Minimizing Escalation by Treating Dangerous Problem Behavior Within an Enhanced Choice Model
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Behavior Analysis in Practice
https://doi.org/10.1007/s40617-020-00548-2
RESEARCH ARTICLE
Minimizing Escalation by Treating Dangerous Problem Behavior
Within an Enhanced Choice Model
Adithyan Rajaraman 1 & Gregory P. Hanley 2 & Holly C. Gover 2,3 & Johanna L. Staubitz 4 & John E. Staubitz 5 &
Kathleen M. Simcoe 5 & Rachel Metras 2
Accepted: 21 December 2020
# Association for Behavior Analysis International 2021
Abstract
To address dangerous problem behavior exhibited by children while explicitly avoiding physical management procedures, we
systematically replicated and extended the skill-based treatment procedures described by Hanley, Jin, Vanselow, and Hanratty
(2014) by incorporating an enhanced choice model with three children in an outpatient clinic and two in a specialized public
school. In this model, several tactics were simultaneously added to the skill-based treatment package to minimize escalation to
dangerous behavior, the most notable of which involved offering children multiple choice-making opportunities, including the
ongoing options to (a) participate in treatment involving differential reinforcement, (b) “hang out” with noncontingent access to
putative reinforcers, or (c) leave the therapeutic space altogether. Children overwhelmingly chose to participate in treatment,
which resulted in the elimination of problem behavior and the acquisition and maintenance of adaptive skills during lengthy,
challenging periods of nonreinforcement. Implications for the safe implementation of socially valid treatments for problem
behavior are discussed.
Keywords Dangerous problem behavior . Enhanced choice model . Extinction without physical guidance . Practical functional
assessment . Skill-based treatment
Hanley et al. (2014) described a distinct set of assessment and consisted of (a) a practical functional assessment process,
treatment procedures for addressing and improving severe which included an open-ended interview and an interview-
problem behavior exhibited by children. The procedures informed synthesized contingency analysis (IISCA); (b) a
Research Highlights
• Although problem behavior occurred at consistently high rates for all
children during baseline, it was eliminated in treatment, and all children
cooperated with nearly 100% of adult expectations shown to evoke
problem behavior in baseline—a process and outcome deemed highly
satisfactory by caregivers.
• It is possible to achieve socially meaningful outcomes with children who
exhibit dangerous problem behavior without any physical management.
• By committing to open-contingency-class analyses, by offering choices
to clients, and by committing to a hands-off treatment model, practitioners
attempting to treat dangerous problem behavior can do so effectively
without evoking any dangerous behavior during any part of the process.
* Adithyan Rajaraman 3
Ivymount School, Rockville, MD, USA
arajaraman@umbc.edu
4
Department of Special Education, Vanderbilt University,
1
Department of Psychology, UMBC, 1000 Hilltop Cir, Nashville, TN, USA
Baltimore, MD 21250, USA
5
2
Department of Psychology, Western New England University, Department of Pediatrics, Vanderbilt University Medical Center,
Springfield, MA, USA Nashville, TN, USABehav Analysis Practice
skill-based treatment developed from the findings of the prac- to evoke the dangerous topography. Dracobly and Smith
tical functional assessment process; and (c) an extension of (2012), Hoffmann et al. (2018), and Najdowski, Wallace,
treatment procedures and effects to relevant caregivers in the Ellsworth, MacAleese, and Cleveland (2008) extended the
child’s natural environment. The particular set of procedures implications of this notion when they eliminated functionally
reported by Hanley et al. (2014) has since been systematically equivalent dangerous and nondangerous problem behavior
replicated and has contributed to socially meaningful behavior with a function-based treatment informed by the results of
change for many individuals across multiple settings (Beaulieu, functional analyses of precursor behavior. Although early ap-
Nostrand, Williams, & Herscovitch, 2018; Ferguson et al., plications of the IISCA may not have targeted nondangerous
Ferguson et al., in press; Hanley et al., 2014; Herman, Healy, topographies in the contingency class (e.g., Hanley et al.,
& Lydon, 2018; Jessel, Hanley, Ghaemmaghami, & Metras, 2014), recent applications have done so explicitly (e.g.,
2019; Jessel, Ingvarsson, Metras, Kirk, & Whipple, 2018 ; Slaton, Hanley, & Raftery, 2017; Warner et al., 2020).
Jessel, Ingvarsson, Metras, Whipple, et al., 2018; Rose & Second, skill-based treatment involves manipulating a syn-
Beaulieu, 2019; Santiago, Hanley, Moore, & Jin, 2016; thesized reinforcement contingency—shown to influence prob-
Strand & Eldevik, 2018; Taylor, Phillips, & Gertzog, 2018). lem behavior via an IISCA—to systematically and progressive-
Socially meaningful resolution of many different types of dan- ly teach social skills such as communication, toleration, and
gerous problem behavior has been shown to be both possible cooperation with adult instruction. Skill-based treatment is
(Hanley et al., 2014) and probable (Jessel, Ingvarsson, Metras, predicated on differential reinforcement with extinction, where-
Kirk, & Whipple, 2018 ) when the practical functional assess- in the emission of targeted social skills results in the delivery of
ment and skill-based treatment were conducted. all synthesized reinforcers identified in the IISCA, whereas
Despite the success of the process and recent attempts to problem behavior results in extinction. Including extinction in
improve its technology and practicality (e.g., Beaulieu et al., differential reinforcement arrangements has been shown to be
2 01 8; G h a e m m a g h a m i , H a n l e y , & J e s s e l , 20 1 6; efficacious (Iwata, Pace, Kalsher, Cowdery, & Cataldo, 1990;
Ghaemmaghami, Hanley, Jessel, & Landa, 2018), some pro- Lalli et al., 1995; Tiger, Hanley, & Bruzek, 2008; Vollmer &
cedural components of the practical functional assessment and Iwata, 1992) and sometimes necessary (Hagopian, Fisher,
skill-based treatment may not be safe or feasible to replicate Sullivan, Acquisto, & LeBlanc, 1998; Shirley, Iwata, Kahng,
under certain conditions, which could limit the generality of Mazaleski, & Lerman, 1997; Worsdell, Iwata, Hanley,
its effectiveness, the acceptability of its procedures, and there- Thompson, & Kahng, 2000; Zarcone, Iwata, Mazaleski, &
fore the scope of its application. Smith, 1994) in the treatment of dangerous problem behavior.
First, implementation of any functional analysis of severe All successful, socially validated applications of skill-based
problem behavior runs the risk of evoking dangerous behav- treatment involved programmed extinction of problem
ior. This could be problematic when serving clients whose behavior.
behavior poses life-threatening risks. Fortunately, researchers Although efficacious and sometimes necessary, the extinc-
have attempted to address this problem by elucidating the link tion component of treatments for problem behavior can pro-
between dangerous topographies of problem behavior and the duce undesirable collateral effects. When a client’s problem
less dangerous responses with which they co-occur. Over a behavior is placed on extinction, this experience can produce
dozen studies have examined less dangerous “precursor” or response bursting (i.e., immediate increases in the frequency
“co-occurring” behavior and have consistently found that and intensity of problem behavior; Lerman & Iwata, 1995;
these responses are sensitive to the same contingencies as Lerman, Iwata, & Wallace, 1999) or induce other forms of
more dangerous topographies (Borlase, Vladescu, Kisamore, dangerous problem behavior (e.g., aggression; Goh & Iwata,
Reeve, & Fetzer, 2017; Borrero & Borrero, 2008; DeRosa, 1994; Lieving et al., 2004). Even if temporary, undesirable
Roane, Doyle, & McCarthy, 2013; Dracobly & Smith, 2012; collateral effects of extinction procedures may not be tenable
Fritz, Iwata, Hammond, & Bloom, 2013; Harding et al., 2001; in practice, especially when working with large clients or in
Herscovitch, Roscoe, Libby, Bourret, & Ahearn, 2009; settings that lack adequate support to manage extended epi-
Hoffmann, Sellers, Halversen, & Bloom, 2018; Lalli, Casey, sodes of escalation.
& Kates, 1995; Langdon, Carr, & Owen-DeSchryver, 2008; Another element of extinction procedures that may pose
Lieving, Hagopian, Long, & O’Connor, 2004; Magee & Ellis, problems in certain contexts pertains to programming extinc-
2000; Richman, Wacker, Asmus, Casey, & Andelman, 1999; tion for behavior sensitive to escape. Extinction of behavior
Schmidt, Kranak, Goetzel, Kaur, & Rooker, 2020; Smith & that characteristically produces escape from aversive events
Churchill, 2002; Warner et al., 2020). This almost-universal requires that the behavior no longer terminates the aversive
finding suggests that (a) inferences about the function of dan- stimulation (Lattal, St. Peter, & Escobar, 2013). When applied
gerous behavior can be made by analyzing less dangerous to problem behavior in practice, this is commonly achieved by
behavior and (b) functional analyses of dangerous problem continuing to present task demands in the presence of problem
behavior can be conducted successfully without ever needing behavior or contextually inappropriate behavior (e.g.,Behav Analysis Practice
noncooperation) and by escalating prompts until the client reinforcement arrangement. For example, it may be possible to
cooperates with the demand (Iwata et al., 1990). In many eliminate problem behavior and teach communication, tolera-
cases, prompts escalate until physical guidance of the client tion, and cooperation skills with a synthesized contingency by
is necessary to achieve cooperation (Iwata et al., 1990; withholding only positive reinforcers, and not negative rein-
Zarcone, Iwata, Hughes, & Vollmer, 1993; Zarcone, Iwata, forcers, when problem behavior occurs (e.g., Hoch, McComas,
Smith, Mazaleski, & Lerman, 1994). When such procedures Thompson, & Paone, 2002; Piazza et al., 1997).
are not implemented with high integrity, which may occur Thus far in the practical functional assessment and skill-
when problem behavior is erratic, unpredictable, and difficult based treatment literature, no attempt has been made to mod-
to manage, it can lead to adverse treatment effects (St. Peter ify treatment procedures to mitigate the collateral effects of
Pipkin, Vollmer, & Sloman, 2010; Wilder, Atwell, & Wine, extinction and the intrusiveness of potential physical manage-
2006). Thus, although shown to be efficacious in many cases, ment. Given the possibility that such procedures can produce
extinction procedures are intrusive, may be considered inap- deleterious effects, and that this may discourage or altogether
propriate for certain clients (e.g., adults, large individuals, cli- preclude the adoption of these procedures in certain practice
ents with sophisticated language), and have been discouraged settings, an investigation into a modified treatment approach
and even prohibited in certain settings (LaVigna & Donnellan, seems timely and warranted. Therefore, in the present study,
1986). Furthermore, the intrusive nature of physical manage- we examined the possibility of achieving the main effects of
ment procedures may be considered a potential violation of the skill-based treatment reported by Hanley et al. (2014)
client autonomy, which, when coupled with the undesirable while minimizing the negative collateral effects associated
collateral effects of extinction procedures (e.g., induced emo- with certain extinction procedures. More specifically, for chil-
tional responding), could inhibit both the development of a dren who were reported to be highly resistant to any type of
positive therapeutic relationship between the client and ana- physical management or guidance, we examined the possibil-
lyst and the overall acceptability of such procedures. ity of conducting the entire practical functional assessment
Escape extinction with physical guidance was included in and skill-based treatment process while avoiding any physical
all published applications of skill-based treatment in which management of children, and while offering them the ongoing
escape was part of the synthesized contingency (42 out of 55 option to participate in their treatment or not. To investigate
applications, or 76% of cases). Because skill-based treatment this, we systematically replicated the skill-based treatment de-
is a multifaceted intervention approach that typically involves scribed in Hanley et al. (2014) within an enhanced choice
synthesizing positive and negative reinforcement contingen- model. In Study 1, we implemented the model in an outpatient
cies, it remains unclear the extent to which escape extinction clinic with three children. In Study 2, we (a) replicated the
with physical guidance was necessary to achieve the desired model in a specialized public school with two children; (b)
behavioral outcomes. Evidence for its efficacy and necessity extended procedures across relevant people, contexts, and
has, however, been shown elsewhere with respect to isolated time periods; and (c) recruited social validity measures from
reinforcement contingencies (e.g., attention only, escape on- classroom teachers.
ly), thus supporting its inclusion in function-based treatment
packages (e.g., Hagopian et al., 1998).
It is worth noting that many researchers have investigated Study 1: Application of the Enhanced Choice
differential reinforcement procedures that do not include es- Model in an Outpatient Clinic
cape extinction or physical guidance. This most commonly
involves arranging concurrent operants wherein one alterna- Method
tive response produces reinforcement that is greater, along
some dimension, than that which is still produced by problem Participants and Setting
behavior (see Trump, Ayres, Quinland, & Zabala, 2020, for a
review of the literature examining differential reinforcement Study 1 was conducted at a university outpatient clinic.
without extinction). However, the majority of these studies Participants could be enrolled in this study if their referrals
avoided extinction by manipulating parameters of a single, to the clinic included reports of (a) dangerous problem behav-
isolated reinforcer to differentially reinforce a single, alterna- ior that posed imminent harm to individuals or property in the
tive response (e.g., providing a greater duration of escape for a participants’ surrounding environment and (b) escalation in
communicative response than for problem behavior; Athens the intensity and danger of problem behavior when physical
& Vollmer, 2010). That the majority of contingencies identified management was attempted. Three children were referred to
in published skill-based treatment studies synthesized both pos- the clinic by their pediatricians due to severe and worsening
itive and negative reinforcement to teach a complex repertoire of problem behavior in their home or school. Clinic personnel
social skills suggests there is some possible latitude with respect involved in the assessment and treatment process included
to manipulating parameters of extinction within a differential licensed Board Certified Behavior Analysts (BCBAs; www.Behav Analysis Practice
bacb.org) and undergraduate research assistants. Although severe problem behavior whenever things did not go exactly
assessment and treatment of dangerous problem behavior “her way,” including when family members would touch her,
were primary functions of the clinic, personnel were not her toys, and any other preferred items. Allie reportedly en-
certified to implement any physical management procedures. gaged in aggression toward her siblings in the home and
Prior to the onset of the current study, the clinic traditionally would regularly engage in hour-long tantrums even in the
did not serve families of children who had significant histories middle of the night.
with physical restraint procedures; parents were asked to Jackson was a White 4-year-old boy who communicated
manage problem behavior as they typically would if vocally at a developmentally appropriate level with no formal
behavior escalated to a point at which restraint may be diagnosis. Similar to Allie, Jackson also had a limited but
warranted. The caregiver interview and all assessment and idiosyncratic repertoire of preferred activities and manners
treatment sessions were conducted by the BCBA (referred to of playing and required frequent interaction and undivided
as the “analyst” in Study 1). attention from caregivers. Jackson reportedly directed much
A summary of child characteristics can be found in Table 1. of his physical aggression toward his younger sister and also
Jeffrey was a White 9-year-old boy who communicated vo- regularly engaged in extended tantrums in the home.
cally and fluently and was diagnosed with generalized anxiety Jackson’s parents described his problem behavior as “a hair-
disorder and attention-deficit/hyperactivity disorder. Jeffrey trigger reaction to not getting his way.”
attended a general education classroom in a public school. All analysis and treatment sessions were conducted in a
Jeffrey’s parents reported that, although Jeffrey could display small room (4 m × 3 m) at the clinic, equipped with a video
age-typical academic and social skills, episodes of problem camera, a one-way observation mirror, two child-sized tables,
behavior frequently interrupted his capacity to demonstrate two to three chairs, and play and academic materials as nom-
such skills in relevant academic and social contexts. inated in each participant’s caregiver interview. In addition, a
Jeffrey’s academic performance appeared to suffer because small family waiting room (4 m × 3 m) adjacent to the treat-
he resisted help from teachers and caregivers, rendering aca- ment room, equipped with two comfortable chairs and an
demic contexts particularly challenging. He was relatively adult-sized table, was a space wherein participants could
larger and stronger than many of his peers and got into argu- “hang out” if they chose to. Parents were asked to be at the
ments and occasional physical altercations with peers and clinic during all sessions and either watched from behind an
teachers whenever they tried to tell him what to do or when observation mirror or participated in the session.
they did not listen to him. In addition to engaging in physical
aggression in the home and school, Jeffrey was reported to Measurement and Response Definitions
elope to dangerous locations when episodes escalated (e.g.,
into the school parking lot, up a tree). Jeffrey had thus required Data on target responses and relevant environmental events
police intervention at his school on several occasions, which were collected on laptop computers by trained observers.
usually resulted in the further escalation of Jeffrey’s problem Targeted topographies of dangerous and nondangerous prob-
behavior. lem behavior for each child can be found along the y-axis of
Allie was a White 4-year-old girl who communicated vo- the graphs in the right column of Figure 1. For all participants,
cally at a developmentally appropriate level and was diag- target dangerous problem behavior included aggression (e.g.,
nosed with autism spectrum disorder. Allie had a limited but hitting, kicking, shoving, grabbing, biting, scratching) and
idiosyncratic repertoire of preferred activities and manners of disruption (e.g., banging surfaces, throwing objects, tipping
playing and required frequent interaction and undivided atten- or kicking furniture). For Jeffrey and Allie, target dangerous
tion from caregivers. As such, Allie’s mother described her as problem behavior also included elopement, which was de-
being “in charge” at home because she would engage in fined as crossing the threshold of a room without adult
Table 1 Participant
Characteristics Name Age Diagnosis Language level Referred for
(years)
Jeffrey 9 ADHD; generalized Developmentally Aggression, elopement,
anxiety disorder appropriate meltdowns
Allie 4 Autism spectrum disorder Developmentally Aggression, disruption,
appropriate elopement, meltdowns
Jackson 4 None Developmentally Aggression, disruption,
appropriate meltdowns
Note. ADHD = attention-deficit/hyperactivity disorder.Behav Analysis Practice
his head down in his arms or on the table. Allie’s
nondangerous topographies included whining, crossing her
arms, and facial grimacing. Jackson’s nondangerous topogra-
phies included screaming and whining. Child-specific target
functional communication responses (FCRs) and tolerance
responses are listed in Table 2, all of which were scored as
independent only if they occurred absent or at least 5 s re-
moved from an analyst prompt. Rates of participants’ danger-
ous and nondangerous problem behavior; simple, intermedi-
ate (Jackson only), and complex FCRs; and tolerance re-
sponses were calculated by recording the number of indepen-
dent responses emitted and dividing by the number of minutes
elapsed per session.
Percentage engagement in contextually appropriate behav-
ior (CAB; a measure of the extent to which children
cooperated with adult instruction during periods of
nonreinforcement) was calculated by dividing the number of
independent CAB observed by the number of CAB expecta-
tions presented per session, and multiplying that quotient by
100. CAB expectations were those that were presented by the
analyst upon termination of reinforcement or a denial cue.
Instructions posed by the analyst were considered CAB ex-
pectations (e.g., instructions to put items away, demands to
Fig. 1 Results of Interview-Informed Synthesized Contingency Analyses
for Jeffrey (Top Panel), Allie (Middle Panel), and Jackson (Bottom complete academic work, suggestions to find something dif-
Panel). Note. The column on the left displays problem behavior aggre- ferent to play with). CAB was scored if the child cooperated
gated into a single measure per session. The column on the right displays with the specific expectation in place in the absence of prob-
counts of occurrences of individual topographies of problem behavior (y-
lem behavior or noncooperation lasting longer than 10 s (e.g.,
axis labels) that are denoted as either dangerous (black bars) or
nondangerous (gray bars). Topog = topography. putting toys away in 5 s, engaging with academic work with-
out problem behavior).
Total session duration was recorded in seconds, along with
permission. Jeffrey’s nondangerous topographies of problem the duration of each session for which the participant experi-
behavior included swiping items, disruptive vocals (e.g., ar- enced reinforcement. A measure of the duration in which the
guing and cursing above conversational volume), and putting participant experienced the programmed establishing
Table 2 IISCA Outcomes, Target Communicative Responses, and Terminal CAB Requirements in Treatment
Name Synthesized contingency identified SimpleFCR Intermediate ComplexFCR Tolerance Terminal CAB expectation in treatment
FCR response
Jeffrey Escape from writing tasks to iPad, My way — Excuse me . . . That’s cool Average of 5 min of writing paragraphs on
Game Boy, table games, please. May I have with me an analyst-directed topic, with proof-
complimentary attention, and mand my way or I’m reading and editing, while analyst
compliance please? cool with diverted attention to a phone
that.
Allie Escape from cleaning, sharing, or My way — Excuse me . . . OK after Average of 5 min of sharing, turn taking,
playing alone to animal and please. My way taking a playing alone with less preferred toys,
imaginary play toys, interactive please? breath and cleaning up play area
role-play, and mand compliance
Jackson Escape from cleaning, sharing, and More time. Can I have Excuse me . . . OK with Average of 3–5 min of sharing toys, tol-
adult-directed play to balls, table more Can I two erating adult-directed play, and cleaning
games, interactive sports play, and time? please thumbs up play area
mand compliance have more up
time?
Note. IISCA = interview-informed synthesized contingency analysis; FCR = functional communication response; CAB = contextually appropriate
behavior; — = not applicable. Font in italics indicates that which was spoken by the child.Behav Analysis Practice
operation (EO; a period of nonreinforcement) was calculated observed only if they were included in the reinforcement con-
by subtracting the duration in reinforcement from the total tingency. Levels of problem behavior and alternative re-
duration of each session. sponses changed, in predictable directions, in correspondence
Time stamps were recorded on choices made by the child with changes to the reinforcement contingency. In addition, a
to either (a) engage the practice context, (b) enter the hangout reversal design was used to evaluate control over problem
space, or (c) leave the clinic for the day. These data were behavior and the simple FCR for Allie. A contingency rever-
collected on paper data sheets; data collectors started a timer sal for problem behavior was not conducted with Jeffrey and
when the analyst greeted the child’s family upon entering the Jackson because (a) it is not necessary in order to demonstrate
clinic, and noted the time at which each choice was made. control in a multiple-baseline design, especially if there are at
Although children could vocally communicate their choice least three different phases across which an independent var-
to practice, hang out, or leave, the time at which “hang out” iable is evaluated (Kazdin, 2011; Kratochwill et al., 2010); (b)
was chosen was only recorded when they entered the hangout several other treatment-oriented studies have demonstrated
room. The choice to leave was scored when the child vocally the effects of a reinforcement contingency on multiple topog-
indicated that they wanted to leave the clinic for the day. All raphies of prosocial responses in the absence of a reversal
other activities (e.g., participating in practice sessions, picking (Ghaemmaghami et al., 2018; Jessel, Ingvarsson, Metras,
toys, going to the bathroom) were scored as “practice” be- Kirk, & Whipple, 2018 ; Rose & Beaulieu, 2019); and (c) a
cause they were typical of the traditional clinic process. The primary aim of the current study was to minimize the occur-
amount of time that elapsed from the start of the visit to the rence of problem behavior during the process.
time when the child made a particular choice was divided by
the total duration of the visit to derive a proportion measure. Procedures
Individual visit durations were generally 60 min long.
Interobserver agreement (IOA) was calculated for an aver- Practical Functional Assessment Process Each child’s clinic
age of 27% of sessions for all children across analysis and process began with a practical functional assessment
treatment phases (range 26%–30%) by having a trained second (Hanley et al., 2014; Slaton et al., 2017). An open-ended in-
observer simultaneously but independently collect data on all terview (Hanley, 2012) was conducted by the analyst with one
dependent measures. Each session was partitioned into 10-s or more parents, the results of which informed the design of a
intervals, and agreement for each rate-measured target response subsequent IISCA. General procedures for the IISCA closely
(e.g., problem behavior, FCRs), as well as time in reinforce- emulated what was described in Hanley et al. (2014), with the
ment, was calculated by dividing the number of agreements per addition of enhanced choice model procedures (described in
interval by the number of agreements plus disagreements per what follows) for Allie and Jackson.
interval and multiplying by 100. One hundred percent agree- Across interviews for all three children, parents reported
ment was scored if both observers scored zero for any measure that dangerous and nondangerous topographies of problem
in a given interval. The IOA for the choice data per visit (i.e., behavior were likely to be evoked when certain demands were
duration spent in either practice, hangout, or out of clinic) was presented, when access to certain tangibles was terminated,
calculated by dividing the shorter duration of a given choice by when attention was diverted or withheld, and when adults
the longer duration for each visit and multiplying by 100. For did not comply with unique child requests. Furthermore, all
all dependent measures, mean IOA was 98% (range 83%– parents reported that their typical strategy for de-escalating
100%) for Jeffrey, 97% (range 84%–100%) for Allie, and episodes of problem behavior involved relenting on those de-
98% (range 86%–100%) for Jackson. mands, providing tangible items, delivering some attention,
and complying with requests. Each child’s IISCA therefore
Experimental Design involved evaluating a synthesized contingency of escape to
tangibles, attention, and mand compliance across rapidly al-
The independent variable was the synthesized reinforcement ternating, 5-min test (contingency present) and control (con-
contingency identified via the practical functional assessment tingency absent) sessions. The specific topographies of dan-
process. Effects of the reinforcement contingency on problem gerous and nondangerous problem behavior that were eligible
behavior were assessed in a multielement design in the IISCA. for reinforcement in the IISCA, as identified via the interview,
In treatment, the synthesized reinforcement contingency was can be found along the y-axis of the graphs in the right column
progressively applied, along with prompting, to multiple al- of Fig. 1. Specific features of the contingencies tested in each
ternative responses, including FCRs, tolerance responses, and child’s analysis are described in Table 2.
CABs. Treatment evaluation involved a multiple-baseline de-
sign across responses with features unique to a changing- Skill-Based Treatment Procedures in treatment emulated what
criterion design. Functional control was demonstrated when was described in Hanley et al. (2014), in which FCRs, toler-
problem behavior and target alternative responses were ance responses, and CABs were vocally prompted (via aBehav Analysis Practice
most-to-least prompting hierarchy) and differentially rein- sessions with zero problem behavior and consistent emission
forced with the synthesized reinforcers identified in the of target skills during EO periods. Skill-based treatment was
IISCA, and problem behavior was placed on extinction (de- considered complete when two visits elapsed without any
tails of extinction procedures are described in what follows). choices made to hang out or leave the clinic, and when two
FCRs, tolerance responses, and CABs were taught across suc- consecutive sessions occurred with zero problem behavior
cessive treatment phases: functional communication training and consistent emission of target skills during EO periods.
(FCT), tolerance response training, and CAB chaining (anal- To avoid physical management of children and in an effort
ogous to delay-tolerance training in Hanley et al., 2014) to minimize the escalation of problem behavior, typical skill-
respectively. based treatment procedures were modified in four ways.
FCT involved gradual shaping to a terminal, complex FCR First, extinction procedures were adjusted with respect to
by first teaching a simple FCR, then an intermediate (for problem behavior and contextually inappropriate behavior.
Jackson only) FCR (Ghaemmaghami et al., 2018). The analyst While positive reinforcers were withheld (e.g., tangibles, at-
began each session by programming reinforcement for the tention, the opportunity to have requests granted), the escape
child, which involved the provision of tangibles, attention, extinction component did not include any physical guidance.
and mand compliance with no demands presented (see Instead, vocal and gestural prompts were re-presented every
Table 2 for personalized descriptions of reinforcers for each 5–10 s if children engaged in problem behavior or contextu-
child). Then, the analyst interrupted reinforcement with the ally inappropriate behavior (Piazza, Moes, & Fisher, 1996).
imposition of an EO, prompted the target response(s), and Second, whereas presession instruction in Hanley et al.
differentially reinforced its occurrence (with programmed ex- (2014) consisted of behavior skills training in which the target
tinction for problem behavior; details of which are described response was taught, modeled, rehearsed, and critiqued, in the
in what follows). At the beginning of each phase, target re- current model, analysts provided additional details of that
sponse prompts were delivered immediately following the im- which was to occur in the practice context and only conducted
position of the EO and were faded in a most-to-least manner as the rehearsal and feedback portion if the child recruited the
children began to independently emit target responses; how- practice opportunity. Prior to beginning the first session of
ever, vocal and gestural prompts were re-presented every 5– each visit, analysts would (a) discuss progress made during
10 s if children engaged in any problem behavior or contex- the prior visit and (b) describe the current training step, includ-
tually inappropriate behavior. As complex FCRs and toler- ing the most challenging EO that would be programmed and
ance responses were acquired, each continued to be reinforced the specific responses required of the child to produce rein-
on an intermittent, unpredictable schedule, such that FCRs forcement. These procedures were repeated between any ses-
were immediately reinforced during 40% of randomly deter- sions in which changes in response requirements or in the
mined trials, but tolerance responses were required to produce presentation of the EO occurred. Furthermore, the analyst,
reinforcement during the other 60% of trials. In the CAB- child, and parent would review participant performance at
chaining phase, CAB expectations were gradually increased the culmination of the day’s visit. This was an opportunity
in both overall amount and difficulty until a predetermined, for (a) the analyst and caregiver to provide specific praise
terminal goal was met (see terminal CAB expectations in about performance in various situations, (b) the child to dis-
Table 2). Intermittent and unpredictable reinforcement of each cuss and evaluate their own performance, (c) the analyst to
social skill continued during CAB chaining, such that 20% of foreshadow what was to occur during the next visit, and (d)
trials in each session involved reinforcement of the complex the child to ask questions or make requests relevant to the
FCR, 20% of trials involved reinforcement of the tolerance treatment process. Speaking loosely, these procedures were
response following a denial of the FCR, and the remaining included to build rapport and increase transparency between
60% of trials involved at least one CAB expectation following the analyst, child, and parent(s). Although expectations were
the emission of a tolerance response, the order of which was made clear prior to entering the practice context, this did not
randomly determined. affect the intermittency and unpredictability with which rein-
Sessions were 5 min during FCT phases (note that Jeffrey’s forcement was delivered within the session. In other words,
FCT sessions were 10 min in duration). Following FCT, ses- although each child was informed about the most challenging
sions were defined by trials, instead of a fixed duration, to EO to expect in the practice session, they were not told when
accommodate the increasing expectations of the child during to expect it; probabilistic reinforcement was still scheduled for
EO periods. Sessions in tolerance response training and CAB each social skill.
chaining were five trials each, with a trial defined as the pre- Third, options pertaining to CAB expectations during
sentation of the putative EO until the point at which reinforce- the CAB-chaining phase were offered to the child some
ment was delivered or after 30 min had elapsed (the latter of the time (i.e., during approximately 33% of trials in
never occurred). Session duration varied between 4 and 35 which CAB expectations were in place). Providing oppor-
min. Criteria to progress across phases were two consecutive tunities for children to make choices during instruction hasBehav Analysis Practice
been shown to decrease problem behavior and increase granted permission by an adult, this would have been scored
cooperation with instruction (Dunlap et al., 1994; as an instance of elopement, but it would not have precluded
Dunlap, Kern-Dunlap, Clarke, & Robbins, 1991; Powell them from entering the hangout context). If children chose to
& Nelson, 1997; Taylor et al., 2018). Whereas in Hanley hang out, they could bring tangible items with them and they
et al. (2014), adults directed the activities of this entire could interact with available adults. Instructions relevant to
period, in the current model, the analyst occasionally of- the skill building in the practice context (i.e., CAB expecta-
fered the child some options and control over what they tions) were never presented in the hangout context, and par-
engaged with. Options included what to work on (e.g., ticipants were free to enter and exit the space at any time. In
reading vs. writing), where to work (e.g., at the desk vs. other words, noncontingent synthesized reinforcement, in-
on the floor), and how the work would be completed (e.g., cluding all of the categorical reinforcers present in the practice
child writes on their own vs. child dictates and analyst context, was arranged in the hangout context. While in the
writes for them). These trials were included to increase hangout context, the analyst re-presented enhanced choice
the likelihood of CAB engagement and to incorporate child options approximately every 5 min.
feedback during treatment (e.g., Jeffrey sometimes re- Children additionally had the continuously available option
quested to work on challenging math homework even to terminate the day’s visit and leave the clinic. Parents agreed
though his IISCA identified writing tasks to be evocative). to join the analyst in honoring this request at any point during
Choice-making opportunities during CAB chaining were any visit, and neither adult attempted to negotiate with the
programmed only on some trials because, although re- child once the request was made.
search has demonstrated their positive impact on problem Jeffrey’s enrollment in the clinic was originally for partic-
behavior and cooperation, terminal treatment goals speci- ipation in another study, and he therefore experienced typical
fied that children cooperate with CAB expectations that clinic procedures during the IISCA. This involved escape ex-
were exclusively adult directed. tinction with physical guidance for contextually inappropriate
Fourth, because skill-based treatment was embedded in the behavior during IISCA test conditions. These procedures led
enhanced choice model, participants always had the opportu- to the unsafe escalation of problem behavior during the anal-
nity to exit the practice context and either “hang out” or leave ysis, which therefore prompted the development of the en-
the clinic for the day. hanced choice model. He did not have options to hang out
or leave until skill-based treatment began, at which point he
Enhanced Choice Model The practical functional assessment had all three options. Allie’s mother drove a long distance to
and skill-based treatment procedures described previously visit the clinic and therefore requested that we omit the option
were embedded in an enhanced choice model, in which chil- to leave from Allie’s enhanced choice model in both the
dren were offered concurrent, continuously available options IISCA and skill-based treatment. Jackson experienced the en-
to (a) enter the “practice” context in which the aforementioned tire enhanced choice model throughout the IISCA and
skill-based treatment procedures were implemented, (b) enter treatment.
a “hangout” context in a different room in which the evocative
conditions of the treatment context were never present, or (c)
leave the clinic altogether with their parents. During the first Results and Discussion
visit in which enhanced choice procedures were in place, each
child’s analyst showed them the various clinic rooms while Practical Functional Assessment Process
describing the contingency arrangement (i.e., the “rules” in
place in each context). It was conveyed to children that, al- Figure 1 depicts the results of the IISCAs for Jeffrey, Allie,
though the analyst would be presenting evocative events in the and Jackson. In all analyses, problem behavior occurred ex-
practice context and teaching skills under those conditions, clusively in the test condition, demonstrating its sensitivity to
they could go “hang out” or “leave” at any point. At the start a synthesized contingency of escape to tangibles, attention,
of every subsequent visit, children were immediately offered and mand compliance (see Table 2 for participant-specific
these options. contingency descriptions).
There was no particular response required within the prac- The graphs in the right column of Fig. 1 depict counts of
tice context in order to choose to hang out, nor was there any occurrences of dangerous and nondangerous topographies of
contingency programmed between problem behavior and the problem behavior across all test sessions. Allie and Jackson
availability of the hangout space, meaning that children could engaged almost exclusively in nondangerous problem behav-
select “hang out” by either requesting it or simply going to the ior (second and third panels of the right column of Fig. 1).
other room, irrespective of the occurrence of problem behav- Jeffrey engaged in some dangerous problem behavior; how-
ior (note that if Jeffrey or Allie was to have exited the practice ever, the majority of responses observed and reinforced during
room during a session without first requesting and being Jeffrey’s IISCA were nondangerous topographies.Behav Analysis Practice
Skill-Based Treatment contingency, and maintained throughout treatment only if
they continued to be reinforced at least intermittently. This
Jeffrey’s, Allie’s, and Jackson’s treatment processes are can be seen in Figs. 2, 3, and 4, and the responses for
depicted in Figs. 2, 3, and 4, respectively. Problem behavior which reinforcement was arranged across phases are
immediately decreased for all children once the reinforcement highlighted with gray shading. These data suggest func-
contingency was withdrawn. Dangerous problem behavior tional control over targeted social skills by the synthesized
never occurred during any treatment phase for Jeffrey and contingency. As such, simple and intermediate (Jackson
Allie; it occurred a total of three times during Jackson’s treat- only) FCRs were acquired in their respective training
ment. Nondangerous problem behavior also seldomly oc- phases and were subsequently extinguished once they were
curred throughout any participant’s treatment process, and no longer supported by the contingency. By the end of
all problem behavior was eliminated by the end of treatment. skill-based treatment, all participants were consistently
Simple, intermediate (Jackson only), and complex emitting (a) complex FCRs when reinforcement was termi-
FCRs, as well as tolerance responses and CABs, which nated, (b) tolerance responses when FCRs were denied,
all occurred at zero or low levels during baseline, emerged and (c) CABs specific to treatment team goals during pro-
only when they were explicitly included in the synthesized grammed delays to reinforcement.
Fig. 2 Enhanced Choice Model
Treatment Evaluation for Jeffrey.
Note. BL = baseline; FCT =
functional communication
training; TRT = tolerance
response training; FCR =
functional communication
response; CAB = contextually
appropriate behavior. Areas
shaded in gray represent
responses to which the
reinforcement contingency was
applied during each phase.Behav Analysis Practice Fig. 3 Enhanced Choice Model Treatment Evaluation for Allie. Note. BL = baseline; FCT = functional communication training; Simp. = simple; FCR = functional communication response; CAB = contextually appropriate behavior. Areas shaded in gray represent responses to which the reinforcement contingency was applied during each phase. A brief contingency reversal was conducted for Allie Enhanced Choice Model following initial simple FCT during which problem be- havior occurred at a level consistent with baseline per- The bottom panels of Figs. 2, 3, and 4 depict choices made to formance. Upon the return to simple FCT, problem be- either practice, hang out, or leave throughout each visit. Each havior was again eliminated immediately and replaced bar represents a visit to the clinic in which enhanced choice with the simple FCR, providing an additional demonstra- procedures were in place. Each bar in this panel aligns verti- tion of functional control over behavior by the synthe- cally with the performance data of the final session of that sized contingency. day’s visit. The graph is meant to be interpreted as a sort of Session duration and time spent experiencing the EO time lapse, wherein the bottom of each bar represents the start gradually increased throughout CAB chaining for all par- of each visit, and participant experience in either practice, ticipants. Across the final three treatment sessions, the hanging out, or neither (i.e., visit termination) is tracked from average proportion of the session in reinforcement was the bottom to the top. 50%, 54%, and 51% for Jeffrey, Allie, and Jackson, Jeffrey’s participation in the IISCA and skill-based respectively. treatment process was completed in 20 clinic visits
Behav Analysis Practice Fig. 4 Enhanced Choice Model Treatment Evaluation for Jackson. Note. BL = baseline; FCT = functional communication training; Interm. = intermediate; FCR = functional communication response; CAB = contextually appropriate behavior. Areas shaded in gray represent responses to which the reinforcement contingency was applied during each phase. across 10 weeks 5 days. Throughout all visits for which 92% of the time. Jackson chose to hang out 10 times for Jeffrey experienced the enhanced choice model (i.e., in 115 min total, and asked to terminate the visit one time. treatment only), he elected to practice 88% of the time. In summary, at the culmination of skill-based treat- Jeffrey chose to hang out one time for 3 min and asked ment embedded within an enhanced choice model, to terminate the visit four times total. Allie’s participa- Jeffrey, Allie, and Jackson were emitting target social tion in the process was completed in 13 clinic visits skills at the exclusion of problem behavior despite across 6 weeks 2 days. Throughout all visits for which lengthy delays to reinforcement in which CAB expecta- Allie experienced the enhanced choice model (i.e., IISCA tions were in place that were shown to be evocative in and treatment), she elected to practice 99% of the time. baseline. In Study 1, we achieved efficacious outcomes Allie chose to hang out three times for 8 min total. in an outpatient clinic with respect to the problem behav- Jackson’s participation in the process was completed in ior of three children without any escalation of dangerous 30 clinic visits across 10 weeks 4 days. Throughout all behavior or physical management. Furthermore, despite visits for which Jackson experienced the enhanced choice having the continuously available options to consume model (i.e., IISCA and treatment), he elected to practice reinforcers noncontingently or to leave the clinic, all
Behav Analysis Practice
children chose to experience differential reinforcement in assessment and treatment process were considered nondistrict
the practice context a majority of the time. personnel, which meant they were strictly prohibited from
Time constraints and parent availability limited our ability putting hands on any students in the school. Thus, the en-
to systematically extend the procedures and effects of skill- hanced choice model of skill-based treatment was an appro-
based treatment to relevant environments. Furthermore, we priate treatment option for the circumstances. The BCBA and
did not obtain measures of social validity with respect to the analyst came to the school for an average of three 1-hr visits
process and outcomes of the enhanced choice model. To ad- per week throughout the assessment, treatment, and extension
dress these shortcomings and to evaluate the generality of the process.
process’s efficacy, in Study 2 we (a) replicated the process A summary of child characteristics can be found in Table 3.
with two children in a specialized public school; (b) extended Peter was a White 8-year-old boy who communicated vocally
the process and outcomes across relevant people, contexts, and was diagnosed with autism spectrum disorder. At the time
and time periods; and (c) obtained social validity measures this study commenced, Peter had just returned to the special-
from teachers with respect to the practical functional assess- ized school from a general education elementary school be-
ment process, the skill-based treatment, and the extension of cause his problem behavior necessitated a more resource-
its procedures and effects back into the classroom. intensive learning environment. Peter displayed a limited at-
tending repertoire during academic instruction and often en-
gaged in dangerous problem behavior when he was offered
Study 2: Extension of the Enhanced Choice help or redirected back to his school work, which sometimes
Model to a Public School necessitated removal from the classroom for extended periods
of time. Episodes of dangerous problem behavior often in-
Method volved a combination of destruction of furniture and class-
room objects, aggression toward adults, head-directed self-in-
Participants and Setting jurious behavior (SIB), and attempted or actual elopement
from the classroom or school. Peter’s classroom teachers
Study 2 was conducted at a specialized public school serv- and paraprofessionals were concerned that his behavior was
ing children with special needs (Grades K–8). The school continuing to interfere with his learning such that it appeared
administration had contracted BCBAs and research assis- less and less likely that he would successfully reintegrate into
tants (i.e., graduate students in special education with an a general education setting without more intensive support.
emphasis on applied behavior analysis certification) from Hank was a Black 9-year-old boy who communicated vo-
an external agency to provide assessment and treatment cally and fluently and was diagnosed with attention-deficit/
services to certain students with dangerous problem behav- hyperactivity disorder and emotional disturbance. Hank re-
ior. Participants were selected from a list of students (all of portedly seldom cooperated with any academic instruction in
whom met the enrollment criteria specified in Study 1) the months leading up to his enrollment in this study. Similar
based on the extent to which their problem behavior inter- to Jeffrey (Study 1), Hank’s teachers reported that although he
fered with daily classroom activities, the perceived urgen- could display age-typical academic and social skills, episodes
cy with which intensive support was needed, and the extent of problem behavior frequently interrupted his capacity to
to which their classroom teacher was willing to (a) allow demonstrate such skills in relevant academic and social con-
their student to be removed from the class periodically to texts. When asked to transition from preferred activities to
participate in the process and (b) be trained on the proce- engage in academic work, Hank often argued with, yelled,
dures so as to implement them in their classroom. Two and cursed at classroom teachers in a manner that routinely
children were selected and enrolled in Study 2. disrupted class proceedings. This often escalated to dangerous
A BCBA supervised a research assistant in the implemen- aggression toward classroom teachers and paraprofessionals,
tation of the IISCA and skill-based treatment procedures in including attempted stabbing with classroom objects (e.g.,
both cases. The BCBA did not conduct any IISCA or treat- pencils). Hank’s problem behavior was so disruptive and fre-
ment procedures, but they conducted the caregiver interview. quent that at the time this study began, he was earning 10 or
To keep consistent with term usage in Study 1, “analyst” will more min of playtime following a 5-min period without prob-
refer to the research assistant who implemented the IISCA and lem behavior (no work completion was required as part of this
skill-based treatment, and “BCBA” will refer to the behavior contingency). Both participants spent a concerning amount of
analyst who supervised the process. Furthermore, “classroom their school day outside of the classroom due to dangerous
teacher” will refer to the participant’s lead classroom teacher, problem behavior.
and “paraprofessional” will refer to any other caregivers who Assessment and treatment sessions were primarily con-
worked with the participant in their classroom. It is important ducted in the school library, a large, multipurpose room (ap-
to note that the BCBAs and analysts contracted to conduct the proximately 12 m by 8 m) equipped with 8 to 10 tables, aboutBehav Analysis Practice
Table 3 Participant
Characteristics Name Age Diagnosis Language level Referred for
(years)
Peter 8 Autism spectrum Developmentally SIB, aggression, elopement,
disorder appropriate disruption
Hank 9 ADHD; emotional Developmentally Aggression, elopement,
disturbance appropriate noncooperation
Note. ADHD = attention-deficit/hyperactivity disorder; SIB = self-injurious behavior.
20 chairs, large bookshelves along the walls, a small desk with topographies of problem behavior included screaming, hiding
a computer, a chalkboard, a handwashing area, storage bins under furniture, putting his head down in his arms or on the
containing miscellaneous school supplies, and play and aca- table, and facial grimacing. Hank’s nondangerous topogra-
demic materials as nominated in each child’s caregiver inter- phies included ripping materials, disruptive vocals (e.g., argu-
view. The BCBA was also present for all sessions and brought ing and cursing above a conversational volume), and putting
with them video recording equipment and paper data sheets his head down in his arms or on the table. Child-specific target
and pencils for data collection. An additional graduate student FCRs and tolerance responses are listed in Table 4. CAB
was occasionally present in the room as a secondary data engagement was specific to the expectation in place for each
collector. If the school library was not available during a child (see Table 4 for terminal CAB expectations in treatment
scheduled visit, the team conducted sessions in a guidance and extension).
counselor’s office, a smaller room (6 m × 2 m) equipped with IOA was calculated for an average of 61% of sessions for
two tables, four chairs, a bulletin board, two bookshelves, and both children across assessment, treatment, and extension
a filing cabinet. phases (range 47%–73%). The IOA for the rate-measured
Unlike the outpatient clinic model described in Study 1, the target responses was calculated as a total agreement (this is
treatment team did not have reliable access to a second room different from the IOA calculation in Study 1 because data
to serve as a “hangout” space. Instead, using tape on the floor, collectors used paper data sheets instead of computer soft-
they delineated an area of each room with a table and two ware). The IOA for duration measures was calculated in the
chairs and used a red equilateral triangle (sides approximately same way that the choice measures were calculated in Study 1
8 cm in length) made of laminated card stock to signal to the (i.e., total duration IOA). For all dependent measures, mean
child where they could hang out.
Measurement and Response Definitions
Data on target responses, relevant environmental events, and
enhanced choices made were collected on paper data sheets by
trained observers. Recorders used one data sheet each per
session. Video cameras recorded all sessions but were turned
off between sessions to preserve storage space. All target de-
pendent variables recorded in Study 1 were measured and
calculated in the same way in Study 2, with the exception of
the time-stamp data representing enhanced choices made by
the participant. Choice data were added to a more comprehen-
sive data sheet for use in this replication. Due to the constraints
the data sheet imposed on data collection (i.e., that data were
only recorded during a session), and because time in between
sessions was not video recorded, choice data are only reported
within sessions.
Targeted topographies of nondangerous problem behavior Fig. 5 Results of Interview-Informed Synthesized Contingency Analyses
for each child can be found along the y-axis of the graphs in for Peter (Top Panel) and Hank (Bottom Panel). Note. SIB = self-
the right column of Fig. 5. Target dangerous problem behavior injurious behavior. The column on the left displays problem behavior
aggregated into a single measure per session. The column on the right
for Peter included head-directed SIB, aggression, disruption, displays counts of occurrences of individual topographies of problem
and elopement. Target dangerous problem behavior for Hank behavior (y-axis labels) that are denoted as either dangerous (black bars)
included aggression and elopement. Peter’s nondangerous or nondangerous (gray bars). Topog = topography.You can also read
