Effectiveness of functional communication training with and without extinction and punishment: a summary of 21 inpatient cases

A Quantitative Systematic Literature Review of Combination Punishment Literature: Progress Over the Last Decade

This review evaluated single-case experimental design research that examined challenging behavior interventions utilizing punishment elements. Thirty articles published between 2013 and 2022 met study inclusion criteria. Study quality was also assessed. Through multiple levels of analysis (e.g., descriptive statistics, non-parametric statistics), we examined (a) participant and study trends, (b) differential outcomes related to temporal reinforcement approaches (antecedent, consequent, or combined reinforcement) applied alongside punishment element(s), (c) differential outcomes related to the punishment type (negative, positive) applied alongside reinforcement, and (d) effect sizes associated with study rigor across peer-reviewed and gray literature. Our results may tentatively suggest that, for certain situations, concurrently applying punishment with antecedent reinforcement approaches may coincide with significantly larger effect sizes compared to combined temporal reinforcement approaches, while positive punishment applied concurrently with reinforcement may coincide with larger but non-significant intervention effects. Most featured articles met rigor criteria, but larger effects were seen in peer-reviewed literature.

A demonstration of incorporating discriminative stimuli into an AAC device during functional communication training

Functional communication training (FCT) is an effective intervention for teaching communication responses and reducing challenging behavior. One limitation of FCT is that frequent reinforcement may be impractical or impossible in many situations. Recently, Mitteer et al. published a tutorial in the journal AAC that provided video models on how to implement an empirically supported strategy for thinning reinforcement during FCT, known as FCT with discriminative stimuli, when teaching with an augmentative and alternative communication (AAC) device. However, no study has empirically evaluated the approach described in that tutorial. This paper details a case study using several single-case experimental designs to teach a non-vocal autistic adult who did not use speech to communicate requests only when reinforcement was signaled to be available by the color of the AAC icons. We demonstrated the efficacy of this approach with unique pairs of discriminative stimuli for tangible and edible items, thinning reinforcement for each stimulus class independently. We then rapidly transferred stimulus control to new icons and integrated both classes of stimuli into a single AAC grid. This first demonstration of embedding discriminative stimuli into an AAC device represents a promising advancement for individuals who do not use speech and may not readily respond to delay or denial cues.

Characterization and Outcomes of Profoundly and Non-profoundly Autistic Individuals Admitted to a Specialized Psychiatric Inpatient Unit

PURPOSE

The prevalence of autism spectrum disorder (ASD) is currently estimated to be 1 in 36 children. While much is known about the impact of ASD on family and community functioning as well as treatment outcomes, less is known about a relatively new categorization of ASD, called "profound autism."

METHODS

The current study evaluated 14 consecutively admitted patients meeting criteria for profound autism to a specialized psychiatric inpatient and partial hospitalization program. We then selected 15 non-profoundly autistic youth admitted immediately before or after each profoundly autistic youth to serve as a comparison. Patient caregivers completed measures about parental stress and the severity and frequency of patient problem behavior, and patients participated in functional analyses of problem behavior and function-based treatment programs during their admission.

RESULTS

Results showed profoundly autistic youth spent an average of 14 more days admitted to the psychiatric unit, and they engaged in higher parent-reported severity and frequency of self-injurious and stereotypic behavior. Functional analysis results for profoundly autistic youth showed a higher occurrence of automatically reinforced problem behavior but otherwise similar results. As well, profoundly autistic youth showed a lower percentage reduction in problem behavior at the end of the psychiatric hospitalization than their non-profoundly autistic peers.

CONCLUSION

Profoundly autistic youth seem to require a high level of behavioral support, even after psychiatric hospitalization. Insurance companies and therapists need to recognize these challenges and invest sufficient resources to meet their treatment needs.

Evaluation of resurgence following differential reinforcement of alternative behavior with and without extinction in a human operant model

One of the most common treatments for severe challenging behavior involves placing the challenging behavior on extinction and differentially reinforcing an alternative response (DRA). However, extinction is not always feasible and may be unsafe or impractical to implement in some circumstances. Thus, implementing a DRA without extinction intervention may be necessary for some cases. Currently, the extent to which DRA without extinction produces durable treatment outcomes, particularly as it relates to the resurgence of challenging behavior, is unclear. The present study investigated resurgence following DRA with and without extinction using a three-phase resurgence evaluation in a translational human operant model with college students as participants. All participants demonstrated resurgence across both experimental groups. Although there were no statistically significant differences in the prevalence, magnitude, or persistence of resurgence between groups, levels of resurgence magnitude were relatively higher in the DRA-without-extinction group than in the DRA-with-extinction group. Clinical implications of these findings and directions for future human operant investigations of resurgence are discussed.

Psychotropic Medication Use and Polypharmacy Among Children and Adolescents Initiating Intensive Behavioral Therapy for Severe Challenging Behavior

OBJECTIVE

To evaluate the prevalence, trends, and factors associated with psychotropic medication use and polypharmacy among children and adolescents initiating intensive behavioral therapy for severe challenging behavior over a 10-year period.

STUDY DESIGN

In this retrospective observational study, we examined data from caregiver interviews and patient medical records on the number and types of psychotropic medications prescribed to patients initiating intensive behavioral therapy between January 1, 2013, and December 31, 2022. Trends in medication use and polypharmacy across the 10-year period were analyzed using regression analysis, while differences in demographics and clinical factors for patients with use and polypharmacy were analyzed using nonparametric statistical analysis with odds ratios presented for significant factors.

RESULTS

Data from all 302 pediatric patients initiating intensive behavioral therapy across the 10-year period were analyzed. Among all patients and all years, 83.8% were taking at least 1 psychotropic medication and 68.2% experienced polypharmacy. There were no changes in the prevalence of use, mean number of medications taken, or polypharmacy across the 10-year period. Patients diagnosed with attention-deficit/hyperactivity disorder or anxiety disorder, as well as those exhibiting self-injurious behavior had higher use of psychotropic medication and polypharmacy and were taking more medications overall.

CONCLUSIONS

Psychotropic medication use and polypharmacy were extremely high for children and adolescents with severe challenging behavior, but use and polypharmacy did not change over the 10-year period of data collection. Further research is needed to establish the generality of these findings to other regions of the US.

Reinforcer value moderates response magnitude and persistence during extinction: A randomized trial

Extinction bursts, or temporary increases in rates and intensities of behavior during extinction, can preclude the inclusion of extinction in intervention packages meant to suppress severe challenging behavior. To identify underlying behavioral mechanisms responsible for response persistence and bursting, 69 adults with developmental disabilities completed a low-stakes translational investigation employing a 2 × 2 factorial, crossed, and randomized matched blocks design, with batched randomization logic. In each of the four test groups, we made distinct antecedent manipulations with two value parameters commonly studied through behavioral economics (i.e., demand intensity, Pmax) and evaluated the extent to which each of these manipulations influenced target responding during extinction. Although we found statistically significant differences attributable to both parameters, variations in reinforcer consumption relative to demand intensity were most influential across all dependent variables. This outcome implicates consumption relative to demand intensity as both a mitigating and exacerbating preextinction factor that influences the prevalence of adverse collateral extinction effects (e.g., bursts).

Application of a terminal schedule probe method to inform schedule thinning with multiple schedules

Multiple schedules are effective at decreasing challenging behavior and maintaining alternative behavior at acceptable levels. Currently, no conclusive guidance is available for empirically deriving multiple-schedule components (continuous reinforcement for alternative behavior and extinction for challenging behavior [discriminative stimulus] and extinction for both alternative and challenging behavior [delta stimulus]) during the schedule-thinning process. In the current investigation, we describe a terminal schedule probe method to determine delta stimulus starting points and strategies for subsequent schedule-thinning progressions to reach caregiver-informed terminal schedules. We review schedule-thinning outcomes for a clinical cohort using a consecutive controlled case series approach and report results for two groups: One group included applications of terminal probe thinning (n = 24), and the other involved traditional dense-to-lean thinning (n = 18). Outcomes suggest that the terminal schedule probe method produced effective treatments with less resurgence of challenging behavior and leaner, more feasible, multiple schedules.

Exploring factors that influence the efficacy of functional communication training

Understanding factors that influence the efficacy of functional communication training has both practical and conceptual benefits. The current study extended research in this area by exploring data from 95 consecutive applications of functional communication training with extinction across two independent clinics. We selected candidate predictor variables based on conceptual analysis, conducted preliminary exploratory analyses, and then selectively applied quantitative methods that are used in precision medicine to examine their accuracy and predictive utility. Treatment outcomes were better when challenging behavior was maintained by a single function than they were when it was maintained by multiple functions; however, these differences were most apparent among cases with an escape function. We also analyzed within-session responding to explore the potential influence of unprogrammed establishing operations on decrements in treatment efficacy. Our within-session measure only distinguished responders from nonresponders when escape was one of the multiple functions. Additional research is needed to validate these findings with an independent sample and to address a number of clinical conceptual issues.

Long-term effectiveness and generality of practical functional assessment and skill-based treatment

There are several considerations to address when conducting functional communication training for challenging behavior in a school setting, such as the need for schedule thinning and maintenance across staff and the need to establish a variety of appropriate classroom skills. There are several strategies for conducting schedule thinning following functional communication training and for transferring effects across people or settings. However, there are few examples of these processes in natural settings with relevant caregivers and with long-term maintenance of effects. We implemented a functional assessment and skill-based treatment process with six children with autism in a specialized school setting and extended treatment until challenging behavior was reduced to near-zero levels across multiple staff and settings. Follow-up data indicate that effects were still observed 1 year posttreatment and the use of crisis procedures (e.g., physical restraint) was eliminated for all participants.

Differential Reinforcement without Extinction: An Assessment of Sensitivity to and Effects of Reinforcer Parameter Manipulations

Although functional communication training (FCT) usually includes extinction, withholding reinforcement is not possible or ethical with certain individuals, for some topographies of problem behavior, or in certain contexts. The current study evaluates the effects of two variations of FCT, both without extinction, on problem behavior and communication. Further, the intervention procedures were designed to evaluate participant reactivity to reinforcer parameters (e.g., magnitude, delay, and quality) in the context of the FCT variations. The parameter sensitivity assessments were effective at identifying relevant reinforcer parameters for each participant and both FCT interventions were effective in decreasing problem behavior and increasing communication for all participants. The results demonstrated that FCT was effective regardless of which reinforcer parameter was manipulated. Moreover, all sessions were conducted in participants' homes and caregivers reported high degrees of social validity for the intervention procedures and outcomes.

Exploratory Time-Series Analysis of Consecutive Case Series Data: A Quality Improvement and Adherence Study of a Behavior Analytic Service Provider

Program evaluation is an essential practice for providers of behavior analytic services, as it helps providers understand the extent to which they are achieving their intended mission to the community they serve. A proposed method for conducting such evaluations, is through the use of a consecutive case series design, for which cases are sequentially gathered following the onset of a specific occurrence. Given the sequential nature in which data are collected within a consecutive case series, analytic techniques that adopt a time-series framework may be particularly advantageous. Although such methods are commonly used for program evaluation in medicine and economics, their application within the field of applied behavior analysis is largely absent. To serve as a model for providers undertaking evaluation efforts, I conducted a program evaluation of an outpatient severe behavior clinic, in which I employed quasi-experimental methods using an interrupted time-series analysis.

Stimulus Avoidance Assessment: A Systematic Literature Review

Board certified behavior analysts are ethically required to first address destructive behavior using reinforcement-based and other less intrusive procedures before considering the use of restrictive or punishment-based procedures (ethics standard 2.15; Behavior Analyst Certification Board, 2020). However, the inclusion of punishment in reinforcement-based treatments may be warranted in some cases of severe forms of destructive behavior that poses risk of harm to the client or others. In these cases, behavior analysts are required to base the selection of treatment components on empirical assessment results (ethics standard 2.14; Behavior Analyst Certification Board, 2020). One such preintervention assessment is the stimulus avoidance assessment (SAA), which allows clinicians to identify a procedure that is likely to function as a punisher. Since the inception of this assessment approach, no studies have conducted a systematic literature review of published SAA cases. These data may be pertinent to examine the efficacy, generality, and best practices for the SAA. The current review sought to address this gap by synthesizing findings from peer-reviewed published literature including (1) the phenomenology and epidemiology of the population partaking in the SAA; (2) procedural variations of the SAA across studies (e.g., number of series, session length); (3) important quality indicators of the SAA (i.e., procedural integrity, social validity); and (4) how the SAA informed final treatment efficacy. We discuss findings in the context of the clinical use of the SAA and suggest several avenues for future research.

Updated Recommendations for Reinforcement Schedule Thinning following Functional Communication Training

Schedule thinning is a necessary treatment procedure following the acquisition of a communication response during functional communication training. In this article, we update and extend the Hagopian et al. Behavior Analysis in Practice, 4, 4-16, (2011) review and recommendations on schedule-thinning procedures following functional communication training. Since their publication, substantial research has been published on the efficacy, efficiency, and social validity of schedule-thinning methods. We provide updated recommendations for schedule thinning based on contemporary literature that has been published since 2011, as well as discuss key areas for future research.

Relative preference for distinct reinforcers maintaining destructive behavior

The literature offers few recommendations for sequencing exposure to treatment conditions with individuals with multiply maintained destructive behavior. Identifying relative preference for the functional reinforcers maintaining destructive behavior may be one means of guiding that decision. The present study presents a preliminary attempt at developing a robust relative preference and reinforcer assessment for individuals with multiply maintained destructive behavior. Guided and free-choice trials were implemented in which participants chose between two multiple-schedule arrangements, each of which programmed signaled periods of isolated reinforcer availability and unavailability. Consistent participant choice and responding during free-choice trials was then used to thin the corresponding schedule of reinforcement. The results demonstrated a strong preference for one of the two functional reinforcers for all four participants, yet preferences differed across participants and were not well predicted by responding in prior analyses.

Report of the ABAI Task Force on Contingent Electric Skin Shock

As a task force appointed by the Executive Council of the Association for Behavior Analysis International (ABAI), we investigated the clinical use of contingent electric skin shock (CESS) in behavior analytic treatments for severe problem behavior. We studied how CESS is used in contemporary behavior analysis, reinforcement-based alternatives to CESS, and current ethical and professional guidelines for applied behavior analysts. We recommended that ABAI uphold clients' right to receive CESS when it is restricted to extreme cases and used under rigorous professional and legal oversight. Our recommendation was rejected by a vote of the full members of ABAI, who instead endorsed an alternative recommendation, developed by members of the Executive Council, that opposed the use of CESS under any condition. Here we present for the record our report and initial recommendations, the formal statement that was rejected by the members of ABAI, and the statement that was endorsed.

Modeling Behavioral Persistence with Resurgence as Choice in Context (RaC2): A Tutorial

Resurgence as Choice in Context (RaC2) is a quantitative model for evaluating the reemergence of a previously extinguished response when alternative reinforcement is worsened. Rooted in the matching law, RaC2 proposes that allocation between target and alternative responding is based on changes in the relative value of each response option over time, accounting for periods with and without alternative reinforcement. Given that practitioners and applied researchers may have limited experience with constructing quantitative models, we provide a step-by-step task analysis for building RaC2 using Microsoft Excel 2013. We also provide a few basic learning activities to help readers better understand RaC2 itself, the variables that affect the model's predictions, and the clinical implications of those predictions.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40617-023-00796-y.

Additional Comments on the Use of Contingent Electric Skin Shock

Prior to the ABAI member vote to decide between two alternative position statements on contingent electric skin shock (CESS), the current authors helped draft a consensus statement supporting the abolition of CESS. In this commentary, we provide additional, supporting information for that consensus statement by (1) showing that the extant literature does not support the supposition that CESS is more efficacious than less-intrusive interventions; (2) providing data showing that implementing interventions that are less intrusive than CESS does not lead to overreliance on the use of physical or mechanical restraint to control destructive behavior; and (3) discussing the ethical and public relations issues that arise when behavior analysts use painful skin shock to reduce destructive behavior in persons with autism or intellectual disability.

Relapse and its mitigation: Toward behavioral inoculation

Relapse following the successful treatment of problem behavior can increase the likelihood of injury and the need for more intensive care. Current research offers some predictions of how treatment procedures may contribute to relapse, and conversely, how the risk of relapse can be mitigated. This review describes relapse-mitigation procedures with varying levels of support, the quantitative models that have influenced the research on relapse mitigation, different experimental methods for measuring relapse mitigation, and directions for future research. We propose that by viewing the implementation of relapse-mitigation procedures as a means of producing behavioral inoculation, clinicians are placed in the proactive and intentional role of exposing their client's behavior to an array of reinforcement and stimulus conditions during treatment with the goal of decreasing the detrimental impact of future treatment challenges.

Multiple Schedules Facilitate Rapid Noncontingent Reinforcement Schedule Thinning

We evaluated a noncontingent reinforcement treatment that included initial brief exposures to signaled alternation of availability and nonavailability of reinforcement, followed by rapid schedule thinning. Results confirmed findings from previous research (typically with differential reinforcement schedules) that establishing stimulus control across multiple treatment components facilitated schedule thinning. We discuss both the clinical utility of this procedure and the utility of stimulus control for making interventions more practical for clinicians.

Barriers to Accessing Effective Treatments for Destructive Behavior

The field of applied behavior analysis has developed and refined a comprehensive methodology for the assessment and successful treatment of destructive behavior: An individualized approach emphasizes (a) function of responding (or its cause) over its form; (b) objective and reliable measurement of behavior; (c) systematic procedures and their application; (d) rigorous, single-case experimental designs; and (e) determinations of successful intervention judged by improvements in the same individual's performance. Outcomes of this approach are often dramatic and reliably surpass those obtained by alternative means. However, significant barriers limit the accessibility of this proven therapy. Too few intensive behavioral intervention units, diagnosis- and age-dependent insurance authorization and reimbursement practices, long waitlists and slow approval processes, and the possibility of treatment relapse represent a few such barriers. This article describes these barriers and suggests some potential solutions.

Varying reinforcer dimensions during differential reinforcement without extinction: A translational model

Procedural arrangements of differential reinforcement of alternative behavior without extinction often involve presenting the same reinforcers for problem behavior and appropriate behavior, which is typically ineffective at reducing problem behavior and increasing an alternative response. However, manipulating reinforcement dimensions such that the contingencies favor the alternative response may improve treatment outcomes when using differential reinforcement of alternative behavior without extinction by increasing appropriate behavior and reducing problem behavior. We conducted this translational study with 32 college students completing a button-pressing task on a computer program in which they could engage in analogs to problem behavior and appropriate behavior. The effects of manipulating magnitude, immediacy, quality, and a combination of all three dimensions for the alternative response were evaluated. Overall, all dimension manipulations reduced the analog to problem behavior, with the largest reductions observed during the quality probe and the probe with all dimensions combined. These results support the notion that differential reinforcement of alternative behavior without extinction can be an effective form of treatment.

Description and evaluation of a function-informed and mechanisms-based framework for treating challenging behavior

Individualization and iterative design are essential components of the assessment and treatment of challenging behavior. Currently, there are few validated frameworks for engaging in iterative processes. Due to the nature of single-case design, empirically rigorous evaluations of decision-tree processes are particularly prohibitive. Notwithstanding, evaluations are needed. In this paper we first describe a function-informed and mechanisms-based (FIMB) framework for selecting treatment components employed by a university-based practicum experience designed to expose pre-service practitioners to a valid treatment process for challenging behavior. Then, we share a completed retrospective consecutive case series across a 6-year period in which we conducted a technique analysis to identify which procedures were most commonly selected in the practicum, and the impact of those choices on client outcomes. The results suggest that the model can be highly effective for some, but not all, cases. Implications are discussed.

Revisiting the social validity of services rendered through a university-based practicum addressing challenging behavior

This paper represents the third in a three-part series intended to challenge the social validity of the services provided by a university-based practicum for addressing the challenging behavior of individuals with disabilities. In this paper, we surveyed referring stakeholders (e.g., parents, teachers) of past service recipients to explore the acceptability of the service model's goals, methods, and outcomes. We probed for tensions resultant from the model's threefold mission (service, training, and research) and explored how conflicts between these goals affected the quality of our services. Generally, results were favorable and appeared to support continued model implementation, but not without qualification. Emergent themes, areas for improvement, and future directions for intervention research are all discussed.

Modeling resurgence with an evolutionary theory of behavior dynamics

McDowell's (2004) Evolutionary Theory of Behavior Dynamics (ETBD) is a computational theory that has reproduced a wide variety of behavioral phenomena observed in material reality. Here, we extended the generality of the ETBD by successfully replicating laboratory studies of resurgence with live animals using artificial organisms (AOs) animated by the theory. We ran AOs on concurrent random-interval random-interval (conc RI RI) schedules of reinforcement wherein one alternative (i.e., a target behavior) was reinforced while the other alternative (i.e., an alternative behavior) was not reinforced. Then, we placed the target behavior on extinction and reinforced the alternative response, producing a shift in allocation of responding from the target behavior to the alternative response. Finally, schedule thinning of the alternative response (i.e., downshifts) resulted in resurgence of target behavior. Our findings indicated that resurgence increased as a function of the relative downshift in reinforcement rate and magnitude, replicating findings from previous studies with live animals. These results further illustrate the utility of the ETBD for generating dynamic behavioral data and serve as a proof-of-concept for a novel computational approach for studying and understanding resurgence in future studies.

Gradual Change Procedures in Behavior Analysis

A wide variety of procedures within behavior analysis use gradual change in stimuli, response requirements, reinforcement, or some combination thereof, to effectively change behavior. Such procedures include shaping, thinning, fading, and chaining. Collectively, gradual change procedures represent a conceptually systematic technology of behavior change with wide-ranging empirical support across diverse settings and contexts. However, navigating the gradual change literature can be challenging. Similar terms are used to describe functionally distinct procedures (e.g., stimulus fading, delay fading, demand fading), and distinct terms are used to describe functionally similar procedures (e.g., leaning, demand fading). I propose a taxonomy in which gradual change procedures are categorized according to the functional component of the contingency on which they act. Three broad categories are proposed: Gradual Changes in Discriminative Stimuli, Response Requirement, and Reinforcement. I provide examples of research in each category, across basic and applied settings, including terminology used by the author(s) to describe each procedure. Finally, I discuss benefits of this framework for consumers of the literature.

Using Chained or Tandem Schedules With Functional Communication Training: A Systematic Review

Chained and tandem schedules are a common method for thinning schedules of reinforcement following functional communication training (FCT) in the treatment of problem behavior. We conducted a systematic literature review and meta-analysis of chained and tandem schedules following FCT to describe treatment characteristics and evaluate effects. We identified 38 articles and found reductions in problem behavior across four measures. Results of a random-effects multilevel meta-analysis of rigorous evaluations showed a significant effect of chained or tandem schedules + FCT on problem behavior relative to baseline. We observed resurgence in 77% of cases and 31% of schedule-thinning transitions. Results showed chained schedules resulted in greater reductions in problem behavior relative to tandem schedules. Exploratory moderator analyses suggested extinction, combined reinforcement, and delay and denial tolerance training procedures were associated with greater reductions in problem behavior relative to other treatment characteristics. Implications for practice and future research are discussed.

Phase duration and resurgence

Resurgence, the recurrence of responding due to a worsening of reinforcement conditions for current behavior, is a prevalent form of treatment relapse. Resurgence as Choice in Context predicts that increasing the duration of exposure to reinforcement for target responding during Phase 1 will increase resurgence magnitude, whereas increasing the duration of exposure to reinforcement for alternative responding and extinction for target responding during Phase 2 will decrease resurgence magnitude. We conducted an experiment evaluating these predictions with human participants recruited through Amazon's Mechanical Turk platform. We varied Phase 1 and Phase 2 durations across 4 experimental groups. Resurgence as Choice in Context successfully predicted the differences in resurgence magnitude across these groups, and fitting the quantitative model to the obtained data yielded an exceptional coefficient of determination. We discuss the implications of these results for using Resurgence as Choice in Context to inform experiments with human participants and the feasibility of using human-operant preparations to evaluate resurgence.

Contingency-based delay to reinforcement following functional communication training for autistic individuals: A multilevel meta-analysis

LAY ABSTRACT

Functional communication training, an intervention for challenging behavior rooted in principles of applied behavior analysis, has copious empirical support dating back to the mid-1980s for autistic individuals. Recently, there has been a concerted effort to thin reinforcement delivery during functional communication training using contingency-based delays that, in turn, are designed to enhance practicality and feasibility while not compromising efficacy. In this synthesis, we meta-analyzed the literature base with the goal of investigating both combined and across type effectiveness of contingency-based delays. We also aimed to investigate moderating variables that might impact intervention outcomes. Findings showed that contingency-based delays were effective for individuals with an autism spectrum disorder diagnosis and most effective when the delay incorporated some form of positive reinforcement. In addition, differential reinforcement of alternative-based delays was overall more effective when compared to differential reinforcement of other behavior-based delays. Noteworthy moderating variables found to impact contingency-based delay efficacy included the intervention dosage and the topography of behavior. We discuss these findings and highlight directions where additional empirical research is warranted to improve our understanding about contingency-based delays for individuals diagnosed with autism spectrum disorder.

Procedures for determining and then modifying the extinction component of multiple schedules for destructive behavior

As a component of reinforcer schedule thinning following functional communication training, multiple schedules of reinforcement produce desirable rates and patterns of communication responses as an alternative response to destructive behavior. However, reinforcement schedule thinning is a gradual process that can take many sessions to obtain therapeutic goals. The desired outcome is that manding occurs only during signaled intervals of reinforcement with a sufficiently lean terminal schedule of reinforcement availability and low rates of destructive behavior. The purposes of this study were to (a) evaluate an assessment for informing the initial duration of extinction for alternative responding, (b) evaluate the utility of competing stimuli during extinction for alternative responding, and (c) assess a method for fading the availability of competing stimuli. With these procedures, all 4 participants experienced terminal schedules of reinforcement with rapid, robust reductions in destructive behavior soon after baseline. We discuss the implications and directions for future research.

On the generality of preference for contingent reinforcement

Reinforcers can be delivered dependent on or independent of responding. Both human and nonhuman animals have shown a preference for contexts involving contingent reinforcement, but the generality of this phenomenon to humans and its implications have not yet been described. We present an integrative summary of studies evaluating preference for contingent versus noncontingent reinforcement, including (a) study participants, reinforcer types, response topographies, and contexts; (b) outcomes; (c) potential variables influencing preference outcomes; and (d) suggestions regarding research to expand behavior analysts' ability to design preferred contexts.

Understanding the effects of prompting immediately after problem behavior occurs during functional communication training

When reported, the methods for prompting functional communication responses (FCRs) following problem behavior during functional communication training (FCT) vary. Some researchers have prompted the FCR immediately following problem behavior but doing so may inadvertently strengthen problem behavior as the first link in an undesirable response chain. This study investigated the effects of prompting FCRs following problem behavior during FCT with 4 children who exhibited severe problem behavior. Problem behavior remained low and FCR rates were near optimal when prompts were delivered immediately following problem behavior for 2 participants. Delaying prompts following problem behavior was instrumental for FCR acquisition for 1 participant but led to escalation of problem behavior for a 2nd participant. The conditions under which immediate prompts following problem behavior may improve or worsen FCT are discussed.

Empirically Deriving Omission and Commission Errors for Relapse Tests: A Demonstration of Reverse Translation

Most studies examine treatment relapse by programming contextual changes with perfect treatment integrity or with omission errors in the absence of a context change (i.e., all alternative responses placed on extinction). Recently, Mitteer et al. (2018) examined caregiver behavior in response to a confederate playing the role of a child with destructive behavior, providing the opportunity for researchers to empirically derive reinforcement schedules and test caregiver error patterns within future relapse tests with children. The present study represents a pilot demonstration of methods for reverse translating findings from caregivers to relapse preparations with children. We used a human-operant arrangement with three children with autism spectrum disorder in which they (a) emitted a target response (i.e., pad touch) for a preferred item in a home-like context, (b) emitted an alternative response (e.g., card touch) for the item in a clinic context while the target response was extinguished, and (c) experienced a relapse test in which the experimenter programmed the same low-rate omission and commission errors that caregivers made in the prior study within the home-like context. During the relapse test, target responding approximated or exceeded baseline ranges for all cases, and alternative behavior extinguished for two of the three cases. We discuss how researchers might incorporate similar translation processes in future relapse research.

Efficiency and preference for alternative activities during schedule thinning with functional communication training

Functional communication training is an effective treatment for decreasing socially reinforced destructive behavior (Carr & Durand, 1985). Clinicians frequently use multiple schedules to thin the reinforcement schedule (Hanley et al., 2001). Individuals are often taught to wait for functional reinforcers without alternative programmed stimuli. However, concurrently available items and activities are often accessible in the natural environment. In this study, we taught 4 participants a functional communication response to access functional reinforcers. We implemented a multiple schedule during schedule thinning, comparing a control condition (nothing available during S^Δ intervals) to separate conditions with items/activities (moderately preferred tangible items, attention, demands) noncontingently available during S^Δ intervals. After reaching the terminal schedule in one condition, therapists assessed participant preference across S^Δ conditions. For all participants, the terminal schedule was reached with alternative items and activities, and participant preference corresponded with the most efficient schedule thinning condition. Therapists also indicated preference for alternative items/activities.

Schedule Thinning Following Functional Communication Training: Effects of Chained and Multiple Schedules

Functional communication training (FCT) is used to reduce rates of problem behavior by teaching communicative responses that access functionally equivalent reinforcers. During FCT, the communicative response is typically placed on a dense schedule of reinforcement that is unlikely to be maintained in the natural environment. Experiment 1 evaluated the effects of two schedule-thinning procedures (chained schedules and multiple schedules) on problem behavior maintained by escape from demands for three participants following FCT. The chained and multiple-schedule procedures were effective in reducing rates of problem behavior. Compliance increased under both schedules, but the chained schedule resulted in higher levels of compliance with two participants. In Experiment 2, participants' preference for the chained or multiple-schedule procedure was evaluated using a modified concurrent-chain procedure. One participant preferred the chained schedule. One participant preferred the multiple schedule. One participant did not appear to discriminate between conditions.

Increasing passive compliance to wearing a facemask in children with autism spectrum disorder

The current study taught 6 children with autism spectrum disorder (ASD) to increase passive compliance of wearing a facemask across sequentially increasing durations of time. A changing-criterion design embedded within a nonconcurrent multiple baseline design was used to evaluate the effectiveness of a resetting differential reinforcement of other behavior (DRO) without escape extinction procedure on passive compliance. Terminal probe sessions determined DRO fading intervals. Results showed that 2 participants acquired mastery level passive compliance (30 min) without fading during the initial baseline sessions. The remaining 4 participants acquired mastery level passive compliance following fading intervals within the DRO intervention. Participants' passive compliance generalized across 2 novel settings. This study replicates previous studies and extends empirical support for the use of DRO without escape extinction interventions for increasing passive compliance with medical devices in children with ASD.

Sustaining behavior reduction by transitioning the topography of the functional communication response

When a functional communication response (FCR) can be reliably occasioned, destructive behavior tends to be lower. However, the form of FCR may affect the durability of functional communication training, as missing FCR materials may promote resurgence. Experiment 1 demonstrated that resurgence of target responding was lower when a vocal FCR remained available but was placed on extinction compared to when a card-based FCR was unavailable. Experiment 2 replicated the finding that initiating treatment with a card FCR produced less target responding than when initiating treatment with a vocal FCR. We then evaluated a set of procedures for transitioning the card FCR to the previously unlearned vocal FCR. These findings suggest benefits of training different types of FCRs at different stages of treatment and provide a preliminary set of procedures for transitioning between FCR topographies while occasioning minimal target responding.

Punishment and its putative fallout: A reappraisal

In his book Coercion and Its Fallout Murray Sidman argued against the use of punishment based on concerns about its shortcomings and side effects. Among his concerns were the temporary nature of response suppression produced by punishment, the dangers of conditioned punishment, increases in escape and avoidance responses, punishment-induced aggression, and the development of countercontrol. This paper revisits Sidman's arguments about these putative shortcomings and side effects by examining the available data. Although Sidman's concerns are reasonable and should be considered when using any form of behavioral control, there appears to be a lack of strong empirical support for the notion that these potential problems with punishment are necessarily ubiquitous, long-lasting, or specific to punishment. We describe the need for additional research on punishment in general, and especially on its putative shortcomings and side effects. We also suggest the need for more effective formal theories of punishment that provide a principled account of how, why, and when lasting effects of punishment and its potential side effects might be expected to occur or not. In addition to being necessary for a complete account of behavior, such data and theories might contribute to improved interventions for problems of human concern.

Telehealth-enabled behavioral treatment for problem behaviors in boys with fragile X syndrome: a randomized controlled trial

Background

Children with fragile X syndrome (FXS) are at increased risk for exhibiting problem behaviors such as aggression and self-injury. However, many children with FXS have limited access to behavioral treatments that have known efficacy due to the low availability of treatment providers and the wide geographical dispersion of families with FXS across the country. Telehealth may offer a cost-effective and practical solution to overcome these significant barriers. We examined the effect of administering an established behavior analytic intervention called functional communication training (FCT) via telehealth on levels of problem behaviors exhibited by boys with FXS. We also examined treatment acceptability, as well as the effect of the treatment on levels of parenting stress.

Methods

Boys with FXS, aged 3 to 10 years, who displayed problem behaviors daily, were randomized to receive FCT via telehealth (n = 30) or treatment as usual (n = 27) over 12 weeks. Outcome measures included in-session observations of problem behavior, the Aberrant Behavior Checklist—Community (ABC-C), the Treatment Acceptability Rating Form—Revised (TARF-R), and the Parenting Stress Index, 4th edition (PSI-4).

Results

Intention-to-treat analyses indicated that scores on the irritability subscale of the ABC-C, our primary outcome measure, decreased significantly for boys who received FCT via telehealth compared to boys who received treatment as usual (p < .001, Cohen’s d = 0.65). In-session observations conducted for those who received treatment showed that levels of problem behavior decreased by 91% from baseline. Levels of parenting stress related to child behavioral problems were also lower following FCT treatment, and caregivers reported that the intervention was acceptable.

Conclusions

These findings support telehealth-enabled FCT as a framework for expanding access to behavioral treatments for problem behaviors in children with FXS. Expanded delivery of behavior analytic treatment via telehealth also has the potential to lower healthcare costs, improve child and family quality of life, and lead to advances in the treatment of problem behavior in the broader population of individuals with neurodevelopmental disorders.

Trial registration

ClinicalTrials.gov, NCT03510156. Registered 27 April 2018

A translational comparison of contingency-based progressive delay procedures and their effects on contextually appropriate behavior

Schedule thinning is an essential step in treating problem behavior, yet little research has been conducted to determine the method associated with sustained treatment effects. A frequently used method for thinning reinforcement is contingency-based progressive delay, which requires the individual to meet some criteria before the reinforcers are returned. The response requirement could be dependent on (a) contextually appropriate behavior (differential reinforcement of alternative behavior-based thinning) or (b) absence of problem behavior (differential reinforcement of other behavior-based thinning). A translational arrangement with college students was implemented to determine the effects of these 2 response requirements. Tolerance was observed regardless of thinning method and was indicated by low rates of responding to the analogue problem behavior; however, more contextually appropriate behavior occurred during differential reinforcement of alternative behavior-based thinning. These results support the use of response requirements for behaviors that are expected of the individual when reinforcement is not immediately forthcoming.

Resurgence and downshifts in alternative reinforcement rate

Resurgence refers to an increase in a previously suppressed target behavior with a relative worsening of conditions for a more recently reinforced alternative behavior. This experiment examined the relation between resurgence and the magnitude of a reduction in the rate of reinforcement for the alternative behavior. Groups of both male and female rats initially pressed a target lever for food on a variable-interval (VI) 30-s schedule. In a second phase, responding to the target lever was extinguished for all groups and pressing an alternative lever was reinforced on a VI 10-s schedule. Next, the rate of reinforcement for alternative behavior was reduced differentially across groups by arranging extinction, VI 80-s, VI 40-s, VI 20-s, or continued VI 10-s reinforcement. Target responding increased as an exponential function of the magnitude of the reduction in alternative reinforcement rates. With the exception that males appeared to show higher rates of target responding in baseline and higher rates of alternative responding in other phases, the overall pattern of responding across phases was not meaningfully different between sexes. The pattern of both target and alternative response rates across sessions and phases was well described quantitatively by the Resurgence as Choice in Context model.

Competing stimulus assessments: A systematic review

The current review summarizes the literature on competing stimulus assessments (CSAs). CSAs are pretreatment assessments designed to systematically identify stimuli that reduce problem behavior (PB), ostensibly through reinforcer competition or substitution. We report on the participant characteristics, outcomes, and predictive validity of published CSAs that included (a) no-stimulus control trial(s), (b) test trials during which each stimulus was available singly and noncontingently, and (c) measurement of PB and stimulus engagement or contact. Results showed that CSAs have broad utility across a variety of topographies and functions of PB. In the majority of CSA applications for which extended analyses, or validations, were performed, stimuli shown to reduce PB during the CSA produced similar reductions during extended analysis. This was the case regardless of topography or function of PB, or whether the stimuli were assumed to be "matched" to the stimulation thought to be produced by PB. Implications for future research are discussed.

Further extensions of precision medicine to behavior analysis: A demonstration using functional communication training

The potential applicability of concepts and methods of the paradigm of precision medicine to the field of applied behavior analysis is only beginning to be explored. Both precision medicine and applied behavior analysis seek to understand and classify clinical problems through identification of their causal pathways. Both aim to develop treatments directly targeting those causal pathways, which also requires an understanding of the mechanisms by which treatments produce change (treatment-action pathways). In the current study, we extend the data-analytic methods and concepts described by Hagopian et al. (2018) toward the identification of variables that predict response to functional communication training (FCT). We discuss emerging conceptual issues, including the importance of distinguishing predictive behavioral markers from predictor variables based on their purported involvement in the causal or treatment-action pathways. Making these discriminations is a complex undertaking that requires knowledge of these mechanisms and how they interact.