an interview-informed synthesized contingency …...an interview-informed synthesized contingency...

7
Full Terms & Conditions of access and use can be found at http://www.tandfonline.com/action/journalInformation?journalCode=ipdr20 Developmental Neurorehabilitation ISSN: 1751-8423 (Print) 1751-8431 (Online) Journal homepage: http://www.tandfonline.com/loi/ipdr20 An interview-informed synthesized contingency analysis to inform the treatment of challenging behavior in a young child with autism Ciara Herman, Olive Healy & Sinéad Lydon To cite this article: Ciara Herman, Olive Healy & Sinéad Lydon (2018): An interview-informed synthesized contingency analysis to inform the treatment of challenging behavior in a young child with autism, Developmental Neurorehabilitation, DOI: 10.1080/17518423.2018.1437839 To link to this article: https://doi.org/10.1080/17518423.2018.1437839 Published online: 15 Feb 2018. Submit your article to this journal Article views: 27 View related articles View Crossmark data

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Page 1: An interview-informed synthesized contingency …...An interview-informed synthesized contingency analysis to inform the treatment of challenging behavior in a young child with autism

Full Terms amp Conditions of access and use can be found athttpwwwtandfonlinecomactionjournalInformationjournalCode=ipdr20

Developmental Neurorehabilitation

ISSN 1751-8423 (Print) 1751-8431 (Online) Journal homepage httpwwwtandfonlinecomloiipdr20

An interview-informed synthesized contingencyanalysis to inform the treatment of challengingbehavior in a young child with autism

Ciara Herman Olive Healy amp Sineacutead Lydon

To cite this article Ciara Herman Olive Healy amp Sineacutead Lydon (2018) An interview-informedsynthesized contingency analysis to inform the treatment of challenging behavior in a young childwith autism Developmental Neurorehabilitation DOI 1010801751842320181437839

To link to this article httpsdoiorg1010801751842320181437839

Published online 15 Feb 2018

Submit your article to this journal

Article views 27

View related articles

View Crossmark data

An interview-informed synthesized contingency analysis to inform the treatment ofchallenging behavior in a young child with autismCiara Hermana Olive Healya and Sineacutead Lydonab

aSchool of Psychology Trinity College Dublin Dublin Ireland bDiscipline of General Practice National University of Ireland Galway Ireland

ABSTRACTPurpose Experimental Functional analysis (EFA) is considered the ldquogold standardrdquo of behaviouralassessment and its use is predictive of treatment success However EFA has a number of limitationsincluding its lengthy nature the high level of expertise required and the reinforcement of challengingbehaviour This study aimed to further validate a novel interview-informed synthesised contingencyanalysis (IISCA)Methods An open-ended interview and brief direct observation informed an IISCA for a young boy withautism who engaged in challenging behaviour Resulting data supported the hypothesis that the targetbehaviour was multiply controlled by escape from demands and access to tangible items An interven-tion comprised of most-to-least prompting escape extinction differential reinforcement and a high-probability instruction sequence was evaluated using a reversal designResults This intervention reduced challenging behaviour to low levels and resulted in increasedcomplianceConclusions Findings support the status of the IISCA as a valid practical and effective process fordesigning function-based interventions

ARTICLE HISTORYReceived 10 October 2016Revised 29 January 2018Accepted 4 February 2018

KEYWORDSAutism challengingbehavior functional analysisinterview-informed analysissynthesized contingencyanalysis

Challenging behavior (CB) occurs commonly among personswith autism spectrum disorder (ASD) McTiernan et al1

reported that 937 of a sample of 174 children with ASDpresented with some form of CB CB has been found toimpede quality of life to predict parental stress to reducesocietal inclusion and to negatively impact upon the emo-tional and physical well-being of both the individual and theirfamily23

The effectiveness of interventions based on the science ofApplied Behavior Analysis (ABA) for reducing CB amongpersons with developmental disabilities has been demon-strated for a variety of topographies of CB including self-injurious behavior4 and repetitive stereotyped behavior5

The effectiveness of behavioral interventions is greater whenthey are selected utilizing the results of an experimental func-tional analysis (EFA) than when they are developed withoutregard for behavioral function6ndash8 An EFA is an assessment inwhich environmental variables are systematically manipulatedrelative to a control condition and the effects of these manip-ulations on the rate of the behavior under investigation aremeasured9 This assessment allows for the determination ofenvironmental variables that are contributing to engagementin CB by comparing the rate of behavior during a controlcondition to the test conditions

To date over 400 studies involving individuals with autismutilizing EFAs have been published10 An EFA has beenshown repeatedly to have good internal and external validitythat prescribes successful interventions1112 A meta-analysisof EFA research12 reported interpretable results that could

inform subsequent treatments in 959 of included studiesHowever despite EFArsquos status as the ldquogold standardrdquo of beha-vioral assessment13 p 5 a number of limitations to tradi-tional EFAs have been described These include the lengthynature of the process the high level of expertise required thepossible reinforcement of the target behavior and the pur-ported unsuitability of EFAs for certain behaviors or settings(see14 for a review) These shortcomings have led to thedevelopment and evaluation of a number of variations ofEFA14

Most recently Hanley and colleagues15 have described aninterview-informed synthesized contingency analysis (IISCA)that comprises an open-ended interview that probes for infor-mation on potential maintaining contingencies brief directobservation and a two-condition EFA in lieu of the tradi-tional four or five condition EFA The two-condition EFAincludes one test condition which evaluates the effects of thecontingency believed to maintain the CB and one controlcondition which does not contain the contingency thoughtto maintain the CB If the open-ended interview suggests thatcontingencies are operating simultaneously (ie the behavioris multiply controlled) multiple contingencies are synthesizedinto one test condition Therefore a key feature of the IISCAis that the contingencies that maintain CB are interactive andmay not evoke CB when operating in isolation Hanley et al15

reported on the successful use of the IISCA to assess anddevelop behavioral interventions for several topographies ofCB including verbal and physical aggression Researchershave begun to further evaluate the utility of the IISCA

CONTACT Olive Healy olivehealytcdie School of Psychology Trinity College Dublin College Green Dublin 2 Ireland

DEVELOPMENTAL NEUROREHABILITATIONhttpsdoiorg1010801751842320181437839

copy 2018 Taylor amp Francis

process1617 and these studies have generally yielded positiveoutcomes in terms of reduced assessment duration sociallyvalid reduction of CB and concurrent increases in alternativeappropriate behavior However Fisher and colleagues18 com-pared the outcomes of IISCA to those of a traditional EFAOne of the findings identified low levels of agreement betweenthe outcomes produced by the two forms of EFA and cautionagainst its use without further examination of its validity andthe accuracy of the outcomes that it produces

Thus the aim of the current study was to add to the smallbody of literature to date describing the use of IISCA for theassessment and treatment of CB and to evaluate the effective-ness of interventions designed directly from it Specifically anIISCA was used to assess and inform the treatment of CBexhibited by a young boy diagnosed with ASD and co-occur-ring oppositional defiant disorder

Method

Participant and setting

Dillon was a 46 year old boy diagnosed with ASD and co-occurring oppositional defiant disorder Extant school recordsreported that he presented with a full scale IQ of 66 and anadaptive composite score of 63 according to the Stanford-Binet Intelligence Scale and the Vineland Adaptive BehaviorScales respectively The preschool specialized in the deliveryof ABA educational interventions overseen by a behavioranalyst who held BCBAreg certification Dillon attended 5days per week for 4 h per day He had been receiving thisABA educational provision for 8 months prior to participat-ing in the current study All sessions were conducted inDillonrsquos classroom within the preschool

Response measurement and interobserver agreement

The target behavior in the current study was inappropriatetime spent on the floor defined as dropping to the floor from aseated or standing position andor lying or sitting on thefloor during designated work periods or refusing to stand upwhen asked or prompted to do so Each instance of CB wasseparated by Dillon standing up on both feet Observers used10 s partial interval recording to measure the percentage ofintervals in which the target behavior occurred Compliancewith demands defined as initiation of the requested actionwithin 10 s of the first instruction delivery and completion ofthe request within 30 s of initiation in the absence of CB wasalso measured during the intervention phase A percentage ofcompliance with demands was calculated by dividing the totalnumber of compliant responses by the total number ofdemands multiplied by 100

IOA was assessed by having two observers simultaneouslybut independently collect data on the two target behaviors for100 of sessions during the IISCA and 21 of treatmentsessions Mean agreement coefficients for inappropriate timeon the floor was 986 during the IISCA (range 933ndash100) and 99 during the treatment phase (range 998ndash100) Mean agreement coefficients for compliance were100 during the IISCA and 100 during the treatment phase

Design

The IISCA15 was conducted using a multielement design andan ABAB reversal design was used to evaluate the effects ofthe intervention

Procedure

Interview-informed synthesized contingency analysisThe IISCA15 began with a 45-min observation period duringwhich Dillon was observed engaging in his normal schoolroutine and his tutor was asked to provide and remove pre-ferred tangibles attention and demands The therapist (firstauthor) observed and recorded CB while the tutor interactedwith Dillon Similarly to Hanley et al15 data were collected onthe number of CBs observed functional communicativeresponses emitted tolerance of demands and reinforcementduration Data were also collected on the type of demandsprovided their duration and compliance by Dillon to suchdemands Dillon was observed to drop to the floor consis-tently when demands were presented by the tutor He wouldalways access tangible items while on the floor and spent longperiods in the absence of attention from others He refused tocomply with redirection and did not use any functional com-municative response

Subsequently 20 questions from the open-ended question-naire designed by Hanley [see Appendix in 19] was used toconduct an informal interview with Dillonrsquos teacher that wasfocused on his CB and the circumstances in which it typicallyoccurred The results of the interview suggested that CBoccurred when staff delivered an instruction or interruptedan activity and that both terminating the demand and gainingaccess to a preferred item or activity were maintainingDillonrsquos problem behavior

Preferred tangibles (iPhone a portable DVD player pop-corn playdoh magnet letters and two colored balls) high andlow-probability instructions were identified from a pairedstimulus preference assessment and the open-endedquestionnaire19 Low-probability instructions consisted ofdirections to stand up from the floor and engage in educa-tional activities These instructions were selected fromDillonrsquos current educational plan which showed that he hadnot reached the long-term goals but continued to work on theshort-term objectives toward those goals Low-probabilityinstructions showed a daily percentage of responding ofbelow 80 or incomplete responding as a result of Dillondropping to the floor when the instruction was deliveredThese instructions included a visual task (completing ablock design) labelling objects and a listener task (identifyingobjects in a picture book) The high-probability instructionswere tasks that had previously been in Dillonrsquos educationalplan and were currently targeted as maintenance goals Dailyscores indicated that he continued to respond to these instruc-tions accurately and fluently (80ndash100 within 3 s) Suchtasks included gross motor imitation tasks (do this) and one-step directions (eg clap handstouch nosepoint topick upetc) Preferred tangibles high and low-probability instructionswere the same during the IISCA conditions baseline andintervention phases

2 C HERMAN ET AL

An IISCA was conducted across one school day Sessionswere conducted in 5 min blocks The IISCA alternatedbetween one control condition which was conducted firstand one test condition with the availability of the suspectedreinforcement contingency differentiating between condi-tions In the control condition no demands were made andDillon had uninterrupted access to an array of preferred itemsthroughout the entire session As observation and interviewdata suggested that the behavior was multiply controlled bysources of positive and negative reinforcement the test con-dition presented a synthesized escape and tangible contin-gency These conditions began with a 30 s period ofengagement with tangibles before these were removedFollowing this the therapist presented educational activities(demands) to Dillon Contingent upon the occurrence of CBthe therapist immediately terminated the demand returnedthe tangible items and turned away from Dillon for 30 s

Intervention evaluation

Baseline (A)Five baseline sessions were conducted with each session last-ing 1 h each day During baseline sessions Dillon was pre-sented with educational activities Contingent on CB Dillonwas asked to stand up from the floor however the tutordiscontinued educational activities The instruction to standwas redelivered every minute when Dillon did not complyTangibles that were accessible on the floor were availableAccess to reinforcement (escape and tangibles) continued aslong as Dillon refused to comply

Intervention (B)Intervention sessions were conducted 5 days per week threetimes each day and each session was 1 h in duration At leastone intervention session was conducted at the same time ofday as baseline sessions At the beginning of a session thetherapist removed any preferred tangible items and presenteda high-probability verbal instruction (demands eg ldquoDillonclap your handsrdquo) followed by the delivery of a token con-tingent on compliance (FR1 schedule of reinforcement) Aconditioning program for tokens had been implemented 3months prior to the onset of this study During the interven-tion Dillon gained access to a ldquobreakrdquo away from the educa-tional activity and access to preferred tangibles contingent onearning five tokens for following each verbal instruction pro-vided Tokens were small colored disks placed on a brightlycolored token board with the numbers 1ndash10 A digital timerindicated the end of each 2 min ldquobreakrdquo and the therapistremoved any tangible items and delivered a new demandTwo minute breaks were provided based on the averagetime spent with each reinforcing item during the 45-minobservation period

During intervention sessions differential reinforcementwas utilized If Dillon engaged in the target behavior thetherapist followed him to the floor and immediately re-pre-sented the verbal instruction (demand) Most-to-leastprompting was used to guide Dillon to provide the responseDillon was then asked to ldquostand uprdquo Compliance with theverbal instruction ldquostand uprdquo resulted in both social praise

and delivery of one token If Dillon did not comply with thisinstruction and continued to engage in CB the therapist beganto deliver a sequence of high-probability instructions usingmost-to-least prompting procedures while interspersing thelow-probability verbal demand ldquostand uprdquo Full physical gui-dance was used during most-to-least prompting to allowreinforcement delivery and was faded to partial physical gui-dance and no guidance on the presentation of each successivedemand While engaging in CB most-to-least prompting tofollow the demand earned Dillon one token on a variable ratioschedule of reinforcement (VR5 tokens were delivered forevery 3 5 or 7 correct responses to demands) Contingenton earning five tokens while still engaging in the CB resultedin a 10-s only break without access to any tangible itemsFollowing this 10-s break instructional demands recom-menced This pattern was repeated until Dillon stood up

The type of demand during the session the schedule ofreinforcement and the prompt level utilized was progressivelyaltered during the intervention phase To increase treatmentefficacy the intervention began by utilizing a high-probabilityinstruction sequence a dense schedule of reinforcement forcompliance (FR1) and simultaneous prompting procedures toevoke compliance with demand (Sessions 6ndash47) During thefinal phase of treatment (Sessions 54ndash98) both high-probabil-ity and low-probability instructions a variable schedule ofreinforcement for compliance (VR5) and a three-stepprompting procedure (guided compliance to reduce relianceon physical prompts and allow immediate independentresponding) were utilized Changes to the intervention pack-age were made across sessions following 0ndash10 min of CB and90ndash100 compliance for three consecutive sessions

Staff trainingThe therapist provided training to Dillonrsquos classroom teacherand tutor regarding implementation of the intervention Thistraining was comprised of a detailed review and explanationof the intervention the observation of the therapist imple-menting the procedure with Dillon contingent on the occur-rence of CB the rehearsal of the intervention and datacollection procedures by the staff members and the imple-mentation of the intervention by each staff member over fourconsecutive sessions under the therapistrsquos supervision

Social validity

To determine the acceptability of the intervention packageDillonrsquos teacher and the schoolrsquos BCBAreg completed theTreatment Acceptability Rating Form Revised (TARF-R20)

Results and discussion

Data obtained from the interview and direct observationsupported the hypothesis that Dillonrsquos CB was maintainedby social positive and negative reinforcement contingenciesin the form of escape from demands and access to tangibleitems Figure 1 presents the rates of CB observed across IISCAconditions High rates of CB were observed exclusively in thetest conditions when CB resulted in escape from demands andaccess to tangible items (M = 8667) while CB was at zero

DEVELOPMENTAL NEUROREHABILITATION 3

levels during the control conditions which were free fromdemand and during which preferred tangibles were non-con-tingently available

CB and compliance across the baseline and interventionphases are depicted in Figure 2 During the initial baselinephase high levels of CB (M = 70) and low levels ofcompliance (M = 2921) were observed Across interven-tion sessions CB decreased to lower levels (M = 1739)and compliance increased significantly (M = 8929) Areversal to baseline conditions resulted in an increase inthe level of CB (M = 3991) and a decrease in the levelof compliance (M = 7333) indicating a functional rela-tionship between the intervention and CB When theintervention package was reintroduced the CB decreasedonce again (M = 501) and compliance increased to highlevels (M = 9760) CB remained low and complianceremained high as demands were increased and the rate ofreinforcement with tokens decreased from a FR1 (Session6) to a VR5 (Session 54) and Dillonrsquos classroom teacherand tutor began to serve as therapists (Session 19) and asthe regular classroom schedule was reintroduced(Session 72)

Results from the TARF-R20 completed by Dillonrsquos teacherand the schoolrsquos BCBAreg indicated that the intervention pro-cedures were perceived as highly acceptable by both staffmembers (M = 97) Both staff members reported finding theintervention package acceptable and effective and they alsoindicated a willingness to change their routines in order tocontinue the delivery of the intervention

The primary aim of this research was to add to the smallbody of literature describing the use of the IISCA15 to ascer-tain behavioral function and guide the development of func-tion-based behavioral interventions Data obtained from theIISCA and treatment evaluation conducted for the severe CBof a young boy with ASD and oppositional defiant disorderindicate that the intervention package informed by the resultsof the IISCA was both a socially acceptable and effective

method for decreasing escape behavior and increasing com-pliance Prior to the intervention inappropriate time spent onthe floor often preceded other CB (eg skin picking urina-tion spitting removing shoes and blowing mucous from thenasal cavity) Pre-intervention these instances of severe CBsoccurred more than 30 times per day Post-intervention theseCBs no longer occurred supporting the idea of targetingprecursors to more severe CB in clinical practice21

The findings of the current study replicate and extendprevious work on the efficacy of an IISCA to produce indivi-dualized function-based interventions that cause meaningfulimprovements in CB15ndash17 These findings are positive giventhat researchers and practitioners alike may shy away fromthe other more traditional EFA processes as they may beconsidered time-consuming complex and risky1422 Thisstudy found the IISCA offers a fast practical and reliablemethod to determine the function of CB and to provideguidance for treatment development It may be particularlyuseful when a function-based intervention is promptlyrequired to reduce severe CB Prior to intervention Dillonwas engaging in CB for over half of the school day Hisacademic work program had been placed on hold and thetargeted behavior of dropping to the floor often acted as aprecursor for other serious CBs The expedited IISCA allowedfor the implementation of an intervention and effective reme-diation of the target behaviors as well as a decrease in moredisruptive and dangerous behavior

The current study had several limitations that must benoted First data on the generalization of treatment effectsacross settings (eg in the home in the community) was notcollected so it is not possible to determine if improvements inCB were confined to the school setting in which the interven-tion was delivered Second research2324 has demonstratedgreater treatment efficiency when functional communicationtraining is included within a treatment package Teaching afunctional alternative response to the CB such as a commu-nication response may have decreased the participantrsquos CB

Figure 1 Outcomes of the Interview-informed Synthesised Contingency Analysis for Dillonrsquos challenging behaviour

4 C HERMAN ET AL

more quickly15 and future research should explore this possi-bility Third although the study involved collaboration withmultiple members of Dillonrsquos educational team the super-vising BCBAreg only played a role in the delivery of the inter-vention and not in its design Training staff in theinterpretation of IISCA outcomes and subsequent behavioralinterventions may be important for clinically relevant applica-tions in future Fourth a variable ratio schedule was employedwith token delivery during the intervention However data onthe procedural fidelity of the implementation of this scheduleof reinforcement were not collected and therefore it is difficultto determine how schedule thinning played a role in theintervention package In addition tokens were also deliveredduring most-to-least prompting when the participant wasengaging in CB Token exchange resulted in differential rein-forcement for compliance producing either a 2-min breakwith access to tangibles (no CB occurring) or a 10-s break

with no access to tangibles (CB occurring) It is unclear there-fore whether praise alone would have produced the sameoutcomes Future researchers may consider a componentanalysis to determine which specific variables alter the effec-tiveness of such an intervention Finally this study describedthe IISCA process and intervention for a single participantand therefore the external validity of the results may bequestioned

Fisher and colleagues18 have recommended caution in theutilization of the IISCA as their research suggested low levelsof agreement between IISCA outcomes and those of othertraditional EFAs Additionally they cautioned that theIISCA may overestimate the frequency of multiply controlledbehavior and result in test conditions examining a contin-gency that does not actually maintain CB The targeted beha-vior in the current study was suggested by the IISCA to bemultiply controlled by social positive and negative

Figure 2 Percentage of challenging behaviour (top panel) and compliance (lower panel) across baseline and intervention conditions for Dillon

DEVELOPMENTAL NEUROREHABILITATION 5

reinforcement contingencies and these were synthesizedwithin one test condition within the IISCA While it remainedunknown whether Dillonrsquos CB was exclusively sensitive toeither contingency it was deemed less important to assessthe independent contributions of each contingency andmore important to promptly implement a function-basedintervention to decrease Dillonrsquos severe CB Scholars haveemphasized that the validity of an EFA should be judged bythe success of the intervention that arises from it25 In thisrespect a growing body of research including the currentstudy support the validity of the IISCA However it isimperative that future research further assess the correspon-dence between other types of EFAs and IISCAs and continueto explore the validity of the IISCA through the experimentalevaluation of treatments prescribed by its results

This study contributes to a growing body of literature thatsuggests that the IISCA is a fast practical reliable and effec-tive EFA process that can (a) successfully identify the con-tingency maintaining CB (b) be easily conducted withintypical service settings without any specialized equipmentand (c) be used to design individualized function-basedbehavioral intervention packages that can successfully reduceor eliminate severe CB in individuals with ASD

Declaration of Interest

This research was conducted at Trinity College Dublin the University ofDublin The authors report no conflicts of interest

References

1 McTiernan A Leader G Healy O Mannion A Analysis of riskfactors and early predictors of challenging behavior for childrenwith autism spectrum disorder Res Autism Spectr Disord201151215ndash22 doi101016jrasd201101009

2 Benson PR Coping and psychological adjustment among mothersof children with ASD an accelerated longitudinal study J AutismDev Disord 2014441793ndash807 doi101007s10803-014-2079-9

3 Walsh CE Mulder E Tudor ME Predictors of parent stress in asample of children with ASD pain problem behavior and par-ental coping Res Autism Spectr Disord 20137256ndash64doi101016jrasd201208010

4 Kahng S Iwata BA Lewin AB Behavioral treatment of self-injury1964 to 2000 Am J Ment Retard 2002107212ndash21 doi1013520895-8017(2002)107lt0212BTOSITgt20CO2

5 Mulligan S Healy O Lydon S Moran L Foody C An analysis oftreatment efficacy for stereotyped and repetitive behaviors inautism Rev J Autism Dev Disord 20141143ndash64 doi101007s40489-014-0015-8

6 Campbell JM Efficacy of behavioral interventions for reducingproblem behavior in persons with autism a quantitative synthesisof single-subject research Res Dev Disabil 200324120ndash38doi101016S0891-4222(03)00014-3

7 Didden R Korzilius H Van Oorsouw W Sturmey P Behavioraltreatment of challenging behaviors in individuals with mild men-tal retardation meta-analysis of single-subject research Am JMent Retard 2006111290ndash98 doi1013520895-8017(2006)111[290BTOCBI]20CO2

8 Heyvaert M Saenen L Campbell JM Maes B Onghena PEfficacy of behavioral interventions for reducing problem

behavior in persons with autism an updated quantitative synth-esis of single-subject research Res Dev Disabil 2014352463ndash76doi101016jridd201406017

9 Iwata BA Dorsey MF Slifer KJ Bauman KE Richman GSToward a functional analysis of self injury J Appl Behav Anal199427197ndash209 doi101901jaba199427-197

10 Beavers GA Iwata BA Lerman DC Thirty years of research onthe functional analysis of problem behavior J Appl Behav Anal2013461ndash21 doi101002jabav461

11 Bloom SE Lambert JM Dayton E Samaha AL Teacher con-ducted trial based functional analyses as the basis for interven-tion J Appl Behav Anal 201346208ndash18 doi101002jabav461

12 Hanley GP Iwata BA McCord BE Functional analysis of pro-blem behavior a review J Appl Behav Anal 200336147ndash85doi101901jaba200336-147

13 Delfs CH Campbell JM A quantitative synthesis of developmen-tal disability research the impact of functional assessment meth-odology on treatment effectiveness Behav Anal Today 2010114ndash19 doi101037h0100685

14 Lydon S Healy O OrsquoReilly MF Lang R Variations in functionalanalysis methodology a systematic review J Dev Phys Disabil201224301ndash26 doi101007s10882-012-9267-3

15 Hanley GP Jin CS Vanselow NR Hanratty LA Producing mean-ingful improvements in problem behavior of children with autismvia synthesized analyses and treatments J Appl Behav Anal20144716ndash36 doi101002jaba106

16 Santiago JL Hanley GP Moore K Jin CS The generality ofinterview-informed functional analyses systematic replicationsin school and home J Autism Dev Disord 201646797ndash811doi101007s10803-015-2617-0

17 Jessel J Hanley GP Ghaemmaghami M Interview-informedsynthesized contingency analyses thirty replications and rea-nalysis J Appl Behav Anal 2016491ndash22 doi101002jaba316

18 Fisher WW Greer BD Romani PW Zangrillo AN Owen TMComparisons of synthesized and individual reinforcement contin-gencies during functional analysis J Appl Behav Anal201649596ndash616 doi101002jaba201649issue-3

19 Hanley GP Functional assessment of problem behavior dispellingmyths overcoming implementation obstacles and developingnew lore Behav Anal Pract 2012554ndash72 doi101007BF03391818

20 Reimers TM Wacker DP Cooper LJ Evaluation of the accept-ability of treatments for childrenrsquos behavioral difficulties ratingsby parents receiving services in an outpatient clinic Child FamBehav Ther 19911353ndash71 doi101300J019v13n02_04

21 Smith RG Churchill RM Identification of environmental deter-minants of behavior disorders through functional analysis of pre-cursor behaviors J Appl Behav Anal 200235125ndash36 doi101901jaba200235-125

22 Hanley GP Prevention and treatment of severe problem beha-vior In Mayville E Mulick J editors Behavioral foundationsof effective autism treatment New York NY Sloan 2010 p233ndash55

23 Hagopian LP Fisher WW Sullivan MT Acquisto J LeBlanc LAEffectiveness of functional communication training with andwithout extinction and punishment a summary of 21 inpatientcases J Appl Behav Anal 199831211ndash35 doi101901jaba199831-211

24 Tiger JH Hanley GP Bruzek J Functional communication train-ing a review and practical guide Behav Anal Pract 2008116ndash23doi101007BF03391716

25 Smith RG Iwata BA Vollmer TR Zarcone JR Experimentalanalysis and treatment of multiply controlled self injury J ApplBehav Anal 199326183ndash96 doi101901jaba199326-183

6 C HERMAN ET AL

  • Abstract
  • Method
    • Participant and setting
    • Response measurement and interobserver agreement
    • Design
    • Procedure
      • Interview-informed synthesized contingency analysis
        • Intervention evaluation
          • Baseline (A)
          • Intervention (B)
          • Staff training
            • Social validity
              • Results and discussion
              • Declaration of Interest
              • References
Page 2: An interview-informed synthesized contingency …...An interview-informed synthesized contingency analysis to inform the treatment of challenging behavior in a young child with autism

An interview-informed synthesized contingency analysis to inform the treatment ofchallenging behavior in a young child with autismCiara Hermana Olive Healya and Sineacutead Lydonab

aSchool of Psychology Trinity College Dublin Dublin Ireland bDiscipline of General Practice National University of Ireland Galway Ireland

ABSTRACTPurpose Experimental Functional analysis (EFA) is considered the ldquogold standardrdquo of behaviouralassessment and its use is predictive of treatment success However EFA has a number of limitationsincluding its lengthy nature the high level of expertise required and the reinforcement of challengingbehaviour This study aimed to further validate a novel interview-informed synthesised contingencyanalysis (IISCA)Methods An open-ended interview and brief direct observation informed an IISCA for a young boy withautism who engaged in challenging behaviour Resulting data supported the hypothesis that the targetbehaviour was multiply controlled by escape from demands and access to tangible items An interven-tion comprised of most-to-least prompting escape extinction differential reinforcement and a high-probability instruction sequence was evaluated using a reversal designResults This intervention reduced challenging behaviour to low levels and resulted in increasedcomplianceConclusions Findings support the status of the IISCA as a valid practical and effective process fordesigning function-based interventions

ARTICLE HISTORYReceived 10 October 2016Revised 29 January 2018Accepted 4 February 2018

KEYWORDSAutism challengingbehavior functional analysisinterview-informed analysissynthesized contingencyanalysis

Challenging behavior (CB) occurs commonly among personswith autism spectrum disorder (ASD) McTiernan et al1

reported that 937 of a sample of 174 children with ASDpresented with some form of CB CB has been found toimpede quality of life to predict parental stress to reducesocietal inclusion and to negatively impact upon the emo-tional and physical well-being of both the individual and theirfamily23

The effectiveness of interventions based on the science ofApplied Behavior Analysis (ABA) for reducing CB amongpersons with developmental disabilities has been demon-strated for a variety of topographies of CB including self-injurious behavior4 and repetitive stereotyped behavior5

The effectiveness of behavioral interventions is greater whenthey are selected utilizing the results of an experimental func-tional analysis (EFA) than when they are developed withoutregard for behavioral function6ndash8 An EFA is an assessment inwhich environmental variables are systematically manipulatedrelative to a control condition and the effects of these manip-ulations on the rate of the behavior under investigation aremeasured9 This assessment allows for the determination ofenvironmental variables that are contributing to engagementin CB by comparing the rate of behavior during a controlcondition to the test conditions

To date over 400 studies involving individuals with autismutilizing EFAs have been published10 An EFA has beenshown repeatedly to have good internal and external validitythat prescribes successful interventions1112 A meta-analysisof EFA research12 reported interpretable results that could

inform subsequent treatments in 959 of included studiesHowever despite EFArsquos status as the ldquogold standardrdquo of beha-vioral assessment13 p 5 a number of limitations to tradi-tional EFAs have been described These include the lengthynature of the process the high level of expertise required thepossible reinforcement of the target behavior and the pur-ported unsuitability of EFAs for certain behaviors or settings(see14 for a review) These shortcomings have led to thedevelopment and evaluation of a number of variations ofEFA14

Most recently Hanley and colleagues15 have described aninterview-informed synthesized contingency analysis (IISCA)that comprises an open-ended interview that probes for infor-mation on potential maintaining contingencies brief directobservation and a two-condition EFA in lieu of the tradi-tional four or five condition EFA The two-condition EFAincludes one test condition which evaluates the effects of thecontingency believed to maintain the CB and one controlcondition which does not contain the contingency thoughtto maintain the CB If the open-ended interview suggests thatcontingencies are operating simultaneously (ie the behavioris multiply controlled) multiple contingencies are synthesizedinto one test condition Therefore a key feature of the IISCAis that the contingencies that maintain CB are interactive andmay not evoke CB when operating in isolation Hanley et al15

reported on the successful use of the IISCA to assess anddevelop behavioral interventions for several topographies ofCB including verbal and physical aggression Researchershave begun to further evaluate the utility of the IISCA

CONTACT Olive Healy olivehealytcdie School of Psychology Trinity College Dublin College Green Dublin 2 Ireland

DEVELOPMENTAL NEUROREHABILITATIONhttpsdoiorg1010801751842320181437839

copy 2018 Taylor amp Francis

process1617 and these studies have generally yielded positiveoutcomes in terms of reduced assessment duration sociallyvalid reduction of CB and concurrent increases in alternativeappropriate behavior However Fisher and colleagues18 com-pared the outcomes of IISCA to those of a traditional EFAOne of the findings identified low levels of agreement betweenthe outcomes produced by the two forms of EFA and cautionagainst its use without further examination of its validity andthe accuracy of the outcomes that it produces

Thus the aim of the current study was to add to the smallbody of literature to date describing the use of IISCA for theassessment and treatment of CB and to evaluate the effective-ness of interventions designed directly from it Specifically anIISCA was used to assess and inform the treatment of CBexhibited by a young boy diagnosed with ASD and co-occur-ring oppositional defiant disorder

Method

Participant and setting

Dillon was a 46 year old boy diagnosed with ASD and co-occurring oppositional defiant disorder Extant school recordsreported that he presented with a full scale IQ of 66 and anadaptive composite score of 63 according to the Stanford-Binet Intelligence Scale and the Vineland Adaptive BehaviorScales respectively The preschool specialized in the deliveryof ABA educational interventions overseen by a behavioranalyst who held BCBAreg certification Dillon attended 5days per week for 4 h per day He had been receiving thisABA educational provision for 8 months prior to participat-ing in the current study All sessions were conducted inDillonrsquos classroom within the preschool

Response measurement and interobserver agreement

The target behavior in the current study was inappropriatetime spent on the floor defined as dropping to the floor from aseated or standing position andor lying or sitting on thefloor during designated work periods or refusing to stand upwhen asked or prompted to do so Each instance of CB wasseparated by Dillon standing up on both feet Observers used10 s partial interval recording to measure the percentage ofintervals in which the target behavior occurred Compliancewith demands defined as initiation of the requested actionwithin 10 s of the first instruction delivery and completion ofthe request within 30 s of initiation in the absence of CB wasalso measured during the intervention phase A percentage ofcompliance with demands was calculated by dividing the totalnumber of compliant responses by the total number ofdemands multiplied by 100

IOA was assessed by having two observers simultaneouslybut independently collect data on the two target behaviors for100 of sessions during the IISCA and 21 of treatmentsessions Mean agreement coefficients for inappropriate timeon the floor was 986 during the IISCA (range 933ndash100) and 99 during the treatment phase (range 998ndash100) Mean agreement coefficients for compliance were100 during the IISCA and 100 during the treatment phase

Design

The IISCA15 was conducted using a multielement design andan ABAB reversal design was used to evaluate the effects ofthe intervention

Procedure

Interview-informed synthesized contingency analysisThe IISCA15 began with a 45-min observation period duringwhich Dillon was observed engaging in his normal schoolroutine and his tutor was asked to provide and remove pre-ferred tangibles attention and demands The therapist (firstauthor) observed and recorded CB while the tutor interactedwith Dillon Similarly to Hanley et al15 data were collected onthe number of CBs observed functional communicativeresponses emitted tolerance of demands and reinforcementduration Data were also collected on the type of demandsprovided their duration and compliance by Dillon to suchdemands Dillon was observed to drop to the floor consis-tently when demands were presented by the tutor He wouldalways access tangible items while on the floor and spent longperiods in the absence of attention from others He refused tocomply with redirection and did not use any functional com-municative response

Subsequently 20 questions from the open-ended question-naire designed by Hanley [see Appendix in 19] was used toconduct an informal interview with Dillonrsquos teacher that wasfocused on his CB and the circumstances in which it typicallyoccurred The results of the interview suggested that CBoccurred when staff delivered an instruction or interruptedan activity and that both terminating the demand and gainingaccess to a preferred item or activity were maintainingDillonrsquos problem behavior

Preferred tangibles (iPhone a portable DVD player pop-corn playdoh magnet letters and two colored balls) high andlow-probability instructions were identified from a pairedstimulus preference assessment and the open-endedquestionnaire19 Low-probability instructions consisted ofdirections to stand up from the floor and engage in educa-tional activities These instructions were selected fromDillonrsquos current educational plan which showed that he hadnot reached the long-term goals but continued to work on theshort-term objectives toward those goals Low-probabilityinstructions showed a daily percentage of responding ofbelow 80 or incomplete responding as a result of Dillondropping to the floor when the instruction was deliveredThese instructions included a visual task (completing ablock design) labelling objects and a listener task (identifyingobjects in a picture book) The high-probability instructionswere tasks that had previously been in Dillonrsquos educationalplan and were currently targeted as maintenance goals Dailyscores indicated that he continued to respond to these instruc-tions accurately and fluently (80ndash100 within 3 s) Suchtasks included gross motor imitation tasks (do this) and one-step directions (eg clap handstouch nosepoint topick upetc) Preferred tangibles high and low-probability instructionswere the same during the IISCA conditions baseline andintervention phases

2 C HERMAN ET AL

An IISCA was conducted across one school day Sessionswere conducted in 5 min blocks The IISCA alternatedbetween one control condition which was conducted firstand one test condition with the availability of the suspectedreinforcement contingency differentiating between condi-tions In the control condition no demands were made andDillon had uninterrupted access to an array of preferred itemsthroughout the entire session As observation and interviewdata suggested that the behavior was multiply controlled bysources of positive and negative reinforcement the test con-dition presented a synthesized escape and tangible contin-gency These conditions began with a 30 s period ofengagement with tangibles before these were removedFollowing this the therapist presented educational activities(demands) to Dillon Contingent upon the occurrence of CBthe therapist immediately terminated the demand returnedthe tangible items and turned away from Dillon for 30 s

Intervention evaluation

Baseline (A)Five baseline sessions were conducted with each session last-ing 1 h each day During baseline sessions Dillon was pre-sented with educational activities Contingent on CB Dillonwas asked to stand up from the floor however the tutordiscontinued educational activities The instruction to standwas redelivered every minute when Dillon did not complyTangibles that were accessible on the floor were availableAccess to reinforcement (escape and tangibles) continued aslong as Dillon refused to comply

Intervention (B)Intervention sessions were conducted 5 days per week threetimes each day and each session was 1 h in duration At leastone intervention session was conducted at the same time ofday as baseline sessions At the beginning of a session thetherapist removed any preferred tangible items and presenteda high-probability verbal instruction (demands eg ldquoDillonclap your handsrdquo) followed by the delivery of a token con-tingent on compliance (FR1 schedule of reinforcement) Aconditioning program for tokens had been implemented 3months prior to the onset of this study During the interven-tion Dillon gained access to a ldquobreakrdquo away from the educa-tional activity and access to preferred tangibles contingent onearning five tokens for following each verbal instruction pro-vided Tokens were small colored disks placed on a brightlycolored token board with the numbers 1ndash10 A digital timerindicated the end of each 2 min ldquobreakrdquo and the therapistremoved any tangible items and delivered a new demandTwo minute breaks were provided based on the averagetime spent with each reinforcing item during the 45-minobservation period

During intervention sessions differential reinforcementwas utilized If Dillon engaged in the target behavior thetherapist followed him to the floor and immediately re-pre-sented the verbal instruction (demand) Most-to-leastprompting was used to guide Dillon to provide the responseDillon was then asked to ldquostand uprdquo Compliance with theverbal instruction ldquostand uprdquo resulted in both social praise

and delivery of one token If Dillon did not comply with thisinstruction and continued to engage in CB the therapist beganto deliver a sequence of high-probability instructions usingmost-to-least prompting procedures while interspersing thelow-probability verbal demand ldquostand uprdquo Full physical gui-dance was used during most-to-least prompting to allowreinforcement delivery and was faded to partial physical gui-dance and no guidance on the presentation of each successivedemand While engaging in CB most-to-least prompting tofollow the demand earned Dillon one token on a variable ratioschedule of reinforcement (VR5 tokens were delivered forevery 3 5 or 7 correct responses to demands) Contingenton earning five tokens while still engaging in the CB resultedin a 10-s only break without access to any tangible itemsFollowing this 10-s break instructional demands recom-menced This pattern was repeated until Dillon stood up

The type of demand during the session the schedule ofreinforcement and the prompt level utilized was progressivelyaltered during the intervention phase To increase treatmentefficacy the intervention began by utilizing a high-probabilityinstruction sequence a dense schedule of reinforcement forcompliance (FR1) and simultaneous prompting procedures toevoke compliance with demand (Sessions 6ndash47) During thefinal phase of treatment (Sessions 54ndash98) both high-probabil-ity and low-probability instructions a variable schedule ofreinforcement for compliance (VR5) and a three-stepprompting procedure (guided compliance to reduce relianceon physical prompts and allow immediate independentresponding) were utilized Changes to the intervention pack-age were made across sessions following 0ndash10 min of CB and90ndash100 compliance for three consecutive sessions

Staff trainingThe therapist provided training to Dillonrsquos classroom teacherand tutor regarding implementation of the intervention Thistraining was comprised of a detailed review and explanationof the intervention the observation of the therapist imple-menting the procedure with Dillon contingent on the occur-rence of CB the rehearsal of the intervention and datacollection procedures by the staff members and the imple-mentation of the intervention by each staff member over fourconsecutive sessions under the therapistrsquos supervision

Social validity

To determine the acceptability of the intervention packageDillonrsquos teacher and the schoolrsquos BCBAreg completed theTreatment Acceptability Rating Form Revised (TARF-R20)

Results and discussion

Data obtained from the interview and direct observationsupported the hypothesis that Dillonrsquos CB was maintainedby social positive and negative reinforcement contingenciesin the form of escape from demands and access to tangibleitems Figure 1 presents the rates of CB observed across IISCAconditions High rates of CB were observed exclusively in thetest conditions when CB resulted in escape from demands andaccess to tangible items (M = 8667) while CB was at zero

DEVELOPMENTAL NEUROREHABILITATION 3

levels during the control conditions which were free fromdemand and during which preferred tangibles were non-con-tingently available

CB and compliance across the baseline and interventionphases are depicted in Figure 2 During the initial baselinephase high levels of CB (M = 70) and low levels ofcompliance (M = 2921) were observed Across interven-tion sessions CB decreased to lower levels (M = 1739)and compliance increased significantly (M = 8929) Areversal to baseline conditions resulted in an increase inthe level of CB (M = 3991) and a decrease in the levelof compliance (M = 7333) indicating a functional rela-tionship between the intervention and CB When theintervention package was reintroduced the CB decreasedonce again (M = 501) and compliance increased to highlevels (M = 9760) CB remained low and complianceremained high as demands were increased and the rate ofreinforcement with tokens decreased from a FR1 (Session6) to a VR5 (Session 54) and Dillonrsquos classroom teacherand tutor began to serve as therapists (Session 19) and asthe regular classroom schedule was reintroduced(Session 72)

Results from the TARF-R20 completed by Dillonrsquos teacherand the schoolrsquos BCBAreg indicated that the intervention pro-cedures were perceived as highly acceptable by both staffmembers (M = 97) Both staff members reported finding theintervention package acceptable and effective and they alsoindicated a willingness to change their routines in order tocontinue the delivery of the intervention

The primary aim of this research was to add to the smallbody of literature describing the use of the IISCA15 to ascer-tain behavioral function and guide the development of func-tion-based behavioral interventions Data obtained from theIISCA and treatment evaluation conducted for the severe CBof a young boy with ASD and oppositional defiant disorderindicate that the intervention package informed by the resultsof the IISCA was both a socially acceptable and effective

method for decreasing escape behavior and increasing com-pliance Prior to the intervention inappropriate time spent onthe floor often preceded other CB (eg skin picking urina-tion spitting removing shoes and blowing mucous from thenasal cavity) Pre-intervention these instances of severe CBsoccurred more than 30 times per day Post-intervention theseCBs no longer occurred supporting the idea of targetingprecursors to more severe CB in clinical practice21

The findings of the current study replicate and extendprevious work on the efficacy of an IISCA to produce indivi-dualized function-based interventions that cause meaningfulimprovements in CB15ndash17 These findings are positive giventhat researchers and practitioners alike may shy away fromthe other more traditional EFA processes as they may beconsidered time-consuming complex and risky1422 Thisstudy found the IISCA offers a fast practical and reliablemethod to determine the function of CB and to provideguidance for treatment development It may be particularlyuseful when a function-based intervention is promptlyrequired to reduce severe CB Prior to intervention Dillonwas engaging in CB for over half of the school day Hisacademic work program had been placed on hold and thetargeted behavior of dropping to the floor often acted as aprecursor for other serious CBs The expedited IISCA allowedfor the implementation of an intervention and effective reme-diation of the target behaviors as well as a decrease in moredisruptive and dangerous behavior

The current study had several limitations that must benoted First data on the generalization of treatment effectsacross settings (eg in the home in the community) was notcollected so it is not possible to determine if improvements inCB were confined to the school setting in which the interven-tion was delivered Second research2324 has demonstratedgreater treatment efficiency when functional communicationtraining is included within a treatment package Teaching afunctional alternative response to the CB such as a commu-nication response may have decreased the participantrsquos CB

Figure 1 Outcomes of the Interview-informed Synthesised Contingency Analysis for Dillonrsquos challenging behaviour

4 C HERMAN ET AL

more quickly15 and future research should explore this possi-bility Third although the study involved collaboration withmultiple members of Dillonrsquos educational team the super-vising BCBAreg only played a role in the delivery of the inter-vention and not in its design Training staff in theinterpretation of IISCA outcomes and subsequent behavioralinterventions may be important for clinically relevant applica-tions in future Fourth a variable ratio schedule was employedwith token delivery during the intervention However data onthe procedural fidelity of the implementation of this scheduleof reinforcement were not collected and therefore it is difficultto determine how schedule thinning played a role in theintervention package In addition tokens were also deliveredduring most-to-least prompting when the participant wasengaging in CB Token exchange resulted in differential rein-forcement for compliance producing either a 2-min breakwith access to tangibles (no CB occurring) or a 10-s break

with no access to tangibles (CB occurring) It is unclear there-fore whether praise alone would have produced the sameoutcomes Future researchers may consider a componentanalysis to determine which specific variables alter the effec-tiveness of such an intervention Finally this study describedthe IISCA process and intervention for a single participantand therefore the external validity of the results may bequestioned

Fisher and colleagues18 have recommended caution in theutilization of the IISCA as their research suggested low levelsof agreement between IISCA outcomes and those of othertraditional EFAs Additionally they cautioned that theIISCA may overestimate the frequency of multiply controlledbehavior and result in test conditions examining a contin-gency that does not actually maintain CB The targeted beha-vior in the current study was suggested by the IISCA to bemultiply controlled by social positive and negative

Figure 2 Percentage of challenging behaviour (top panel) and compliance (lower panel) across baseline and intervention conditions for Dillon

DEVELOPMENTAL NEUROREHABILITATION 5

reinforcement contingencies and these were synthesizedwithin one test condition within the IISCA While it remainedunknown whether Dillonrsquos CB was exclusively sensitive toeither contingency it was deemed less important to assessthe independent contributions of each contingency andmore important to promptly implement a function-basedintervention to decrease Dillonrsquos severe CB Scholars haveemphasized that the validity of an EFA should be judged bythe success of the intervention that arises from it25 In thisrespect a growing body of research including the currentstudy support the validity of the IISCA However it isimperative that future research further assess the correspon-dence between other types of EFAs and IISCAs and continueto explore the validity of the IISCA through the experimentalevaluation of treatments prescribed by its results

This study contributes to a growing body of literature thatsuggests that the IISCA is a fast practical reliable and effec-tive EFA process that can (a) successfully identify the con-tingency maintaining CB (b) be easily conducted withintypical service settings without any specialized equipmentand (c) be used to design individualized function-basedbehavioral intervention packages that can successfully reduceor eliminate severe CB in individuals with ASD

Declaration of Interest

This research was conducted at Trinity College Dublin the University ofDublin The authors report no conflicts of interest

References

1 McTiernan A Leader G Healy O Mannion A Analysis of riskfactors and early predictors of challenging behavior for childrenwith autism spectrum disorder Res Autism Spectr Disord201151215ndash22 doi101016jrasd201101009

2 Benson PR Coping and psychological adjustment among mothersof children with ASD an accelerated longitudinal study J AutismDev Disord 2014441793ndash807 doi101007s10803-014-2079-9

3 Walsh CE Mulder E Tudor ME Predictors of parent stress in asample of children with ASD pain problem behavior and par-ental coping Res Autism Spectr Disord 20137256ndash64doi101016jrasd201208010

4 Kahng S Iwata BA Lewin AB Behavioral treatment of self-injury1964 to 2000 Am J Ment Retard 2002107212ndash21 doi1013520895-8017(2002)107lt0212BTOSITgt20CO2

5 Mulligan S Healy O Lydon S Moran L Foody C An analysis oftreatment efficacy for stereotyped and repetitive behaviors inautism Rev J Autism Dev Disord 20141143ndash64 doi101007s40489-014-0015-8

6 Campbell JM Efficacy of behavioral interventions for reducingproblem behavior in persons with autism a quantitative synthesisof single-subject research Res Dev Disabil 200324120ndash38doi101016S0891-4222(03)00014-3

7 Didden R Korzilius H Van Oorsouw W Sturmey P Behavioraltreatment of challenging behaviors in individuals with mild men-tal retardation meta-analysis of single-subject research Am JMent Retard 2006111290ndash98 doi1013520895-8017(2006)111[290BTOCBI]20CO2

8 Heyvaert M Saenen L Campbell JM Maes B Onghena PEfficacy of behavioral interventions for reducing problem

behavior in persons with autism an updated quantitative synth-esis of single-subject research Res Dev Disabil 2014352463ndash76doi101016jridd201406017

9 Iwata BA Dorsey MF Slifer KJ Bauman KE Richman GSToward a functional analysis of self injury J Appl Behav Anal199427197ndash209 doi101901jaba199427-197

10 Beavers GA Iwata BA Lerman DC Thirty years of research onthe functional analysis of problem behavior J Appl Behav Anal2013461ndash21 doi101002jabav461

11 Bloom SE Lambert JM Dayton E Samaha AL Teacher con-ducted trial based functional analyses as the basis for interven-tion J Appl Behav Anal 201346208ndash18 doi101002jabav461

12 Hanley GP Iwata BA McCord BE Functional analysis of pro-blem behavior a review J Appl Behav Anal 200336147ndash85doi101901jaba200336-147

13 Delfs CH Campbell JM A quantitative synthesis of developmen-tal disability research the impact of functional assessment meth-odology on treatment effectiveness Behav Anal Today 2010114ndash19 doi101037h0100685

14 Lydon S Healy O OrsquoReilly MF Lang R Variations in functionalanalysis methodology a systematic review J Dev Phys Disabil201224301ndash26 doi101007s10882-012-9267-3

15 Hanley GP Jin CS Vanselow NR Hanratty LA Producing mean-ingful improvements in problem behavior of children with autismvia synthesized analyses and treatments J Appl Behav Anal20144716ndash36 doi101002jaba106

16 Santiago JL Hanley GP Moore K Jin CS The generality ofinterview-informed functional analyses systematic replicationsin school and home J Autism Dev Disord 201646797ndash811doi101007s10803-015-2617-0

17 Jessel J Hanley GP Ghaemmaghami M Interview-informedsynthesized contingency analyses thirty replications and rea-nalysis J Appl Behav Anal 2016491ndash22 doi101002jaba316

18 Fisher WW Greer BD Romani PW Zangrillo AN Owen TMComparisons of synthesized and individual reinforcement contin-gencies during functional analysis J Appl Behav Anal201649596ndash616 doi101002jaba201649issue-3

19 Hanley GP Functional assessment of problem behavior dispellingmyths overcoming implementation obstacles and developingnew lore Behav Anal Pract 2012554ndash72 doi101007BF03391818

20 Reimers TM Wacker DP Cooper LJ Evaluation of the accept-ability of treatments for childrenrsquos behavioral difficulties ratingsby parents receiving services in an outpatient clinic Child FamBehav Ther 19911353ndash71 doi101300J019v13n02_04

21 Smith RG Churchill RM Identification of environmental deter-minants of behavior disorders through functional analysis of pre-cursor behaviors J Appl Behav Anal 200235125ndash36 doi101901jaba200235-125

22 Hanley GP Prevention and treatment of severe problem beha-vior In Mayville E Mulick J editors Behavioral foundationsof effective autism treatment New York NY Sloan 2010 p233ndash55

23 Hagopian LP Fisher WW Sullivan MT Acquisto J LeBlanc LAEffectiveness of functional communication training with andwithout extinction and punishment a summary of 21 inpatientcases J Appl Behav Anal 199831211ndash35 doi101901jaba199831-211

24 Tiger JH Hanley GP Bruzek J Functional communication train-ing a review and practical guide Behav Anal Pract 2008116ndash23doi101007BF03391716

25 Smith RG Iwata BA Vollmer TR Zarcone JR Experimentalanalysis and treatment of multiply controlled self injury J ApplBehav Anal 199326183ndash96 doi101901jaba199326-183

6 C HERMAN ET AL

  • Abstract
  • Method
    • Participant and setting
    • Response measurement and interobserver agreement
    • Design
    • Procedure
      • Interview-informed synthesized contingency analysis
        • Intervention evaluation
          • Baseline (A)
          • Intervention (B)
          • Staff training
            • Social validity
              • Results and discussion
              • Declaration of Interest
              • References
Page 3: An interview-informed synthesized contingency …...An interview-informed synthesized contingency analysis to inform the treatment of challenging behavior in a young child with autism

process1617 and these studies have generally yielded positiveoutcomes in terms of reduced assessment duration sociallyvalid reduction of CB and concurrent increases in alternativeappropriate behavior However Fisher and colleagues18 com-pared the outcomes of IISCA to those of a traditional EFAOne of the findings identified low levels of agreement betweenthe outcomes produced by the two forms of EFA and cautionagainst its use without further examination of its validity andthe accuracy of the outcomes that it produces

Thus the aim of the current study was to add to the smallbody of literature to date describing the use of IISCA for theassessment and treatment of CB and to evaluate the effective-ness of interventions designed directly from it Specifically anIISCA was used to assess and inform the treatment of CBexhibited by a young boy diagnosed with ASD and co-occur-ring oppositional defiant disorder

Method

Participant and setting

Dillon was a 46 year old boy diagnosed with ASD and co-occurring oppositional defiant disorder Extant school recordsreported that he presented with a full scale IQ of 66 and anadaptive composite score of 63 according to the Stanford-Binet Intelligence Scale and the Vineland Adaptive BehaviorScales respectively The preschool specialized in the deliveryof ABA educational interventions overseen by a behavioranalyst who held BCBAreg certification Dillon attended 5days per week for 4 h per day He had been receiving thisABA educational provision for 8 months prior to participat-ing in the current study All sessions were conducted inDillonrsquos classroom within the preschool

Response measurement and interobserver agreement

The target behavior in the current study was inappropriatetime spent on the floor defined as dropping to the floor from aseated or standing position andor lying or sitting on thefloor during designated work periods or refusing to stand upwhen asked or prompted to do so Each instance of CB wasseparated by Dillon standing up on both feet Observers used10 s partial interval recording to measure the percentage ofintervals in which the target behavior occurred Compliancewith demands defined as initiation of the requested actionwithin 10 s of the first instruction delivery and completion ofthe request within 30 s of initiation in the absence of CB wasalso measured during the intervention phase A percentage ofcompliance with demands was calculated by dividing the totalnumber of compliant responses by the total number ofdemands multiplied by 100

IOA was assessed by having two observers simultaneouslybut independently collect data on the two target behaviors for100 of sessions during the IISCA and 21 of treatmentsessions Mean agreement coefficients for inappropriate timeon the floor was 986 during the IISCA (range 933ndash100) and 99 during the treatment phase (range 998ndash100) Mean agreement coefficients for compliance were100 during the IISCA and 100 during the treatment phase

Design

The IISCA15 was conducted using a multielement design andan ABAB reversal design was used to evaluate the effects ofthe intervention

Procedure

Interview-informed synthesized contingency analysisThe IISCA15 began with a 45-min observation period duringwhich Dillon was observed engaging in his normal schoolroutine and his tutor was asked to provide and remove pre-ferred tangibles attention and demands The therapist (firstauthor) observed and recorded CB while the tutor interactedwith Dillon Similarly to Hanley et al15 data were collected onthe number of CBs observed functional communicativeresponses emitted tolerance of demands and reinforcementduration Data were also collected on the type of demandsprovided their duration and compliance by Dillon to suchdemands Dillon was observed to drop to the floor consis-tently when demands were presented by the tutor He wouldalways access tangible items while on the floor and spent longperiods in the absence of attention from others He refused tocomply with redirection and did not use any functional com-municative response

Subsequently 20 questions from the open-ended question-naire designed by Hanley [see Appendix in 19] was used toconduct an informal interview with Dillonrsquos teacher that wasfocused on his CB and the circumstances in which it typicallyoccurred The results of the interview suggested that CBoccurred when staff delivered an instruction or interruptedan activity and that both terminating the demand and gainingaccess to a preferred item or activity were maintainingDillonrsquos problem behavior

Preferred tangibles (iPhone a portable DVD player pop-corn playdoh magnet letters and two colored balls) high andlow-probability instructions were identified from a pairedstimulus preference assessment and the open-endedquestionnaire19 Low-probability instructions consisted ofdirections to stand up from the floor and engage in educa-tional activities These instructions were selected fromDillonrsquos current educational plan which showed that he hadnot reached the long-term goals but continued to work on theshort-term objectives toward those goals Low-probabilityinstructions showed a daily percentage of responding ofbelow 80 or incomplete responding as a result of Dillondropping to the floor when the instruction was deliveredThese instructions included a visual task (completing ablock design) labelling objects and a listener task (identifyingobjects in a picture book) The high-probability instructionswere tasks that had previously been in Dillonrsquos educationalplan and were currently targeted as maintenance goals Dailyscores indicated that he continued to respond to these instruc-tions accurately and fluently (80ndash100 within 3 s) Suchtasks included gross motor imitation tasks (do this) and one-step directions (eg clap handstouch nosepoint topick upetc) Preferred tangibles high and low-probability instructionswere the same during the IISCA conditions baseline andintervention phases

2 C HERMAN ET AL

An IISCA was conducted across one school day Sessionswere conducted in 5 min blocks The IISCA alternatedbetween one control condition which was conducted firstand one test condition with the availability of the suspectedreinforcement contingency differentiating between condi-tions In the control condition no demands were made andDillon had uninterrupted access to an array of preferred itemsthroughout the entire session As observation and interviewdata suggested that the behavior was multiply controlled bysources of positive and negative reinforcement the test con-dition presented a synthesized escape and tangible contin-gency These conditions began with a 30 s period ofengagement with tangibles before these were removedFollowing this the therapist presented educational activities(demands) to Dillon Contingent upon the occurrence of CBthe therapist immediately terminated the demand returnedthe tangible items and turned away from Dillon for 30 s

Intervention evaluation

Baseline (A)Five baseline sessions were conducted with each session last-ing 1 h each day During baseline sessions Dillon was pre-sented with educational activities Contingent on CB Dillonwas asked to stand up from the floor however the tutordiscontinued educational activities The instruction to standwas redelivered every minute when Dillon did not complyTangibles that were accessible on the floor were availableAccess to reinforcement (escape and tangibles) continued aslong as Dillon refused to comply

Intervention (B)Intervention sessions were conducted 5 days per week threetimes each day and each session was 1 h in duration At leastone intervention session was conducted at the same time ofday as baseline sessions At the beginning of a session thetherapist removed any preferred tangible items and presenteda high-probability verbal instruction (demands eg ldquoDillonclap your handsrdquo) followed by the delivery of a token con-tingent on compliance (FR1 schedule of reinforcement) Aconditioning program for tokens had been implemented 3months prior to the onset of this study During the interven-tion Dillon gained access to a ldquobreakrdquo away from the educa-tional activity and access to preferred tangibles contingent onearning five tokens for following each verbal instruction pro-vided Tokens were small colored disks placed on a brightlycolored token board with the numbers 1ndash10 A digital timerindicated the end of each 2 min ldquobreakrdquo and the therapistremoved any tangible items and delivered a new demandTwo minute breaks were provided based on the averagetime spent with each reinforcing item during the 45-minobservation period

During intervention sessions differential reinforcementwas utilized If Dillon engaged in the target behavior thetherapist followed him to the floor and immediately re-pre-sented the verbal instruction (demand) Most-to-leastprompting was used to guide Dillon to provide the responseDillon was then asked to ldquostand uprdquo Compliance with theverbal instruction ldquostand uprdquo resulted in both social praise

and delivery of one token If Dillon did not comply with thisinstruction and continued to engage in CB the therapist beganto deliver a sequence of high-probability instructions usingmost-to-least prompting procedures while interspersing thelow-probability verbal demand ldquostand uprdquo Full physical gui-dance was used during most-to-least prompting to allowreinforcement delivery and was faded to partial physical gui-dance and no guidance on the presentation of each successivedemand While engaging in CB most-to-least prompting tofollow the demand earned Dillon one token on a variable ratioschedule of reinforcement (VR5 tokens were delivered forevery 3 5 or 7 correct responses to demands) Contingenton earning five tokens while still engaging in the CB resultedin a 10-s only break without access to any tangible itemsFollowing this 10-s break instructional demands recom-menced This pattern was repeated until Dillon stood up

The type of demand during the session the schedule ofreinforcement and the prompt level utilized was progressivelyaltered during the intervention phase To increase treatmentefficacy the intervention began by utilizing a high-probabilityinstruction sequence a dense schedule of reinforcement forcompliance (FR1) and simultaneous prompting procedures toevoke compliance with demand (Sessions 6ndash47) During thefinal phase of treatment (Sessions 54ndash98) both high-probabil-ity and low-probability instructions a variable schedule ofreinforcement for compliance (VR5) and a three-stepprompting procedure (guided compliance to reduce relianceon physical prompts and allow immediate independentresponding) were utilized Changes to the intervention pack-age were made across sessions following 0ndash10 min of CB and90ndash100 compliance for three consecutive sessions

Staff trainingThe therapist provided training to Dillonrsquos classroom teacherand tutor regarding implementation of the intervention Thistraining was comprised of a detailed review and explanationof the intervention the observation of the therapist imple-menting the procedure with Dillon contingent on the occur-rence of CB the rehearsal of the intervention and datacollection procedures by the staff members and the imple-mentation of the intervention by each staff member over fourconsecutive sessions under the therapistrsquos supervision

Social validity

To determine the acceptability of the intervention packageDillonrsquos teacher and the schoolrsquos BCBAreg completed theTreatment Acceptability Rating Form Revised (TARF-R20)

Results and discussion

Data obtained from the interview and direct observationsupported the hypothesis that Dillonrsquos CB was maintainedby social positive and negative reinforcement contingenciesin the form of escape from demands and access to tangibleitems Figure 1 presents the rates of CB observed across IISCAconditions High rates of CB were observed exclusively in thetest conditions when CB resulted in escape from demands andaccess to tangible items (M = 8667) while CB was at zero

DEVELOPMENTAL NEUROREHABILITATION 3

levels during the control conditions which were free fromdemand and during which preferred tangibles were non-con-tingently available

CB and compliance across the baseline and interventionphases are depicted in Figure 2 During the initial baselinephase high levels of CB (M = 70) and low levels ofcompliance (M = 2921) were observed Across interven-tion sessions CB decreased to lower levels (M = 1739)and compliance increased significantly (M = 8929) Areversal to baseline conditions resulted in an increase inthe level of CB (M = 3991) and a decrease in the levelof compliance (M = 7333) indicating a functional rela-tionship between the intervention and CB When theintervention package was reintroduced the CB decreasedonce again (M = 501) and compliance increased to highlevels (M = 9760) CB remained low and complianceremained high as demands were increased and the rate ofreinforcement with tokens decreased from a FR1 (Session6) to a VR5 (Session 54) and Dillonrsquos classroom teacherand tutor began to serve as therapists (Session 19) and asthe regular classroom schedule was reintroduced(Session 72)

Results from the TARF-R20 completed by Dillonrsquos teacherand the schoolrsquos BCBAreg indicated that the intervention pro-cedures were perceived as highly acceptable by both staffmembers (M = 97) Both staff members reported finding theintervention package acceptable and effective and they alsoindicated a willingness to change their routines in order tocontinue the delivery of the intervention

The primary aim of this research was to add to the smallbody of literature describing the use of the IISCA15 to ascer-tain behavioral function and guide the development of func-tion-based behavioral interventions Data obtained from theIISCA and treatment evaluation conducted for the severe CBof a young boy with ASD and oppositional defiant disorderindicate that the intervention package informed by the resultsof the IISCA was both a socially acceptable and effective

method for decreasing escape behavior and increasing com-pliance Prior to the intervention inappropriate time spent onthe floor often preceded other CB (eg skin picking urina-tion spitting removing shoes and blowing mucous from thenasal cavity) Pre-intervention these instances of severe CBsoccurred more than 30 times per day Post-intervention theseCBs no longer occurred supporting the idea of targetingprecursors to more severe CB in clinical practice21

The findings of the current study replicate and extendprevious work on the efficacy of an IISCA to produce indivi-dualized function-based interventions that cause meaningfulimprovements in CB15ndash17 These findings are positive giventhat researchers and practitioners alike may shy away fromthe other more traditional EFA processes as they may beconsidered time-consuming complex and risky1422 Thisstudy found the IISCA offers a fast practical and reliablemethod to determine the function of CB and to provideguidance for treatment development It may be particularlyuseful when a function-based intervention is promptlyrequired to reduce severe CB Prior to intervention Dillonwas engaging in CB for over half of the school day Hisacademic work program had been placed on hold and thetargeted behavior of dropping to the floor often acted as aprecursor for other serious CBs The expedited IISCA allowedfor the implementation of an intervention and effective reme-diation of the target behaviors as well as a decrease in moredisruptive and dangerous behavior

The current study had several limitations that must benoted First data on the generalization of treatment effectsacross settings (eg in the home in the community) was notcollected so it is not possible to determine if improvements inCB were confined to the school setting in which the interven-tion was delivered Second research2324 has demonstratedgreater treatment efficiency when functional communicationtraining is included within a treatment package Teaching afunctional alternative response to the CB such as a commu-nication response may have decreased the participantrsquos CB

Figure 1 Outcomes of the Interview-informed Synthesised Contingency Analysis for Dillonrsquos challenging behaviour

4 C HERMAN ET AL

more quickly15 and future research should explore this possi-bility Third although the study involved collaboration withmultiple members of Dillonrsquos educational team the super-vising BCBAreg only played a role in the delivery of the inter-vention and not in its design Training staff in theinterpretation of IISCA outcomes and subsequent behavioralinterventions may be important for clinically relevant applica-tions in future Fourth a variable ratio schedule was employedwith token delivery during the intervention However data onthe procedural fidelity of the implementation of this scheduleof reinforcement were not collected and therefore it is difficultto determine how schedule thinning played a role in theintervention package In addition tokens were also deliveredduring most-to-least prompting when the participant wasengaging in CB Token exchange resulted in differential rein-forcement for compliance producing either a 2-min breakwith access to tangibles (no CB occurring) or a 10-s break

with no access to tangibles (CB occurring) It is unclear there-fore whether praise alone would have produced the sameoutcomes Future researchers may consider a componentanalysis to determine which specific variables alter the effec-tiveness of such an intervention Finally this study describedthe IISCA process and intervention for a single participantand therefore the external validity of the results may bequestioned

Fisher and colleagues18 have recommended caution in theutilization of the IISCA as their research suggested low levelsof agreement between IISCA outcomes and those of othertraditional EFAs Additionally they cautioned that theIISCA may overestimate the frequency of multiply controlledbehavior and result in test conditions examining a contin-gency that does not actually maintain CB The targeted beha-vior in the current study was suggested by the IISCA to bemultiply controlled by social positive and negative

Figure 2 Percentage of challenging behaviour (top panel) and compliance (lower panel) across baseline and intervention conditions for Dillon

DEVELOPMENTAL NEUROREHABILITATION 5

reinforcement contingencies and these were synthesizedwithin one test condition within the IISCA While it remainedunknown whether Dillonrsquos CB was exclusively sensitive toeither contingency it was deemed less important to assessthe independent contributions of each contingency andmore important to promptly implement a function-basedintervention to decrease Dillonrsquos severe CB Scholars haveemphasized that the validity of an EFA should be judged bythe success of the intervention that arises from it25 In thisrespect a growing body of research including the currentstudy support the validity of the IISCA However it isimperative that future research further assess the correspon-dence between other types of EFAs and IISCAs and continueto explore the validity of the IISCA through the experimentalevaluation of treatments prescribed by its results

This study contributes to a growing body of literature thatsuggests that the IISCA is a fast practical reliable and effec-tive EFA process that can (a) successfully identify the con-tingency maintaining CB (b) be easily conducted withintypical service settings without any specialized equipmentand (c) be used to design individualized function-basedbehavioral intervention packages that can successfully reduceor eliminate severe CB in individuals with ASD

Declaration of Interest

This research was conducted at Trinity College Dublin the University ofDublin The authors report no conflicts of interest

References

1 McTiernan A Leader G Healy O Mannion A Analysis of riskfactors and early predictors of challenging behavior for childrenwith autism spectrum disorder Res Autism Spectr Disord201151215ndash22 doi101016jrasd201101009

2 Benson PR Coping and psychological adjustment among mothersof children with ASD an accelerated longitudinal study J AutismDev Disord 2014441793ndash807 doi101007s10803-014-2079-9

3 Walsh CE Mulder E Tudor ME Predictors of parent stress in asample of children with ASD pain problem behavior and par-ental coping Res Autism Spectr Disord 20137256ndash64doi101016jrasd201208010

4 Kahng S Iwata BA Lewin AB Behavioral treatment of self-injury1964 to 2000 Am J Ment Retard 2002107212ndash21 doi1013520895-8017(2002)107lt0212BTOSITgt20CO2

5 Mulligan S Healy O Lydon S Moran L Foody C An analysis oftreatment efficacy for stereotyped and repetitive behaviors inautism Rev J Autism Dev Disord 20141143ndash64 doi101007s40489-014-0015-8

6 Campbell JM Efficacy of behavioral interventions for reducingproblem behavior in persons with autism a quantitative synthesisof single-subject research Res Dev Disabil 200324120ndash38doi101016S0891-4222(03)00014-3

7 Didden R Korzilius H Van Oorsouw W Sturmey P Behavioraltreatment of challenging behaviors in individuals with mild men-tal retardation meta-analysis of single-subject research Am JMent Retard 2006111290ndash98 doi1013520895-8017(2006)111[290BTOCBI]20CO2

8 Heyvaert M Saenen L Campbell JM Maes B Onghena PEfficacy of behavioral interventions for reducing problem

behavior in persons with autism an updated quantitative synth-esis of single-subject research Res Dev Disabil 2014352463ndash76doi101016jridd201406017

9 Iwata BA Dorsey MF Slifer KJ Bauman KE Richman GSToward a functional analysis of self injury J Appl Behav Anal199427197ndash209 doi101901jaba199427-197

10 Beavers GA Iwata BA Lerman DC Thirty years of research onthe functional analysis of problem behavior J Appl Behav Anal2013461ndash21 doi101002jabav461

11 Bloom SE Lambert JM Dayton E Samaha AL Teacher con-ducted trial based functional analyses as the basis for interven-tion J Appl Behav Anal 201346208ndash18 doi101002jabav461

12 Hanley GP Iwata BA McCord BE Functional analysis of pro-blem behavior a review J Appl Behav Anal 200336147ndash85doi101901jaba200336-147

13 Delfs CH Campbell JM A quantitative synthesis of developmen-tal disability research the impact of functional assessment meth-odology on treatment effectiveness Behav Anal Today 2010114ndash19 doi101037h0100685

14 Lydon S Healy O OrsquoReilly MF Lang R Variations in functionalanalysis methodology a systematic review J Dev Phys Disabil201224301ndash26 doi101007s10882-012-9267-3

15 Hanley GP Jin CS Vanselow NR Hanratty LA Producing mean-ingful improvements in problem behavior of children with autismvia synthesized analyses and treatments J Appl Behav Anal20144716ndash36 doi101002jaba106

16 Santiago JL Hanley GP Moore K Jin CS The generality ofinterview-informed functional analyses systematic replicationsin school and home J Autism Dev Disord 201646797ndash811doi101007s10803-015-2617-0

17 Jessel J Hanley GP Ghaemmaghami M Interview-informedsynthesized contingency analyses thirty replications and rea-nalysis J Appl Behav Anal 2016491ndash22 doi101002jaba316

18 Fisher WW Greer BD Romani PW Zangrillo AN Owen TMComparisons of synthesized and individual reinforcement contin-gencies during functional analysis J Appl Behav Anal201649596ndash616 doi101002jaba201649issue-3

19 Hanley GP Functional assessment of problem behavior dispellingmyths overcoming implementation obstacles and developingnew lore Behav Anal Pract 2012554ndash72 doi101007BF03391818

20 Reimers TM Wacker DP Cooper LJ Evaluation of the accept-ability of treatments for childrenrsquos behavioral difficulties ratingsby parents receiving services in an outpatient clinic Child FamBehav Ther 19911353ndash71 doi101300J019v13n02_04

21 Smith RG Churchill RM Identification of environmental deter-minants of behavior disorders through functional analysis of pre-cursor behaviors J Appl Behav Anal 200235125ndash36 doi101901jaba200235-125

22 Hanley GP Prevention and treatment of severe problem beha-vior In Mayville E Mulick J editors Behavioral foundationsof effective autism treatment New York NY Sloan 2010 p233ndash55

23 Hagopian LP Fisher WW Sullivan MT Acquisto J LeBlanc LAEffectiveness of functional communication training with andwithout extinction and punishment a summary of 21 inpatientcases J Appl Behav Anal 199831211ndash35 doi101901jaba199831-211

24 Tiger JH Hanley GP Bruzek J Functional communication train-ing a review and practical guide Behav Anal Pract 2008116ndash23doi101007BF03391716

25 Smith RG Iwata BA Vollmer TR Zarcone JR Experimentalanalysis and treatment of multiply controlled self injury J ApplBehav Anal 199326183ndash96 doi101901jaba199326-183

6 C HERMAN ET AL

  • Abstract
  • Method
    • Participant and setting
    • Response measurement and interobserver agreement
    • Design
    • Procedure
      • Interview-informed synthesized contingency analysis
        • Intervention evaluation
          • Baseline (A)
          • Intervention (B)
          • Staff training
            • Social validity
              • Results and discussion
              • Declaration of Interest
              • References
Page 4: An interview-informed synthesized contingency …...An interview-informed synthesized contingency analysis to inform the treatment of challenging behavior in a young child with autism

An IISCA was conducted across one school day Sessionswere conducted in 5 min blocks The IISCA alternatedbetween one control condition which was conducted firstand one test condition with the availability of the suspectedreinforcement contingency differentiating between condi-tions In the control condition no demands were made andDillon had uninterrupted access to an array of preferred itemsthroughout the entire session As observation and interviewdata suggested that the behavior was multiply controlled bysources of positive and negative reinforcement the test con-dition presented a synthesized escape and tangible contin-gency These conditions began with a 30 s period ofengagement with tangibles before these were removedFollowing this the therapist presented educational activities(demands) to Dillon Contingent upon the occurrence of CBthe therapist immediately terminated the demand returnedthe tangible items and turned away from Dillon for 30 s

Intervention evaluation

Baseline (A)Five baseline sessions were conducted with each session last-ing 1 h each day During baseline sessions Dillon was pre-sented with educational activities Contingent on CB Dillonwas asked to stand up from the floor however the tutordiscontinued educational activities The instruction to standwas redelivered every minute when Dillon did not complyTangibles that were accessible on the floor were availableAccess to reinforcement (escape and tangibles) continued aslong as Dillon refused to comply

Intervention (B)Intervention sessions were conducted 5 days per week threetimes each day and each session was 1 h in duration At leastone intervention session was conducted at the same time ofday as baseline sessions At the beginning of a session thetherapist removed any preferred tangible items and presenteda high-probability verbal instruction (demands eg ldquoDillonclap your handsrdquo) followed by the delivery of a token con-tingent on compliance (FR1 schedule of reinforcement) Aconditioning program for tokens had been implemented 3months prior to the onset of this study During the interven-tion Dillon gained access to a ldquobreakrdquo away from the educa-tional activity and access to preferred tangibles contingent onearning five tokens for following each verbal instruction pro-vided Tokens were small colored disks placed on a brightlycolored token board with the numbers 1ndash10 A digital timerindicated the end of each 2 min ldquobreakrdquo and the therapistremoved any tangible items and delivered a new demandTwo minute breaks were provided based on the averagetime spent with each reinforcing item during the 45-minobservation period

During intervention sessions differential reinforcementwas utilized If Dillon engaged in the target behavior thetherapist followed him to the floor and immediately re-pre-sented the verbal instruction (demand) Most-to-leastprompting was used to guide Dillon to provide the responseDillon was then asked to ldquostand uprdquo Compliance with theverbal instruction ldquostand uprdquo resulted in both social praise

and delivery of one token If Dillon did not comply with thisinstruction and continued to engage in CB the therapist beganto deliver a sequence of high-probability instructions usingmost-to-least prompting procedures while interspersing thelow-probability verbal demand ldquostand uprdquo Full physical gui-dance was used during most-to-least prompting to allowreinforcement delivery and was faded to partial physical gui-dance and no guidance on the presentation of each successivedemand While engaging in CB most-to-least prompting tofollow the demand earned Dillon one token on a variable ratioschedule of reinforcement (VR5 tokens were delivered forevery 3 5 or 7 correct responses to demands) Contingenton earning five tokens while still engaging in the CB resultedin a 10-s only break without access to any tangible itemsFollowing this 10-s break instructional demands recom-menced This pattern was repeated until Dillon stood up

The type of demand during the session the schedule ofreinforcement and the prompt level utilized was progressivelyaltered during the intervention phase To increase treatmentefficacy the intervention began by utilizing a high-probabilityinstruction sequence a dense schedule of reinforcement forcompliance (FR1) and simultaneous prompting procedures toevoke compliance with demand (Sessions 6ndash47) During thefinal phase of treatment (Sessions 54ndash98) both high-probabil-ity and low-probability instructions a variable schedule ofreinforcement for compliance (VR5) and a three-stepprompting procedure (guided compliance to reduce relianceon physical prompts and allow immediate independentresponding) were utilized Changes to the intervention pack-age were made across sessions following 0ndash10 min of CB and90ndash100 compliance for three consecutive sessions

Staff trainingThe therapist provided training to Dillonrsquos classroom teacherand tutor regarding implementation of the intervention Thistraining was comprised of a detailed review and explanationof the intervention the observation of the therapist imple-menting the procedure with Dillon contingent on the occur-rence of CB the rehearsal of the intervention and datacollection procedures by the staff members and the imple-mentation of the intervention by each staff member over fourconsecutive sessions under the therapistrsquos supervision

Social validity

To determine the acceptability of the intervention packageDillonrsquos teacher and the schoolrsquos BCBAreg completed theTreatment Acceptability Rating Form Revised (TARF-R20)

Results and discussion

Data obtained from the interview and direct observationsupported the hypothesis that Dillonrsquos CB was maintainedby social positive and negative reinforcement contingenciesin the form of escape from demands and access to tangibleitems Figure 1 presents the rates of CB observed across IISCAconditions High rates of CB were observed exclusively in thetest conditions when CB resulted in escape from demands andaccess to tangible items (M = 8667) while CB was at zero

DEVELOPMENTAL NEUROREHABILITATION 3

levels during the control conditions which were free fromdemand and during which preferred tangibles were non-con-tingently available

CB and compliance across the baseline and interventionphases are depicted in Figure 2 During the initial baselinephase high levels of CB (M = 70) and low levels ofcompliance (M = 2921) were observed Across interven-tion sessions CB decreased to lower levels (M = 1739)and compliance increased significantly (M = 8929) Areversal to baseline conditions resulted in an increase inthe level of CB (M = 3991) and a decrease in the levelof compliance (M = 7333) indicating a functional rela-tionship between the intervention and CB When theintervention package was reintroduced the CB decreasedonce again (M = 501) and compliance increased to highlevels (M = 9760) CB remained low and complianceremained high as demands were increased and the rate ofreinforcement with tokens decreased from a FR1 (Session6) to a VR5 (Session 54) and Dillonrsquos classroom teacherand tutor began to serve as therapists (Session 19) and asthe regular classroom schedule was reintroduced(Session 72)

Results from the TARF-R20 completed by Dillonrsquos teacherand the schoolrsquos BCBAreg indicated that the intervention pro-cedures were perceived as highly acceptable by both staffmembers (M = 97) Both staff members reported finding theintervention package acceptable and effective and they alsoindicated a willingness to change their routines in order tocontinue the delivery of the intervention

The primary aim of this research was to add to the smallbody of literature describing the use of the IISCA15 to ascer-tain behavioral function and guide the development of func-tion-based behavioral interventions Data obtained from theIISCA and treatment evaluation conducted for the severe CBof a young boy with ASD and oppositional defiant disorderindicate that the intervention package informed by the resultsof the IISCA was both a socially acceptable and effective

method for decreasing escape behavior and increasing com-pliance Prior to the intervention inappropriate time spent onthe floor often preceded other CB (eg skin picking urina-tion spitting removing shoes and blowing mucous from thenasal cavity) Pre-intervention these instances of severe CBsoccurred more than 30 times per day Post-intervention theseCBs no longer occurred supporting the idea of targetingprecursors to more severe CB in clinical practice21

The findings of the current study replicate and extendprevious work on the efficacy of an IISCA to produce indivi-dualized function-based interventions that cause meaningfulimprovements in CB15ndash17 These findings are positive giventhat researchers and practitioners alike may shy away fromthe other more traditional EFA processes as they may beconsidered time-consuming complex and risky1422 Thisstudy found the IISCA offers a fast practical and reliablemethod to determine the function of CB and to provideguidance for treatment development It may be particularlyuseful when a function-based intervention is promptlyrequired to reduce severe CB Prior to intervention Dillonwas engaging in CB for over half of the school day Hisacademic work program had been placed on hold and thetargeted behavior of dropping to the floor often acted as aprecursor for other serious CBs The expedited IISCA allowedfor the implementation of an intervention and effective reme-diation of the target behaviors as well as a decrease in moredisruptive and dangerous behavior

The current study had several limitations that must benoted First data on the generalization of treatment effectsacross settings (eg in the home in the community) was notcollected so it is not possible to determine if improvements inCB were confined to the school setting in which the interven-tion was delivered Second research2324 has demonstratedgreater treatment efficiency when functional communicationtraining is included within a treatment package Teaching afunctional alternative response to the CB such as a commu-nication response may have decreased the participantrsquos CB

Figure 1 Outcomes of the Interview-informed Synthesised Contingency Analysis for Dillonrsquos challenging behaviour

4 C HERMAN ET AL

more quickly15 and future research should explore this possi-bility Third although the study involved collaboration withmultiple members of Dillonrsquos educational team the super-vising BCBAreg only played a role in the delivery of the inter-vention and not in its design Training staff in theinterpretation of IISCA outcomes and subsequent behavioralinterventions may be important for clinically relevant applica-tions in future Fourth a variable ratio schedule was employedwith token delivery during the intervention However data onthe procedural fidelity of the implementation of this scheduleof reinforcement were not collected and therefore it is difficultto determine how schedule thinning played a role in theintervention package In addition tokens were also deliveredduring most-to-least prompting when the participant wasengaging in CB Token exchange resulted in differential rein-forcement for compliance producing either a 2-min breakwith access to tangibles (no CB occurring) or a 10-s break

with no access to tangibles (CB occurring) It is unclear there-fore whether praise alone would have produced the sameoutcomes Future researchers may consider a componentanalysis to determine which specific variables alter the effec-tiveness of such an intervention Finally this study describedthe IISCA process and intervention for a single participantand therefore the external validity of the results may bequestioned

Fisher and colleagues18 have recommended caution in theutilization of the IISCA as their research suggested low levelsof agreement between IISCA outcomes and those of othertraditional EFAs Additionally they cautioned that theIISCA may overestimate the frequency of multiply controlledbehavior and result in test conditions examining a contin-gency that does not actually maintain CB The targeted beha-vior in the current study was suggested by the IISCA to bemultiply controlled by social positive and negative

Figure 2 Percentage of challenging behaviour (top panel) and compliance (lower panel) across baseline and intervention conditions for Dillon

DEVELOPMENTAL NEUROREHABILITATION 5

reinforcement contingencies and these were synthesizedwithin one test condition within the IISCA While it remainedunknown whether Dillonrsquos CB was exclusively sensitive toeither contingency it was deemed less important to assessthe independent contributions of each contingency andmore important to promptly implement a function-basedintervention to decrease Dillonrsquos severe CB Scholars haveemphasized that the validity of an EFA should be judged bythe success of the intervention that arises from it25 In thisrespect a growing body of research including the currentstudy support the validity of the IISCA However it isimperative that future research further assess the correspon-dence between other types of EFAs and IISCAs and continueto explore the validity of the IISCA through the experimentalevaluation of treatments prescribed by its results

This study contributes to a growing body of literature thatsuggests that the IISCA is a fast practical reliable and effec-tive EFA process that can (a) successfully identify the con-tingency maintaining CB (b) be easily conducted withintypical service settings without any specialized equipmentand (c) be used to design individualized function-basedbehavioral intervention packages that can successfully reduceor eliminate severe CB in individuals with ASD

Declaration of Interest

This research was conducted at Trinity College Dublin the University ofDublin The authors report no conflicts of interest

References

1 McTiernan A Leader G Healy O Mannion A Analysis of riskfactors and early predictors of challenging behavior for childrenwith autism spectrum disorder Res Autism Spectr Disord201151215ndash22 doi101016jrasd201101009

2 Benson PR Coping and psychological adjustment among mothersof children with ASD an accelerated longitudinal study J AutismDev Disord 2014441793ndash807 doi101007s10803-014-2079-9

3 Walsh CE Mulder E Tudor ME Predictors of parent stress in asample of children with ASD pain problem behavior and par-ental coping Res Autism Spectr Disord 20137256ndash64doi101016jrasd201208010

4 Kahng S Iwata BA Lewin AB Behavioral treatment of self-injury1964 to 2000 Am J Ment Retard 2002107212ndash21 doi1013520895-8017(2002)107lt0212BTOSITgt20CO2

5 Mulligan S Healy O Lydon S Moran L Foody C An analysis oftreatment efficacy for stereotyped and repetitive behaviors inautism Rev J Autism Dev Disord 20141143ndash64 doi101007s40489-014-0015-8

6 Campbell JM Efficacy of behavioral interventions for reducingproblem behavior in persons with autism a quantitative synthesisof single-subject research Res Dev Disabil 200324120ndash38doi101016S0891-4222(03)00014-3

7 Didden R Korzilius H Van Oorsouw W Sturmey P Behavioraltreatment of challenging behaviors in individuals with mild men-tal retardation meta-analysis of single-subject research Am JMent Retard 2006111290ndash98 doi1013520895-8017(2006)111[290BTOCBI]20CO2

8 Heyvaert M Saenen L Campbell JM Maes B Onghena PEfficacy of behavioral interventions for reducing problem

behavior in persons with autism an updated quantitative synth-esis of single-subject research Res Dev Disabil 2014352463ndash76doi101016jridd201406017

9 Iwata BA Dorsey MF Slifer KJ Bauman KE Richman GSToward a functional analysis of self injury J Appl Behav Anal199427197ndash209 doi101901jaba199427-197

10 Beavers GA Iwata BA Lerman DC Thirty years of research onthe functional analysis of problem behavior J Appl Behav Anal2013461ndash21 doi101002jabav461

11 Bloom SE Lambert JM Dayton E Samaha AL Teacher con-ducted trial based functional analyses as the basis for interven-tion J Appl Behav Anal 201346208ndash18 doi101002jabav461

12 Hanley GP Iwata BA McCord BE Functional analysis of pro-blem behavior a review J Appl Behav Anal 200336147ndash85doi101901jaba200336-147

13 Delfs CH Campbell JM A quantitative synthesis of developmen-tal disability research the impact of functional assessment meth-odology on treatment effectiveness Behav Anal Today 2010114ndash19 doi101037h0100685

14 Lydon S Healy O OrsquoReilly MF Lang R Variations in functionalanalysis methodology a systematic review J Dev Phys Disabil201224301ndash26 doi101007s10882-012-9267-3

15 Hanley GP Jin CS Vanselow NR Hanratty LA Producing mean-ingful improvements in problem behavior of children with autismvia synthesized analyses and treatments J Appl Behav Anal20144716ndash36 doi101002jaba106

16 Santiago JL Hanley GP Moore K Jin CS The generality ofinterview-informed functional analyses systematic replicationsin school and home J Autism Dev Disord 201646797ndash811doi101007s10803-015-2617-0

17 Jessel J Hanley GP Ghaemmaghami M Interview-informedsynthesized contingency analyses thirty replications and rea-nalysis J Appl Behav Anal 2016491ndash22 doi101002jaba316

18 Fisher WW Greer BD Romani PW Zangrillo AN Owen TMComparisons of synthesized and individual reinforcement contin-gencies during functional analysis J Appl Behav Anal201649596ndash616 doi101002jaba201649issue-3

19 Hanley GP Functional assessment of problem behavior dispellingmyths overcoming implementation obstacles and developingnew lore Behav Anal Pract 2012554ndash72 doi101007BF03391818

20 Reimers TM Wacker DP Cooper LJ Evaluation of the accept-ability of treatments for childrenrsquos behavioral difficulties ratingsby parents receiving services in an outpatient clinic Child FamBehav Ther 19911353ndash71 doi101300J019v13n02_04

21 Smith RG Churchill RM Identification of environmental deter-minants of behavior disorders through functional analysis of pre-cursor behaviors J Appl Behav Anal 200235125ndash36 doi101901jaba200235-125

22 Hanley GP Prevention and treatment of severe problem beha-vior In Mayville E Mulick J editors Behavioral foundationsof effective autism treatment New York NY Sloan 2010 p233ndash55

23 Hagopian LP Fisher WW Sullivan MT Acquisto J LeBlanc LAEffectiveness of functional communication training with andwithout extinction and punishment a summary of 21 inpatientcases J Appl Behav Anal 199831211ndash35 doi101901jaba199831-211

24 Tiger JH Hanley GP Bruzek J Functional communication train-ing a review and practical guide Behav Anal Pract 2008116ndash23doi101007BF03391716

25 Smith RG Iwata BA Vollmer TR Zarcone JR Experimentalanalysis and treatment of multiply controlled self injury J ApplBehav Anal 199326183ndash96 doi101901jaba199326-183

6 C HERMAN ET AL

  • Abstract
  • Method
    • Participant and setting
    • Response measurement and interobserver agreement
    • Design
    • Procedure
      • Interview-informed synthesized contingency analysis
        • Intervention evaluation
          • Baseline (A)
          • Intervention (B)
          • Staff training
            • Social validity
              • Results and discussion
              • Declaration of Interest
              • References
Page 5: An interview-informed synthesized contingency …...An interview-informed synthesized contingency analysis to inform the treatment of challenging behavior in a young child with autism

levels during the control conditions which were free fromdemand and during which preferred tangibles were non-con-tingently available

CB and compliance across the baseline and interventionphases are depicted in Figure 2 During the initial baselinephase high levels of CB (M = 70) and low levels ofcompliance (M = 2921) were observed Across interven-tion sessions CB decreased to lower levels (M = 1739)and compliance increased significantly (M = 8929) Areversal to baseline conditions resulted in an increase inthe level of CB (M = 3991) and a decrease in the levelof compliance (M = 7333) indicating a functional rela-tionship between the intervention and CB When theintervention package was reintroduced the CB decreasedonce again (M = 501) and compliance increased to highlevels (M = 9760) CB remained low and complianceremained high as demands were increased and the rate ofreinforcement with tokens decreased from a FR1 (Session6) to a VR5 (Session 54) and Dillonrsquos classroom teacherand tutor began to serve as therapists (Session 19) and asthe regular classroom schedule was reintroduced(Session 72)

Results from the TARF-R20 completed by Dillonrsquos teacherand the schoolrsquos BCBAreg indicated that the intervention pro-cedures were perceived as highly acceptable by both staffmembers (M = 97) Both staff members reported finding theintervention package acceptable and effective and they alsoindicated a willingness to change their routines in order tocontinue the delivery of the intervention

The primary aim of this research was to add to the smallbody of literature describing the use of the IISCA15 to ascer-tain behavioral function and guide the development of func-tion-based behavioral interventions Data obtained from theIISCA and treatment evaluation conducted for the severe CBof a young boy with ASD and oppositional defiant disorderindicate that the intervention package informed by the resultsof the IISCA was both a socially acceptable and effective

method for decreasing escape behavior and increasing com-pliance Prior to the intervention inappropriate time spent onthe floor often preceded other CB (eg skin picking urina-tion spitting removing shoes and blowing mucous from thenasal cavity) Pre-intervention these instances of severe CBsoccurred more than 30 times per day Post-intervention theseCBs no longer occurred supporting the idea of targetingprecursors to more severe CB in clinical practice21

The findings of the current study replicate and extendprevious work on the efficacy of an IISCA to produce indivi-dualized function-based interventions that cause meaningfulimprovements in CB15ndash17 These findings are positive giventhat researchers and practitioners alike may shy away fromthe other more traditional EFA processes as they may beconsidered time-consuming complex and risky1422 Thisstudy found the IISCA offers a fast practical and reliablemethod to determine the function of CB and to provideguidance for treatment development It may be particularlyuseful when a function-based intervention is promptlyrequired to reduce severe CB Prior to intervention Dillonwas engaging in CB for over half of the school day Hisacademic work program had been placed on hold and thetargeted behavior of dropping to the floor often acted as aprecursor for other serious CBs The expedited IISCA allowedfor the implementation of an intervention and effective reme-diation of the target behaviors as well as a decrease in moredisruptive and dangerous behavior

The current study had several limitations that must benoted First data on the generalization of treatment effectsacross settings (eg in the home in the community) was notcollected so it is not possible to determine if improvements inCB were confined to the school setting in which the interven-tion was delivered Second research2324 has demonstratedgreater treatment efficiency when functional communicationtraining is included within a treatment package Teaching afunctional alternative response to the CB such as a commu-nication response may have decreased the participantrsquos CB

Figure 1 Outcomes of the Interview-informed Synthesised Contingency Analysis for Dillonrsquos challenging behaviour

4 C HERMAN ET AL

more quickly15 and future research should explore this possi-bility Third although the study involved collaboration withmultiple members of Dillonrsquos educational team the super-vising BCBAreg only played a role in the delivery of the inter-vention and not in its design Training staff in theinterpretation of IISCA outcomes and subsequent behavioralinterventions may be important for clinically relevant applica-tions in future Fourth a variable ratio schedule was employedwith token delivery during the intervention However data onthe procedural fidelity of the implementation of this scheduleof reinforcement were not collected and therefore it is difficultto determine how schedule thinning played a role in theintervention package In addition tokens were also deliveredduring most-to-least prompting when the participant wasengaging in CB Token exchange resulted in differential rein-forcement for compliance producing either a 2-min breakwith access to tangibles (no CB occurring) or a 10-s break

with no access to tangibles (CB occurring) It is unclear there-fore whether praise alone would have produced the sameoutcomes Future researchers may consider a componentanalysis to determine which specific variables alter the effec-tiveness of such an intervention Finally this study describedthe IISCA process and intervention for a single participantand therefore the external validity of the results may bequestioned

Fisher and colleagues18 have recommended caution in theutilization of the IISCA as their research suggested low levelsof agreement between IISCA outcomes and those of othertraditional EFAs Additionally they cautioned that theIISCA may overestimate the frequency of multiply controlledbehavior and result in test conditions examining a contin-gency that does not actually maintain CB The targeted beha-vior in the current study was suggested by the IISCA to bemultiply controlled by social positive and negative

Figure 2 Percentage of challenging behaviour (top panel) and compliance (lower panel) across baseline and intervention conditions for Dillon

DEVELOPMENTAL NEUROREHABILITATION 5

reinforcement contingencies and these were synthesizedwithin one test condition within the IISCA While it remainedunknown whether Dillonrsquos CB was exclusively sensitive toeither contingency it was deemed less important to assessthe independent contributions of each contingency andmore important to promptly implement a function-basedintervention to decrease Dillonrsquos severe CB Scholars haveemphasized that the validity of an EFA should be judged bythe success of the intervention that arises from it25 In thisrespect a growing body of research including the currentstudy support the validity of the IISCA However it isimperative that future research further assess the correspon-dence between other types of EFAs and IISCAs and continueto explore the validity of the IISCA through the experimentalevaluation of treatments prescribed by its results

This study contributes to a growing body of literature thatsuggests that the IISCA is a fast practical reliable and effec-tive EFA process that can (a) successfully identify the con-tingency maintaining CB (b) be easily conducted withintypical service settings without any specialized equipmentand (c) be used to design individualized function-basedbehavioral intervention packages that can successfully reduceor eliminate severe CB in individuals with ASD

Declaration of Interest

This research was conducted at Trinity College Dublin the University ofDublin The authors report no conflicts of interest

References

1 McTiernan A Leader G Healy O Mannion A Analysis of riskfactors and early predictors of challenging behavior for childrenwith autism spectrum disorder Res Autism Spectr Disord201151215ndash22 doi101016jrasd201101009

2 Benson PR Coping and psychological adjustment among mothersof children with ASD an accelerated longitudinal study J AutismDev Disord 2014441793ndash807 doi101007s10803-014-2079-9

3 Walsh CE Mulder E Tudor ME Predictors of parent stress in asample of children with ASD pain problem behavior and par-ental coping Res Autism Spectr Disord 20137256ndash64doi101016jrasd201208010

4 Kahng S Iwata BA Lewin AB Behavioral treatment of self-injury1964 to 2000 Am J Ment Retard 2002107212ndash21 doi1013520895-8017(2002)107lt0212BTOSITgt20CO2

5 Mulligan S Healy O Lydon S Moran L Foody C An analysis oftreatment efficacy for stereotyped and repetitive behaviors inautism Rev J Autism Dev Disord 20141143ndash64 doi101007s40489-014-0015-8

6 Campbell JM Efficacy of behavioral interventions for reducingproblem behavior in persons with autism a quantitative synthesisof single-subject research Res Dev Disabil 200324120ndash38doi101016S0891-4222(03)00014-3

7 Didden R Korzilius H Van Oorsouw W Sturmey P Behavioraltreatment of challenging behaviors in individuals with mild men-tal retardation meta-analysis of single-subject research Am JMent Retard 2006111290ndash98 doi1013520895-8017(2006)111[290BTOCBI]20CO2

8 Heyvaert M Saenen L Campbell JM Maes B Onghena PEfficacy of behavioral interventions for reducing problem

behavior in persons with autism an updated quantitative synth-esis of single-subject research Res Dev Disabil 2014352463ndash76doi101016jridd201406017

9 Iwata BA Dorsey MF Slifer KJ Bauman KE Richman GSToward a functional analysis of self injury J Appl Behav Anal199427197ndash209 doi101901jaba199427-197

10 Beavers GA Iwata BA Lerman DC Thirty years of research onthe functional analysis of problem behavior J Appl Behav Anal2013461ndash21 doi101002jabav461

11 Bloom SE Lambert JM Dayton E Samaha AL Teacher con-ducted trial based functional analyses as the basis for interven-tion J Appl Behav Anal 201346208ndash18 doi101002jabav461

12 Hanley GP Iwata BA McCord BE Functional analysis of pro-blem behavior a review J Appl Behav Anal 200336147ndash85doi101901jaba200336-147

13 Delfs CH Campbell JM A quantitative synthesis of developmen-tal disability research the impact of functional assessment meth-odology on treatment effectiveness Behav Anal Today 2010114ndash19 doi101037h0100685

14 Lydon S Healy O OrsquoReilly MF Lang R Variations in functionalanalysis methodology a systematic review J Dev Phys Disabil201224301ndash26 doi101007s10882-012-9267-3

15 Hanley GP Jin CS Vanselow NR Hanratty LA Producing mean-ingful improvements in problem behavior of children with autismvia synthesized analyses and treatments J Appl Behav Anal20144716ndash36 doi101002jaba106

16 Santiago JL Hanley GP Moore K Jin CS The generality ofinterview-informed functional analyses systematic replicationsin school and home J Autism Dev Disord 201646797ndash811doi101007s10803-015-2617-0

17 Jessel J Hanley GP Ghaemmaghami M Interview-informedsynthesized contingency analyses thirty replications and rea-nalysis J Appl Behav Anal 2016491ndash22 doi101002jaba316

18 Fisher WW Greer BD Romani PW Zangrillo AN Owen TMComparisons of synthesized and individual reinforcement contin-gencies during functional analysis J Appl Behav Anal201649596ndash616 doi101002jaba201649issue-3

19 Hanley GP Functional assessment of problem behavior dispellingmyths overcoming implementation obstacles and developingnew lore Behav Anal Pract 2012554ndash72 doi101007BF03391818

20 Reimers TM Wacker DP Cooper LJ Evaluation of the accept-ability of treatments for childrenrsquos behavioral difficulties ratingsby parents receiving services in an outpatient clinic Child FamBehav Ther 19911353ndash71 doi101300J019v13n02_04

21 Smith RG Churchill RM Identification of environmental deter-minants of behavior disorders through functional analysis of pre-cursor behaviors J Appl Behav Anal 200235125ndash36 doi101901jaba200235-125

22 Hanley GP Prevention and treatment of severe problem beha-vior In Mayville E Mulick J editors Behavioral foundationsof effective autism treatment New York NY Sloan 2010 p233ndash55

23 Hagopian LP Fisher WW Sullivan MT Acquisto J LeBlanc LAEffectiveness of functional communication training with andwithout extinction and punishment a summary of 21 inpatientcases J Appl Behav Anal 199831211ndash35 doi101901jaba199831-211

24 Tiger JH Hanley GP Bruzek J Functional communication train-ing a review and practical guide Behav Anal Pract 2008116ndash23doi101007BF03391716

25 Smith RG Iwata BA Vollmer TR Zarcone JR Experimentalanalysis and treatment of multiply controlled self injury J ApplBehav Anal 199326183ndash96 doi101901jaba199326-183

6 C HERMAN ET AL

  • Abstract
  • Method
    • Participant and setting
    • Response measurement and interobserver agreement
    • Design
    • Procedure
      • Interview-informed synthesized contingency analysis
        • Intervention evaluation
          • Baseline (A)
          • Intervention (B)
          • Staff training
            • Social validity
              • Results and discussion
              • Declaration of Interest
              • References
Page 6: An interview-informed synthesized contingency …...An interview-informed synthesized contingency analysis to inform the treatment of challenging behavior in a young child with autism

more quickly15 and future research should explore this possi-bility Third although the study involved collaboration withmultiple members of Dillonrsquos educational team the super-vising BCBAreg only played a role in the delivery of the inter-vention and not in its design Training staff in theinterpretation of IISCA outcomes and subsequent behavioralinterventions may be important for clinically relevant applica-tions in future Fourth a variable ratio schedule was employedwith token delivery during the intervention However data onthe procedural fidelity of the implementation of this scheduleof reinforcement were not collected and therefore it is difficultto determine how schedule thinning played a role in theintervention package In addition tokens were also deliveredduring most-to-least prompting when the participant wasengaging in CB Token exchange resulted in differential rein-forcement for compliance producing either a 2-min breakwith access to tangibles (no CB occurring) or a 10-s break

with no access to tangibles (CB occurring) It is unclear there-fore whether praise alone would have produced the sameoutcomes Future researchers may consider a componentanalysis to determine which specific variables alter the effec-tiveness of such an intervention Finally this study describedthe IISCA process and intervention for a single participantand therefore the external validity of the results may bequestioned

Fisher and colleagues18 have recommended caution in theutilization of the IISCA as their research suggested low levelsof agreement between IISCA outcomes and those of othertraditional EFAs Additionally they cautioned that theIISCA may overestimate the frequency of multiply controlledbehavior and result in test conditions examining a contin-gency that does not actually maintain CB The targeted beha-vior in the current study was suggested by the IISCA to bemultiply controlled by social positive and negative

Figure 2 Percentage of challenging behaviour (top panel) and compliance (lower panel) across baseline and intervention conditions for Dillon

DEVELOPMENTAL NEUROREHABILITATION 5

reinforcement contingencies and these were synthesizedwithin one test condition within the IISCA While it remainedunknown whether Dillonrsquos CB was exclusively sensitive toeither contingency it was deemed less important to assessthe independent contributions of each contingency andmore important to promptly implement a function-basedintervention to decrease Dillonrsquos severe CB Scholars haveemphasized that the validity of an EFA should be judged bythe success of the intervention that arises from it25 In thisrespect a growing body of research including the currentstudy support the validity of the IISCA However it isimperative that future research further assess the correspon-dence between other types of EFAs and IISCAs and continueto explore the validity of the IISCA through the experimentalevaluation of treatments prescribed by its results

This study contributes to a growing body of literature thatsuggests that the IISCA is a fast practical reliable and effec-tive EFA process that can (a) successfully identify the con-tingency maintaining CB (b) be easily conducted withintypical service settings without any specialized equipmentand (c) be used to design individualized function-basedbehavioral intervention packages that can successfully reduceor eliminate severe CB in individuals with ASD

Declaration of Interest

This research was conducted at Trinity College Dublin the University ofDublin The authors report no conflicts of interest

References

1 McTiernan A Leader G Healy O Mannion A Analysis of riskfactors and early predictors of challenging behavior for childrenwith autism spectrum disorder Res Autism Spectr Disord201151215ndash22 doi101016jrasd201101009

2 Benson PR Coping and psychological adjustment among mothersof children with ASD an accelerated longitudinal study J AutismDev Disord 2014441793ndash807 doi101007s10803-014-2079-9

3 Walsh CE Mulder E Tudor ME Predictors of parent stress in asample of children with ASD pain problem behavior and par-ental coping Res Autism Spectr Disord 20137256ndash64doi101016jrasd201208010

4 Kahng S Iwata BA Lewin AB Behavioral treatment of self-injury1964 to 2000 Am J Ment Retard 2002107212ndash21 doi1013520895-8017(2002)107lt0212BTOSITgt20CO2

5 Mulligan S Healy O Lydon S Moran L Foody C An analysis oftreatment efficacy for stereotyped and repetitive behaviors inautism Rev J Autism Dev Disord 20141143ndash64 doi101007s40489-014-0015-8

6 Campbell JM Efficacy of behavioral interventions for reducingproblem behavior in persons with autism a quantitative synthesisof single-subject research Res Dev Disabil 200324120ndash38doi101016S0891-4222(03)00014-3

7 Didden R Korzilius H Van Oorsouw W Sturmey P Behavioraltreatment of challenging behaviors in individuals with mild men-tal retardation meta-analysis of single-subject research Am JMent Retard 2006111290ndash98 doi1013520895-8017(2006)111[290BTOCBI]20CO2

8 Heyvaert M Saenen L Campbell JM Maes B Onghena PEfficacy of behavioral interventions for reducing problem

behavior in persons with autism an updated quantitative synth-esis of single-subject research Res Dev Disabil 2014352463ndash76doi101016jridd201406017

9 Iwata BA Dorsey MF Slifer KJ Bauman KE Richman GSToward a functional analysis of self injury J Appl Behav Anal199427197ndash209 doi101901jaba199427-197

10 Beavers GA Iwata BA Lerman DC Thirty years of research onthe functional analysis of problem behavior J Appl Behav Anal2013461ndash21 doi101002jabav461

11 Bloom SE Lambert JM Dayton E Samaha AL Teacher con-ducted trial based functional analyses as the basis for interven-tion J Appl Behav Anal 201346208ndash18 doi101002jabav461

12 Hanley GP Iwata BA McCord BE Functional analysis of pro-blem behavior a review J Appl Behav Anal 200336147ndash85doi101901jaba200336-147

13 Delfs CH Campbell JM A quantitative synthesis of developmen-tal disability research the impact of functional assessment meth-odology on treatment effectiveness Behav Anal Today 2010114ndash19 doi101037h0100685

14 Lydon S Healy O OrsquoReilly MF Lang R Variations in functionalanalysis methodology a systematic review J Dev Phys Disabil201224301ndash26 doi101007s10882-012-9267-3

15 Hanley GP Jin CS Vanselow NR Hanratty LA Producing mean-ingful improvements in problem behavior of children with autismvia synthesized analyses and treatments J Appl Behav Anal20144716ndash36 doi101002jaba106

16 Santiago JL Hanley GP Moore K Jin CS The generality ofinterview-informed functional analyses systematic replicationsin school and home J Autism Dev Disord 201646797ndash811doi101007s10803-015-2617-0

17 Jessel J Hanley GP Ghaemmaghami M Interview-informedsynthesized contingency analyses thirty replications and rea-nalysis J Appl Behav Anal 2016491ndash22 doi101002jaba316

18 Fisher WW Greer BD Romani PW Zangrillo AN Owen TMComparisons of synthesized and individual reinforcement contin-gencies during functional analysis J Appl Behav Anal201649596ndash616 doi101002jaba201649issue-3

19 Hanley GP Functional assessment of problem behavior dispellingmyths overcoming implementation obstacles and developingnew lore Behav Anal Pract 2012554ndash72 doi101007BF03391818

20 Reimers TM Wacker DP Cooper LJ Evaluation of the accept-ability of treatments for childrenrsquos behavioral difficulties ratingsby parents receiving services in an outpatient clinic Child FamBehav Ther 19911353ndash71 doi101300J019v13n02_04

21 Smith RG Churchill RM Identification of environmental deter-minants of behavior disorders through functional analysis of pre-cursor behaviors J Appl Behav Anal 200235125ndash36 doi101901jaba200235-125

22 Hanley GP Prevention and treatment of severe problem beha-vior In Mayville E Mulick J editors Behavioral foundationsof effective autism treatment New York NY Sloan 2010 p233ndash55

23 Hagopian LP Fisher WW Sullivan MT Acquisto J LeBlanc LAEffectiveness of functional communication training with andwithout extinction and punishment a summary of 21 inpatientcases J Appl Behav Anal 199831211ndash35 doi101901jaba199831-211

24 Tiger JH Hanley GP Bruzek J Functional communication train-ing a review and practical guide Behav Anal Pract 2008116ndash23doi101007BF03391716

25 Smith RG Iwata BA Vollmer TR Zarcone JR Experimentalanalysis and treatment of multiply controlled self injury J ApplBehav Anal 199326183ndash96 doi101901jaba199326-183

6 C HERMAN ET AL

  • Abstract
  • Method
    • Participant and setting
    • Response measurement and interobserver agreement
    • Design
    • Procedure
      • Interview-informed synthesized contingency analysis
        • Intervention evaluation
          • Baseline (A)
          • Intervention (B)
          • Staff training
            • Social validity
              • Results and discussion
              • Declaration of Interest
              • References
Page 7: An interview-informed synthesized contingency …...An interview-informed synthesized contingency analysis to inform the treatment of challenging behavior in a young child with autism

reinforcement contingencies and these were synthesizedwithin one test condition within the IISCA While it remainedunknown whether Dillonrsquos CB was exclusively sensitive toeither contingency it was deemed less important to assessthe independent contributions of each contingency andmore important to promptly implement a function-basedintervention to decrease Dillonrsquos severe CB Scholars haveemphasized that the validity of an EFA should be judged bythe success of the intervention that arises from it25 In thisrespect a growing body of research including the currentstudy support the validity of the IISCA However it isimperative that future research further assess the correspon-dence between other types of EFAs and IISCAs and continueto explore the validity of the IISCA through the experimentalevaluation of treatments prescribed by its results

This study contributes to a growing body of literature thatsuggests that the IISCA is a fast practical reliable and effec-tive EFA process that can (a) successfully identify the con-tingency maintaining CB (b) be easily conducted withintypical service settings without any specialized equipmentand (c) be used to design individualized function-basedbehavioral intervention packages that can successfully reduceor eliminate severe CB in individuals with ASD

Declaration of Interest

This research was conducted at Trinity College Dublin the University ofDublin The authors report no conflicts of interest

References

1 McTiernan A Leader G Healy O Mannion A Analysis of riskfactors and early predictors of challenging behavior for childrenwith autism spectrum disorder Res Autism Spectr Disord201151215ndash22 doi101016jrasd201101009

2 Benson PR Coping and psychological adjustment among mothersof children with ASD an accelerated longitudinal study J AutismDev Disord 2014441793ndash807 doi101007s10803-014-2079-9

3 Walsh CE Mulder E Tudor ME Predictors of parent stress in asample of children with ASD pain problem behavior and par-ental coping Res Autism Spectr Disord 20137256ndash64doi101016jrasd201208010

4 Kahng S Iwata BA Lewin AB Behavioral treatment of self-injury1964 to 2000 Am J Ment Retard 2002107212ndash21 doi1013520895-8017(2002)107lt0212BTOSITgt20CO2

5 Mulligan S Healy O Lydon S Moran L Foody C An analysis oftreatment efficacy for stereotyped and repetitive behaviors inautism Rev J Autism Dev Disord 20141143ndash64 doi101007s40489-014-0015-8

6 Campbell JM Efficacy of behavioral interventions for reducingproblem behavior in persons with autism a quantitative synthesisof single-subject research Res Dev Disabil 200324120ndash38doi101016S0891-4222(03)00014-3

7 Didden R Korzilius H Van Oorsouw W Sturmey P Behavioraltreatment of challenging behaviors in individuals with mild men-tal retardation meta-analysis of single-subject research Am JMent Retard 2006111290ndash98 doi1013520895-8017(2006)111[290BTOCBI]20CO2

8 Heyvaert M Saenen L Campbell JM Maes B Onghena PEfficacy of behavioral interventions for reducing problem

behavior in persons with autism an updated quantitative synth-esis of single-subject research Res Dev Disabil 2014352463ndash76doi101016jridd201406017

9 Iwata BA Dorsey MF Slifer KJ Bauman KE Richman GSToward a functional analysis of self injury J Appl Behav Anal199427197ndash209 doi101901jaba199427-197

10 Beavers GA Iwata BA Lerman DC Thirty years of research onthe functional analysis of problem behavior J Appl Behav Anal2013461ndash21 doi101002jabav461

11 Bloom SE Lambert JM Dayton E Samaha AL Teacher con-ducted trial based functional analyses as the basis for interven-tion J Appl Behav Anal 201346208ndash18 doi101002jabav461

12 Hanley GP Iwata BA McCord BE Functional analysis of pro-blem behavior a review J Appl Behav Anal 200336147ndash85doi101901jaba200336-147

13 Delfs CH Campbell JM A quantitative synthesis of developmen-tal disability research the impact of functional assessment meth-odology on treatment effectiveness Behav Anal Today 2010114ndash19 doi101037h0100685

14 Lydon S Healy O OrsquoReilly MF Lang R Variations in functionalanalysis methodology a systematic review J Dev Phys Disabil201224301ndash26 doi101007s10882-012-9267-3

15 Hanley GP Jin CS Vanselow NR Hanratty LA Producing mean-ingful improvements in problem behavior of children with autismvia synthesized analyses and treatments J Appl Behav Anal20144716ndash36 doi101002jaba106

16 Santiago JL Hanley GP Moore K Jin CS The generality ofinterview-informed functional analyses systematic replicationsin school and home J Autism Dev Disord 201646797ndash811doi101007s10803-015-2617-0

17 Jessel J Hanley GP Ghaemmaghami M Interview-informedsynthesized contingency analyses thirty replications and rea-nalysis J Appl Behav Anal 2016491ndash22 doi101002jaba316

18 Fisher WW Greer BD Romani PW Zangrillo AN Owen TMComparisons of synthesized and individual reinforcement contin-gencies during functional analysis J Appl Behav Anal201649596ndash616 doi101002jaba201649issue-3

19 Hanley GP Functional assessment of problem behavior dispellingmyths overcoming implementation obstacles and developingnew lore Behav Anal Pract 2012554ndash72 doi101007BF03391818

20 Reimers TM Wacker DP Cooper LJ Evaluation of the accept-ability of treatments for childrenrsquos behavioral difficulties ratingsby parents receiving services in an outpatient clinic Child FamBehav Ther 19911353ndash71 doi101300J019v13n02_04

21 Smith RG Churchill RM Identification of environmental deter-minants of behavior disorders through functional analysis of pre-cursor behaviors J Appl Behav Anal 200235125ndash36 doi101901jaba200235-125

22 Hanley GP Prevention and treatment of severe problem beha-vior In Mayville E Mulick J editors Behavioral foundationsof effective autism treatment New York NY Sloan 2010 p233ndash55

23 Hagopian LP Fisher WW Sullivan MT Acquisto J LeBlanc LAEffectiveness of functional communication training with andwithout extinction and punishment a summary of 21 inpatientcases J Appl Behav Anal 199831211ndash35 doi101901jaba199831-211

24 Tiger JH Hanley GP Bruzek J Functional communication train-ing a review and practical guide Behav Anal Pract 2008116ndash23doi101007BF03391716

25 Smith RG Iwata BA Vollmer TR Zarcone JR Experimentalanalysis and treatment of multiply controlled self injury J ApplBehav Anal 199326183ndash96 doi101901jaba199326-183

6 C HERMAN ET AL

  • Abstract
  • Method
    • Participant and setting
    • Response measurement and interobserver agreement
    • Design
    • Procedure
      • Interview-informed synthesized contingency analysis
        • Intervention evaluation
          • Baseline (A)
          • Intervention (B)
          • Staff training
            • Social validity
              • Results and discussion
              • Declaration of Interest
              • References