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Introduction
The behavioral approach to assessment and intervention has had a major impact on the field of developmental disabilities. Behavioral interventions are among the most frequently used treatments and have considerable research support (Sturmey, 2012). Behavioral techniques are considered evidence-based practice for a number of challenging behaviors (Jennett and Hagopian, 2008; Carr et al., 2009; Kurtz et al., 2011) and are a first-line treatment according to professional consensus (Rush and Frances, 2000).
The behavioral approach applies the principles of learning to change behavior and is effective in teaching adaptive skills as well as in reducing maladaptive behavior. Using objective description and systematic observation, the environmental variables that influence behavior are identified and customized interventions are implemented to produce change. Data collection continues throughout intervention to document progress. Behavioral interventions are effective with individuals of all ages and levels of functioning.
Assessment
The behavioral approach to assessment includes identifying the antecedents to the behavior (A), defining the behavior of concern in specific, concrete language (B), and examining the consequent events that follow the behavior (C). The A–B–C model guides assessment and intervention. A goal of behavioral assessment is to determine the function of the behavior or what the behavior accomplishes for the individual. A behavior may result in gaining attention (social), obtaining tangibles, sensory stimulation (internal), or escape from demands. There are several methods of behavioral assessment and a combination of approaches is most often used in clinical practice.
A scatterplot is a record of the occurrence of behavior during predefined time periods throughout the day over a period of days or weeks. Data from a scatterplot is used to identify trends and patterns in the occurrence/non-occurrence of the behavior.
A–B–C charts are narrative recordings in which each occurrence of the behavior is described according to the antecedents, the behavior during that incident, and the consequences. Information from a number of occurrences is reviewed to identify common factors. A–B–C charts can be used to generate hypotheses about the function of a behavior that can be followed up with other assessment methods (Lanovaz et al., 2013).
A functional analysis (FA) of behavior, or experimental FA, refers to an analog procedure in which brief, controlled sessions are arranged to present specific environmental conditions (Iwata et al., 1994). The frequency of the problem behavior and possibly the latency to the behavior are recorded. Comparisons are made across conditions to identify the likely behavioral function. For example, if a FA of self-injurious behavior, defined as fist hits to the head, indicated that a greater frequency of head hits occurred during a demand condition in which school work was presented than in either an alone condition or an attention condition in which each hit was followed by a verbal comment from an observer, then an escape function for self-injury would be hypothesized. If an FA is not conclusive in identifying a functional relationship, then follow-up sessions can be conducted to further refine the environmental variables under consideration (Tiger et al., 2009; Hagopian et al., 2013). Attention and escape are among the most commonly identified functions of challenging behavior in persons with ID (Matson et al., 2011). Interventions that are preceded by a FA are more likely to be effective (Harvey et al., 2009).
The limitations of FA are that conducting the sessions is time-consuming, requires specialized training, and is usually completed in laboratory, inpatient, or clinic settings. However, in one study, master’s-level residential supervisors and assistants were trained to conduct FA sessions (Lambert et al., 2014). The appropriateness of FA to assess low-frequency challenging behavior has also been questioned, and other assessment methods, such as sequential analysis of case records, were proposed in such cases (Whitaker et al., 2004).
The functional assessment questionnaires are rating scales that focus on the probable maintaining variables of problem behavior. The two most commonly used scales are the Motivation Assessment Scale (MAS; Durand and Crimmins, 1988) and the Questions About Behavioural Function scale (QABF; Matson et al., 1999). The MAS addresses four categories of reinforcement, including attention, escape, tangible, and sensory. The QABF assesses possible maintaining variables of physical discomfort, social attention, escape, tangible, and non-social reinforcement (sensory). Both scales are intended to be completed by someone who knows the individual well. An advantage of functional assessment questionnaires is that they do not require extensive time or training and several respondents can provide input about an individual. Obtaining input from multiple respondents may improve the correspondence of the findings with other, more direct methods of assessment (Smith et al., 2012).
Another type of behavioral assessment that may be conducted is preference assessment. The goal of preference assessment is to identify potential reinforcers for an individual through interview, observation, or structured sessions in which choices are offered to the individual and selections are noted. Exercising choice is a method of expressing a preference (Cannella et al., 2005). Various methods of preference assessment have been developed, including offering a choice between stimuli, such as leisure items, activities, or edibles. A rank-ordered list of preferred items is constructed based on the selections. Preferred items can then be incorporated into an intervention program.
Interventions
Behavioral interventions are selected based on the results of the functional assessment and are chosen to match the behavioral function (Denis et al., 2011). The behavioral interventions may aim to modify the antecedent conditions that are frequently associated with the behavior, disrupt the link between the problem behavior and the consequences, or some combination of these. In recent years, there has been an increased emphasis on the use of non-aversive interventions (Harvey et al., 2009). Positive behavior support, an approach that integrates applied behavior analysis with person-centered philosophy, promotes the use of non-aversive interventions, intervening in the natural environment, incorporating the individual’s choices and preferences, and using multicomponent treatment plans (McClean and Grey, 2012).
Antecedent stimuli
Antecedent factors can increase the probability that problem behavior will occur. Many procedures have been used to modify antecedent conditions, such as reducing noise or crowding, changing staffing, offering more choice of activities or sequencing of tasks, presenting tasks that are commensurate with abilities (rather than too complex), and addressing physical conditions that may be affecting behavior such as sleep deprivation, hunger, or pain. The procedures may be conceptualized as impacting the physical environment, the social environment, or the biological environment. Interventions directed at antecedent conditions aim to meet the needs of the individual in the environment and are ongoing. Greater attention is being paid to these contextual variables, sometimes referred to as setting events, and their influence on behavior (Carr et al., 2008).
Consequences
Behavioral interventions alter the consequences of problem behavior by removing reinforcement for challenging behavior (extinction) and by providing reinforcement for alternative, more acceptable behaviors. Differential reinforcement (DR) is a non-aversive intervention that aims to alter the reinforcing consequences of behavior. There are several forms of DR, all involve withholding reinforcement for a behavior and providing reinforcement for other, more acceptable behaviors. The most frequently used DR strategies are DRI, differential reinforcement of incompatible behavior, DRO, differential reinforcement of other behavior, and DRA, differential reinforcement of alternate behavior. DR strategies, when used alone or in combination with other interventions, are an effective intervention for a variety of behavioral concerns in persons with ID (Chowdhury and Benson, 2011).
Functional communication training (FCT) is a reinforcement-based intervention that develops a communication response in order to access a reinforcer that was linked with problem behavior (Tiger et al., 2008). First, an FA is completed and then an alternate behavior that is a communicative response is developed as a replacement. The alternative response is a form of communication that is recognized by others. Several different communication responses have been taught, including sign language, vocalizations, picture exchanges, and activation of a communication device. FCT is typically paired with extinction, that is, the withholding of reinforcement for problematic behavior. FCT meets the criteria to be considered a “well-established” treatment for problem behavior in children with ID and/or autism spectrum disorders and is “probably efficacious” for adults (Kurtz et al., 2011).
Non-contingent reinforcement (NCR) is a procedure in which a reinforcer that has been available contingent on problem behavior, is provided independent of the occurrence of that behavior. NCR is a function-based intervention that has been used with a number of different topographies of problem behavior, including aggression, self-injury, stereotypy, pica, and disruptive behavior (Carr et al., 2009). NCR has been administered with various schedules of reinforcement, schedules that are thinned over time, and with or without an extinction component. There is sufficient evidence to consider NCR with a fixed-time reinforcement schedule and planned thinning plus extinction as a “well-established” treatment (Carr et al., 2009).
Considerable debate has occurred about the role of aversive interventions in behavior change programs for individuals with developmental disabilities. The use of the least restrictive intervention is considered a best practice in the field. There has been a concerted effort to reduce the use of restrictive procedures and to evaluate the need for and effectiveness of the procedures when they are used.
Response cost is a punishment procedure in which reinforcement is removed contingent on an inappropriate behavior. Response cost can be implemented as a fine applied to points or tokens that were previously earned, or by withholding access to preferred items or activities. Response cost is often combined with other behavioral interventions, such as reinforcement of appropriate behavior.
Physical and mechanical restraint and timeout are aversive interventions that are used at times to manage severe challenging behavior, generally when health and safety concerns are prominent. Physical restraint, or restricting voluntary movement contingent on behavior (Luiselli, 2009), tends to be used in response to physical aggression, particularly when there is a sustained episode (Emerson et al., 2000). In extreme cases of self-injury, mechanical restraints, such as arm splints or other protective equipment, are sometimes used. Restraints can be examined according to whether they are part of a planned intervention to specific circumstances or used in unplanned situations. Planned use is a safer alternative for all involved (Matson and Boisjoli, 2009). Restraints should be used infrequently to protect the individual and others from harm, be implemented by trained people, monitored for effectiveness, and have stated criteria for discontinuation. There should also be concurrent interventions to increase appropriate behavior (Luiselli, 2009).
Timeout is a procedure that imposes a loss of access to reinforcement contingent on a behavior. When implemented in group settings, the individual may be prompted to go to a set location, sometimes a separate room. Returning to the group may require a minimum period of time without the problem behavior occurring. The safety of the individual when in a separate location must be monitored (Iwata et al., 2009).
Efforts to reduce or eliminate the use of restraint and timeout in program-wide initiatives have been successful. Timeout use was successfully withdrawn from one community residential program and replaced with alternative procedures that were less intrusive (Iwata et al., 2009). Likewise, the use of physical restraint has been reduced in organizations through staff-training programs, increased use of behavioral plans, and defining clear criteria for the use of the restraint (Gaskin et al., 2013). On an individual level, successful procedures to reduce restraint use include conducting a more precise assessment of antecedent conditions, analyzing location and activity factors that are correlated with restraint use, identifying precursor behaviors that result in restraint use, and making changes to address those factors (Luiselli, 2009).
Challenging behavior
Challenging behavior is a term that is used to refer collectively to some or all of the following behaviors: aggression; self-injury; destructive behavior; pica; and stereotypy. Challenging behaviors are a concern because they can present a danger to the individual and/or others, and they interfere with the acquisition of and engagement in adaptive behavior. If not addressed, challenging behavior tends to persist in individuals with developmental disabilities (Murphy et al., 2005).
Aggression
Most aggressive behavior is learned and is socially mediated. The most common functions of aggression are escape, attention, and tangible (Rojahn et al., 2012). Several behavioral interventions have been used successfully to reduce or eliminate aggressive behavior. Brosnan and Healy (2011) completed a review of behavioral interventions for the treatment of aggression in children with developmental disabilities. They found that three main types of interventions were used: (i) those that changed antecedent conditions; (ii) those that were reinforcement based; and (iii) those that focused on the consequences of behavior. The antecedent conditions that were altered included offering choices among tasks and reinforcers and introducing visual schedules. The reinforcement-based interventions included FCT, DR, and NCR procedures. The interventions that altered the consequences of behavior included extinction, response cost, and overcorrection, in which an effortful behavior that has some similarity to the target behavior is required. Many interventions were used in combination.
Self-injury
Self-injury is self-harming behavior that can result in tissue damage, such as head banging, hitting self, biting self, and skin picking. Self-injury tends to co-occur with other challenging behaviors (Matson et al., 2008). Behavioral interventions for self-injury have demonstrated effectiveness, especially when preceded by a FA (Harvey et al., 2009). Changing antecedent conditions and skills training, both non-aversive interventions, are effective treatments (Denis et al., 2011).
Pica
Pica refers to repeatedly eating inedible items or non-nutritious substances (Hagopian et al., 2011). Pica can have serious and even life-threatening consequences resulting in repeated surgeries and permanent physical damage. Sensory stimulation, or automatic reinforcement, is frequently hypothesized as the function for pica, although social contingencies should also be considered. Effective interventions for pica include environmental modifications, behavioral skills training, reinforcement, or response-reduction procedures (response blocking, effort manipulation, and punishment), or a combination of these (Hagopian et al., 2011). According to Matson et al. (2013), conducting a FA followed by non-aversive interventions such as NCR is an appropriate initial course of action for pica.
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