PRODUCING MEANINGFUL IMPROVEMENTS IN PROBLEMBEHAVIOR OF CHILDREN WITH AUTISM VIA SYNTHESIZED

ANALYSES AND TREATMENTS

GREGORY P. HANLEY, C. SANDY JIN, NICHOLAS R. VANSELOW, ANDLAURA A. HANRATTY

WESTERN NEW ENGLAND UNIVERSITY

Problem behaviors like self-injury, aggression, or disruption will likely require intervention at somepoint in the life of a person diagnosed with autism. Behavioral intervention has been proven to beeffective for addressing these problems, especially when a functional assessment is conducted.Comprehensive treatment for problem behavior is, however, often fractured across studies,resulting in a dearth of studies that show socially validated improvements in these problembehaviors or illustrate the assessment and treatment process from start to finish. In this article, wedescribe an effective, comprehensive, and parent-validated functional assessment and treatmentprocess for the severe problem behaviors of 3 children with autism. After an 8- to 14-weekoutpatient clinic consultation, no problem behavior was observed at the clinic and in the home.Furthermore, behavior that did not occur during baseline (e.g., functional communication, delayand denial tolerance, and compliance with instructions) occurred with regularity.

Key words: autism, compliance, delay tolerance, functional analysis, open-ended interviews,functional communication, severe problem behavior, social validity

About 1 in 50 children have been identified ashaving an autism spectrum disorder (Blumberget al., 2013). There is no biological determina-tion of autism; however, the behavioral symp-toms are typically apparent before 3 years of age.Autism is characterized by impairments in socialinteraction and communication and by restric-ted, repetitive, or stereotyped patterns of behav-ior (Blumberg et al., 2013). Children withautism often display additional problem behav-iors such as self-injurious behavior (SIB),aggression, disruption, extreme emotional out-bursts, or sleep disturbance (Dominick, OrnsteinDavis, Lainhart, Tager-Flusberg, & Folstein,2007; Murphy, Healy, & Leader, 2009).Single-subject analyses (Carr & Durand,

1985; Iwata, Pace, Cowdery, & Miltenberger,

1994) and meta-analyses (Kahng, Iwata, &Lewin, 2002; Scotti, Evans, Meyer, & Walker,1991) provide robust evidence to support theshort-term efficacy of behavioral intervention, ingeneral, and function-based treatments, inparticular, for self-injury, aggression, and disrup-tion. For example, Campbell (2003) conducted ameta-analysis that showed the short-term posi-tive effects of behavioral intervention for theseproblem behaviors among persons with autism.Campbell also found that larger reductions inproblem behavior were evident when thetreatment was based on a functional assessment;even larger reductions were apparent when afunctional analysis was part of the functionalassessment process (see also Betz & Fisher,2011).Functional assessment is a general process

aimed at identification of the variables thatinfluence problem behavior before treatment.The functional assessment usually involves somesort of combination of indirect assessment (e.g.,interviews), descriptive assessment, and functionalanalysis (Iwata & Dozier, 2008). Descriptiveassessment entails observation and measurement

Sandy Jin is currently at Eastern Connecticut StateUniversity, and Nicholas Vanselow is currently at SalveRegina University.Correspondence can be directed to Gregory P. Hanley,

Department of Psychology, Western New England Univer-sity, 1215 Wilbraham Road, Springfield, Massachusetts01119 (e-mail: ghanley@wne.edu).doi: 10.1002/jaba.106

JOURNAL OF APPLIED BEHAVIOR ANALYSIS 2014, 47, 1636 NUMBER 1 (SPRING)

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of the problem behavior and the context inwhich the behavior occurs. By contrast, functionalanalysis consists of observation and measurementof problem behavior in at least two contexts, eachdistinctly designed so that the variables suspectedof influencing problem behavior are conspi-cuously present in the test condition and absentin the control condition (Hanley, Iwata, &McCord, 2003).Functional analyses of problem behavior are

prominent in the behavioral assessment litera-ture, having appeared in at least 435 studiesthrough 2012 with at least 117 involving personswith autism (Beavers, Iwata, & Lerman, 2013;Hanley et al., 2003). Functional analysis researchoften focuses on detection and evaluation of theimpact of single variables, and as a result, usefultechnologies relevant to effective assessment andtreatment of problem behaviors associated withautism are often fractured across studies. In fact,few, if any, individual studies have illustrated theassessment and treatment process from start tofinish, a comprehensiveness required for produc-ing socially valid improvements in SIB, aggres-sion, or disruption in children with autism. Inaddition, there is considerable variability in themanner in which functional assessments areconducted, the speed and success of the initialanalysis in detecting a function of problembehavior, and the extent to which types ofindirect and descriptive assessments are used inthe functional assessment process (Beavers et al.,2013; Hagopian, Rooker, Jessel, & DeLeon,2013; Hanley et al., 2003).Hanley (2010, 2011, 2012) recently described

a particular functional assessment process thatwas intended to increase its efficiency whilepreserving its scientific rigor. He emphasizedstarting with an open-ended interview to identifythe type of contingencies that may influenceproblem behavior. The interview results werethen used to design individualized and intimatelymatched testcontrol analyses that differed onlyin that the test condition included the putativereinforcement contingency and the control

condition did not. This testcontrol analysiswas presented as an alternative to the standard-ized, comprehensive functional analysis (Iwata,Dorsey, Slifer, Bauman, & Richman, 1982/1994), which typically involves multiple testconditions that evaluate generic contingenciesand a single control condition that varies fromthe test conditions in multiple ways. Hanley alsoargued against the use of closed-ended indirectassessments (e.g., rating scales) and formaldescriptive assessments due to recurrent prob-lems with measurement reliability for the formerand the predictive validity of both (Iwata,DeLeon, & Roscoe, 2013; Newton & Sturmey,1991; Nicholson, Konstantinidi, & Furniss,2006; Shogren & Rojahn, 2003; St. Peteret al., 2005; Thompson & Iwata, 2007; Zarcone,Rodgers, Iwata, Rourke, & Dorsey, 1991).We applied the functional assessment model

described by Hanley (2010, 2011, 2012) in thecurrent study to address the severe problembehavior of three children who had been diag-nosed with autism. Our purpose was to demon-strate the utility of the model in an outpatientclinic with the first three families who attendedthe clinic by implementing, generalizing, andsocially validating the treatments designed fromthe results of the interview-informed analyses.Single-subject designs demonstrated the influ-ence of the separate treatment components thatwere progressively synthesized to produce sociallyvalid outcomes for participating families.

METHOD

ParticipantsThe three participating families learned of the

university-based outpatient clinic through theirlocal pediatricians office. Services were providedwithout charge as part of the research andtraining mission of the university. All childrenengaged in episodes of problem behavior multi-ple times each day and had been receivingbehavior-analytic services for at least 1 year priorto being served in our clinic. Gail was a 3-year-

SEVERE PROBLEM BEHAVIOR 17

old girl with pervasive developmental disordernot otherwise specified, Dale was an 11-year-oldboy with autism, and Bob was an 8-year-old boywith autism. All children could follow multistepvocal instructions (but usually did not do so),imitate, and speak in short sentences. Dale andBob attended specialized classrooms in publicschools and received one-on-one paraprofes-sional support. Both were included in regularclassrooms with paraprofessional support forabout 1 hr each day. Gail was receiving speechlanguage services at the time of her evaluation.Parents reported that their children exhibitedproblem behavior when they could not havetheir way and that the form, intensity, andduration of the problem behavior were highlydisproportionate with the situation. The goal oftreatment for all three children was to reduceproblem behavior and increase the amount oftime they would comply with adult instructionsand accommodate others preferences.Gail reportedly had difficulty when her

mother asked her to clean up her toys or playindependently while her mother was working onother tasks. For example, when her motherattempted to cook dinner or clean the house,Gail screamed, cried, and hit her mother or hersister. Gails mother frequently repeated instruc-tions to go play or to wait a bit, but problembehavior persisted for long periods (i.e., fromminutes to hours). It was reported that Gailfrequently controlled the activities of the house-hold with her problem behavior.Dale reportedly had trouble tolerating periods

of time when adults did not honor his requestsfor items or idiosyncratic activities. Parents alsoreported that his problem behavior reliablyoccurred when adults interrupted his ongoingactivity (e.g., watching movies or wanderingthrough the house) with an instruction to dosomething else. Parents accommodated as manyof Dales requests as possible and rarelyinstructed him to engage in any adult-ledactivities. Parents also reported spending a lotof money to accommodate his preferences and to

avoid problem behavior (e.g., purchasing movies,games, and particular foods). The intensity ofproblem behavior had resulted in the termina-tion of several home-based behavioral supportservices prior to this study.Bob was reported to have trouble regulating

his emotions when parents or teachers said noand when there was some loss of control in hisenvironment. He was reported to often have ameltdown (i.e., screaming and aggression)when parents took away his iPad or interruptedhis games on the iPad or other electronic devices.Meltdowns also occurred when teachers cor-rected his math work or instructed him totransition to a nonpreferred (nonmath) academictask. Parents and teachers had gone to greatlengths to accommodate Bobs preferences, buthis meltdowns reportedly occurred multipletimes per day. Bob had physically injuredchildren and adults in both the home and atschool. Parents reported that they had not takenBob out of the house to anywhere but school(i.e., no restaurants or family day trips) for over2 years due to the frequency of, and risksassociated with, his meltdowns.

SettingAll functional analysis and treatment sessions

were conducted in therapy rooms (4m by 3m)with one-way observation panels and audio-video equipment located in the psychologydepartment of a university. All session roomscontained a table, two chairs, and other materialsrelevant to ongoing observations. Due to thenature of some of Dales requests, some of hissessions were also conducted in a computer lab,hallway, and classrooms in the psychologydepartment. The classroom was equipped witha computer and overhead projector that couldplay DVDs that the family brought to sessions.Visits to the clinic occurred 3 to 4 days per weekand lasted about 1 hr. Sessions were conductedthree to six times per visit. Session duration forGail was 5min throughout the analysis, treat-ment, and treatment extension. Session duration

18 GREGORY P. HANLEY et al.

for Dale was 5min and increased to 10minapproximately halfway through his assessment.Session duration for Bob was 4min andincreased to 6min approximately halfwaythrough his assessment. Gails treatment exten-sion sessions began in the home. Treatmentextension sessions for Dale and Bob began in thesession rooms and other areas around thepsychology department and outside the building(e.g., walking to the car in the parking lot).Eventually, treatment for all children wasimplemented in various locations in the partic-ipants homes (e.g., kitchen, bedroom, etc.).

MeasurementTrained observers collected data using soft-

ware on small laptops. Data were collectedduring continuous 10-s intervals and weresummarized as number of responses per minuteor percentage of session. Data were collected onthe number of problem behaviors, functionalcommunicative responses (FCRs), toleranceresponses, and reinforcement duration. Datawere also collected on the duration and type ofinstructions and compliance to the instructions.Problem behavior for all participants includedloud vocalizations (e.g., shouting, screaming, oryelling), disruption (e.g., throwing items ortearing homework sheets), and aggression (e.g.,head butting, hitting, grabbing, spitting, orpunching). Observers scored two types ofFCRs, simple and complex, that varied slightlyfor each participant based on their languageabilities and the reinforcers that maintained theirproblem behavior. Gails simple communicationresponse was toys, please. Dale and Bobssimple communication response was my way,please. The complex response required theparticipant to say excuse me and then waitfor adult acknowledgment before engaging in alonger FCR. Gail was required to say, May Ihave toys, please? Will you play with me? orMay I have , please? Bobs and Dalescomplex FCR was May I have my way, please?Tolerance responses were scored anytime the

child stopped what he or she was doing, orientedtoward the adult, and said okay. IndependentFCRs and tolerance responses were recordedwhen the correct phrasing was emitted withappropriate tone and volume. FCRs and toler-ance responses were considered to be prompted ifthe analyst or parent provided a vocal model ofall or any part of the response before the childindependently emitted the complete responsecorrectly (e.g., Excuse me, may I have my wayplease?). Only independent responses are plot-ted on the figures.The percentage of session with reinforcement

was calculated by dividing the duration ofreinforcement time by the session duration.Reinforcement duration included all of thesession time in which the participant had accessto the reinforcer identified in the functionalanalysis. For Gail, reinforcement duration wasscored when she was allowed access to both toysand her mothers attention. For Dale, reinforce-ment duration was scored when the analyst orparent removed demands, provided access to thepreferred activity, and honored his request foridiosyncratic reinforcers (e.g., sitting in aparticular place, changing the movie). For Bob,reinforcement duration was scored when theanalyst or parent allowed Bob to play with theiPad or solve the math problems his way.Observers began recording the duration of a

particular type of demand as soon as thatdemand was given and stopped recording whenanother type of demand was given or thereinforcer was delivered. Observers scored com-pliance with demands when the participantactively responded to or oriented toward taskmaterials, toys, or other activities as instructed bythe analyst or parent without problem behavior,refusal (e.g., no or I dont want to), orphysical guidance to complete an activity.Compliance continued to be scored betweeninstructions if the child continued to behave inthis manner. For example, the analyst might taketime between instructions to erase the boardand draft a new math problem; compliance

SEVERE PROBLEM BEHAVIOR 19

continued to be scored during this time if thechild remained at the board and did not engagein problem behavior. The percentage of compli-ance with each type of demand was calculated bydividing the duration of compliance with thedemand by the total duration during which thedemand was given.Interobserver agreement was assessed by having

a second observer collect data on all target beha-viors simultaneously but independently during atleast 20% of each condition for all participants.Observers records were compared on an interval-by-interval basis, and agreement percentages werecalculated by dividing the smaller number ofresponses or duration (in seconds) in each intervalby the larger number. If both observers scoredzero, the interval was scored as 100% agreement.Quotients were then averaged and converted to apercentage. Interobserver agreement averaged99% (range, 80% to 100%) for Gail, 98%(range, 82% to 100%) for Dale, and 98% (range,73% to 100%) for Bob.

DesignA multielement design was used to compare

the test and control conditions of the functionalanalysis, and a reversal design was used tocompare parent- and therapist- implementedanalyses (Gail only). The design for thetreatment analyses followed the logic of achanging-criterion design. Functional controlwas demonstrated by showing that levels ofproblem behavior and alternative responsesclosely corresponded, in the predicted direction,to four successive changes in reinforcementcontingencies for those responses.

Functional AssessmentAn open-ended functional assessment inter-

view with the participants parents (see Appendixin Hanley, 2012) followed by, or concurrent with,a brief observation of the child was arranged todiscover potential factors that may influenceproblem behavior. The open-ended interviewlasted between 30 and 45min and included

questions about the participants current abilities(e.g., Describe your childs language abilitiesand Describe your childs play skills andpreferred toys or leisure activities), problembehavior (e.g., What are the problem behav-iors? and What is the single most concerningproblem behavior?), contexts in which problembehavior is likely to occur (e.g., Under whatconditions or situations are the problem behav-iors most likely to occur?), and parents responsesto problem behavior (e.g., What do you do tocalm you child down during a meltdown?).Questions were sometimes individualized as theopen-ended interview progressed based on thecontent of the parents responses. During the 15-to 30-min observation, the analyst noted thelanguage ability of the child and any problembehavior that occurred while the analyst inter-acted with the child. The analyst initially sat andmade him- or herself available to the child andthen provided and removed toys, attention, andactivities as well as instructions during theobservation.A functional analysis, informed by the results

of the interview and observation, was thenconducted to test the apparent reinforcementcontingencies. Functional analyses involved al-ternating between a test and a control condition(or for Gail and Bob, a series of test and controlconditions). During each control condition,which was always conducted first, the putativereinforcers were available throughout the session.During each test condition, the putative rein-forcers were removed every 30 s and were onlyreturned contingent on problem behavior. Thesame materials were always available across eachcorresponding test and control condition, andreinforcers that were not part of the suspectedcontrolling contingency were available noncon-tingently in both the test and control conditions.Therefore, the only difference between test andcontrol conditions was the suspected reinforce-ment contingency.

Gail. Results of the interview and briefobservation suggested that problem behavior

20 GREGORY P. HANLEY et al.

was evoked when adult attention was diverted orwhen preferred activities were removed and thatcontingent access to adult attention, preferredactivities, or both, reinforced Gails problembehavior. Both attention and tangible reinforce-ment contingencies were simultaneously evalu-ated first. In the synthesized tangible andattention control condition, both tangible items(e.g., dolls, dress-up clothes, picture books, andpuzzles) and adult attention were availablethroughout the entire session, and no instruc-tions were provided. In the synthesized tangibleand attention test condition, both were removedat the beginning of the session, and both werereturned contingent on problem behavior for30 s. A control session was conducted first; testand control sessions were then alternatelyconducted. The analyst and mother also alter-nated implementation of the test and controlconditions. The analyst was present in theroom when the mother implemented thesessions and provided coaching on implementa-tion as needed.Attention and tangible reinforcement contin-

gencies were also analyzed in isolation. Thecontrol condition was as described above: Theanalyst or mother provided attention throughoutthe session, and tangible items were continuouslyavailable (no instructions were provided). In theattention test condition, Gail was allowed toaccess a variety of preferred toys (e.g., dolls,dress-up clothes, and puzzles); however, at thebeginning of the session, the analyst or motherremoved attention by turning away from Gailand working on another task (Gail couldcontinue to play with the available toys in theabsence of adult interaction). Attention wasreturned for 30 s immediately following problembehavior.In the tangible test condition, Gail was placed

at a table away from tangible items; however, theanalyst or parent was at the table with Gail andprovided attention. Gail was allowed to leave thetable and play with the toys for 30 s contingenton problem behavior; however, the parent or

analyst remained at the table and did not interactwith Gail while she played with the toys.

Dale. Results of the open-ended interviewand brief observation suggested that Dalesproblem behavior was evoked by an adultsinterruption of activities that were initiated byDale or when his requests were denied, and thatterminating adult instructions, regaining accessto his activity, or having his requests honoredwere maintaining Dales problem behaviors. Inthe control condition, he was given uninterrupt-ed access to the activities of his choosing (e.g.,watching movies, playing on a computer, talkingabout preferred topics), no demands were made,and the analyst honored all reasonable requests.Reasonable requests were those that could begranted in the space provided and with accessiblematerials (e.g., changing the movie in the DVDplayer); unreasonable requests were those thatwere impossible to grant at the time (e.g., askingto go to a movie theater, asking to buy a new toy)or those that created a nuisance for others ifgranted (e.g., providing access to the laptop andprojector in a classroom occupied by a graduateseminar). In the test condition, the analystinterrupted the ongoing activity initiated byDale and instructed him to complete homework(e.g., math worksheets, writing and readingassignments). A three-step prompting hierarchywas used to promote compliance with thehomework-related instructions. The analystdelivered praise if Dale complied with instruc-tions, but the occurrence of problem behaviorresulted in the removal of demands, reaccess tothe activity Dale originally initiated, and theanalyst complying with his reasonable requests.Contingencies involving attention, escape, tangi-ble items, or compliance with his requests werenot evaluated in isolation because the interviewsuggested that they often occurred simultaneous-ly. Only synthesized contingencies were analyzedwith Bob for similar reasons.

Bob. The results of the interview and briefobservation suggested that Bobs problem behav-ior was evoked by an adults interruption and

SEVERE PROBLEM BEHAVIOR 21

redirection of his play with his iPad or interrup-tion and correction of his math work, and thatregaining access to his way of interacting with hisiPad or math work were maintaining Bobsproblem behavior. It is important to note thatBob was very skilled with both math and withmost of the applications on his iPad. Twocontexts defined by the activity, iPad or mathworkbooks, were arranged as separate analyses.In the control conditions for both analyses, Bobwas allowed his way of playing with the iPad orsolving the math problems throughout thesession. An adult was present and commentedon his activity but did not interrupt, redirect, orcorrect him. In the test conditions, the analyst orthe parent either interrupted and redirectedBobs iPad play (e.g., requested that he turn offthe open application and open a differentapplication) or interrupted, redirected, or cor-rected his math work. The iPad was not availableduring sessions with the math materials, andmath materials were not available during sessionswith the iPad. When problem behavior occurred,the analyst immediately stopped the interrup-tion, redirection, or correction and allowed Bob

30 s to play his way with the iPad or work on hismath workbooks.

TreatmentTreatment for all children included (a)

teaching a simple FCR to replace problembehavior (Carr & Durand, 1985), (b) increasingthe complexity and developmental appropriate-ness of the FCR, (c) introducing delays anddenials from an adult and teaching a specificresponse to cues of reinforcement denial anddelay, (d) chaining simple responses duringdenial- and delay-tolerance training, (e) chainingmore difficult responses during denial- anddelay-tolerance training, and (f ) extending thetreatment to ecologically relevant situations (seeTable 1).

Baseline. The test condition sessions from thedifferentiated functional analyses were used asthe baselines for the treatment process with allchildren.

Simple FCT. Immediately before the simpleFCT sessions, the analyst taught each child asimple FCR using behavior skills training (BST;instructions, modeling, role play, and feedback).

Table 1Steps for Addressing Severe Problem Behavior and the Time Expended and Extrapolated Costs

Participants

Gail Dale Bob Average

Steps Visitsa Costb Visits Cost Visits Cost Visits Cost

Interview 1 200 1 200 1 200 1 200Functional analysis 4 800 0.8 160 2.2 440 2.3 460Functional communication training 1 200 2.7 540 2.3 460 2 400Complex FCT 2 400 1 200 4.3 860 2.4 480Tolerance response training 7 1,400 1.5 300 5.2 1,040 4.6 920Easy response chaining 2 400 4.8 960 1 200 2.6 520Difficult response chaining 3 600 11.2 2,240 2 400 5.4 1,080Treatment extension 2 400 9 1,800 9 1,800 6.7 1,340

Total 22 4,400 32 6,400 27 5,400 27 5,400Supervision meetingsc 16 1,000 28 1,750 16 1,000 20 1,250Report writing and planningd 4 500 4 500 4 500 4 500Grand total 5,900 8,650 6,900 7,150

aEach family visit lasted 1 hr; lead BCBA and BCaBA were present at each visit.bCost is in US dollars; hourly rate of supervising and lead BCBA was $125; hourly rate of BCaBA was $75.cSupervision meetings between supervising and lead BCBA lasted 30min and occurred approximately twice per week.dReport writing and planning periods required 1 hr and occurred after each step noted by an asterisk.

22 GREGORY P. HANLEY et al.

Gail was taught to say toys, please to access toysand attention. Bob and Dale were taught to saymy way, please to terminate adult instructions(corrections, etc.) and regain access to preferredactivities (and preferred ways of interacting withactivities for Bob and having requests honoredfor Dale). If the child did not engage in theresponse within 5 s, the adult verbally promptedthe response by saying, say . Problembehavior no longer resulted in reinforcement(i.e., extinction was programmed). If the FCRwas closely preceded by problem behavior, theadult did not provide access to the reinforcer(i.e., the adult ensured that at least 5 s elapsedbetween the occurrence of problem behavior andthe FCR; this was exclusively relevant to Dale).

Complex FCT. After the child emitted inde-pendent FCRs for at least two sessions, the adultattempted to increase the complexity of theresponse. The complex FCR consisted ofteaching the child to say excuse me slowlyand softly while making eye contact with anadult, and then waiting for an adult toacknowledge them before emitting a moredevelopmentally appropriate FCR. The childwas taught to say May I have, please? slowlyand softly to request access to the reinforcers. Ifthe child did not engage in the appropriate FCRwithin 5 s, a verbal prompt, an expectant look, orboth were provided. The analyst withheld accessto the reinforcers if problem behavior occurred.

Delay and denial baseline. After the childacquired the complex FCR and problem behav-ior remained at low levels, the adult introduceddenials by saying no or some variant (e.g., notnow, later) after 60% of the FCRs (three ofevery five FCRs produced the denial responsefrom the adult; the remaining two producedreinforcement). In addition, if problem behavior(rather than another FCR) followed the denial,the adult then delivered the reinforcer contingenton problem behavior. In other words, during thedelay and denial baseline, problem behaviorremained on extinction until the child emittedthe complex FCR and the adult denied access to

the reinforcer. After the adult denied access tothe reinforcer, subsequent problem behaviorproduced the reinforcer. This condition wasdesigned to emulate conditions under whichparents reported to give in after telling their childno in order to prevent escalation of problembehavior. This condition also served to show thatthe reinforcement contingency determined fromthe functional assessment process was stillcontrolling problem behavior.

Delay- and denial-tolerance training. In thiscondition, as in the previous, two of every fiveFCRs resulted in immediate reinforcement, andthree of every five FCRs resulted in a delay ordenial response from the analyst or parent. Allproblem behavior was placed on extinction.Using BST, the analyst taught the child a specificresponse to the denial cue which was to take abreath and say okay while orienting toward theadult when the adult said no (or other termsthat signaled a delay or denial of the requestedreinforcer). The requested reinforcer was initiallyprovided immediately after the child emitted thistolerance response. The delay to reinforcementwas then gradually increased by requiring Gail toengage in an alternative and less preferred activity(i.e., she was directed to play alone and with lesspreferred toys), requiring Bob to tolerate redirec-tion or correction and comply with any adultinstructions, and requiring Dale to comply withadult instructions. Delays were gradually in-creased until each child accommodated adultdirectives for approximately 67% of the session(i.e., the child spent at least 67% of the session inthe less preferred activities without access to thereinforcers that maintained their problem behav-ior). The delay was increased only when the FCRwas independent and when the rate of problembehavior was zero. It is also important to notethat initially, the adult required little behaviorfrom their child (Gail) or provided only a fewsimple and brief instructions (Dale and Bob). Werefer to these as Level 1 instructions; theseincluded simple motor instructions for Gail andDale or a brief (2 to 30 s) requirement to engage

SEVERE PROBLEM BEHAVIOR 23

in less preferred activities for Bob and Gail. Thecomplexity and duration of the play requirementor instructional periods were gradually increasedduring this phase to produce long chains ofdevelopmentally appropriate responding thatyielded the functional reinforcer. Level 2instructions involved simple academic tasks andtransitions for Gail and Dale and a longerduration of engagement in less preferred activi-ties for Bob and Gail (45 to 90 s). Level 3instructions were introduced last and involvedalternate play, self-help activities (e.g., washinghands), and developmentally appropriate andchallenging preacademic (Gail) or academic tasks(e.g., math and reading comprehension for Dale)or extended engagement in less and nonpreferredactivities (e.g., transitioning, meals for Bob).Approximately halfway through delay- and

denial-tolerance training, enhanced differentialreinforcement was introduced with Dale due tosome persistence of problem behavior duringdelays. If Dale engaged in no problem behaviorduring the delay and complied with instructionswithout requiring physical guidance to completean activity, the analyst provided a longerreinforcement period (3min) with high-qualityreinforcers (e.g., preferred movies, snack foods,and high-quality attention). Any problem be-havior or noncompliance during the delayresulted in a relatively brief reinforcement period(30 s) with lower quality reinforcers (e.g., amovie with no snack).

Treatment extension. To evaluate the practical-ity and generality of the treatment, the interven-tion was extended outside the therapy rooms tomore relevant situations. The manner in whichtreatment was extended differed slightly for eachchild according to their parents initial goals. Inmost cases, parents (or the teacher for Bob) weretaught to implement the session contingenciesin the session room first. The parents then werecoached on implementation of the treatment invarious areas of the outpatient clinic. The analystthen went to the childs home and coached theparents to implement the treatment during tasks

typical of the home environment (e.g., eatingdinner, cleaning up toys, and completinghomework) that had been described as beingthe most troublesome during the initialinterview.

Social ValidityTo assess whether the functional assessment

and treatment process was acceptable andresulted in socially meaningful outcomes forthe participating families, parents were given aquestionnaire at the end of the treatment. Weasked parents four questions about the extent towhich they (a) found the assessment acceptable,(b) found the treatment procedures acceptable,(c) were satisfied with amount of improvementobserved in problem behavior, and (d) weresatisfied with the overall helpfulness of consulta-tion. We also asked the parents about theircomfort levels with presenting the situationreported to evoke problem behavior before andafter the transfer of the treatment to their homes(e.g., comfort level in removing electronicdevices, telling the child no, interrupting thechilds preferred activity, and telling them to dohomework or other nonpreferred activities).

RESULTS

Functional AssessmentsThe interview resulted in the hypotheses that

Gails problem behavior was maintained by socialpositive reinforcement in the form of adultattention, tangible items, or both. When bothtangible items and adult attention were providedcontingent on Gails problem behavior by theanalyst (Figure 1, left), undifferentiated analyseswere obtained. Differentiation between the testand control conditions was, however, obtainedwhen Gails mother implemented the condi-tions. The effect of the implementer was thenreplicated. When the independent effects of thetangible and attention reinforcement contingen-cies were assessed, neither appeared to influenceproblem behavior, despite Gail contacting each

24 GREGORY P. HANLEY et al.

contingency. The results of the functionalassessment process with Gail showed that herproblem behavior was sensitive to the combina-tion of tangible items and attention as reinforce-ment when provided by her mother.Parents reported during the interview that

Dales problem behavior occurred primarilywhen he was interrupted from preferred activitiesor when his requests were not reinforced.Problem behavior was observed at zero or near-zero rates when he was allowed to engagewithout interruption in preferred activities andwhen his reasonable requests were grantedduring his control condition (Figure 1, topright). When his problem behavior yieldedescape from adult instructions and access to

preferred activities, adult attention, and havinghis reasonable requests granted, we observedrelatively high rates of problem behavior. Resultsof the functional assessment process showed thathis problem behavior was probably maintainedby multiple social positive and negative rein-forcement contingencies. Speaking loosely, itappeared that his problem behavior was main-tained by access to his way, which was usuallyspecified by Dale either before or after engagingin problem behavior (cf. Bowman, Fisher,Thompson, & Piazza, 1997).Parents reported that Bobs problem behavior

occurred whenever someone attempted toprompt him to engage his electronic devices orassigned math problems in a different way than

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Figure 1. Interview-informed functional analyses for all three participants. The contingencies assessed with each childare noted in italics.

SEVERE PROBLEM BEHAVIOR 25

that which he was doing. Problem behavior wasobserved exclusively in the test sessions (Figure 1,middle and bottom right), which is when hisproblem behavior terminated interruptions andallowed him to regain access to his way with theiPad or math workbook. As with Dale, Bobsproblem behavior appeared to be maintainedby access to his way, or more technically,maintained by the termination of adult interrup-tion and prompting (social negative reinforce-ment), access to his self-directed activity with hisiPad or math workbook (positive reinforcement;cf. Fisher, Adelinis, Thompson, Worsdell, &Zarcone, 1998), or some combination.

Comprehensive Treatment EvaluationsThe test conditions of the functional analyses

served as the baselines from which to evaluate theeffects of teaching FCTand delay-tolerance skillswith all three children (see Figures 2, 3, and 4).FCT resulted in immediate elimination ofproblem behavior for Gail and acquisition ofthe simple FCR of play with me. Five sessionswere required for the complex FCR to begin tooccur independently. At this point, when toysand attention were removed by her mother, Gailobtained her mothers attention by sayingexcuse me. After being acknowledged by hermother, Gail would then say May I have toys,please? or some variation. The denial baselineresulted in reemergence of problem behavior andsome emotional responding (the latter is notdepicted in the figure).In denial- and delay-tolerance training, prob-

lem behavior returned to near-zero levels whilecomplex FCRs and tolerance responses persisted.Gails mother then added in instructions to eitherplay independently with nonpreferred toys or tocomplete nonpreferred tasks when complexFCRs yielded delays or denials. As additionalresponses were being chained to the toleranceresponse or longer periods of independent playwas required, (a) problem behavior remained atnear-zero levels, (b) complex FCRs and toleranceresponses persisted, (c) the amount of time with

reinforcement gradually decreased (i.e., Gailplayed without her mother and with lesspreferred toys for longer periods of time), and(d) compliance with the mothers instructionsoccurred at high levels despite the gradualintroduction of more challenging instructions(e.g., playing alone). Some small variability in allresponses was observed as the treatment wasextended to different contexts; nevertheless,when the evaluation was terminated, Gailsproblem behavior was at zero and her complexFCRs, tolerance responses, and compliancepersisted despite the fact that her requests werehonored only about half the time, the amount ofreinforcement time was routinely less than 50%,and her mother placed difficult demands on herto play independently and with nonpreferredactivities. Control of the treatment was evidentvia the return of problem behavior in the denialbaseline and by the fact that the social skillsemerged when and only when the reinforcementcontingency was assigned to those responses.The results obtained with Gail were systemat-

ically replicated with Dale. The main differenceswere (a) slightly more variability in problembehavior for Dale than that observed for Gailprior to the treatment extension phase of theevaluation, (b) more time spent on the gradualintroduction of more challenging situationsduring the delay, and (c) less variability inproblem behavior during the treatment exten-sion phase. The variability in problem behaviorwas probably a function of not being able toreinforce all his requests during the reinforce-ment interval in the initial treatment phases,because some of his requests were unreasonable.The extended time during delay-tolerance train-ing was primarily due to the greater amount ofdevelopmentally advanced behaviors that neededto be introduced, given his age and parentalexpectations. Multiple consecutive sessions withzero levels of problem behavior towards the endof the evaluation were probably a function of thequalitative difference in the type of reinforcersavailable for him to request which depended on

26 GREGORY P. HANLEY et al.

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28 GREGORY P. HANLEY et al.

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SEVERE PROBLEM BEHAVIOR 29

his behavior during the delays. Nevertheless,when the evaluation was terminated, Dalesproblem behavior was at zero and his complexFCRs, tolerance responses, and compliancepersisted despite the facts that his requests werehonored only about 40% of the time, theamount of reinforcement time was routinelyless than 40%, and his parents placed difficultdemands on him during the delays.The effects of the comprehensive skill-based

treatments observed with Gail and Dale werealso systematically replicated with Bob in boththe iPad and math contexts. We observed whatappeared to be generalized extinction of problembehavior in the math context when FCT wasinitiated in the iPad context, but FCT wasnecessary for the simple FCR to be acquired inthe math context. Some variability in problembehavior was observed while the complex FCRwas being taught in the iPad context. After thecomplex FCR was acquired in the iPad context,it generalized to the math context. As with Gailand Dale, problem behavior reemerged whendelays and denials were introduced followingsome complex FCRs. Nevertheless, by the end ofthe evaluation and despite having his way only20% of the time, Bob engaged in zero levels ofproblem behavior, consistently engaged in thecomplex FCR and tolerance responses, andcomplied with instructions to play with hiselectronics or do his math in the mannerrequested by his parent and teachers.

Social Validity EvaluationsAfter the final treatment extension session,

families returned to the outpatient clinic tocomplete a social validity questionnaire and toask any questions about treatment implementa-tion. All parents reported that they found theassessment procedures and treatment packageshighly acceptable, the improvement in problembehavior highly acceptable, and overall consulta-tion very helpful (M 6.9 on a 7-point Likertscale for the four social validity questions for thethree families). When asked about their comfort

level with presenting the specific situations thatwere initially reported to evoke problem behav-ior, ratings improved for all parents between theinitial and final meetings with the behavioranalyst (mean improvement was 3.7, rangingfrom 2 to 6 units, with 6 being the mostimprovement possible), and the parents reportedbeing very comfortable with presenting evocativesituations following the consultation process.

Time and Cost ExpendituresAlthough families were not charged for

participation, it is informative to consider timeand cost expenditures if fees had been rendered.The outpatient consultation lasted 8 to 14 weeks(M 11.3 weeks) and required 22 to 32 1-hrvisits (M 27 visits) for the three families. A leadand assistant behavior analyst were present ateach visit. Assuming an hourly rate of $125 perhour for the lead analyst (27 $125 $3,375)and a rate of $75 per hour for the assistantbehavior analyst (27 $75 $2,025), and fac-toring in the costs associated with supervision(5 sessions per patient at $200 $1,000) andreport writing (4 reports per patient at$125 $500), the extrapolated costs of thiseffective and socially validated assessment andtreatment process was between $5,900 and$8,650 (M $6,900). The costs of the differentsteps in the assessment and treatment process areshown in Table 1.

DISCUSSION

The problem behavior of three children withautism was effectively eliminated and multipleimportant social skills were acquired whenbehavioral interventions were developed froman abbreviated functional assessment process andthen gradually brought to scale in an outpatientclinic. The effective treatments were thenimplemented by the parents of the children intheir homes and during the conditions initiallyreported as evoking severe problem behavior.Despite the length of the consultation process, all

30 GREGORY P. HANLEY et al.

parents reported that the consultation was veryhelpful and that they were satisfied with theprocess and the amount of improvement in theirchilds problem behavior.Almost 1,000 distinct functional analyses of

severe problem behavior have been published inover 430 highly analytic studies over the last50 years (Beavers et al., 2013). Many studies thatinvolve functional analyses of problem behaviorare methodological and aim to improve readersunderstanding of how to best conduct ananalysis. Methodological functional analysisstudies are important because they can improvethe efficiency (Bloom, Iwata, Fritz, Roscoe, &Carreau, 2011; Northup et al., 1991; Wallace &Iwata, 1999) or accuracy (Fisher, Piazza, &Chiang, 1996; Hagopian et al., 1997; Thomp-son, Fisher, Piazza, & Kuhn, 1998) of thefunctional assessment process. In most otherresearch, functional analyses serve as the primarycriterion to include participants in studies thatevaluate treatment for a particular function ofbehavior, and the treatment analyses usuallyevaluate a single aspect of the treatment processvia comparative analysis (e.g., Fisher et al., 1993;Fisher, Piazza, & Hanley, 1998; Hanley, Piazza,& Fisher, 1997; Horner & Day, 1991; Kahng,Iwata, DeLeon, & Worsdell, 1997; Zarcone,Iwata, Hughes, & Vollmer, 1993). These sortsof analyses are important, in that they permit afunction-based treatment technology to emergewhile influential variables (e.g., the importanceof extinction) are isolated, thus resulting in aprecise behavior-change technology.The behavior-analytic literature relevant to the

treatment of severe problem behavior is not,however, without its limitations. The almostexclusive focus on the analysis of single featuresof assessments or on single aspects of treatmentshas drawn behavior analysts away from publish-ing studies that are capable of presenting theentire assessment and treatment process anddemonstrating socially meaningful effects onsevere problem behavior. In the current study,we focused on synthesizing particular assess-

ments and multiple treatment components witheach child to obtain large and socially valideffects. These case examples illustrate a synthesisof behavioral technology, most of which hasalready been demonstrated to be efficacious andinterpreted in conceptually systematic ways.Without the highly analytic studies that focuson single features of assessments or treatments,case examples of the synthesized approach, likethose in the current study, would not be possible.However, without empirical syntheses of theseanalytic studies, we will not create sufficientlylarge and meaningful changes in behavior thatoccurs across enough contexts for the change tobe considered socially acceptable and recognizedas important by colleagues and constituents whoare not behavior analysts.Although hundreds of highly analytic studies

have informed the technology applied in thecurrent study, the relation between these studiesand the type of empirical synthesis found in thecurrent study is not unidirectional. Outcomesfrom highly analytic studies can be stitchedtogether to form applied behavioral synthesesthat yield socially important changes in problembehavior; for recent examples, see Luczynski andHanley (2013), Jin, Hanley, and Beaulieu(2013), or Potter, Hanley, Augustine, Clay, andPhelps (2013). Empirical syntheses may alsopresent new independent variables that are inneed of further analysis, in addition to replicatingthe effects of previously described variables.Hence, there is a bidirectional relation betweenhighly analytic and highly synthetic studies inthat each can occasion the other variety.Replications of important variables from the

extant assessment-based treatment literature,as well as some independent variables worthyof additional analysis, can be gleaned from thepractice commitments evident in the treatmentapplied in this study. First, it is important tobegin with a simple high-probability request (seeHorner & Day, 1991, for the importance ofsimple FCRs during the initial stage of FCT)that yields all relevant reinforcers (i.e., an

SEVERE PROBLEM BEHAVIOR 31

omnibus request) in the context of extinction forproblem behavior (see Fisher et al., 1993; Iwata,Pace, Cowdery et al., 1994; Worsdell, Iwata,Hanley, Thompson, & Kahng, 2000, for theimportance of extinction during FCT). Second,it is important to teach children to say excuseme and wait to be acknowledged before theyengage in a more developmentally and sociallyappropriate omnibus request (see Hernandez,Hanley, Ingvarsson, & Tiger, 2007, for theimportance of teaching framed requests). Third,it is important to teach all children a specificresponse (e.g., taking a breath and saying okaywhile looking at an adult) to a variety ofintermittently presented cues that signal rein-forcement delay or denial (see Luczynski &Hanley, 2013). Fourth, it is important not onlyto gradually increase the amount of timereinforcers will be delayed but also to requirespecific behaviors during the delay (e.g., playingindependently, playing someone elses way, orcomplying with adult instruction) and thenprovide that delayed reinforcer contingent onthose required behaviors (see Fisher, Thompson,Hagopian, Bowman, & Krug, 2000, for theimportance of alternative activities during delays,and see Dixon & Cummings, 2001, for atranslational analysis suggesting the importanceof requiring engagement in alternative activitiesto access delayed reinforcers). Fifth, it isimportant to gradually increase the behavioralexpectations during the delays until they emulatethose conditions parents reported as mostchallenging in the home. Sixth, it is importantto introduce parents into the context in whichtreatment effects were originally achieved beforetransitioning treatments into the home.It should be noted that several commitments

were not followed by a relevant reference; theserepresent opportunities for future highly analyticresearch. For instance, teaching an omnibusrequest (e.g., May I have my way, please?) thatprovides access to various reinforcers (escape,preferred activities, adult attention, and a periodduring which more specific requests will be

granted) seems to confer advantage over attempt-ing to teach specific FCRs for each distinctreinforcer because, with the latter, problembehavior persists while each FCR is being taught(Ghaemmaghami, Hanley, Jin, & Vanselow,2013). Nevertheless, future research on theimportance of teaching an omnibus requestwhen multiple reinforcers influence problembehavior is necessary. There is indirect supportfor teaching children to obtain adult attention viaan excuse me response and wait for acknowl-edgement before making more specific requestsfor attention, materials, or breaks from instruc-tions or other nonpreferred tasks. These commit-ments are found in Hanley, Heal, Tiger, andIngvarsson (2007) and in Luczynski and Hanley(2013), studies that showed the weakening orprevention of problem behavior in preschoolers,respectively. More rigorous analyses should beconducted to determine the precise benefits ofteaching children to request and wait for adultattention. Advantages of teaching a specificresponse to delay cues (a commitment in ourtreatment process) versus simply providing thereinforcer after progressively longer delays alsoawait more systematic inquiry, as does theimportance of gradually increasing the durationand developmental complexity of the expect-ations during delay-tolerance training. In all,highly synthetic studies are important forproviding socially meaningful behavior changes,for contributing systematic replications of pub-lished findings, and for occasioning relevantfuture research.Another distinct advantage of empirical syn-

theses is that useful data regarding time and costexpenditures can be determined. Our extrapolat-ed cost analysis showed that severe problembehaviors commonly seen in children withautism can be eliminated while important socialskills are developed, at least in some cases, forbetween roughly $6,000 and $9,000. Given therise in insurance legislation relevant to autismand applied behavior-analytic services (NationalConference of State Legislatures, 2012) and the

32 GREGORY P. HANLEY et al.

current ambiguity regarding how much time andresources are needed to adequately addressproblem behaviors, publication of time andcost assessments from additional behavioralsyntheses will be needed to determine moreaccurate time and cost ranges associated withassessment and treatment of problem behaviorsassociated with autism. These analyses may alsooccasion researcher and practitioner commit-ments to assessment and treatment procedures ofoptimal utility and efficiency.The functional assessment process in the

current study was sufficiently useful for discov-ering via interview and demonstrating viaanalysis one or more functions of the severeproblem behavior of the participating children.The functional analyses differed from mostfunctional analyses in that we manipulatedmultiple contingencies in a single test conditionrather than arranging the analyses to assess theindependent contributions of each contingency.Thus, following Dales and Bobs synthesizedanalyses, it was not known whether theirproblem behavior was exclusively sensitive tonegative reinforcement in the form of escapefrom adult instructions or corrections or sensitiveto positive reinforcement in the form of access topreferred activities or adult attention. Becausethese contingencies were reported to occur inconcert in their homes (and in school for Bob),isolation of these contingencies in a functionalanalysis seemed less important than the assess-ment and treatment of problem behavior in thecontext in which it typically occurred.For instance, when adult instructions or

corrections were terminated at home or school,Bob was then able to engage in his activities inthe manner he apparently preferred. Hisfunctional analysis, which involved arrangingboth positive and negative reinforcement simul-taneously, was clearly analogous to the con-ditions under which his behavior was reportedto occur; arranging single test conditions foreach contingency would not have emulated theconditions described as evoking his problem

behavior. In addition, the synthesized contin-gency analyses for all children detected behav-ioral function at a contextual level and provideda useful baseline from which to teach function-ally equivalent responses and appropriateresponses to reinforcement denial and parentalinstructions. Further support for the synthesizedcontingency analyses used in this study comesfrom the meaningful outcomes produced for allthree participants.The importance of synthesizing contingen-

cies, which has been implied in previous work(e.g., Bowman et al., 1997; Fisher, Adelinis,Thompson, Worsdell, & Zarcone, 1998), was bestdemonstrated in Gails analyses. Her analysescaptured two important interactions: The effect ofthe synthesized contingency depended on themothers implementation of the contingency, andthe effect of each distinct social-positive reinforce-ment contingency (i.e., attention and tangiblecontingencies) depended on the availability ofthe other contingency. It seems reasonable toconclude that the mother established the value ofthe attention and interactive play as a reinforcerfor her daughters problem behavior and thusevoked problem behavior in her presence (seeRingdahl & Sellers, 2000, for a similar effect). Italso seems likely that the presence of toys mayhave abolished the value of attention and that thepresence of attention may have abolished thevalue of the toys so that problem behavior wasevoked when and only when both contingencieswere simultaneously arranged for problem behav-ior. The implication of Gails analysis is thatwhen contingencies are only assessed separately,behavioral function may go undetected. Whencaregivers report multiple changes that occursimultaneously following problem behavior (e.g.,I calm my child down by giving her a toy shelikes and playing with her), it may be prudent toassess both contingencies simultaneously andanalyze the independent effects of the individualelements only when there is a clear reason to doso (e.g., to simplify the treatment or to answer aresearch question).

SEVERE PROBLEM BEHAVIOR 33

The synthesized contingency analyses, indi-vidualized from the interviews with families,allowed us to move to treatment quickly.Treatment sessions required about 90% of theconsultation time, with delay and denial trainingand treatment extension requiring the majorityof the total treatment duration (see Table 1). Thelarge literatures on functional analysis (Beaverset al., 2013; Hanley et al., 2003; Iwata, Pace,Dorsey, et al., 1994) and FCT (Hagopian, Fisher,Sullivan, Acquisto, & LeBlanc, 1998; Tiger,Hanley, & Bruzek, 2008) have allowed greaterefficiency with respect to these assessment andtreatment strategies, but more research is clearlyneeded on teaching children to tolerate delaysand denials of function-based reinforcers and onstrategies for extending treatment to homes andschools. Other additional research is apparentwhen the three primary limitations of our studyare considered: (a) the lack of measures to showthe effect of this assessment and treatmentprocess throughout the day and over an extensiveperiod of time following the consultations, (b)the omission of global measures of functioningbefore and after the consultations, and (c) theomission of additional participants randomlyassigned to receive this particular assessment andtreatment process or to receive traditional care.Greater recognition of and support for highlyefficacious functional assessment and treatmentprocesses is probably dependent on the inclusionof these additional measures in randomizedcontrolled trials in future research.

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Received June 14, 2013Final acceptance November 17, 2013Action Editor, Wayne Fisher

36 GREGORY P. HANLEY et al.