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Functional Assessment and the Treatment Planning Process

Treatment planning to reduce challenging behavior (e.g., aggression and property destruction) can be complex and requires a prescriptive interprofessional team-based approach. As with other problems that interfere with an individual’s quality of life, such as health issues, the best course of treatment is one that accurately assesses the problem, leads to effective treatment for the issue of concern, and is empirically supported. This is especially important when treating individuals who display challenging behavior which frequently interfere with their opportunities to learn and to live and be educated in less-restrictive settings (Matson, Mayville, & Laud, 2003). The utility of functional behavior assessments (FBAs) and functional analyses (FAs) in the identification of the specific function or purpose of challenging behavior has been embraced commonly by persons charged with supporting individuals who display challenging behavior (e.g., behavior analysts and educators). This is demonstrated by the laws requiring FBAs be conducted when individuals are struggling in educational environments (Individuals with Disabilities Education Improvement Act, 2004) and the belief that the assessments conducted should result in the development of interventions that help preserve the child’s placement in the least restrictive appropriate educational setting. The utility of these assessments has been repeatedly demonstrated in the published literature (e.g., Derby et al., 1992; Iwata, Dorsey, Slifer, Bauman, & Richman, 1994; Kennedy & Souza, 1995; Kern, Childs, Dunlap, Clarke & Falk, 1994; McCord, Thompson, & Iwata, 2001; Ellingson, Miltenberger, Stricker, Galensky, & Garlinghouse, 2000). Several excellent reviews of this extensive literature have been conducted and have independently identified functional analysis and assessment as best practice (e.g., Carr, 1994; Hanley, Iwata, & McCord, 2003).

Research using functional analyses and assessments has demonstrated that challenging behavior is maintained by both social and nonsocial factors (Hanley et al., 2003). In the majority of cases, the challenging behavior of persons have proven functional for the individual by allowing them to obtain desired social reinforcers (positive reinforcement) such as toys or attention (e.g., Kodak, Northup, & Kelly, 2007), to avoid or eliminate aversive events (negative reinforcement) such as instructional demands or proximity to other people (e.g., Moore & Edwards, 2003), and to identify internally occurring (automatic) reinforcers (e.g., Kuhn, DeLeon, Fisher, & Wilke, 1999). Thus, an assessment process that successfully identifies these factors is a powerful tool in providing the members of an individual’s treatment team with the necessary information to choose among potentially effective evidence-based strategies to reduce the individual’s challenging behavior (Horner, 1994).

Why Choose a Function-Based Intervention?

There have been many demonstrations that the identification of function of a person’s challenging behavior can help researchers develop an effective function-based intervention (Kurtz et al., 2003). In addition to functional assessment, federal law (Individuals with Disabilities Education Improvement Act, 2004) also mandates that for individuals demonstrating challenging behavior, the results should be used to identify potentially effective, function-based interventions [e.g., functional communication training (FCT), differential reinforcement of other behavior (DRO), or extinction]. This seems logical given that researchers have demonstrated that function-based interventions are more effective than nonfunction-based or generic interventions. Ingram, Lewis-Palmer, and Sugai (2005), for example, conducted a comprehensive functional assessment for two boys in sixth grade. Based on the results of the FBA, they then compared the effectiveness of a function-based and a nonfunction-based intervention plan. The function-based intervention plan included setting event manipulations, preventative antecedent strategies, behavior teaching, and consequence strategies such as DRO. Whereas, the nonfunction-based plan included strategies not linked to the function of a participant’s challenging behavior. Both plans were then implemented by the student’s teachers within the framework of an ABCBC reversal design. Results showed that the function-based plans produced decreases in challenging behavior, whereas the implementation of the nonfunction-based plans did not result in a clinically significant change in behavior.

In a related study, Newcomer and Lewis (2004) compared function-based interventions to general classroom procedures. Using a multiple baseline across three participants, the researchers demonstrated that function-based interventions produced significant reductions in challenging behavior when compared to baseline and nonfunction-based interventions. Although teachers expressed some concern about the time involved in the assessment process, they rated the use of function-based interventions very positively. Other researchers have demonstrated high-social acceptability (social validity) of and a clear preference by practitioners (e.g., school teachers) for function-based interventions (Ervin, DuPaul, Kern, & Friman, 1998; McLaren & Nelson, 2009; Nahgahgwon, Umbreit, Liaupsin, & Turton, 2010). Given this information, it seems that the use of functional assessment and function-based intervention is the key component in successful treatment planning for the reduction of challenging behavior.

Despite the superiority of function-based interventions to nonfunction-based interventions, the understanding of the necessity and/or the skill of how to move from functional assessment to function-based treatment is still lacking. Several researchers have examined whether function-based interventions are typically used by non-researchers. They also have examined whether practitioners who routinely develop and write behavioral intervention and support plans know how to correctly develop and implement function-based interventions. Two published studies have examined whether, given the correct function of challenging behavior, teachers would choose function-based strategies (Scott et al., 2005; Sugai, Lewis-Palmer, & Hagan, 1998). In both cases, teachers tended to choose nonfunction-based, contraindicated interventions, such as time-out when behavior was described as being maintained by escape or avoidance of low-preference activities (e.g., math and activities of daily living). In an interesting study, Scott et al. (2005) trained key school team members (e.g., school psychologists and teachers) to rigorous criteria on functional assessment and function-based intervention planning. Areas trained included restructuring antecedent conditions, instructional techniques, consequences for positive behavior, and consequences for negative behavior. Thirty-one students were chosen of those referred to the school treatment team due to the display of recurring challenging behavior. With the guidance of a trained facilitator, the school teams determined the function of the challenging behavior based on available assessment information. The teams then created behavior intervention plans based on the hypothesized function of problem behavior for all 31 students. Experts (i.e., persons who had published in the area of functional assessment and intervention) also chose interventions based on the same hypothesized functions. Experts were more likely to identify teaching strategies (e.g., teaching an alternative communication response) and were less likely to identify the need to use reductive strategies (e.g., response cost). School teams included an exclusionary strategy such as time-out in 70% of the interventions developed. In contrast, the experts identified no students who required the use of exclusionary strategies. Despite being trained to rigorous criteria, school personnel continued to select nonfunction-based reductive interventions. There were some limitations to this study such as discrepancy between choices of interventions by the experts. Despite these limitations, however, this study highlights the concern over FBAs leading to well-designed, function-based interventions in the “real world.” These results provide strong support for the need to increase practitioner’s skills in developing and implementing function-based interventions.

Umbreit and his colleagues provide several examples of the use of a decision model (see Umbreit, Ferro, Liaupsin, & Lane, 2007 for complete description of the model) for developing function-based interventions across several ­populations (e.g., Nahgahgwon, et al., 2010; Underwood, Umbreit, & Liaupsin, 2009; Wood, Ferro, Umbreit, & Liaupsin, 2011). The model is designed to facilitate the correct identification of function-based replacement behaviors (e.g., appropriately requesting a break), antecedent arrangements (e.g., visual supports such as a picture activity schedule), and extinction. Underwood et al. (2009) for example, examined the efficacy of the model for the development of a function-based intervention for three adults with intellectual disabilities. The function-based interventions selected using the decision model was effective in reducing the challenging behavior of all three participants. Wood et al. (2011) examined the efficacy of the decision model for three preschool students with intellectual and developmental disabilities. In this study, the student’s teachers actively participated in the development of the intervention; however, the researchers took the lead on the development. For all three participants, interventions chosen using the decision model were very effective in reducing the targeted challenging behavior. Despite the demonstrated effectiveness of the decision model, teachers and family members did not take the lead in the development of the interventions. This, combined with the results of the Scott et al. (2005) study, suggests the further need for increased education and training for practitioners in function-based intervention planning.

The Need for Interprofessional Team Planning

In addition to training, effective treatment planning begins with the selection of key team members or stakeholders. In an editorial in the Journal of Intellectual Disability Research, Holland (2011) described a changing landscape in the development of interventions for individuals with intellectual disabilities. Practitioners and researchers are increasingly recognizing the need for assessment and intervention that are designed by teams which include professionals from multiple disciplines. Although Holland states that there is a great need for multidisciplinary evaluations, he also acknowledges the challenges involved. Given that both biological and environmental variables may contribute to an individual’s challenging behavior, an appropriate, interprofessional team should include experts from the fields of behavior analysis, education (both general and special education teachers), medicine (e.g., nursing, physician, and psychiatry), psychology, support staff (e.g., one-to-one paraprofessionals), family members, and the individual whose challenging behavior is being targeted for reduction whenever possible.

An interprofessional team approach to treatment planning can lead to improved outcomes through systematic evaluation of all variables impacting the individual and a coordinated delivery of care. The work of an interprofessional team is focused on the individual and there is a sense of shared responsibility in the decision-making process. This opportunity for shared decision making allows for increased focus on the integration of disciplines and can lead to innovative interventions for complex problems (Patel, Pratt, & Patel, 2008).

An interprofessional team is in a unique position to evaluate and interpret assessment results and to use the information obtained to develop function-based interventions. All decisions regarding intervention should be based on the most comprehensive data available (Matson et al., 2003). After all contributing factors have been identified, the team can start problem solving to identify an appropriate function-based intervention. Generally, the team begins by identifying effective interventions for setting events or establishing operations. That is, the events which increase the likelihood that the reinforcer for challenging behavior will either be more or less desirable or potent to the individual.

Treatment Planning

In considering how to develop a function-based intervention, it is important to consider all the factors serving to maintain the challenging behavior as well as factors that may make the reinforcer more or less potent (establishing operations/setting events). Additionally, a thorough understanding of positive and negative reinforcement is critical to the designing of an effective intervention. As a general rule, interventions should target each critical variable.

The competing behavior model (O’Neill et al., 1997) is a helpful tool to guide the interprofessional team in the development of a function-based behavior intervention plan (see http://www.pbis.org/common/pbisresources/tools/BSP_Template.doc).

It provides a nice visual representation of the critical variables related to treatment planning. This model identifies (1) setting events, (2) antecedents, (3) replacement behavior, and (4) consequences as the primary targets for intervention. Interventions should be considered based on the factors contributing to the challenging behavior, both distal events and immediate contingencies. The interprofessional team should consider interventions to (1) minimize the impact of setting events, (2) minimize the impact of antecedents, (3) teach replacement skills, and (4) target the consequence events by increasing reinforcement for appropriate behavior (e.g., differential reinforcement) and decreasing reinforcement for targeted challenging behavior (i.e., extinction). By identifying these variables, the interprofessional team can focus on conducting problem solving to identify function-based interventions that matched the function and the contributing variables of the person’s challenging behavior. For example, a substitute teacher (setting event) gave the student a worksheet to complete (antecedent stimulus), which resulted in flopping to the floor (problem behavior), which allowed the student to successfully escape from having to do the math (maintaining consequence). From this scenario, the team then determines the desired behavior, or the behavior in which you would prefer this ­student to engage in and its consequence. For example, the desired behavior is completing a worksheet and the current consequence for that is earning a sticker which is then placed on their sticker chart. Finally, the team identifies a behavior that is an adaptive alternative to the problem behavior that will result in the same maintaining consequence as engaging in the problem ­behavior. For example, requesting a break from math (alternative adaptive behavior) will result in a brief escape from the instructional demand (maintaining consequence).

Essential to the competing behavior model is to identify strategies that make the challenging behavior “irrelevant, ineffective, and inefficient” (O’Neill et al., 1997, p. 66). Identifying and arranging setting events and antecedents so that the challenging behavior would not occur is key in making the problem behavior irrelevant. Any situational and contextual rearrangements might result in a relatively artificial environment for the individual, but helpful in reducing challenging behavior, so it is important to gradually reinstitute any changes that were made gradually and systematically over time. Providing an adaptive alternative to the challenging behavior that is easier to obtain or requires less response effort is key in making the challenging behavior inefficient. An adaptive alternative might include one rudimentary task or gesture which immediately results in the same maintaining consequence as the display of the challenging behavior. Over time the adaptive alternative behavior should be systematically shaped to become more complex and effortful. Withholding the maintaining consequence or reinforcer after the display of challenging behavior is key to making the behavior ineffective. The challenging behavior is placed on extinction. The challenging behavior should no longer result in the maintaining consequence and the individual should be provided with multiple opportunities to engage in the adaptive alternative behavior, which is easier and more quickly results in gaining access to the maintaining consequence. Strategies to ensure that the challenging behavior becomes irrelevant, inefficient, and ineffective should be listed for each of the four major areas of the competing behavior pathways (setting event, antecedent event, problem behavior, and maintaining consequence).

Choosing a Setting Event Intervention

Setting events may sometimes be as simple as a child having a substitute teacher, as described above. Setting events, however, are often events that are related to complex situations (e.g., family instability) or medical concerns (e.g., mental health challenges or an illness such as chronic ear infections). When setting events are successfully identified, they may be the most difficult factors for the interprofessional team to address successfully. The primary goal when designing an intervention for a setting event is to minimize the impact it may have on the antecedent and consequence to the challenging behavior. This is often difficult to do (e.g., changing family interaction styles) and is best accomplished when an interprofessional team including members with varying expertise are involved in the problem-solving process related to treatment plan development. For example, in the case of increased family stressors, such as lack of health insurance and a family member with high medical needs, a social worker might be prepared to assist the family to identify solutions. In another example, in the case of a child experiencing mental health concerns, having a psychiatrist on the interprofessional team may be critical given their expertise in understanding the effects of medication and the empirical research which suggests that for some individuals the combination of a medication and a behavioral intervention might be more effective than either alone (Napolitano et al., 1999). Other examples of setting events might be specific genetic conditions (e.g., Prader–Willi syndrome and Smith–Magenis syndrome). For genetic conditions such as these the inclusion of an expert on the specific condition might be invaluable. Additionally related to behavioral needs and educational difficulties, an expert may have particularly important contributions in the assessment of learning needs related the genetic condition (e.g., persons with Down syndrome generally show higher levels of adaptive behavior in comparison to intellectual ability). While we may not be able to totally eliminate a setting event, understanding the impact it may have on challenging behavior is extremely valuable in planning an effective intervention. Additionally, minimizing its impact may make a significant difference in the ability of the interpersonal team to develop an intervention which produces a clinically significant effect.

Many researchers have described or investigated the impact of setting events and establishing operations on challenging behavior and effective interventions to eliminate or reduce the impact on the challenging behavior. Specific examples include constipation (e.g., Christensen et al., 2009), menstrual pain (Carr & Smith, 1995), psychiatric disorders (e.g., Baker, Blumberg, Freeman, & Wieseler, 2002), medication (e.g., DiCesare, McAdam, Toner, & Varrell, 2005; Northup, Fussilier, Swanson & Borrero, 1997), and social reinforcers such as attention (e.g., Edrisinha, O’Reilly, Sigafoos, Lancioni, & Choi, 2010).

O’Reilly, Lacey, and Lancioni (2000) evaluated the degree to which noise affected challenging behavior of a child with Williams Syndrome. The authors evaluated the effects of noise using a functional analysis. Three conditions (noise in the background, no noise, and noise plus earplugs) were tested. During the demand condition, when noise was present but no earplugs, the child engaged in aggression to avoid instructional demands. When there was no background noise or noise was present, but the child wore earplugs, he engaged in no or low rates of aggression. Based on the assessment results, the authors recommended a quiet instructional environment for the child and guidelines for the use of earplugs to attenuate the effect of environmental noise.

Consider the following example:

Matilda, a 9-year-old girl, has always enjoyed school and generally received good grades. Recently, however, she has struggled in most classes and particularly in math. Although she had no history of being “rude” to adults, over the last few months she has been sent to the principal’s office (often during math) quite frequently for what teachers describe as being “rude, defiant, and unwilling to listen.” Some school personnel are even beginning to wonder if she has Oppositional Defiant Disorder (ODD). She was referred to the school’s assessment team to do a functional assessment and develop an intervention. Based on a functional assessment, which included an analysis of the setting events, antecedents, and consequences maintaining the challenging behavior, it was determined that there were several possible setting events. First, Matilda’s grandmother, who had lived with her family, recently passed away suddenly. Matilda was very close with her grandmother and her grandmother had been a secondary care giver for her when her mother was away on frequent business trips. Additionally, Matilda’s grandmother was a great support for her, especially with school and often supervised her homework completion. She also was able to help provide tutoring of sorts for math, a subject that Matilda has not always been as successful in as her other subjects. Likely related to the recent family stressors with Matilda’s grandmother passing away, her parents have decided to divorce. This is an additional loss for Matilda during an already difficult time. Finally, Matilda’s father reported that several nights a week Matilda has had difficulty sleeping and has been getting up and watching TV in the middle of the night. On the days she has not slept well, data indicate that she is most likely to engage in the challenging behavior.

The example above highlights how complex challenging behavior can be. The setting events identified by the school team are significant and appear to be very difficult, if not impossible to fully eliminate. This is a great example of when an interprofessional team is necessary to treat challenging behavior. Upon review, the interprofessional team determined the following intervention strategies: The social worker determined that it was appropriate to provide some in-home family therapy. This would focus on minimizing the impact of the stressors and specific ways to support Matilda to better cope when she is experiencing difficulties. Matilda’s father said that the family were very interested and in full support of this idea. The psychiatrist determined that it would be appropriate for Matilda to be evaluated for depression and ideally receive counseling focusing on how to better cope with her feelings of loss. The teacher identified opportunities for Matilda to receive tutoring in math at least twice per week from a student teacher. Matilda’s father identified several consistent times that she could do her homework completion when he could provide her with encouragement and tutoring. The nurse identified that Matilda may be in need to have a sleep study, but the team determined that the behavior analyst should help the family with develop and evaluate a behavioral sleep intervention first.

While these interventions cannot eliminate all concerns (i.e., grandmother passing away and parents divorcing), they are designed to minimize the impact of these events on Matilda’s active participation in her educational program. Through the active participation of a carefully constructed interprofessional team Matilda is much better able to cope and more actively participate in her life.

Choosing an Antecedent Intervention

Similar to the goal for setting event intervention, our goal for antecedent intervention is to minimize their impact, modify them, or eliminate them altogether. They also can provide increased structure in the environment (Kern & Clemens, 2007). It is critical that the event preceding or setting the occasion for the challenging behavior have been correctly identified to develop a successful antecedent intervention. Many researchers have demonstrated methods for identifying effective antecedent interventions to decrease the likelihood that challenging behavior will occur. For example if the antecedent is deprivation from attention, how might a situation in which minimal attention is available be made less problematic for the individual? If the antecedent is academic demands (tasks which require hand writing), is there a way to decrease how aversive these are to the individual? A number of researchers have identified interventions that, when the function of the challenging behavior is correctly identified, can be very successful in minimizing the impact of the antecedent on the challenging behavior.

Much research has been conducted on the efficacy of antecedent manipulations on the reduction of challenging behavior. In one example, Mace and Belfiore (1990) demonstrated the efficacy of behavioral momentum to increase compliance and decrease escape-maintained stereotypy in a woman with an intellectual disability. A functional analysis indicated that the stereotypy was maintained by escape from demands. The authors used a high-probability demand sequence followed by a low-probability demand with extinction to increase compliance to demands and decrease stereotypy. This intervention was successful and demonstrated how manipulating antecedent conditions can reduce repetitive escape maintained stereotypic behavior.

Vollmer, Iwata, Zarcone, Smith, and Mazaleski (1993) demonstrated the efficacy of another antecedent intervention, noncontingent reinforcement (NCR) on the self-injurious behavior (SIB) (e.g., head hitting and head banging) of three adult women with intellectual disabilities. A pretreatment functional analysis was conducted for each of the participants and identified attention as a factor-maintaining SIB. Two interventions were then compared, attention provided noncontingently (NCR) and attention provided according to a DRO schedule. The results obtained showed that both interventions were equally successful in reducing SIB. However, the authors argue that NCR was the better intervention option due to a reduced likelihood that the individual will have an extinction burst and the potential ease of implementation.

The clinical efficacy of many other antecedent function-based interventions has been demonstrated in the published literature including matched stimuli, demand fading, and choice. Piazza, Adelinis, Hanley, Goh, and Delia, (2000), for example, demonstrated that matched stimuli was effective in reducing automatically maintained challenging behavior (climbing, saliva manipulation, and hand mouthing) for three individuals with severe developmental disabilities. In another study, Demand fading, an antecedent intervention for escape maintained challenging behavior was demonstrated to be effective in reducing destructive behavior when combined with escape extinction and differential reinforcement (Piazza, Moes, & Fisher, 1996). Choice was demonstrated to be an effective intervention on increasing assignment completion and decreasing noncompliance to complete school assignments (Stenhoff, Davey, & Linugaris/Kraft, 2008).

All of these interventions demonstrate that manipulation of the antecedent variables can be an effective interventions both alone and in combination with other interventions in the reduction of challenging behavior. Now consider our example of Matilda, described above. The antecedent condition which routinely set the occasion for her problem behavior was instructional demands to complete academic assignments, particularly math. The function identified by Matilda’s interprofessional team was social-negative reinforcement in the form of escape or avoidance of academic demands. Based on this information, several of the antecedent interventions described above might be appropriate for Matilda’s interdisciplinary team to evaluate. Demand fading, for example, might be an appropriate intervention to consider. Using this approach, Matilda is initially asked to complete a smaller number of tasks (e.g., single-digit addition problems), then is slowly prompted to complete an increased number of math problems contingent on success. Providing Matilda with the opportunity to choose among several math worksheets might also be effective in providing her with the opportunity to have more control over the aversive instructional situation.

Choosing Replacement/Teaching Strategy/Strategies

While antecedent interventions are very important and effective, they are typically not highly effective in the absence of teaching the individual a new skill. It is important that the new skill taught allows the individual to obtain the same reinforcer which they receive through the display of challenging behavior to promote their long-term success (Carr & Durand, 1985). Additionally, the challenging behavior likely has a history of being extremely functional for the individual. That is, it has served them well to this point; therefore, a replacement behavior that allows the individual to gain access to the same or similar reinforcer has the greatest likelihood of working. For example, a child that throws a pencil at the teacher to get her attention can be reinforced for the absence of throwing pencils; however, what adaptive alternative will the student use to get the teacher’s attention now? Without a better option or skill to communicate their need the child may resort to another challenging behavior.

Some important considerations in teaching replacement skills are first that it must require less response effort than the challenging behavior. Most people would not work an additional 40 h in a week unless there was something they were trying to avoid (e.g., missing a big payroll deadline) or earn (e.g., a monetary bonus). The same concept applies to challenging behavior. An individual who can access what they want through the display of challenging behavior will not typically exert greater effort to use a new skill, despite it yielding the same result as their challenging behavior. Therefore, we must take this into consideration when writing a treatment plan.

Sufficient reinforcement must also be available for the replacement behavior and at a greater rate than for challenging behavior, in the natural environment. An individual may attempt to use a replacement behavior if the reinforcer associated it is more potent than the reinforcer associated with the replacement skill.

Take the following example into consideration:

A child runs out of the classroom for a break. The child is taught to raise his hand and ask for a break when he wants one. He raises his hand appropriately and asks for a break; however, the teacher rarely calls on him. The child gives up on raising his hand and goes back to running out of the classroom.

Although the replacement behavior may not be available in all situations and at all times, it is important to teach something that will be reinforced frequently during the learning phase of implementation. From there, programming for generalization and thinning of the reinforcement schedule can occur after the individual is using the replacement behavior consistently.

FCT is one of the most common replacement behavior interventions. The alternative behavior that is reinforced during FCT is a communication behavior designed to allow the individual to more efficiently access the reinforcer maintaining their challenging behavior. An individual can communicate using a variety of modulates including sign language, pictures communication system such as The Picture Exchange Communication System (PECS), and vocal statements (e.g., talk to me please). Durand and Carr (1991) evaluated the effects of FCT on reducing the challenging behavior (e.g., aggression and SIB) of three boys between 9 and 12 years of age. All three participants had an intellectual disability and engaged in frequent challenging behavior. For two participants, a functional analysis indicated that the reinforcer was to escape demands, while the results of the analysis for the third participant identified both escape from demands and attention as reinforcers for problem behavior. After baseline observation in the natural environment, participants were taught to either request help or attention, based on the results of the functional analysis. The results indicated clinically significant reductions in challenging behavior for all three participants. Two years post the initial intervention, observation indicated that one participant’s challenging behavior had returned to the baseline rate. When a booster session was conducted to help this participant more clearly communicate his requests, challenging behavior again reduced significantly.

Many researchers have examined FCT since the initial studies by Carr and Durand (1985) and Durand and Carr (1991). Fisher, et al. (1993), for example, examined the necessity of extinction and a punishment procedure combined with FCT to reduce challenging behavior. Results were mixed, indicating that some participants were successful with FCT alone, some with FCT  +  extinction, and for some participants the inclusion of a punishment component was a necessary to produce a clinically significant reduction. More recently, Worsdell, Iwata, Hanley, Thompson, and Kahng (2000) determined that errors in the FCT response might result in its ineffectiveness as an intervention; however, the results also suggested that small errors in the implementation of extinction (e.g., occasional reinforcement of an individual’s challenging behavior) may not compromise the effectiveness of FCT.

Consider again our example of Matilda. It was determined that in the context of numerous setting events, given the demand to complete assignments, particularly math, she was likely to engage in inappropriate comments (e.g., being “rude”) for negative reinforcement (i.e., to avoid her work). If we were to develop an intervention for this using FCT we might teach her to request help when she is struggling with a particular problem or to request a short break when she is feeling the task is too difficult.

Choosing Consequence Interventions

To complete the treatment, based on the results of the functional assessment or analysis, it is important to consider how to reduce the likelihood the reinforcer for challenging behavior is available and how to motivate the individual to want to engage in the desired and replacement behaviors.

Extinction

After the interprofessional team has identified the function of the individual’s challenging behavior, they should include extinction in the plan. Extinction is the process of withholding the reinforcer maintaining a student’s challenging behavior. To be successfully implemented, this intervention requires an educational team to conduct a comprehensive functional assessment or analysis. If you do not have a clear understanding of why the person is displaying challenging behavior, you cannot successfully terminate the relationship between the student’s behavior and what he or she gets out of the behavior. For example, if an individual’s challenging behavior occurs to obtain attention (positive reinforcement) from their teacher, extinction would involve withholding attention contingent on challenging behavior. In contrast, if a student displays challenging behavior to get out of difficult academic work (negative reinforcement), extinction would involve preventing them from using their challenging behavior to get out of their work. This might involve continuing to prompt a person to engage in work despite his or her continued resistance or attempts to get out of the activity. The main advantage of extinction is that it is an intervention that is based on the specific reason why an individual displays his or her challenging behavior. Extinction also has several possible limitations. First, an individual may experience an extinction burst. These bursts are commonly occurring phenomena in which the rate or intensity of a person’s challenging behavior may initially increase before decreasing (Lerman, Iwata, & Wallace, 1999). Such behavior can be very problematic for parents or teachers because they may not be able to successfully work with a student during this difficult time. This may be especially true if the individual’s increase in challenging behavior jeopardizes their educational or residential placement or occurs in public places such as the grocery store or on field trips. Additionally, placing one challenging behavior on extinction sometime results in an individual ­displaying forms of challenging of behavior that they have not typically displayed in the past (i.e., extinction-induced resurgence; Lieving, Hagopian, Long, & O’Connor, 2004). Research­ers, for example, have shown that placing SIB such as hand biting on extinction can result in an increase in aggression (Magee & Ellis, 2000). Finally, it might not be realistic to expect people to withhold the reinforcer for a behavior. For example, it might not be possible to physically prompt a child who is very resistant and strong to complete their math and not get out of their chair. The failure to successfully implement extinction can result in a student’s challenging behavior being strengthened. This process of accidentally strengthening behavior is referred to as intermittent reinforcement by behavior analysts (Kendall, 1974). Due to the concerns described above, extinction in real-life settings is very seldom used in isolation; instead it should be used in combination with other behavioral treatment strategies often differential reinforcement of other or alternative behavior (Lerman & Iwata, 1995). Iwata, Pace, Cowdery, and Milternberger (1994) conducted a study which illustrated both the clinical usefulness of extinction and the need to match the extinction procedure used to the function of the individual’s challenging behavior. Three persons with developmental disabilities who engaged in head banging participated in the study. A pretreatment functional analysis demonstrated that the head banging of the three participants was maintained by different consequences (i.e., social attention from other people, escape or avoidance behavior, or automatic reinforcement). Two forms of extinction were implemented for each participant’s head banging and only the form that matched the results of the behavioral function identified in the functional analysis was effective in reducing their SIB.

The use of extinction for our example, Matilda, while difficult, is likely an important component of an effective intervention. The interprofessional team and especially the educational professionals on the team need to determine whether the possible extinction burst from not allowing her to leave the classroom might be able to be tolerated by the educational team members who work with her in the classroom. The implementation of extinction might be necessary to promote Matilda’s understanding that making inappropriate statements to her teacher will no longer be effective in allowing her to leave the classroom. Extinction, combined with the initial lessening of demands and communication instruction to obtain help and/or a break should be effective in eliminating the extinction burst. If the team determines that a potential extinction burst cannot be handled safely in the classroom, alternative strategies should be identified prior to implementation of the plan. For example, since math is the primary work task Matilda is trying to avoid, can she go to a room with few distractions (e.g., less people, no materials associated with high-preference activities in clear view) to complete her work contingent on challenging behavior, rather than to the office?

Differential Reinforcement

Differential reinforcement involves providing reinforcement for a functionally alternative behavior or the absence of a challenging behavior for a predetermined interval of time while minimizing reinforcement for the challenging behavior of concern. Clinical experience suggests that differential reinforcement may be particularly useful when people cannot implement extinction perfectly. There are two commonly used differential reinforcement procedures. Differential reinforcement of other behavior (DRO) involves the ­delivery of a positive consequence (reinforcer) contingent on the absence of a challenging behavior during a predetermined period of time (e.g., 15 min, 1 h). Differential reinforcement of alternative behavior (DRA) involves the delivery of a positive consequence contingent on the display of an alternative response such as compliance or appropriate communication (e.g., asking your teacher to talk to you about a topic in which you have lots of interest, such as baseball). Differential reinforcement procedures should be designed to address the function of an individual’s challenging behavior. That is, the reinforcer identified through the functional assessment process to be maintaining the individual’s challenging behavior should be used to reinforce either the absence of challenging behavior or the display of an alternative behavior. For example, in the case of a child who becomes upset when he or she is asked to do their spelling, a low-preference activity, DRA might consist of having his one-on-one paraprofessional staff provide him with token each time he spells a word without throwing his pencil or hitting his desks. After earning the required tokens, the child then would have the opportunity to exchange his tokens for the opportunity for a break and to engage in a high-preference activity, preferably one identified as high-preference by a preference assessment.

Punishment

Punishment involves the contingent delivery of an item or event that a student find to be at least mildly aversive or the removal of a preferred item or event (Cooper, Heron, & Heward, 2007). Punishment procedures such as time out and response cost, while widely used in natural environments (Peterson & Martens, 1995), can be controversial particularly with individuals perceived as being highly vulnerable (e.g., persons with intellectual disabilities). Accurate identification of the function of challenging behavior increases the likelihood that effective, non-punishment-based interventions should be used to decrease the likelihood that a punishment procedure is necessary (Pelios, Morren, Tesch, & Axelrod, 1999). Unfortunately, recent research (i.e., Scott et al., 2005 described above) has indicated that despite identification of function, educators still chose punishment-based strategies. Additionally, these strategies were often contraindicated of the behavioral function (e.g., time out for negatively reinforced challenging behavior).

While caution should be used when considering a punishment-based strategy, they should not be excluded when appropriate. Interprofessional team members should recognize that there may be instances where the use of punishment-based intervention components may be necessary components of successful interventions (van Houten et al., 1988). Interventions may be more effective with the inclusion of punishment procedures and may even be preferred to non-punishment-based interventions by the individual participating in the intervention (Hanley, Piazza, Fisher, & Maglieri, 2005). Hagopian, Fisher, Sullivan, Acquisito, and LeBlanc (1998) summarized the use of FCT to increase replacement skills for challenging behavior for 21 individuals. Functional analyses were conducted for each participant. Ten participants engaged in challenging behavior for positive reinforcement in the form of attention (nine) or tangible items (one), seven participants engaged in challenging behaviors to escape demands (negative reinforcement), four had mixed results (problem behavior was maintained by both positive and negative reinforcement). While the intervention was very successful for all participants, without the use of extinction or punishment, FCT was not successful for any participant. FCT with extinction was implemented 25 times across 19 participants (some participants challenging behavior was maintained by more than one consequence). FCT combined with extinction initially reduced challenging behavior by 90% for 11 of the 25 participants. The addition of a punishment procedure was necessary for 14 participants to reduce the challenging behavior by 90%. This result was particularly evident when demands were increased and reinforcement was delayed.

When an interprofessional team is considering the use of punishment-based interventions some precautions should be taken. First, the intervention should not be contraindicated to the function of the challenging behavior. That is, if the challenging behavior is maintained by negative reinforcement (e.g., escaping instructional demands) the intervention chosen should not also remove the individual from an environment in which the demands are provided. This would likely compete with the other interventions being implemented. Additionally, adequate reinforcement should be available to maintain the desired or competing behaviors (Lerman & Vorndran, 2002).

Developing a Function-Based Treatment Plan

Once the interprofessional team has determined the interventions to be implemented, a treatment plan must be developed. When developing an intervention plan, the interprofessional team must give careful thought to who will be using the plan and implementing the strategies outlined. Is the plan to be carried out by parents or professionals with training in applied behavior analysis, with little or no training or both? The interprofessional team must carefully tailor the strategies described to match the level of knowledge of the people who will be implementing them to ensure ease of implementation. Functional treatment plans should be easy to read yet include all the key components described above. This includes highlighting important aspects, pointing out details in a concise manner, and using a consistent familiar format (see http://www.pbis.org/common/pbisresources/tools/BSP_Template.doc for one example of a suggested format for a behavior intervention and support plans).

Comprehensive intervention plans should include the following components:

  • What is contributing to this behavior? (Setting events)

  • What happens leading up to this behavior, and what can I do to help with that? (Antecedent interventions)

  • What does the behavior look like? (Behavioral definition)

  • How do I best respond? (Consequence inter-ventions)

Importance of Clarifying Function and Procedures

Often the function of problem behavior is misunderstood by professionals, parents, and support staff who interact with the person on a daily basis. There are several common misinterpretations of problem behavior. First, people might believe that the individual displaying problem behavior is intentionally attempting to manipulate them (e.g., the individual is displaying problem behavior to make other people mad). This can lead to caregivers wanting to implement nonfunctional, consequence-based interventions to establish “control.” Second, people might believe that random events that are correlated with the occurrence of challenging behavior even when the results of functional assessment or analysis has determined there is no relationship between these events and an individual’s problem behavior. For example, an individual who displays challenging behavior often receives attention from others in the form of a shocked or angry verbal reaction or reprimand. These forms of contingent verbal attention might result in people believing that challenging behavior that is actually maintained by social-negative reinforcement in the form of escape or avoidance behavior is maintained by social-positive reinforcement in the form of attention from other people (Thompson & Iwata, 2007). Finally, some people might believe in faulty or nonevidence-based conceptualization of problem behavior (e.g., that escape-maintained behavior is due to a child’s deficits related to the processing of information, stereotypic behavior is due to sensory disregulation). Understanding why the behavior is occurring, or what the function of the behavior is, may help the caregiver intervene more objectively. For example, if a child yells at his teacher to get out of science work specifically, giving the child a math paper to do in place of science will not be appropriate. Understandably, this might be very frustrating for the science teacher though, who might interpret the behavior as aimed at him, rather than occasioned by the class topic. This again is an additional rationale for inclusion of all members of the interprofessional team in assessment and treatment planning.

The professionals and caregivers that implement a plan might not have the same knowledge about variables affecting the challenging behavior as the person writing the plan. This factor illustrates why it is important to state other setting events that may be affecting the behavior, in accordance with the interprofessional team perspectives. Medication side effects, physical pains, trauma, or other nonsocial factors affecting the behavior may provide the caregiver with additional understanding of the factors which set the occasion for a participant’s problem behavior. This may lead to decreased frustration and increased compliance with the implementation of the intervention. Stating this briefly in the beginning of the functional treatment plan will set the stage for the rest of the plan, much as the setting events of the individual set the stage for the problem behavior.

Defining and Measuring Behavior

During the assessment process, a definition of the challenging behavior was developed and methods for measurement created (see Chap. 7). The goal of a functional treatment plan is for all caregivers to respond in a standardized way and to modify the behavior. As such, all persons implementing the plan should be able to identify when a behavior is occurring and when it is not. Defining behavior in an observable way assists in reaching this goal of treatment planning. This should be stated clearly in the beginning of the plan to focus the attention of the behavioral intervention.

It is important that data are collected prior to the intervention (baseline) and during the intervention. This is to determine whether the intervention is successfully reducing the challenging behavior. It is also ideal to empirically evaluate the intervention by briefly withdrawing the intervention then reinstating it to determine whether the intervention is what is causing behavior change.

Implementation

It is important in beginning a new plan that the person(s) responsible for the daily implementation have received some training on basic behavioral principles, factors that maintain challenging behavior, and the purpose of function-based intervention. Additionally, clinical experience suggests that the more professionals and stakeholders who can participate in the assessment and treatment planning process, the more likely the interprofessional team will be invested in the success of the plan. Team members, including parents and teachers, should be encouraged to be active participants in the intervention planning process.

Behavioral Skills Training for Implementation

Following caregiver feedback to the clinician writing the plan, and revising when appropriate, teaching can begin. Plan implementation can be broken down into the steps used in Behavioral Skills Training (BST) (see Miltenberger, 2008 for a complete description). These steps include modeling, instruction, rehearsal, and feedback. BST has been demonstrated to be an effective strategy in teaching others to implement a new skill. Some examples of skills taught using BST include safety skills (Himle, Miltenberger, Gatheridge, & Flessner, 2004), and preventing gun play (Miltenberger et al., 2004), instructional skills at a community setting (Wood, Luiselli, & Harchik, 2007), and discrete trial teaching by staff (Sarakoff & Sturmey, 2004). Using a multiple-baseline design, Sarakoff and Sturmey (2004) demonstrated that BST was a useful strategy for teaching staff to implement discrete trial teaching. Three staff members providing support in the participant’s group home were trained to implement ten key components of discrete trial teaching (e.g., eye contact, providing immediate reinforcement for correct responding) to 100% accuracy. All four components of BST were used, and the discrete-trial teaching skills were acquired quickly. Sarakoff and Sturmey note that the components of the BST intervention package have not been evaluated separately to determine whether it is necessary to use all of the components; however, given the data on the effectiveness of the intervention package and responsible costs associated with it makes good sense to use all the components when teaching people how to implement a behavior intervention plan.

To use BST to train staff to implement a behavior intervention plan, the staff should first have an opportunity to read the description of function, the rationale for writing the plan, and the intervention steps. Modeling the intervention components, by the clinician writing the plan, other members of the interprofessional team or another highly trained staff member is the next step. This step is essential to further problem solve any idiosyncratic aspects of the plan. During the modeling phase, it is essential that the learner (caregiver) is fully dedicated to learning the plan and is not distracted by other factors (e.g., work responsibilities). Once the opportunity for initial observational learning has occurred, additional modeling may need to occur numerous times, until the key stakeholders can implement the plan fluently with few errors. The clinician must be aware throughout the modeling process that both correct and incorrect procedures can be learned by the caregiver, and therefore there must be a high degree of consistency and accuracy in implementation.

Continuing to have the written plan to refer to while the modeling is taking place will help with the instruction. By giving the caregiver a visual representation of the intervention while modeling (written instruction), as well as providing instruction and feedback after modeling has occurred, the caregiver will have multiple opportunities to ask questions about how to implement the plan correctly. The caregiver should be encouraged to rehearse implementation of the plan soon after the modeling has occurred. The clinician should be present at the time of rehearsal, to provide feedback immediately. Feedback, including praise for correct implementation and correcting errors, should occur immediately after rehearsal has occurred. Predetermined criteria for successful implementation should be determined prior to BST and all steps should continue to be used until the criteria are met. Finally, BST should also be implemented in the natural environment, whenever possible, to provide opportunities for modeling, instruction, rehearsal, and feedback in the environment in which the challenging behavior routinely occurs.

Additional Caregiver Training

A similar process can be used to train multiple caregivers in implementing behavior intervention plans. Once lead or primary caregivers such as parents and teachers are trained to preestablished criteria, they can use the process of ­modeling, instruction, rehearsal, and feedback to teach secondary or new caregivers (line staff, grandparents, or support staff). This “train the trainer” model is often necessary when a large number of persons will be implementing the intervention. Consistency of implementation is critical and all persons charged with supporting the individual should be trained to the same criteria. Additionally, it is important to have the primary trainers or clinicians do fidelity checks with all persons implementing the intervention. This may prevent problems with the plan due to lack of fidelity.

Modifications

The need to modify a behavior plan should not be thought of as a setback, but rather an opportunity to clarify the details of intervention components and to conduct additional problem solving by the interprofessional team. First, a check for fidelity of implementation should be conducted. If the plan is being implemented correctly, without anticipated results, the potency of the reinforcers being delivered should be tested (e.g., has the individual become satiated with the reinforcers used?). This is particularly true if a plan initially reduced challenging behavior, but is no longer as effective. In the absence of problems with fidelity and reinforcers, the interprofessional team should problem solve reasons for the lack of success (e.g., has there been a change in important variables, such as change in family situation?) and consider whether additional assessment is necessary.

The published behavioral literature has repeatedly demonstrated the clinical efficacy of a function-based approach to reduce challenging behavior. Crafting a successful, individualized intervention is best accomplished through an interprofessional team problem-solving model which uses function-based intervention planning. Through careful ­problem solving, the interprofessional team may successfully address the various factors which occasion an individual’s problem behavior such as setting events and maintaining consequences.