negative side effects are not as pervasive as once believed (Lerman, Iwata, & Wallace, 1999), they can include: (a) response bursting (i.e., behavior increasing in intensity, rate, or both before improving), (b) emotional behavior such as crying, (c) response variation that might include the emergence of other forms of problem behavior, and (d) spontaneous recovery (i.e., after a period away from extinction trials, the behavior resurfaces in a similar context), among others. In addition to potential side effects, it is sometimes difficult or even impossible to implement extinction with high integrity. Some reasons for difficult implementation include (but are not limited to) the following: (a) large or fast individuals might be able to escape or avoid an instructional activity despite the best efforts of a parent, teacher, or therapist. (b) Some severe SIB and aggression cannot be allowed to occur for safety reasons, so it is impossible to “ignore” the behavior, and response blocking might serve as a source of reinforcement in the form of physical contact. (c) Well-trained individuals will occasionally make integrity errors. Even if someone implements extinction correctly on average 95% of the time (but accidently reinforces the behavior 5% of the time), this integrity lapse represents a variable ratio (VR) schedule of reinforcement which tends to make behavior exceptionally resistant to extinction (Ferster & Skinner, 1957). As a result of the potential side effects, and as a result of some implementation problems associated with extinction, extinction is not usually recommended as a stand-alone treatment. Rather, it is more often a component of a larger treatment approach. One good example of that larger treatment approach is known as differential reinforcement.

Differential Reinforcement of Alternative Behavior Differential reinforcement of alternative (DRA) behavior involves providing reinforcement for some specific response while minimizing (ideally, eliminating) reinforcement for problem behavior (Vollmer & Iwata, 1992). This means DRA is often implemented along with extinction as described above. One common example of DRA is functional communication training (FCT; Carr & Durand, 1985). In FCT, the specific alternative response is some type of verbal behavior (i.e., communication), often

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taking the form of vocalizations, augmentative devices, picture cards, sign language, or some combination. Usually, the reinforcer in a DRA procedure is the reinforcer previously shown via a functional analysis to maintain problem behavior. For example, a person who exhibits attention-maintained problem behavior would receive attention when the alternative response occurs but not when the problem behavior occurs. At times, this arrangement yields a very high rate of the alternative response, which in itself can become problematic. For example, a child might begin to ask for attention more frequently than a parent or teacher is willing or able to give attention. Similarly, a student might ask for a break before any work has been completed (Marcus & Vollmer, 1995). One way to address this problem is to provide signals to indicate when the reinforcer is or is not available (Hanley, Iwata, & Thompson, 2001). Because it might not be feasible or desired for the teacher or caregiver to provide a reinforcer immediately and following every response, it is advisable to thin the schedule of reinforcement to a more practical goal (Hanley et al., 2001). In addition, the appropriate alternative response might not only occur at an undesirable frequency, but also occur at inappropriate times. For example, a student could begin to repeatedly recruit attention during quiet reading time or while the teacher is attending to another student. Responding during periods in which reinforcement is not readily available might weaken the contingency and possibly would result in extinction or weakening of the newly acquired response. In some cases, a teacher or caregiver might intermittently reinforce the alternative responses during these periods; this outcome could result in strengthening that response during undesirable times. Several methods for thinning a DRA schedule of reinforcement have been evaluated and include increasing the delay to reinforcement (Hagopian, Contrucci-Kuhn, Long, & Rush, 2005) and delivering reinforcers on an initially dense and progressively leaner fixed-interval schedule of reinforcement (Hanley et al., 2001). Both methods of thinning can result in undesirable responding during periods in which reinforcement is not available and might result in inadvertently weakening the alternative response. Hanley et al. presented a solution with adults with developmental disabilities that involved alternating between signaled periods of continuous reinforcement and extinction for the appropriate alternative response, specifically mands (requests) for attention. This specific schedule of reinforcement is known as a multiple schedule. In a multiple schedule, there are two alternating schedules of reinforcement (in the case of Hanley et al., the

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alternating schedules were reinforcement and extinction), and each schedule is associated with a specific stimulus. A multiple schedule provides a means of maintaining the newly acquired appropriate response while also implementing periods in which the reinforcer is unavailable, thus making the DRA procedure more practical (Hanley et al., 2001; Tiger & Hanley, 2004). When implementing a multiple schedule, the delivery of rules describing the schedule-specific stimuli, at the beginning of each session, results in more discriminated responding compared to a multiple schedule without rules (Tiger & Hanley, 2004). Multiple schedules have been demonstrated to be effective at a class-wide level as well (Cammilleri, Tiger, & Hanley, 2008). Cammilleri et al. evaluated the effectiveness of multiple schedules in the classroom and were able to maintain approaches for teacher attention during desirable periods and minimize approaches during undesirable periods even with somewhat low levels of treatment integrity during the reinforcement conditions (i.e., classroom treatment integrity averaged between 51% and 61%). In addition, Tiger and Hanley (2006) found that children preferred conditions with signaled availability and unavailability of reinforcement in comparison to conditions in which the signals were absent or unclear, and Luczynski and Hanley (2009) found that children preferred a multiple schedule of reinforcement to a briefly signaled delay to reinforcement, such as “wait please.” Because DRA ideally involves an extinction component, some of the practical issues surrounding the implementation of extinction surface when using DRA. For example, it is possible that the therapist is not strong or fast enough to physically guide compliance as treatment for escape behavior. It is also possible that attention-maintained problem behavior requires physical attention to protect the individual or others in the environment. In these cases, though not ideal, DRA can be arranged such that the reinforcer(s) for appropriate behavior outweigh the reinforcer(s) for problem behavior along one or more dimensions, with no true extinction component in place (Athens & Vollmer, 2010). For example, even if an attention-maintained problem behavior must be blocked (i.e., attended to), the appropriate alternative could be reinforced more frequently, with a shorter delay, with higher-quality attention (e.g., verbal and physical attention), with a greater duration of attention, or some combination. DRA involves providing the reinforcer contingent on some specific alternative response while minimizing reinforcement for an undesired response. This is one variation of the larger treatment approach of differential reinforcement, a second variation is known as differential reinforcement of other behaviors (DRO).

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Differential Reinforcement of Other Behaviors DRO involves the delivery of reinforcers contingent on the omission of the target behavior. Typically, the reinforcer maintaining problem behavior (as identified via a functional analysis) is the reinforcer presented contingent on the nonoccurrence of problem behavior for some specified interval of time. Further, as with the DRA procedure discussed previously, extinction is often embedded into this procedure such that while appropriate behavior results in the functional reinforcer, problem behavior does not. There are numerous variations of DRO that have been discussed elsewhere (e.g., Vollmer & Iwata, 1992). In short, these variations include but are not limited to a resetting DRO, a whole-interval DRO, and a momentary DRO (mDRO). In a resetting DRO, a reinforcer is delivered after a period of time during which no target behavior has occurred, and any occurrence of the target behavior resets the interval. For example, in a 5-min resetting DRO, if the target behavior occurs 3 min into the interval, the interval would reset, and the individual would need to refrain from engaging in the target behavior for 5 new minutes to obtain the reinforcer (e.g., Repp & Deitz, 1974). In a whole-interval DRO, a reinforcer is delivered after a period of time in which no target behavior has occurred, and any occurrence of the target behavior results in a loss of opportunity to obtain a reinforcer for that specific interval of time. For example, in a 5-min whole-interval DRO, if a target behavior occurs 3 min into the interval, the interval continues to time out at 5 min, but no reinforcer is delivered at the end of that 5-min interval. It would not be until the end of the next scheduled 5-min interval that a reinforcer becomes available (pending nonoccurrence of the target behavior throughout that ensuing 5-min interval; Repp, Barton, & Brulle, 1983). In a mDRO, a reinforcer is delivered if the target behavior does not occur at the very “moment” of a scheduled reinforcer delivery. In a 5-min mDRO, early instances of the target behavior have no effect on reinforcer delivery. If the target behavior is not occurring at the end of the interval (i.e., at the 5-min mark), the reinforcer is delivered. If the target behavior is occurring at the end of the interval (i.e., at the 5-min mark), the reinforcer is not delivered. In some variations of mDRO, the timer resets to some relatively small value such as 10 or 15 s to ensure that the behavior and reinforcer are not contiguous (e.g., Britton, Carr, Kellum, Dozier, & Weil, 2000; Hagopian, Crockett, van Stone, DeLeon, & Bowman, 2000). In other variations of mDRO, the reinforcer does not become available again until the next scheduled delivery (so, in a 5-min mDRO, it would be 5 min later).

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In recent years, DRA applications tend to be more prevalent than DRO applications. There are several possible reasons for this. (1) DRA teaches a specific alternative response, whereas DRO does not. (2) DRA is relatively insensitive to integrity failures (St. Peter Pipkin, Vollmer, & Sloman, 2010). Yet, any error of commission in DRO (i.e., delivering the reinforcer when the behavior has, in fact, occurred) changes the schedule from DRO to a VR schedule of reinforcement for the target behavior. (3) If schedules based on time intervals are preferred over DRA for some reason, time-based schedules such as NCR seem to be easier to implement than DRO (Vollmer, Iwata, Zarcone, Smith, & Mazaleski, 1993), have similar effects as DRO, and can be used readily in conjunction with DRA (Goh, Iwata, & DeLeon, 2000; Marcus & Vollmer, 1996). The selection of NCR over DRO further reduces the relative usage of DRO in comparison to DRA.

Noncontingent Reinforcement NCR-based treatments involve the delivery of reinforcers on a time-based schedule such as a fixed-time or variable-time schedule, independent of the occurrence of target behavior (Vollmer & Sloman, 2005). Typically, the reinforcer maintaining problem behavior (as identified via a functional analysis) is the reinforcer presented in NCR. This arrangement is designed to reduce motivation to engage in problem behavior (i.e., the reinforcer is made available freely and frequently) and also to disrupt the contingency between problem behavior and the functional reinforcer (i.e., the problem behavior no longer results in contingent reinforcement). Dozens of studies have shown the efficacy of NCR as treatment for behavior maintained by positive reinforcement (e.g., Hagopian, Fisher, & Legacy, 1994; Vollmer et al., 1993) and by negative reinforcement (e.g., Vollmer, Marcus, & Ringdahl, 1995). One concern with NCR is that, because the reinforcer delivery is strictly time-based, it is possible that the delivery of the reinforcer will occur in close proximity with the occurrence of the target behavior, and hence, the target behavior will be accidentally reinforced. However, this effect has been reported rarely in the literature (but see Vollmer, Ringdahl, Roane, & Marcus, 1997, for an exception) and, if accidental reinforcement occurs, a fairly simple solution is to add an omission contingency using mDRO as described previously. That is, the reinforcer would be delivered on some schedule independent of problem behavior with the exception that if problem behavior is occurring at the exact time a scheduled reinforcer is to be delivered, the reinforcer is withheld until the next scheduled reinforcer. A second concern related to NCR-based treatment is that NCR by itself

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does not strengthen specific alternative skills. However, most behavior analysts would agree that NCR should not be used in isolation. Rather, it should be “superimposed” on an individual’s daily schedule in which all sorts of appropriate skills and alternative behaviors produce reinforcement.

Punishment As discussed above, behavior maintained by social reinforcers is typically treated with reinforcement-based procedures, such as DRA, DRO, and NCR. That being said, these procedures do not always produce clinically acceptable reductions in problem behavior (Grace, Kahng, & Fisher, 1994; Hagopian et al., 1998; Wacker et al., 1990) or do not reduce behavior rapidly enough (Dura, 1991; see also Iwata et al., 1990; Vollmer & Iwata, 1993). Another method to treat socially reinforced behavior disorders is through the use of punishment procedures. Similar to reinforcement procedures, punishment procedures of this sort should be functionally based. Without knowledge of the behavioral function, procedures intended to punish behavior can be ineffective or, worse, counter-therapeutic. Consider common punishment procedures such as timeout, contingent demands (sometimes called contingent effort or overcorrection), and response cost. Problem behavior maintained by negative reinforcement probably will not decrease if timeout is the selected punishment procedure. If, contingent on problem behavior, the individual is removed from the current environment, one might actually see a reinforcement effect. Instead, a more effective punishment procedure might be contingent demands (Fischer & Nehs, 1978; Fisher et al., 1993) or overcorrection (Foxx & Azrin, 1972). In these procedures, contingent on problem behavior, an individual would be required to complete demands. For an individual who finds the presentation of demands aversive, these procedures should result in a decreased likelihood of problem behavior in the future. Now, consider behavior maintained by social-positive reinforcement in the form of attention. Providing contingent demands when problem behavior occurs might be counter-therapeutic. The presentation of those demands might serve as a reinforcer (i.e., presenting demands coincides with the presentation of attention). The result would be an increase in problem behavior. Instead, timeout from positive reinforcement or attention might be effective at reducing the problem behavior (Hagopian et al., 1998; Kazdin, 1980). Finally, for behavior maintained by positive reinforcement in the form of tangible items, one might select response cost as a punishment procedure (Pietras, Brandt, & Searcy, 2010). In this procedure, a preferred item is

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removed for some period of time contingent on problem behavior. If that item is preferred and access to that item is the functional reinforcer, this punishment procedure should be effective at reducing the likelihood of problem behavior in the future.

EMERGENCY TREATMENTS FOR SOCIALLY REINFORCED BEHAVIOR There are cases in which problem behavior is so severe that it cannot be allowed to occur at all, or at least its occurrence must be minimized as quickly as possible. In decades past, such severe behavior was likely treated with some type of arbitrary punishment procedure to obtain a rapid cessation of the behavior. More recently, knowledge of behavioral function can suggest the use of particular treatments to immediately reduce the occurrence of behavior without the necessity of relying on punishment procedures.

Elimination of the Establishing Operation In the case of an emergency, it is possible to completely eliminate the establishing operation(s) related to the problem behavior to produce an immediate suppression of the behavior. For example, if problem behavior is maintained by attention, the individual could receive free attention throughout the day. The eventual goal would be to thin the schedule of attention. However, to deal with the behavioral emergency, it is possible that the initial schedule of attention could be continuous. Evidence for this approach can be seen in NCR studies in which behavior is suppressed immediately and substantially when the initial schedule is rich or continuous (e.g., Vollmer et al., 1993, 1998). An argument against this approach might relate to resources (e.g., not enough personnel to provide continuous attention); however, the assumption of this emergency approach is that the target behavior requires continuous or nearly continuous attention to block the behavior or to protect others in the environment, and possibly from more than one adult, so there may be no net increased time expenditure. Analogously, if the problem behavior is reinforced by access to tangible items, the individual could be given continuous access to the item(s) to immediately suppress dangerous behavior. A clear case of this approach was demonstrated in Vollmer et al. (1997). When a girl who was referred for the treatment of severe aggression was given continuous access to magazines (which she would hold, clutch, and sometimes leaf through), she displayed zero instances of aggression.

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Similarly, if behavior is reinforced by escape from an instructional activity, all instructional activities can be stopped. Evidence for this approach can be seen at the beginning of interventions using continuous noncontingent escape (e.g., Vollmer et al., 1995) or instructional fading (e.g., Zarcone et al., 1993). Of course, this approach might be contested in educational settings because instructional activity is initially terminated. However, the disruption to educational activities must be balanced against the need to stop extremely dangerous behavior immediately. Educational or other normal activities can then gradually be reinstituted.

Instructional Fading Behavior maintained by negative reinforcement occurs in the presence of an aversive stimulus. As implied above, the emergency procedure for this type of behavior would be to stop presenting that aversive stimulus. If the aversive stimulus is an instructional activity, no instructional demands would be given initially. Contingent on low levels of problem behavior, demands would be slowly and systematically introduced (Pace, Iwata, Cowdery, Andree, & McIntyre, 1993; Zarcone et al., 1993). This procedure is known commonly as instructional or demand fading. Instructional demands can be introduced along the dimension of frequency (e.g., Pace et al., 1993), difficulty (Mace et al., 1988), or duration of instructional sessions (Smith, Iwata, Goh, & Shore, 1995).

DRA with Socially Unacceptable Sources of Reinforcement At times, behavior occurs because it is intermittently reinforced by access to reinforcers that normally would be considered unacceptable to provide to the individual. For example, a student might engage in severe behavior because he or she is sent home from school (i.e., escape from school and access to whatever preferred items or people might be found in the home environment). Using the logic of DRA, it might seem counterintuitive to provide such reinforcers contingent on appropriate requests. For example, most school personnel would likely balk at a suggestion to honor a student’s request (using a communication board, for instance) to “go home now.” However, the administrative choice actually reduces to the following: the student could either go home by asking calmly or go home by engaging in extremely dangerous behavior. In emergency cases, it might be recommended to teach and honor the appropriate request, and subsequently use stimulus-control procedures such as those described previously using multiple schedules to gradually increase intervals of time in which the individual is in school. Similar procedures could be used when an alternative

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behavior occurs frequently to gain access to food or other items that would not be appropriate to deliver throughout the day. An interesting finding in the behavioral treatment literature is that at times escape behavior can be suppressed by using food reinforcers during instructional activity (e.g., Lalli et al., 1999; Lomas, Fisher, & Kelley, 2010; Piazza et al., 1997). Evidence supporting this approach as an emergency procedure can be seen at the beginning of these treatment studies where response rates are typically very low. Again, many educators are likely to balk at the idea of using food reinforcers throughout the day. However, food reinforcers should be considered a viable option in the case of emergencies wherein behavioral suppression is needed immediately. Again, schedules of food reinforcement can be thinned via use of ratio or interval schedules (Lalli et al., 1999), with an aim toward a more natural academic experience.

TREATMENT OF AUTOMATICALLY REINFORCED BEHAVIOR DISORDERS The prognosis for the treatment of behavior maintained by automatic reinforcement is usually not as favorable as the treatment for behavior maintained by social reinforcement. It is often difficult to identify the specific reinforcers maintaining this type of behavior, and, even when the reinforcers are identified, it is difficult to withhold them or present them contingent on some alternative behavior. In this section we will revisit some of the previously discussed treatments while incorporating a discussion of why these approaches might be limited as interventions for behavior maintained by automatic reinforcement.

Extinction In cases in which behavior is maintained by social reinforcement, extinction of that behavior would consist of withholding access to the socially mediated reinforcer. For problem behavior maintained by adult attention, for example, adults are taught to withhold attention when the behavior occurs. In the case of behavior maintained by automatic reinforcement, extinction can be more difficult because the behavior produces its own reinforcement. The so-called “sensory extinction” approach involves eliminating access to the putative reinforcer by eliminating the stimulation produced by the behavior (Rincover, 1978; Rincover, Cook, Peoples, & Packard, 1979). With sensory extinction, the individual is still able to engage in the target behavior, but the stimulation produced by the problem behavior is discontinued. For example, auditory

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sensation can be discontinued with headphones, and the sensory stimulation produced by head hitting can be discontinued with the use of a helmet. Sensory extinction is presumed to be effective in reducing problem behavior by breaking the contingency between the behavior and the putative reinforcer (Rapp & Vollmer, 2005; Vollmer, 1994). However, it is also possible that the procedures are effective due to punishment (Mazaleski, Iwata, Rodgers, Vollmer, & Zarcone, 1994). For example, the stimulation produced by hitting a helmet might be painful or otherwise aversive. Thus, not only is the reinforcer discontinued, but the aversive stimulation now functions as a punishing stimulus. Response blocking is another method to treat behavior maintained by automatic reinforcement (Lerman & Iwata, 1996; Smith, Russo, & Le, 1999). Response blocking involves physically interrupting the behavior and preventing it from occurring, thus preventing the stimulation associated with that behavior. Like protective equipment, blocking can function in some cases as extinction (Smith et al., 1999) or punishment (Lerman & Iwata, 1996).

Differential Reinforcement Differential reinforcement as treatment for behavior maintained by automatic reinforcement involves reinforcing either some explicit alternative response (such as toy play) in a DRA arrangement or reinforcing periods of time without the target response in a DRO arrangement. Although an extinction component is sometimes difficult to include for socially reinforced behavior, extinction is especially difficult to include for behavior maintained by automatic reinforcement. This difficulty arises when the specific reinforcer has not been identified or when eliminating the reinforcer is difficult because the behavior itself produces the reinforcement. Thus, differential-reinforcement procedures for behavior maintained by automatic reinforcement often rely on the reinforcers used in treatment to “override” the reinforcers maintaining problem behavior. It becomes especially important, then, to conduct stimulus preference assessments (e.g., DeLeon & Iwata, 1996; Fisher et al., 1992; Roane, Vollmer, Ringdahl, & Marcus, 1998) and to attempt some form of extinction. In addition, the use of varied reinforcers can be useful to avoid satiation (e.g., Vollmer, Marcus, & LeBlanc, 1994).

Environmental Enrichment There is a great deal of research suggesting that environmental enrichment (EE), or noncontingent access to preferred stimuli, can be effective in reducing problem behavior maintained by automatic reinforcement. EE might be

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effective because a continuous competing source of reinforcement is provided (Horner, 1980). The research on EE related to automatic reinforcement has evaluated the effects of highly preferred versus less-preferred stimuli (Vollmer et al., 1994) as well as stimuli with sensory consequences matched to that of the consequences hypothesized to maintain the problem behavior versus stimuli with unmatched sensory consequences (Favell, McGimsey, & Schell, 1982; Piazza, Adelinis, Hanley, Goh, & Delia, 2000). Assessing the preference of the alternative stimuli prior to implementing the EE procedure and providing access to items identified as highly preferred likely will produce greater treatment effects compared to lesspreferred items (Ahearn, Clark, DeBar, & Florentine, 2005).

EMERGENCY TREATMENTS FOR AUTOMATICALLY REINFORCED BEHAVIOR When a functional analysis shows that problem behavior is automatically reinforced and the behavior is particularly dangerous, behavior analysts find themselves in one of the most difficult situations. At the least, socially reinforced behavior can often be reduced by manipulating the establishing operation(s). It is possible that dangerous behavior maintained by automatic reinforcement is not receptive to standard treatments. When that happens, there is little choice but to: (a) seek medical consultation to rule out physical problems contributing to the behavior, (b) block or prevent the behavior or dangerous outcomes of the behavior to the greatest extent possible, (c) further increase resources to ensure EE, or (d) implement punishment procedures. These approaches are discussed briefly here.

Medical Consultation In most cases, before beginning a functional analysis, a behavior analyst would attempt to rule out medical variables. A concern about possible medical variables becomes even more salient when a functional analysis shows that problem behavior is maintained by automatic reinforcement. If the behavior is maintained by automatic negative reinforcement, it is possible that there is some physical irritant (e.g., skin allergy associated with skin scratching) or pain (e.g., ear infection) that is momentarily attenuated by the behavior (Cataldo & Harris, 1982). Thus, one emergency procedure is to request a full physical examination when dangerous behavior persists, particularly SIB maintained by automatic reinforcement.

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Blocking or Preventing As mentioned previously, it is possible that all instances of dangerous behavior must be blocked or prevented through some sort of mechanical or physical restraint. Blocking requires a great deal of resources because someone needs to be available at all times. Restraint requires extensive training, monitoring, and approvals (Vollmer et al., 2011). Despite these limitations, in an emergency situation, prevention of the behavior sometimes must occur and in each situation one must measure the ethical considerations of restraint against those that arise from the ongoing occurrence of dangerous behavior.

Continuous EE The same general emergency approach described under “treatment of socially reinforced problem behavior” applies to behavior maintained by automatic reinforcement. In short, the notion is to provide as many alternative sources of reinforcement as possible to compete with the problem behavior. Any time the individual spends interacting with items is presumably time they are not engaging in the problem behavior.

Punishment When a functional analysis has shown that behavior is not socially reinforced, and the behavior has persisted in the face of NCR, differential reinforcement, attempted extinction, medical intervention, and continuous EE, there might be a need for emergency procedures involving punishment. Punishment can take forms that are relatively innocuous. For example, the previously discussed use of protective equipment and response blocking might function as punishment (e.g., Mazaleski et al., 1994). Other procedures that have been used include overcorrection (Peters & Thompson, 2013) and body holds (Favell, McGimsey, & Jones, 1978). Some procedures that have been used in the past, including noxious taste (Sajwag, Libet, & Agras, 1974), noxious odor (Singh, Dawson, & Gregory, 1980), contingent shock (e.g., Linscheid, Iwata, Ricketts, Williams, & Griffin, 1990), and water misting (Dorsey, Iwata, Ong, & McSween, 1980), are considered controversial and usually would require extensive peer review, consent, and institutional approvals. In fact, to be safe, behavior analysts should solicit formal or informal peer review for any use of punishment procedures (Bailey & Burch, 2011). It is important to recognize that the behavior is being punished, in a technical sense. The individual is not being “punished” for engaging in the behavior. Although the technical and lay terms are the same, their meaning and implications are disparate.

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CONCLUSIONS Understanding the notion that severe behavior disorders are learned, operant forms of behavior provides a framework for decision-making in the development of behavioral interventions. The prognosis for effective treatment is generally good when the behavior is socially reinforced. In such cases, the reinforcer(s) maintaining problem behavior can be withheld contingent on problem behavior and presented contingent on some alternative, adaptive behavior. Interventions become a bit more complex when there is a need to immediately stop the behavior. In this chapter, we have referred to interventions designed to immediately stop the behavior as “emergency” procedures. By understanding the operant mechanisms supporting the behavior, it is possible to stop socially reinforced behavior without the use of punishment. This represents a significant advance in the field over the past several decades. The complexity of intervention is often increased when the functional analysis shows that behavior is maintained by automatic reinforcement. In these cases, the therapist does not have direct control over the delivery of the reinforcer(s). In fact, at times, the specific form of the reinforcer is difficult to ascertain. The principles of extinction and differential reinforcement still apply in the case of automatic reinforcement, but they are more difficult to implement effectively. Behavior maintained by automatic reinforcement becomes an even greater challenge when the behavior is so dangerous it must be stopped immediately. In such cases, medical evaluations, response blocking, and protective equipment might enter into consideration as treatment components. The use of arbitrary aversive stimuli as punishers was posed as a last resort that should only be used under the umbrella of the standard ethical guidelines for behavior analysts.

ACKNOWLEDGMENT A portion of this work was conducted with support from the Autism Speaks’ Dennis Weatherstone Predoctoral Fellowship, #9166, PI: Sarah Slocum.

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