Protective equipment as treatment for stereotypic hand mouthing: sensory extinction or punishment effects?

Resurgence of a target behavior suppressed by a combination of punishment and alternative reinforcement

Differential-reinforcement-based treatments involving extinction of target problem behavior and reinforcement of an alternative behavior are highly effective. However, extinction of problem behavior is sometimes difficult or contraindicated in clinical settings. In such cases, punishment instead of extinction may be used in combination with alternative reinforcement. Although it is well documented that omitting alternative reinforcement can produce recurrence (i.e., resurgence) of behavior previously suppressed by extinction plus alternative reinforcement, it remains unclear if resurgence similarly occurs for behavior previously suppressed by punishment plus alternative reinforcement. The present experiment examined this question with rats. In Phase 1, a target behavior (lever pressing) was reinforced with food pellets. In Phase 2, the target behavior continued to be reinforced, but it also produced mild foot shock and an alternative behavior (nose poking) also produced food. Finally, all consequences were removed and resurgence of target behavior occurred. Resurgence did not occur for another group that similarly received punishment of target behavior in Phase 2 but not alternative reinforcement. These results indicate that resurgence was a product of the history of exposure to and then removal of alternative reinforcement and that the removal of punishment alone did not produce resurgence of target behavior.

Differential Reinforcement of Other Behaviour for the Reduction of Severe Nail Biting

The effects of differential reinforcement of other behaviour (DRO) were investigated for the treatment of severe self-injurious nail biting in an individual diagnosed with autism. A functional behaviour assessment (FBA) identified that the behaviour was maintained by automatic reinforcement. Following the implementation of the DRO procedure and access to reinforcing stimuli that were believed to provide similar sensory feedback to that of the self-injurious nail biting, the results indicate that the nail biting was successfully reduced and maintained at near zero levels.

Clarifying inconclusive functional analysis results: Assessment and treatment of automatically reinforced aggression

We conducted a series of studies in which multiple strategies were used to clarify the inconclusive results of one boy's functional analysis of aggression. Specifically, we (a) evaluated individual response topographies to determine the composition of aggregated response rates, (b) conducted a separate functional analysis of aggression after high rates of disruption masked the consequences that maintained aggression during the initial functional analysis, (c) modified the experimental design used during the functional analysis of aggression to improve discrimination and decrease interaction effects between conditions, and (d) evaluated a treatment matched to the reinforcer hypothesized to maintain aggression. An effective yet practical intervention for aggression was developed based on the results of these analyses and from data collected during the matched-treatment evaluation.

Chin prompt plus re-presentation as treatment for expulsion in children with feeding disorders

Expulsion (spitting out food) is a problem behavior observed in many children with feeding disorders. In the current investigation, we identified 4 children diagnosed with a feeding disorder who exhibited high rates of expulsion. Treatment with re-presentation (placing expelled liquids or solids back into the child's mouth) was not effective in reducing expulsion. Therefore, we added a chin-prompt procedure (the feeder applied gentle upward pressure to the child's chin and lower lip) for the initial presentation and the re-presentation. Chin prompt plus re-presentation resulted in low rates of expulsion for all 4 children. The results are discussed in terms of the potential underlying mechanisms behind the effectiveness of the chin-prompt procedure.

Treatment of hand mouthing in individuals with severe to profound developmental disabilities: a review of the literature

This paper reviews studies investigating the assessment and treatment of hand mouthing in individuals with severe to profound developmental disabilities. A literature search identified 101 studies carried out between 1969 and 2004. The trend in the studies indicated a shift away from aversive interventions in the last 10 years, so this review included studies conducted from 1995. Twenty-three studies were identified within this period and were included in this review. The 23 studies were sorted into seven intervention categories and one assessment category. The seven intervention categories included (a) antecedent interventions, (b) multicomponent interventions (e.g., differential reinforcement and response effort), (c) pharmacological interventions, (d) interventions that utilized reinforcement, (e) response blocking interventions, (f) response effort interventions, and (g) sensory stimulation interventions. The one assessment category included studies that investigated the function of hand mouthing. One main finding in these studies was that the various intervention strategies led to decreases in hand mouthing in individuals with severe to profound developmental disabilities. This finding is discussed in relation to its effect on issues of health, adaptive behavior, and social functioning. A second finding indicated that hand mouthing is often maintained by automatic reinforcement (i.e., non-social contingencies). The implications of this finding are discussed in terms of how assessments and treatments associated with automatically maintained challenging behavior might be more effectively linked. Potential issues for future research are also examined.

On the status of knowledge for using punishment implications for treating behavior disorders

In this paper, we review basic and applied findings on punishment and discuss the importance of conducting further research in this area. The characteristics of responding during punishment and numerous factors that interact with basic processes are delineated in conjunction with implications for the treatment of behavior disorders in clinical populations. We conclude that further understanding of punishment processes is needed to develop a highly systematic, effective technology of behavior change, including strategies for improving the efficacy of less intrusive procedures and for successfully fading treatment.

Functional analysis of problem behavior in children with mental retardation

Pediatric nurses are frequently asked to give advice on behavior management. This can become considerably more difficult when the child in question has limited cognitive abilities and communication skills. It is especially complex when the behavior in question involves self-injury or aggression. Frequently used behavior modification strategies such as time-out may actually reinforce the inappropriate behavior in these children by allowing them to escape from an aversive task. Likewise, other common behavior management strategies such as discussion, saying "no," or yelling at the child, may reinforce the inappropriate behavior by providing attention for it. It is sometimes difficult to identify the antecedents of self-injurious or aggressive behavior, making appropriate behavior management plans elusive. However, functional analysis can be used to identify the functions that serve to maintain a child's inappropriate behavior, and may provide a basis for developing and implementing an individualized behavior management plan. The possibility that discomfort from an untreated or undertreated physiologic problem is exacerbating the behavior should not be overlooked.

Analysis and treatment of finger sucking

We analyzed and treated the finger sucking of 2 developmentally typical children aged 7 and 10 years. The functional analysis revealed that the finger sucking of both children was exhibited primarily during alone conditions, suggesting that the behavior was maintained by automatic reinforcement. An extended analysis provided support for this hypothesis and demonstrated that attenuation of stimulation produced by the finger sucking resulted in behavior reductions for both children. Treatment consisted of having each child wear a glove on the relevant hand during periods when he or she was alone. Use of the glove produced zero levels of finger sucking for 1 participant, whereas only moderate reductions were obtained for the other. Subsequently, an awareness enhancement device was used that produced an immediate reduction in finger sucking.

Effects of increased response effort on self-injury and object manipulation as competing responses

We evaluated the effects of a response-effort intervention on the occurrence of self-injurious hand mouthing and a competing response (object manipulation) with 4 individuals who had profound developmental disabilities. During Phase 1, results of functional analyses showed that all participants engaged in high levels of hand mouthing in the absence of social contingencies, suggesting that the behavior was maintained by automatic reinforcement. In Phase 2, preferred leisure items were identified for participants during assessments in which duration of leisure item manipulation was used as the index of preference. In Phase 3, participants were observed to engage in high levels of hand mouthing and in varying levels of object manipulation when they had free access to their most preferred leisure items during baseline. The effects of increased response effort on hand mouthing and object manipulation were then evaluated in mixed multiple baseline and reversal designs. The response-effort condition was identical to baseline, except that participants wore soft, flexible sleeves that increased resistance for elbow flexion but still enabled participants to engage in hand mouthing. Results showed consistent decreases in SIB and increases in object manipulation during the response-effort condition for all participants. These results suggested that a less preferred reinforcer (produced by object manipulation) may substitute for a more highly preferred reinforcer (produced by hand mouthing) when response effort for hand mouthing was increased.

DESCRIPTORS

self-injurious behavior, automatic reinforcement, reinforcer substitutability, response effort

A comparison of noncontingent reinforcement and sensory extinction as treatments for self-injurious behavior

We compared the effects of two treatments, noncontingent reinforcement (NCR) and sensory extinction (EXT), on the self-injurious behavior (SIB) exhibited by 3 individuals with developmental disabilities. Results of a functional analysis indicated that their SIB was not maintained by social reinforcement, as indicated by undifferentiated responding across assessment conditions or higher rates of responding in the along condition. Prior to treatment, leisure probes were conducted to identify highly preferred items for use in the NCR condition, and equipment probes were conducted to identify devices that produced the greatest behavioral suppression for use in the EXT condition. Following baseline, treatment was implemented in a multiple baseline across subjects design, and the effects of NCR and EXT were compared in a multielement format. During NCR sessions, participants had continuous access to a highly preferred item. During EXT sessions, participants wore equipment (gloves or protective sleeves) that seemed to attenuate stimulation directly produced by their SIB, while still allowing the behavior to occur. Results indicated that both procedures were effective in reducing SIB, although NCR was associated with either more rapid or greater overall response suppression.

An analysis of reinforcer substitutability using object manipulation and self-injury as competing responses

The concept of reinforcer substitutability proposes a continuum of interactions among reinforcers in a given situation. At one end of this continuum, reinforcers are substitutable, with one reinforcer being readily traded for another. We conducted an analysis of reinforcers that were substitutable with those produced by self-injurious behavior (SIB). Three individuals with profound developmental disabilities, whose SIB appeared to be maintained by automatic reinforcement, participated. Results of three experiments showed that (a) object manipulation and SIB were inversely related when leisure materials and SIB were concurrently available, with participants showing almost complete preference for object manipulation; (b) attempts to reduce SIB using the preferred objects as reinforcers in differential reinforcement contingencies were unsuccessful for all 3 participants; and (c) participants' preferences for SIB or object manipulation systematically changed when reinforcer cost (the amount of effort required to obtain the object) was varied. Results of the three experiments illustrate the importance of examining interactions among concurrently available reinforcers when conducting reinforcer assessments.

Physical restraint procedures for managing challenging behaviours presented by mentally retarded adults and children

This paper reviews the published research literature on the use of physical restraint with mentally retarded adults and children. Research on three types of restraint is included. One type involves one or more person(s) holding another. A second method is where a mechanical device is fitted to limit movement or reduce injury. The third type is where the person voluntarily applies a personal or mechanical restraint. The following conclusions emerged: (a) there are numerous processes which contribute to the outcomes associated with restraint, and these are poorly understood; (b) different processes mediate the outcomes for contingent and noncontingent restraint; (c) both noncontingent and contingent restraint can result in long-term reductions in target behaviours, especially when fading procedures are employed (noncontingent restraint) and where staff or carers are involved in the treatment plan (contingent restraint); (d) self-restraint seems to be maintained by the reinforcing effects of the restraint procedure or by escape from the aversive consequences of self-injury; (e) there are (negative) reinforcing consequences for staff who use restraint procedures in service settings; (f) and both staff and clients risk injury, especially from emergency or unplanned restraint.

A methodology for distinguishing between extinction and punishment effects associated with response blocking

We present one method for distinguishing between extinction and punishment effects. The proportion of responses that produced a consequence (blocking) was varied while hand mouthing was treated in a man diagnosed with profound mental retardation. Response patterns across the schedule changes suggested that the blocking procedure functioned as a punishing event.

Analog baselines: a critical review of the methodology

Analog baselines are an experimental methodology for identifying the functions of maladaptive behavior in the naturally occurring environment (Iwata, Dorsey, Slifer, Bauman, & Richman, 1982; Iwata et al., 1994). This article identifies a number of potential limitations in this methodology. These include: (a) procedural problems inherent in the use of multielement designs, (b) the fidelity of analog baseline design conditions, (c) the relation of the analog conditions to the naturally occurring environment, (d) a narrow analysis of behavior limited by an implicit adherence to an ABC model of behavior, (e) a limited acknowledgement of multifunction and idiosyncratically motivated behaviors, (f) problems in the definition of response classes, and (g) difficulties in the use of analog baselines to design interventions. Future research should attend to three main questions. First, the convergent validity of different assessment methodologies, including analog baselines, should be evaluated. Future research should attend to procedures that can integrate the entire clinical process of referral, identifying the functions of the target behavior, including other methods of identifying the functions of behavior, treatment design, and implementation. Second, assessment failures could be examined carefully to identify ways of developing this methodology further. Third, the process of designing an intervention depends upon input from many sources of information. The use of analog baselines will be enhanced by a greater understanding of the process of clinical decision making.

Treatment of self-injury and hand mouthing following inconclusive functional analyses

Numerous studies have used functional analyses to prescribe interventions for severe behavior disorders. The majority of these studies have focused on behavior that is clearly maintained by socially mediated reinforcement, such as contingent access to attention, tangibles, or escape from instructional demands. However, a significant proportion of functional analyses do not yield conclusive results. We examined interventions for 3 children with severe disabilities following inconclusive functional analyses. First, preferred stimuli were identified for each child via a stimulus preference assessment. Second, a functional analysis was conducted for 2 of the 3 children. High rates of aberrant behavior were seen even (if not especially) in no-interaction sessions. The 3rd child was observed for several consecutive no-interaction sessions; behavior persisted in this condition. Third, interventions based on environmental enrichment were analyzed in an analogue setting. For all of the children, environmental enrichment decreased aberrant behavior if preferred stimuli were used in the procedure. To obtain further reductions in aberrant behavior, explicit reinforcement of toy play was required for 2 children, and a brief (5-s) time-out was necessary with 1 child. Finally, effects of treatment carried over to the school or home environment following teacher or family training. Results are discussed in the context of basic reinforcement principles and future directions for research.

The functions of self-injurious behavior: an experimental-epidemiological analysis

Data are summarized from 152 single-subject analyses of the reinforcing functions of self-injurious behavior (SIB). Individuals with developmental disabilities referred for assessment and/or treatment over an 11-year period were exposed to a series of conditions in which the effects of antecedent and consequent events on SIB were examined systematically by way of multielement, reversal, or combined designs. Data were collected during approximately 4,000 experimental sessions (1,000 hr), with the length of assessment for individuals ranging from 8 to 66 sessions (M = 26.2) conducted over 2 to 16.5 hr (M = 6.5). Differential or uniformly high responding was observed in 145 (95.4%) of the cases. Social-negative reinforcement (escape from task demands or other sources of aversive stimulation) accounted for 58 cases, which was the largest proportion of the sample (38.1%). Social-positive reinforcement (either attention or access to food or materials) accounted for 40 (26.3%) of the cases, automatic (sensory) reinforcement accounted for 39 (25.7%), and multiple controlling variables accounted for 8 (5.3%). Seven sets of data (4.6%) showed either cyclical or inconsistent patterns of responding that were uninterpretable. Overall results indicated that functional analysis methodologies are extremely effective in identifying the environmental determinants of SIB on an individual basis and, subsequently, in guiding the process of treatment selection. Furthermore, an accumulation of assessment data from such analyses across a large number of individuals provides perhaps the most rigorous approach to an epidemiological study of behavioral function.