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Assessment and Treatment of Aggression During Public Outings.

Abstract

Problem behavior occurring during public outings can limit children's participation in these activities and can be disruptive for families. The current study included two children referred for the assessment and treatment of problem behaviors occurring during public outings. Clinic-based functional behavior assessments indicated problem behaviors were likely maintained by access to tangibles. Implementation of the tangible condition of the functional analysis in a hospital-based gift shop or cafeteria confirmed these hypotheses. To address their problem behavior and compliance, both participants participated in differential reinforcement of alternative (DRA) behavior treatment programs. Within an ABAB reversal design, DRA treatment resulted in decreased problem behavior and increased compliance to instructions when compared to the tangible condition of the functional analysis. Collectively, results of this study effectively replicated and extended an assessment and treatment procedure to address problem behaviors exhibited by children during public outings.

Keywords: public outings, functional analysis, differential reinforcement of alternative behavior

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Problem behavior exhibited during non-preferred activities is a clinically significant concern for up to 60% of children and adolescents (Kalb & Loeber, 2003). Visits to public places, such as grocery stores, may occasion problem behavior for some children. Problem behavior in response to these situations can limit participation in public outings and adversely affect the quality of experience for the child, as well as for their family. Therefore, effective assessment and treatment of problem behavior exhibited during public outings is highly important.

Within the field of applied behavior analysis, functional behavior assessment (FBA) is considered best practice for the first step in designing behavioral treatment (Neef & Peterson, 2007). FBAs can consist of indirect assessments, such as questionnaires or interviews (Hanley, 2012), direct assessments, such as antecedent-behavior-consequence (ABC) observations (Carr et al., 1994), or functional analyses of problem behavior (Iwata, Dorsey, Slifer, Bauman, & Richman, 1982/1994). Results of FBAs produce information about behavioral function that inform function-based treatment (Tiger, Hanley, & Bruzek, 2008). Treatment based on the function of problem behavior has been shown to decrease problem behavior more reliably than treatments not based on function (Roane, Fisher, & Carr, 2016).

Limited research has applied FBAs to assess and treat problem behaviors during public outings (Hanley, Iwata, & McCord, 2003). In one exception, Carr and Carlson (1993) applied this method to target problem behaviors exhibited by adults learning grocery-shopping skills. Results of ABC observations generated hypotheses regarding the consequences that may have maintained problem behavior occurrence for each adult. For example, one individual engaged in elopement shortly after entering the store and engaged in more severe forms of problem behavior if the exit was blocked. Based on the results of an FBA, the researchers hypothesized that the individual engaged in elopement to escape from the store. For this individual, a choice of the first activity completed in the store decreased problem behavior. Two other adults demonstrated similar results. Whereas this study provided an example of a procedure for addressing problem behavior exhibited during public outings, one noted limitation was that a functional analysis of problem behavior did not occur. Carr and Carlson (1993) argued that purposely arranging for evocative situations could produce unacceptable rates of problem behaviors. One potential undesirable consequence if this occurred would be the participant's expulsion from the store. Given the potential benefit of functional analysis methodology in leading to effective treatment (Hanley et al., 2003), research is needed to understand ways in which the procedure can be conducted safely in a public setting.

Cihak, Alberto, and Fredrick (2007) investigated the use of brief functional analyses with four young adults engaging in problem behaviors within a public vocational setting. Interviews with caregivers informed the design of the functional analyses. All four participants' functional analyses indicated that problem behavior was maintained by escape from vocational tasks. Differential reinforcement of alternative (DRA) behavior and antecedent-based interventions resulted in decreased levels of problem behavior occurrence. Stakeholders in these young adults' lives reported highly positive social validity data for the assessment and treatment program.

Overall, a limited number of studies have successfully established assessment and treatment procedures to address problem behavior within public settings (Carr & Carlson, 1993; Cihak et al., 2007; Wallace & Knights, 2003), and have focused on the adult population. This highlights the need for more systematic studies that target problem behavior exhibited by children. Thus, the purpose of the current study was to replicate and extend previous approaches to functional assessment and treatment (Carr & Carlson, 1993; Cihak et al., 2007) within public outings by focusing on children exhibiting problem behavior, as well as to determine treatment efficacy within this study population.

Method

Participants

Two children referred for the assessment and treatment of aggression participated in the study. Asik was a 5-year-old boy diagnosed with autism spectrum disorder and unspecified disruptive, impulse-control, and conduct disorder. Asik communicated using gestures and picture exchange. Larry was a 12-year-old boy diagnosed with autism spectrum disorder, mild intellectual disability, and unspecified disruptive, impulse-control, and conduct disorder. He spoke in complete sentences. A psychiatric day treatment program at a university-based hospital provided treatment for both children's aggression during the time of the study. Prior to participation, the authors conducted an interview with caregivers to evaluate relevant antecedent conditions evocative for problem behavior. Interview results for Asik and Larry both suggested aggression was possibly maintained by escape from demands or access to tangibles. The information was then used to design a functional analysis to confirm.

Setting and Materials

Experimental procedures were conducted in a therapy room at the clinic (Asik and Larry), a hospital-based gift shop (Asik), and a hospital-based cafeteria (Larry). The therapy room measured 1.8 m x 2.1 m and contained a table and two chairs. Work activities (as identified via parent report) and preferred activities were available in the room. Work activities for Asik were matching by shape and color and single-by-single digit multiplication for Larry. The preferred activity for Asik was interacting with an iPad. Larry's preferred items were candy and an iPad. The gift shop measured 9.1 m x 6.1 m and contained toys (e.g., coloring books, stuffed animals), clothes (e.g., shirts, sweatshirts), flowers, and other gifts intended for patients receiving medical care. The cafeteria measured 4.6 m x 3.0 m and contained a variety of drinks (e.g., water, soda, energy drinks), sandwiches, chips, and candy. The drinks and sandwiches were in a refrigerator. The chips and candy were located next to each other in a stand.

Preferred edibles or toys used during Asik's behavioral assessment and treatment sessions were identified via a multiple stimulus without replacement preference assessment (MSWO; DeLeon & Iwata, 1996) as potential reinforcers for compliance. Larry's materials were pictures of preferred candy (e.g., M&Ms, Air Heads). Prior to the study, Larry engaged in perseverative speech about candy he observed in magazines. To identify candies relevant for the current study, we conducted a free operant preference assessment (Roane, Vollmer, Ringdahl, & Marcus, 1998) in the cafeteria. Three 5-min sessions of the free operant preference assessment were conducted. Candies that were already available to customers were evaluated. During all sessions, Larry did not manipulate the candies, he only looked at them. Therefore, we measured orientation of Larry's head toward candy. Data coders tracked duration of orientation when Larry's head moved towards a candy and remained in place for at least 3 s. Candies with the longest duration of orientation were identified as highly preferred.

Dependent Variables and Data Collection

Data were collected on aggression and compliance for both Asik and Larry. Data coders recorded aggression when Asik's or Larry's hand or foot contacted the body of another adult resulting in the movement of an adult's body. Frequency of aggression was collected and graphed as responses per minute (RPM). Compliance occurred when Asik or Larry completed a therapist's request within 5 s following delivery. Frequency of compliance was measured and graphed as percentage of opportunities. Percentage of opportunities was calculated by dividing number of tasks completed divided by number of tasks completed plus number of tasks not completed multiplied by 100. Countee, an iPad application, was used by therapists to collect frequency and duration-based data during these sessions with Asik and Larry.

Interobserver Agreement (IOA)

A second, independent observer collected data with the primary observer on a subset of sessions. IOA was determined using interval-by-interval comparisons of both observers' data across each of the dependent variables (Kazdin, 2011). An agreement was defined as both observers recording the same behavior (occurrence) or not recording the same behavior (nonoccurrence) in the same 10-s interval. A disagreement was defined as both observers recording different behaviors in the same 10-s interval. IOA was calculated by dividing the number of agreements by the number of agreements plus disagreements and converting the result to a percentage. IOA data were collected across sessions of each condition of the FA and during each implementation of DRA treatment. For this study, IOA was collected for 50% of functional analysis sessions for Asik, averaging at 85% (range: 70-100%). IOA was collected for 43% of DRA sessions with Asik, with an average of 90% (range: 87-93%). IOA was collected for 17% of functional analysis sessions and 83% DRA sessions for Larry. IOA for these sessions was 100%.

Experimental Design

The functional analysis was conducted within a multi-element design to evaluate the function of aggression. An ABAB (A = tangible baseline; B = DRA treatment) reversal design was applied to evaluate reductions in problem behavior and increases in compliance during the treatment evaluation.

Procedures

Functional analysis of problem behavior. A functional analysis of problem behavior, based on procedures described by Iwata et al. (1982/1994), first occurred in a clinic setting for both Asik and Larry. A tangible condition was added based on parent report of problem behavior occurring when preferred activities were denied. Sessions of each condition lasted 5 min. Preferred activities (as determined via the MSWO preference assessment) and adult attention were continuously available during free play (control condition). A highly preferred item was restricted during the tangible condition, and problem behavior resulted in 30-s access to this item. During the attention condition, Asik and Larry were directed to play alone with a low-preferred item while a therapist read a book. Problem behavior resulted in 30-s access to attention in the form of brief reprimands. An academic task was presented during the escape condition, and the occurrence of problem behavior resulting in 30-s escape from the demand. As such, tangible and attention conditions were conducted to evaluate problem behavior maintenance by positive reinforcement, while the escape condition was conducted to evaluate problem behavior maintenance by negative reinforcement.

Larry's functional analysis was undifferentiated since aggression did not occur. Thus, a follow-up pairwise functional analysis (Iwata, Duncan, Zarcone, Lerman, & Shore, 1994), alternating between control and tangible conditions, was conducted in the hospital cafeteria. During control, Larry could stand in the candy aisle of the cafeteria to look at the candy with continuous adult attention. During tangible, Larry was directed away from the candy aisle. Aggression produced 30-s access to the candy. This variation on the tangible condition evaluated whether aggression occurred to maintain access to the candy aisle.

Treatment Evaluation

Preliminary procedures. Prior to the treatment evaluation, the authors informed parents about potential confidentiality breaches and concerns with implementing procedures in the public setting. After obtaining their consent, the authors informed staff working in the gift shop or cafeteria about the purpose of the sessions. During this conversation, the authors discussed the purpose of behavioral assessment and treatment and the potential harm to patrons or property. To prevent patron harm, we clarified that a therapist would always stand between Asik or Larry and other patrons to prevent aggression. To prevent harm to property, we discussed how therapists would block Asik or Larry from contacting fragile items or throwing items. We communicated expectations to staff working in these environments to ensure that occurrence of problem behavior did not result in the individual's expulsion from the store (Carr & Carlson, 1993).

Treatment evaluation sessions occurred once per day, five days per week. We conducted sessions in 30-min blocks each day. Prior to sessions occurring in the gift shop or cafeteria, Asik and Larry independently walked from the inpatient unit to the public location with the help of two direct-care staff to the hospital gift shop (Asik) or the cafeteria (Larry). Asik and Larry were transitioned back to the inpatient unit at the end of sessions. They did not display problem behaviors when directed to transition between locations throughout the study.

Tangible baseline. The tangible baseline condition for Larry was the same as described in the modified tangible condition of the functional analysis outlined in a previous section. A similar variation on the tangible condition occurred for Asik to establish a control for the treatment evaluation. Sessions continued until problem behavior demonstrated an increasing or stable trend and compliance demonstrated a stable or decreasing trend.

During sessions of the modified tangible condition, the authors (hereafter referred to as therapists) directed Asik to the combined toy and candy aisle of the hospital gift shop. Asik could handle items in this aisle if he independently picked them up. The therapist then directed Asik to put the items down and to walk away from the aisle. Problem behavior resulted in continued access to the toy and candy aisle for 30 s. Compliance with the request to walk away resulted in brief praise and the presentation of another request. This variation on the tangible condition evaluated problem behavior maintenance by access to items in the toy and candy aisle.

DRA. DRA treatment was implemented to decrease problem behavior and increase compliance with instructions. Sessions lasted 5 min. Sessions continued until problem behavior demonstrated a decreasing or stable trend and compliance demonstrated an increasing or stable trend.

At the beginning of each session, a therapist directed Asik and Larry to the front of either the gift shop (Asik) or cafeteria (Larry). Prior to entering the respective locations, the therapist described treatment contingencies. Asik was told that if he followed directions he would earn a small edible or access to a preferred activity. Larry was told that if he followed directions he could look at a picture of a preferred candy. Larry did not access the candy depicted in the picture as part of this project. A therapist subsequently directed Asik and Larry into the gift shop or cafeteria, respectively. The first demand was delivered immediately upon entering the assigned location. An example demand for Asik was "Walk with me to the shirts," and for Larry was "Walk with me to a table" or "Walk with me to the cashier." Problem behavior resulted in least-to-most prompting to comply (Libby, Weiss, Bancoft, & Ahearn, 2008). This process consisted of the therapist first modeling the act of walking to the specified location. If compliance did not occur for another 5 s, the therapist physically guided the participant to walk. Reinforcement delivery did not occur following physical guidance, and the next demand was immediately delivered. If the participant complied with the instruction, reinforcement was immediately delivered. That is, Asik was given access to edibles and Larry was given a picture of candy. After reinforcement was consumed (Asik) or available for 30 s (Asik and Larry), the reinforcer was restricted and the next demand was assigned.

Results

During the clinic-based functional analyses, elevated rates of problem behavior occurred during the tangible condition (M = 1.4 RPM; range: 1.0-2.0 RPM) for Asik (Figure 1, top panel). Zero or near-zero rates of problem behaviors occurred during control and the other test conditions. Larry did not engage in problem behavior during the clinic-based functional analysis (Figure 1, bottom panel). Problem behavior also did not occur during the control condition conducted in the cafeteria. However, problem behavior was observed when the modified tangible condition was conducted in the hospital cafeteria (M = 0.9 RPM; range: 0.8-1.0 RPM; Figure 1, bottom panel). Taken together, these results showed maintenance by tangible reinforcement for Asik and Larry's problem behavior.

For the purpose of the treatment evaluation, Asik and Larry's data from the modified tangible condition served as baseline. Asik showed compliance at an initially high level that decreased over time (M = 59.4%; range: 35-75%; Figure 2). Additionally, aggression occurred at an average rate of 4.8 RPM (range: 3.0-7.6 RPM). Larry demonstrated moderate levels of compliance with demands during these sessions (M = 55%; range: 50-60%; Figure 2). Aggression occurred at an average rate of 0.9 RPM (range: 0.8-1.0 RPM).

Problem behavior decreased for both participants upon initiation of DRA treatment (Figure 2). A decreasing trend in aggressive behavior occurred for Asik (M = 2.8 RPM; range: 1.4-4.8 RPM), with a corresponding increase in compliance (M = 76.1%; range: 60-86.7%). Aggression decreased to zero immediately upon starting treatment for Larry, and compliance increased to 100%.

During the return to the tangible baseline, problem behaviors increased for both participants. Asik's aggressive behavior returned to baseline rates (M = 6.7 RPM; range: 6.6-6.8 RPM), and compliance quickly decreased (M = 44.2%; range: 43.3-45.0%). A similar, but less robust, pattern occurred for Larry. Aggression increased although not to previous baseline rates (M = 0.2 RPM; range: 0-0.4 RPM). Compliance also became more variable (M = 90%; range: 80-90%).

Treatment results were replicated when DRA was reintroduced (Figure 2). Aggressive behavior for Asik demonstrated a decreasing trend and averaged 1.9 RPM (range: 1.0-2.6 RPM). Compliance demonstrated a steep increasing trend (M = 83.3%; range: 76.7-91.7%). Aggression immediately decreased to zero, and compliance occurred on 100% of opportunities for Larry when DRA was reintroduced.

Discussion

This study evaluated an assessment and treatment program to address problem behavior occurring in a public setting for two children. Results from functional analyses indicated that aggression was maintained by social-positive reinforcement, in the form of access to tangibles. During the tangible baseline condition, compliance with instructions from adults was exhibited at moderate to low levels for both children. Subsequently, a differential reinforcement treatment program was effective in reducing these problem behaviors and increasing compliance with requests from adults. For Asik, DRA treatment increased compliance and decreased occurrences of problem behavior relative to baseline levels. Larry's problem behavior did not occur during DRA treatment and compliance always occurred.

This study addressed a critical limitation in the existing literature. That is, adolescent or adult participants comprised the subject populations for previous studies (Carr & Carlson, 1993; Cihak et al., 2007). This may be due to the requirement of school teams to include vocational skills in individualized education plans beginning at 16-years-old (Individuals with Disabilities Education Act, 1997). Despite the fact that problem behaviors exhibited within community settings is a salient concern for this age group, this is also a primary concern for younger children. Occurrence of problem behavior is prevalent in younger children, especially among those that have been diagnosed with a developmental disability (Fombonne, 2009; Kalb & Loeber, 2003). Caregivers of these children often report concerns with taking their child on community outings due to anticipated problem behaviors (Lomas Mevers, Call, & Miller, 2017). Studies, such as the current investigation, extending procedures evaluated with other populations are important toward the goal of establishing standards of practice that can be more broadly applied by practitioners. In addition to replicating the results of this small study, future researchers may also investigate the application of other functional analysis conditions to public settings. Conducting sessions in public settings could help capture naturally occurring variables that can be difficult to contrive in clinical settings (English & Anderson, 2004). As an example of how the typical attention condition could be modified, the child could be directed to a neutral or low-preferred area of the store while an adult restricts their attention by looking at the items in this portion of the store. Contingent attention in the form of reprimands could occur if the child engaged in the targeted problem behavior.

There are ethical concerns associated with the delivery of care in a public setting. For example, there is an increased likelihood that customers or employees will recognize the purpose of the treatment sessions when behavioral treatment is conducted at a public setting. Consequently, this may compromise clients' right to confidentiality. Behavior Analyst Certification Board (BACB) standard 2.06 dictates that a behavior analyst is responsible for protecting the confidentiality of their clients. Thus, behavior analysts should receive written consent and fully describe session procedures (BACB, 2014; Standard 2.05) to clients so they are fully informed about their rights during these observations. When working with children, stakeholders, such as parents or legal caregivers, should provide consent. Such ethical concerns should be considered when designing and implementing similar experimental studies or clinical analyses.

In addition to confidentiality, identification of ways to safely evaluate problem behaviors occurring in public settings is of the utmost importance. BACB standard 4.07 describes the behavior analyst's responsibility to address environmental conditions that interfere with implementation. Asik and Larry both engaged in aggressive behavior, posing a potential safety concern relative to other customers in the environment. The occurrence of problem behavior in the store or cafeteria could have resulted in employees requesting the patient to leave the premises. Two strategies were successfully implemented to address this concern. First, functional analyses in the study were performed in a controlled clinic setting followed by a brief, focused functional analysis (Larry) or baseline (Asik) in the relevant public context. This arrangement decreased the length of time spent in conducting the assessment in the public setting. Second, study investigators enlisted the assistance of Volunteer Services at the hospital to identify periods of low activity in the gift shop and cafeteria. Another benefit of partnering with the employees of the targeted settings was that they knew the purpose of the evaluation. It is possible that employees could respond negatively if they had not been informed of the purpose of the activity. This potential consequence has been extensively discussed by Carr and Carlson (1993). Practitioners might consider using these strategies to improve the safety and efficacy of behavioral assessment and treatment procedures conducted during public outings for children.

There are several limitations associated with this study. First, there was an absence of parental data showing generalization of the current treatment arrangement to Asik and Larry. Anecdotally, we provided caregiver training and consultation on how to implement these treatment procedures. Both Asik and Larry's parents reported the procedures as being acceptable and able to be implemented. Future research, though, should empirically show that key stakeholders in the participant's treatment (such as caregivers) find the treatment procedures feasible to implement. In addition, future researchers should thin the reinforcement schedule for compliance to make these procedures easier to implement by caregivers. Second, despite an immediate increase in problem behavior, Larry's return to baseline resulted in minimal occurrence of aggression. Clinically, the minimal return of aggressive behavior is a positive effect. It could be that small doses of DRA treatment lead to the persistence of treatment effects. Future research should fully evaluate the effect of dose of DRA treatment on persistence of treatment effects (Fisher, Greer, Fuhrman, Saini, & Simmons, 2018). Additional data sets of this analysis should be collected to establish external validity of these results. Third, Asik's and Larry's clinical treatment consisted of brief functional analyses. That is, a limited number of sessions of each condition were evaluated (Northup et al., 1991). Since results of indirect FBAs suggested problem behavior maintenance by escape or tangible, less focus was placed on the attention condition. This is particularly true for Larry in which only one attention condition was conducted during the functional analysis. Future research could conduct full functional analyses to avoid false negative outcomes or consult published studies for guidelines when manipulating functional analysis procedures (e.g., Rooker, DeLeon, Borrero, Frank-Crawford, & Roscoe, 2015).

In summary, this study demonstrated that problem behavior exhibited during public outings could be addressed using FA to identify the relevant maintaining variables and design function-matched treatment. More importantly, this study has extended the literature in the field by showing the effectiveness of these techniques in resolving problem behavior in children. It may be difficult to replicate the relevant establishing operations present in community settings in a clinic-based setting. Results from this study could pave the way for the development of other similar approaches for this age group in a variety of public settings. The implication of such work could improve community opportunities available to these children and their families.

Patrick W. Romani

University of Colorado School of Medicine, Anschutz Medical Campus and Children's Hospital Colorado

Antoinette M. Donaldson

Abigail J. Ager

Jennifer E. Peaslee

Shanna M. Garden

Children's Hospital Colorado

Merlin Ariefdjohan

University of Colorado School of Medicine, Anschutz Medical Campus and Children's Hospital Colorado

Author note: The authors would like to thank Volunteer Services at Children's Hospital Colorado for their assistance with the current project.

Address correspondence to: Patrick W. Romani, Children's Hospital Colorado, 13123 E. 16th Ave, Aurora, CO 80045. E-mail: Patrick.romani@childrens colorado.org. Phone: 720-777-2996

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Caption: Figure 1. Occurrence of problem behavior per minute for Asik (top panel) and Larry (bottom panel) during functional analysis.

Caption: Figure 2. DRA behavior treatment evaluation for Asik (top panel) and Larry (bottom panel).
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Author:Romani, Patrick W.; Donaldson, Antoinette M.; Ager, Abigail J.; Peaslee, Jennifer E.; Garden, Shanna
Publication:Education & Treatment of Children
Article Type:Clinical report
Geographic Code:1USA
Date:Aug 1, 2019
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