Brittany R. Rothe, B.S., BCaBAUniversity of Houston-Clear Lake

Keys to Compliance: Strategies for Increasing Compliance in Learners

with and Without an ASD

Overview Define complianceDetermine who is concerned with complianceProblems with noncomplianceReasons for noncomplianceWays to encourage complianceBreakConsequences for compliance/noncomplianceDifficult casesGeneralizationFinal considerations

What is compliance? Following instructions/directionsIndependently initiating/completing a request Within a time frame (6 s)

Noncompliance: opposite of or lack of complianceSometimes accompanied by problem behavior

Noncompliance—most common childhood problem

Noncompliance vs. Lack of ability

Compliance

Who can be noncompliant? Typically developing learners Learners with an Autism Spectrum Disorder

(ASD)You and me! Noncompliance is not limited to young

children

Compliance

Common situations/instructions for noncomplianceSchoolworkTransitionsActivities of daily living/choresDoctor visits

Who is concerned with compliance?Parents/CaregiversTeachersDoctors/NursesTherapists

Compliance

Creates deficits in skill developmentAcademic skillsSelf-help skillsSocial skills

Affects family life/stressParentsSiblings

Leads to other behavior problems

Problems with Noncompliance

Why does noncompliance occur? Escape from or delay an unpreferred activity

SchoolworkAccess or maintain access to preferred

items/activitiesToys, games, food

Gain attention (verbal, physical, both) Teacher, parents, peers

Noncompliance is tricky because the reason is not always obvious

Common reactions to compliance and noncompliance

Why Noncompliance?

Prevention StrategiesGoals: Prevent noncompliance & encourage

compliance

Consequence StrategiesGoals: Provide rewards for compliance &

encourage future compliance

Treatments/Interventions

Used alone or in combinationWhat works?

Simple Instruction Tips (Package)High-Probability (High-p) Request ProcedureTime-based RewardsLearner Choice

What doesn’t work?Warning or advance notice (transitions or

termination) Rationales

Prevention Strategies

Deliver instruction a short distance from the learner1 ft.

Crouch to small learner’s level Gently touch learner’s shoulderAttempt to make eye contact

Avoidance in ASDInterrupt current play/activity

Gently block hands

Simple Instruction Tips

Should be in statement formCorrect: Pick up the toys. OR Please, pick up

the toys. Incorrect: Will you/can you pick up the toys?

“Do” requestsCorrect: Sit down in the chair.Incorrect: Don’t lay on the floor.

Specific

Keep a neutral tone

Instructions/Demands

High-probability request procedure High-probability request

Compliance likely“Touch your nose” “Clap your hands” Imitation: “Do this”

Low-probability requestCompliance unlikely

“Give me the toy” “Say Mom” “Put on your shoes”

High-p/Low-p

How to use the high-p, low-p instructional sequenceDeliver ~3 high-p instructionsSnacks/toy rewards + praise for compliance~ 10 s between high-p instructions

Speed of demandsBenefits

Widely studiedAppropriate for wide variety of situations

Examples: Medical exams, educational settings, homeWeaknesses

Difficult if very few high-p

High-p/Low-p

Know your learnerOne-step vs. multiple-step instructions

Modify aspects of task that is aversive Make task more manageable/ enjoyable

Break task into stepsReward each step

Don’t modify instruction after giving itIndividuals will learn demands will get easier

if they are noncompliant

Modified Instructions

Who would benefit from breaks?Learners who are noncompliant to escapeWill comply for some period of time

Short breaks interspersed throughout taskExample: Work for 2 min. 30 s break repeat

Length of “work” time between breaksBased on current behaviorDetermine average time before noncompliance

ConsiderationsFeasibility (Tracking time)MotivAiders, timer, watchDifficulty w/ transitions—break in work area

Time-based Breaks

Who would benefit?Learners who are noncompliant to gain attention or

itemsWill comply for some period of time

Looks procedurally similar to time-based breaks

Learner receives attention or toys instead of breakAttention: High-fives, praise, tickles, pat on the backSmall pieces of snacksEasily removable toys

Time-based Attention/Toys

What happens if the individual is noncompliant? Time-based not “behavior-based” Learner receives scheduled break/attention/toy

Why do time-based rewards work? Decreases motivation for noncomplianceLearner already getting what they want

Do I have to do this all day/every day? Tasks when noncompliance likely

Will I have to do this forever? Increase work timeBased on success of learner

Common Questions: Time-based Rewards

Learner can control some aspect of instruction Teacher/Caregiver decision

Allow learner to choose taskOrder of tasks: Math or Science firstType of tasks: Different worksheets

Allow learner to choose location Work at the table or at the desk

Writing workUse a colored pencil or a regular pencil

DressingOrder of dressing, color of

shirt/shorts/underwear

Learner’s Choice

Substantially more effective than antecedent interventions Commonly used in combination

What works?Extinction of noncompliance Guided Compliance (3-step prompting)Rewards (toys, foods, etc.) for complianceCombining breaks with toys/activities as a

rewardNot recommended

Time-out for noncompliance

Consequence Interventions

Behavioral terminologyLearner doesn’t get what he/she wants

BreakAttentionToys, Snacks, Activities

Consider reason for noncomplianceNot always feasible Most effective when combined with

reinforcement for compliance!

Extinction of Noncompliance

Also known as: “Three-step prompting”Caregiver/Teacher guides learner through taskStep 1: Delivery of instructionStep 2: Instruction + Model desired

behaviorStep 3: Instruction + Physical guidance Benefits

Teach learner compliance is mandatoryGives opportunity for independence

FeasibilityLarger learnersOther challenging behaviors

Guided Compliance

“Functional” reinforcersReason for noncompliance

Escape (Break) Tangible (Toys, edibles, etc.)Attention (Praise, reprimands, physical

prompts)Use functional reinforcers for compliance

Noncompliance No break (Extinction) ComplianceBreak (Reinforcement)

Prompted vs. Unprompted ComplianceDifferent rewards

Rewards for Compliance

Rewards should be individualizedAllow learner to choose reward

Verbal learnerNonverbal learner

Preferences for rewards change Frequently reevaluate rewards

Alternate highly-preferred rewardsPrevent satiation

If compliance is not increasing evaluate if reward is really a reward

Rewards for Compliance

PraiseEnthusiasticSpecificPhysical

All Rewards Immediate (within 5 s) Frequent (in the beginning)

Pair praise with other rewardsPreferences for rewards may change

Tips for Delivering Rewards

Allows more time between large rewards

Tokens exchangeable for different rewardsPrevents satiation on one reward

Used across settings

Classroom settingEasy to use with multiple students

Benefits of Token Economies

Large end goalCorrectly complete a math worksheet independently

Break into smaller stepsSit at deskTake out pencilComplete 1 math problem with assistanceIndependently complete 1 math problemComplete multiple problems

Smaller steps receive rewardsGradually increase requirement to receive reward

Shaping Compliance

When physical guidance is not feasible:Do not allow access to preferred itemsDo not acknowledge noncompliance (reprimands)Continue verbal/gestural prompts every 30 sMake noncompliance “uncomfortable” Do not “bribe” or “threaten”

Interference of other problem behaviors Aggression, property destruction, screaming, self-

injuryTreatment for other behaviors

Consider changing the reinforcement for complianceMagnitude, Quantity, Quality….

Difficult Cases

Compliance is a learned skillLearners with ASD may have trouble generalizing

skillsNo experience or “history” of rewards

Compliance needs to be practiced In different settingsWith different people

Understand when compliance does not generalizeKnow when follow-through is not likely

Grandma’s houseBabysitter

Generalization

ALWAYS FOLLOW THROUGH!Don’t give a demand if you can’t follow

through immediatelyMay want to postpone demand

Compliance will not happen overnightMay be regression before progress in the

beginningDon’t use the child’s name exclusively before

demandsLabor intensive in the beginning

You will get out what you put in

Final Considerations

Carlos A. Zuluaga & Matthew P. Normand. (2008) An evaluation of the high-probability instruction sequence with and without programmed reinforcement for compliance with high-probability instructions. Journal of Applied Behavior Analysis, 41, 453-457.

Coleman, C. L., & Holmes, P. A. (1998). The use of noncontingent escape to reduce disruptive behaviors in children with speech delays. Journal of Applied Behavior Analysis, 31, 687-690.

David A. Wilder, Janelle Allison, Katie Nicholson, O. Elizabeth Abellon, & Renee Saulnier (2010). Further evaluation of antecedent interventions on compliance: The effects of rationales to increase compliance among preschoolers. Journal of Applied Behavior Analysis, 43, 601-613.

Einar T. Ingvarsson, SungWoo Kahng, & Nicole L. Hausman. (2008) Some effects of noncontingent positive reinforcement on multiply controlled problem behavior and compliance in a demand context. Journal of Applied Behavior Analysis, 41, 435-440.

Kasey M. Stephenson & Gregory P. Hanley (2010). Preschoolers’ compliance with simple instructions: A descriptive and experimental evaluation. Journal of Applied Behavior Analysis, 43, 229-247.

*Kazdin, A.E. (2009). The KAZDIN METHOD for Parenting the Defiant Child: With no pills, no therapy, no contest of wills. New York, NY: Houghton Mifflin Harcourt

References

Kelly J. Bouxsein, Henry S. Roane, & Tara Harper (2011). Evaluating the separate and combined effects of positive and negative reinforcement on task compliance. Journal of Applied Behavior Analysis, 44, 175-179.

Kodak, T., Miltenberger, R. G., & Romaniuk, C. (2003). The effects of differential negative reinforcement of other behavior and noncontingent escape on compliance. Journal of Applied Behavior Analysis, 36, 379-382.

Marcus, B. A., & Vollmer, T. R. (1995). Effects of differential negative reinforcement on disruption and compliance. Journal of Applied Behavior Analysis, 28, 229-230.

Matthew P. Normand & Lauren Beaulieu (2011). Further evaluation of response-independent delivery of preferred stimuli and child compliance. Journal of Applied Behavior Analysis, 44, 665-669.

Piazza, C. C., Moes, D. R., & Fisher, W. W. (1996). Differential reinforcement of alternative behavior and demand fading in the treatment of escape-maintained destructive behavior. Journal of Applied Behavior Analysis, 29, 569-572.

Rortvedt, A. K., & Miltenberger, R. G. (1994). Analysis of a high-probability instructional sequence and time-out in the treatment of child noncompliance. Journal of Applied Behavior Analysis, 27, 327-330.

References