behavioral approaches to the treatment of autism and severe behavior disorders wayne w. fisher...
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![Page 1: Behavioral Approaches to the Treatment of Autism and Severe Behavior Disorders Wayne W. Fisher University of Nebraska Medical Center’s Munroe-Meyer Institute](https://reader037.vdocument.in/reader037/viewer/2022110322/56649d1a5503460f949f0641/html5/thumbnails/1.jpg)
Behavioral Approaches to the Treatment of Autism and Severe Behavior Disorders
Wayne W. FisherUniversity of Nebraska Medical Center’s
Munroe-Meyer Institute
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UNMC Munroe-Meyer Institute
Autism and Childhood Schizophrenia
Once thought to be a form of
schizophrenia
Differs from schizophrenia in terms
of symptoms, age of onset, family
history, etiology, and response to
treatment
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Definition of Autism
markedly abnormal or impaired
development in:
1. social interaction
2. Communication
and markedly restricted repertoire
of activities and interests.
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Definition of Autism
Definitions are cheap, but
explanations are dear, and we must be
careful not to confuse them.» David Palmer, 2004
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Prevalence of Autism
Typically diagnosed within first three
years
Recent estimate indicate that the
prevalence of ASD is between 1 in 38 and
1 in 88
Four times more prevalent in boys than
girls
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Recurrence Risk for Siblings
If an older sibling has and autism
spectrum disorder, the risk for a
Younger brother is 1 in 4
Younger sister is 1 in 11
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NIH Research Dollars Devoted to Autism
When Compared with Other Serious
Childhood Conditions, Autism is Much
More Common, but Fewer Dollars Per
Case are Spent on Autism.
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0
10
20
30
40
50
60
70
Autism Juvenile DiabetesMuscular Dystrophy Leukemia Cystic Fibrosis
Prevalence of Autism and Other Conditions
(Number of Cases per 10,000 Children)
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$-
$20,000
$40,000
$60,000
$80,000
$100,000
$120,000
$140,000
Autism Juvenile Diabetes Muscular Dystrophy Leukemia Cystic Fibrosis
NIH Research Dollars for Autism and Other Conditions
(Number of Dollars per Case)
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Unfortunately, you have what we call “no insurance.”
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Demographics of Autism
Affects all racial, ethnic, and national groups
Family income, lifestyle, and educational
levels do not affect the chance of autism's
occurrence
Diagnosis of autism is growing at a rate of
10-17 percent per year (U.S. Department of
Education, 2002)
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Assessment and Diagnosis of Autism
No medical tests for diagnosing autism
Accurate diagnosis is based on observation of
the individual's communication, behavior, and
developmental levels. Autism Diagnostic Interview-R (ADI-R)
Autism Diagnostic Observation Schedule (ADOS)
Home and/or school observation
Video analysis of behavioral observation
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Social Behavior Generally Requires Little or No Explicit Training
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Assessment and Acquired Autism
Autism is most often diagnosed between 2 and 5 years of age.
Thus, it is natural for parents to look for environmental events occurring shortly before this time that may have caused the autism, such as childhood vaccines.
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MMR Vaccines and Autism
10 of the original 13 authors of the investigation that started the controversy have retracted the study’s interpretation, as has the journal, The Lancet
Prevalence rates of autism are equivalent in children who have and have not been vaccinated.
Increases in the prevalence of autism did not abate when thimerosal was removed from vaccines.
Regression in autism is no more likely in the months after the MMR vaccine than in the months before the vaccine.
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Identifying the Genetic Bases of Autism Spectrum Disorders
Etiologic Workups Identify Specific
Genetic Causes for Autism in About 20% of
Cases.
At the Munroe Meyer Institute, Shaefer
and Colleagues (2006) have developed a 3-
Tiered Approach that Identifies Genetic
Causes in 40% of Cases.
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Associated Disorders
Mental Retardation 50% 15%
Seizure Disorder 35% 10%
Self-Injury, Aggression 50%
Tourette Disorder
Bipolar Disorder
Autism ASD
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Associated Etiologic Diagnoses
Fragile-X syndromeTuberous SclerosisWilliams syndromeLandau-Kleffner syndromeCongenital RubellaSmith-Magenis syndromeNeurofibromatosis
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Genetics and Twin Studies
Autism runs in familiesHeritability for autism is about 90%Monozygotic twin concordance, 60%-
100%Dizygotic twin concordance, 10%Associated with abnormalities on
chromosomes 7q, 2q, and 15q
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Applied Behavior Analysis (ABA)
What is ABA?
How is it different from other
approaches?
How is it Done?
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How Effective is ABA for Autism?
About 50% of Children with Autism and
no More than Mild Mental Retardation who
Receive Early Intervention with ABA Attain
Normal IQs and are Educated in Regular
Classrooms with Minimal Assistance.
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Outcomes of ABA for Autism
0
5
10
15
20
25
30
35
0 5 10 15 20 25 30 35 40 45
Hours per Week of Treatment
Incr
ease
s in
IQ
Sco
res
r = .79
p < .02
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UNMC Munroe-Meyer InstituteCost-Benefit Analysis of Early, Intensive ABA for Autism
Average Lifetime Cost for a Person with Autism is over $4 million
Average cost of Early, Intensive ABA is $150,000 over about 3 years
Average Lifetime Savings from ABA Treatment is Between $1.6 and $2.7 million
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UNMC Munroe-Meyer Institute
Cost-Benefit Analysis of ABA treatment for Severe Behavior Disorders
Children with Autism and Severe Destructive Behavior Cost $8 million over a lifetime.
Keeping just one child out of chronic care pays for treatment of hundreds more.
Our treatment approach has over an 80% success rate.
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Residential CostsOver 25 Years
Case Example(Costs since 1986)
0
500
1000
1500
2000
2500
3000
Do
llars
in T
ho
us
an
ds
$4,050,000
$85,924
Inpatient and Outpatient Costs
3500
4000
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Autism and Problem Behavior
98% of children with autism have one or more
of the following problems:
1. Feeding problems
2. Sleeping problems
3. Tantrums
4. Self-injurious behavior
5. Aggression
Dominick et al. (2007)
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Variables Related to Problem Behavior in Autism
Lower IQ scores were associated more
problem behaviors
Lower expressive language scores were
associated with more problem behaviors
Increased social deficits were associated with
more problem behaviors
Dominick et al. (2007)
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UNMC Munroe-Meyer Institute
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Functional Analysis and
Treatment of Aberrant Behavior
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Structural vs. Functional Diagnosis
Structural Approach
1. How often a particular set of symptoms
or responses cluster or covary.
Functional Approach
1. Whether and which environmental
variables influence the response.
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Functional AnalysisIdentifies the environmental contexts in
which aberrant behavior is likely and
unlikely.
Identifies the consequences that
reinforce and maintain the behavior.
Used to prescribe effective treatments.
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Common Functions of SIB
Social Positive Reinforcement
(Attention, Tangible items)
Social Negative Reinforcement
(Escape)
Automatic Reinforcement (e.g.,
Sensory Stimulation)
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Essential Features of Functional Analysis Conditions
Unique discriminative stimuli that signal the available of a specific reinforcer
Establishing operation (EO) that increases motivation for the specific reinforcer
1. An EO is an environmental condition that momentarily increases the effectiveness of a reinforcer and that evokes responses that have produced that reinforcer in the past.
Contingency between the target behavior and the specific reinforcer
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Identifying the Essential Features of Functional Analysis Conditions
See if you can identify the
discriminative stimulus, the
establishing operation, and the
reinforcement contingency in each of
the following functional analysis
conditions.
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Attention Condition
Adult is busy reading. Child is expected
to play quietly with toys.
Adult attention shifts to child following
SIB (e.g., “Please don’t hit yourself”).
Determines whether adult attention
functions as reinforcement for SIB.
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Essential Features of the Attention Condition
Discriminative Stimulus: Adult is seated
in a chair reading a book.
EO: Attention is unavailable.
Contingency: SIB produces attention.
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Tangible Condition
Adult takes preferred toys or
leisure materials from the child and
returns them following SIB.
Determines whether access to
preferred items functions as
reinforcement for SIB.
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Essential Features of the Tangible Condition
Discriminative Stimulus: Adult takes and
holds the preferred tangible item at the start
of the session.
EO: Tangible item is unavailable in the
absence of SIB.
Contingency: SIB produces the tangible
item.
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Demand Condition
Child is prompted to complete non-
preferred tasks by an adult.
The task is removed and the child is
given a short break following SIB.
Determines whether termination of non-
preferred activities functions as
reinforcement for SIB.
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Essential Features of the Demand Condition
Discriminative Stimulus: Instructional
materials and demands are presented.
EO: Nonpreferred demands are
presented.
Contingency: SIB results in temporary
removal of the demands.
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Alone Condition
Child is placed in a room alone
without toys or materials.
Indirectly assesses whether SIB
may be maintained by automatic
reinforcement (e.g., sensory
stimulation).
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Essential Features of the Alone Condition
Discriminative Stimulus: Absence of
another individual or materials.
EO: Alternative sources of stimulation are
unavailable.
Contingency: SIB produces self-
stimulation.
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Toy Play Condition
Child and adult play together with
preferred toys or leisure items.
Adult delivers praise about once
every 30 seconds for the absence of SIB.
Designed to be an analogue of an
“enriched environment”, which serves
as a control condition.
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UNMC Munroe-Meyer InstituteEssential Features of the Toy Play Condition
Discriminative Stimulus: Adult and toys
are near the individual.
EO (or AO): Attention and tangible items
(toys) are freely available and no demands
are presented.
Contingency: SIB produces no
consequence.
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0
1
2
3
1 3 5 7 9 11 13 15 17 19 21 23 25 27 29 31 33 35 37 39
Agg
ress
ive
Res
pons
es
Per
Min
ute
Sessions
DemandTangible
Attention
Ignore
Play
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00
22
44
66
88
11 22 33 44 55 66 77 88 99 1010 1111 1212 1313 1414 1515 1616 1717 1818 1919 2020 2121
Res
po
nse
per
Min
ute
KirkKirk
Session
Baseline Extinction BaselineFCT +Extinction
FCT +
DestructiveBehavior
Communication
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Functional Analysis of Covert Drug Ingestion
Three Operant Hypotheses Generated
After Caregiver Interview and Chart
Review
1. Attention/Excitement From Medical
Procedures
2. Attention From Mother
3. Escape From Work Activities
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Functional Analysis of Covert Drug Ingestion (cont.)
Sessions Conducted in a
Classroom and an Adjoining
Medication Room Baited With
Placebos in a Pillbox.
Patient was Left Unsupervised in
the Classroom With a Schoolwork
Assignment.
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Functional Analysis of Covert Drug Ingestion (cont.)
In the Pillbox Were Four Pill Bottles
Containing Placebos.
Each Pill Bottle had a Uniquely
Colored Label.
Consuming Pills From Each Pill
Bottle Produced a Specific
Consequence.
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Functional Analysis of Covert Drug Ingestion (cont.)
Red = Medical Attention
Orange = Attention From Mother
Blue = Rest Period (Escape)
Yellow = Control (Ignore)
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0
5
10
15
20
1 5 10 15
PIL
LS
ING
ES
TE
D P
ER
MIN
UT
E
Escape From Work
Parent Attention
SESSIONS
Control
Medical AttentionLYLE
FUNCTIONAL ANALYSIS
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Treatment of Escape-Maintained Drug Ingestion
Lyle Earned Preferred, Nonwork
Activities for Completing Scheduled
Activities and Turning in Pills.
He was Required to Complete His
Least Preferred Work Activity (Shoe
Polishing) if He Ingested Pills.
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15
20Baseline Treatment Baseline Treatment
30 40 60 80
TREATMENT ANALYSIS
LYLE
0
5
10
10
SESSIONS
20 50 70
PIL
LS
ING
ES
TE
D P
ER
MIN
UT
E
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Treatment Extension of Escape-Maintained Drug Ingestion
Lyle was Gradually Exposed to
Different Settings where He was
Observed and Supervised Less.
Detection Methods Were Faded
From Direct Observation to Pill Bottles
With Residue and Then to Weekly Tox
Screens.
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Functional Communication Training (FCT)
Functional communication training (FCT) is a
treatment commonly prescribed when a functional
analysis has shown that an individual’s problem
behavior is maintained by social consequences
(e.g., Carr & Durand, 1985; Fisher et al., 1993;
Horner, Day, Sprague, O’Brien, & Heathfield, 1991;
Lalli, Casey, & Kates, 1995; Wacker et al., 1990).
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Functional Communication Training (FCT)
With FCT, the individual is taught a
communicative response that produces access to
the reinforcer responsible for maintenance of the
problem.
For example, an individual whose problem
behavior is maintained by escape from tasks might
be taught to request a break by signing ‘‘finished’’
(e.g., Hagopian, Fisher, Sullivan, Acquisto, &
LeBlanc, 1998).
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Unique Features of FCT
FCT is a DRA procedure that:
1. specifies its reinforcer (i.e., a mand specifying the
reinforcer that previously maintained problem behavior),
2. requires minimal response effort,
3. is initially reinforced on a dense schedule (e.g., FR 1),
4. can recruit reinforcement across environmental
contexts.
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Unique Features of FCT
Because of the ease and consistency with which
reinforcement can be obtained during FCT, some
authors have suggested that the client ‘‘controls’’ the
delivery of reinforcement (e.g., Carr & Durand, 1985).
In addition, Carr and Durand suggested that
“control over reinforcement,’’ contributed to the
effectiveness of FCT.
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Unique Features of FCT
Two investigations found that noncontingent
reinforcement (NCR), which does not allow the client to
control the schedule of reinforcement, and FCT, which
does, produced equivalent reductions in problem
behavior (Hanley, Piazza, Fisher, Contrucci, & Maglieri,
1997; Kahng et al., 1997).
Nevertheless, we found that participants preferred
FCT over NCR when given a choice (Hanley et al.,
1997).
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Unique Features of FCT
FCT may promote generalization and
maintenance because the communication response
may prompt both trained and untrained caregivers to
deliver differential reinforcement appropriately (e.g.,
Durand & Carr, 1991).
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Limitations of FCT
Teaching the FCT response may evoke problem
behavior (particularly if it is maintained by escape).
Individuals may display the FCT response at
exceedingly high rates (e.g., requesting a break from
every school task).
Individuals may request reinforcement at times
when it is impossible or inconvenient to deliver (e.g.,
caregiver tending to an infant sibling).
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Selecting the Functional Communication Response (FCR)
The FCR should be simple.
The FCR should produce the reinforcer
identified during the functional analysis.
The FCR should quickly remove the
establishing operation for problem behavior.
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Training the Communication Response
The communication response matches
the function of the child’s problem
behavior.
1. Demand -> “Break please.”
2. Attention -> “Play with me, please.”
3. Tangible -> “Toy please.”
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Training the Communication Response
Children who do not speak are often
taught to use a picture-exchange
communication response.
1. Attention -> Child hands over a picture of
the adult and child playing together.
2. Demand -> Child hands over a picture of the
child leaving a work table.
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Function-Based Extinction
EXT (Att): Attention no longer follows the target behavior
EXT (Tang): Tangible item is longer presented following the target behavior
EXT (Esc): Demands continue following the target behavior
EXT (Auto): The sensory consequences of the target response are eliminated or the response is prevented.
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Stimulus Control Refinements of FCT
Controlling the establishing operation for
problem behavior is particularly important during
the early stages of treatment.
Bringing the functional communication
response under tight discriminative control is
particularly important for increasing the
practicality and generality of FCT.
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Study 1: Does strict control of exposure to the establishing operation (EO) for problem
behavior facilitate the effectiveness of FCT?We compared FCT using a picture exchange (or card touch)
as the FCR with a vocal FCR.
The picture exchange version of FCT (FCT-card) allows strict
control of the EO, because the therapist can immediately
guide the FCR and deliver the reinforcer, which removes the
EO.
The vocal version of FCT (FCT-vocal) does not allow strict
control of the EO, because one cannot guide a vocal
response.
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Study 1: Procedures
Following baseline, the two FCT treatments (FCT-card
and FCT-vocal) were both introduced using a
progressive time-delay procedure to teach each FCR.
The two treatments were compared using a
multielement phase.
Following a return to baseline, the more effective
treatment was re-introduced in the final phase.
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t = 3.0; p = .01
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Study 1: Conclusions
The FCT-card card condition allowed better control of
the EO for problem behavior.
The FCT-card condition produced more rapid
reductions in problem behavior.
The FCT-vocal condition was associated with an
extinction burst for one participant, which was not
observed in the FCT-card condition.
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Controlling the EO While Training the Communication Response
When FCT is initiated, the
communication response should always
produce the reinforcer.
If the child cannot do the response
independently, we help them and then
immediately deliver the reinforcer.
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Stimulus Control Refinements of FCT
Controlling the establishing operation for
problem behavior is particularly important during
the early stages of treatment.
Bringing the functional communication
response under tight discriminative control is
particularly important for increasing the
practicality and generality of FCT.
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Schedule Thinning During Functional Communication Training
Signaled and unsignaled delayed reinforcement
(Vollmer et al., 1999)
Activities or alternative reinforcers during the
reinforcement delays (Fisher et al., 1998; 2000)
Multiple schedules with reinforcement and
extinction components (Betz et al., 2913; Fisher et
al., 1998; Hanley et al., 2001)
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Typical Multiple-Schedule Training During FCT
Quasi-random alternation between and FR-1 schedule and EXT for communication
Each component correlated with a specific signal
Initially, the duration of the reinforcement component is 3 to 4 times longer than the EXT component
Gradually, the EXT component is lengthened relative to the SR+ component
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1
2
3
4
5
6
7
8
FA
DIN
G S
TE
PS
= FR1
= Extinction
Decreases reinforcer deliveries by about 75%
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Purpose
To identify the necessary and sufficient components
for the reinforcement schedule thinning
1. Study 2: Evaluated the effects of contingency-correlated
stimuli during FCT
2. Study 3: Evaluated the necessity of systematic and gradual
fading steps during schedule thinning under multiple
schedule components
3. Study 4: Evaluated the extent to which contingency-
correlated stimuli facilitated generalization across therapists
and environments
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Functional Analysis and FCT Treatment Evaluations
Prior to Studies 2, 3, and 4, we conducted functional
analyses to show that problem behavior was
reinforced by social positive reinforcement for all
participants.
We also conducted treatment evaluations using an
ABAB design to show that FCT was an effective
treatment.
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Study 2: Are contingency-correlated stimuli necessary?
Compared rates of FCR and problem behavior
under equivalent mixed and multiple schedules
using an ABAB design1.Mixed FR-1:60 s / EXT:60 s
2.Multiple FR-1:60 s / EXT:60 s
Data on problem behavior is not shown because
it remained at near-zero levels throughout this study.
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Mixed vs. Multiple Assessment
General Procedures
1. Sessions = 10 min
2. Contingency specifying stimuli in both conditions
3. FR1 = 60 s
4. Extinction = 60 s
5. All sessions started with reinforcement interval
6. All problem behavior was on extinction
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FR1: 60 s
EXT:60 s
CASEY
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Study 3: Is schedule fading necessary?
Compared rates of alternative and problem behavior
when schedules were switched from rich to lean
without schedule fading in a multiple baseline design
Mult FR-1:60 s / EXT:60 s to Mult FR-1:60 s / EXT:240 s
Mixed FR-1:60 s / EXT:60 s to Mult FR-1:60 s / EXT:240 s
Data on problem behavior is not shown because it
remained at near-zero levels throughout this study.
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Study 4: Do contingency-correlated stimuli facilitate generalization across therapists and
settings?
Compared rates of alternative and problem behavior
when a multiple schedule was introduce across
therapists or settings in a multiple baseline design
Mixed FR-1:60 s / EXT:60 s to Mult FR-1:60 s / EXT:60 s
Mult FR-1:60 s / EXT:60 s to Mult FR-1:60 s / EXT:300 s
Data on problem behavior is not shown because it
remained at near-zero levels throughout this study.
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University of Nebraska Medical Center
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University of Nebraska Medical Center
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Conclusions
Study 2 showed that inclusion of contingency-
correlated stimuli was a necessary component of FCT
schedule thinning.
Study 3 showed that inclusion of contingency-
correlated stimuli was sufficient to maintain appropriate
responding without gradually fading the schedule
density during FCT schedule thinning.
Study 4 showed that contingency-correlated stimuli
also facilitated generalization of FCT effects across
therapists and settings.
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Study 5: How effective is Mult-FCT across a large cohort of patients with problem behavior?
Hagopian et al. (1998) found that FCT with EXT (FCTE)
failed in 14 of 25 cases during schedule thinning.
They also found that FCT with punishment (FCTP)
reduced destructive behavior by 90% or more in all
cases, even following reinforcer-schedule thinning.
In the current study, we summarized the results of 14
applications of Mult-FCT implemented with 12 cases and
compared the results with those of Hagopian et al.
212
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Amount of Reinforcer-Schedule Thinning
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Calculating Percentage Reduction in Problem Behavior
Percentage reductions in problem behavior
were calculated using the following formula (same
as in Hagopian et al. [1998]):
Mean rate during last 5 sessions
1 – Mean rate during baseline
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Pe
rce
nt R
ed
uctio
n in
Pro
ble
m B
eh
avi
or
0
10
20
30
40
50
60
70
80
90
100
110
n = 11applications
n = 17applications
n = 14applications
FCTE +Fading
FCTP +Fading
Mult-FCT +
Hagopian et al. (1998)Current
Data Set
Fading
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Future Grants and Research on:Consequence Control Refinements of FCT
Using behavioral momentum theory (BMT) and
accompanying equations to prevent relapse and
resurgence of problem behavior.
BMT makes predictions that are at odds with
current clinical “best practices”.
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Limitations of FCT (cont.)
When a parent is busy and fails to deliver
reinforcement for the child’s FCT response, the child
is likely to revert to problem behavior, a phenomena
called “resurgence”.
Recent research has shown that resurgence of
problem behavior is quite common, and problem
behavior often occurs at pre-treatment levels when
the FCT response goes unreinforced (Mace et al.,
2010; Volkert et al., 2009).
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Mace et al., (2010)
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Volkert et al., (2009)
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Behavioral Momentum Theory
Behavioral momentum theory is a quantitative
theory of behavior that employs a comparative
metaphor based on the classical mechanics of the
momentum of physical objects.
Behavioral momentum theory is relevant to
FCT because it provides quantitative models and
predictions about the persistence and resurgence
of problem behavior when the FCT produces
reinforcement and when it does not.
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The Momentum Metaphor
In classical mechanics, the momentum of an
object is a joint function of its mass and velocity.
Momentum of a moving object =
mass x velocity
Momentum of a response =
rate of reinforcement x response rate
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Equation 7 Predicts the Effects of Adding and Removing Reinforcement for the FCT
Response
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Common Practice Guidelines for FCT
Decreases may occur more rapidly during
treatment if problem behavior is reinforced on a CRF
schedule during baseline (Fisher & Bouxsein, 2011).
“… we strongly recommend that the
communicative response be reinforced on a CRF
schedule initially (Tiger, Hanley, & Bruzek, 2008).
Clinical guidelines on “dosage” levels of FCT are
not available (i.e., How many sessions of FCT are
needed before parent training and discharge?).
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Specific Recommendations of BMT
The magnitude of resurgence predicted by
Equation 7 is minimized by:
1. maximizing the value of t conducting many FCT
sessions before exposure to an EXT challenge;
2. maximizing the value of d by correlating periods of
reinforcement and EXT of the FCR with discriminative
stimuli;
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Specific Recommendations of BMT
The magnitude of resurgence predicted by
Equation 7 is minimized by:
3. minimizing the value of r by delivering the lowest
possible rate of reinforcement for destructive
behavior during baseline; and
4. minimizing the value of Ra by delivering the lowest
possible rate of reinforcement of the FCR during FCT.
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0
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
Des
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es p
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our
Session
Baseline(VI 30)
FCT Extinction Challenge
c = 1, d = .001, p = .05
(VI 20)
Long Exposure(Room 1; Therapist = Purple)
Short Exposure(Room 2; Therapist = Yellow)
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Des
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es p
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our
Session
Baseline FCT Extinction Challenge
c = 1, d = .001, p = .05
(VI 36 s)
VI 20 s(Room 1; Therapist = Red)
VI 120 s*(Room 2; Therapist = Blue)
*This lean schedule will be individually determined based on a progressive-interval assessment and may be different from a VI 120 s.
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Des
truc
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es p
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Session
Baseline (VI 36 s) FCT Extinction Challenge
c = 1, d = .001, p = .05
VI 20 s (Room 1; Therapist = Green)
VI 180 s(Room 2; Therapist = Blue)
PI
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1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31
De
str
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sp
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se
s p
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Ho
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Sessions
BaselineFCT EXT Challenge
c = 1, d = .001, p = .05Long Exposure of Alt VI 120 s*
(Room 1; Therapist = Red)
Short Exposrue ofAlt VI 20 s
(Room 2; Therapist = Blue)
VI 20 s(Room 2; Ther = Blue)
VI 120 s*(Room 1; Ther = Red)
*Lean schedules to be individually determined based on PI assessments; they may be leaner or denser than VI 120 s.
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Concluding Comments
Mathematical models like behavioral momentum
theory provide a method for developing new and
interesting clinical research questions that have the
potential to greatly improve treatments like FCT.
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