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Idiosyncratic functions: severe problem behavior maintained by access to ritualistic behaviors.

Abstract

The development of functional analysis technology has been an important tool in the assessment and treatment of aberrant behaviors among individuals with developmental disabilities. In some cases, the function of problem behavior may be idiosyncratic in nature, making modifications to functional analyses necessary. In the current study, a functional analysis (Iwata et al., 1982/1994) was inconclusive due to low rates of problem behaviors across all conditions. In a subsequent ritualistic behavior assessment, problem behavior was found to be maintained by gaining access to ritualistic behaviors (i.e., changing the position of doors in close proximity). From this assessment, a treatment consisting of functional communication and extinction was introduced. A clinically significant reduction in the rate of problem behavior was observed with the introduction of treatment. These results suggest that in cases where an initial functional analysis is inconclusive, it may be necessary to evaluate more idiosyncratic functions of problem behavior.

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Functional analyses (Iwata, Dorsey, Slifer, Bauman, & Richman, 1982/1994) are commonly used to determine the reinforcer(s) of aberrant behavior exhibited by individuals diagnosed with developmental disabilities. The results of functional analyses allow for the development and empirical validation of treatments that target these destructive behaviors. A functional analysis is designed to test for problem behavior that may be maintained by social positive or negative reinforcement as well as automatic reinforcement. Individuals are typically placed in controlled situations during which antecedent variables that may occasion problem behavior are present (e.g., demands). A consequence, testing a potential function (e.g., escape from demands), is delivered contingent on problem behavior.

Although the development of functional analysis technology (Iwata et al., 1982/1994) has been paramount in advancing the widespread development of individualized, function-based treatments, the variables typically explored in functional analysis of severe problem behaviors may not always be sufficient in determining the maintaining variables for problem behavior. Iwata et al. (1994) reviewed 152 functional analyses of self-injurious behavior (SIB) exhibited by individuals diagnosed with developmental disabilities. They found that of these individuals, 38.1% engaged in SIB that was maintained by escape from demands, 26.3% engaged in SIB that was maintained by access to attention or tangible items, 25.7% engaged in SIB that was maintained by automatic reinforcement, and 5.3% engaged in SIB maintained by more than one environmental variable (e.g., attention and escape). A majority of these individuals engaged in SIB that was maintained by variables systematically manipulated in their functional analyses. However, for the remainder of the subjects in their sample (4.6%), conclusions about the functions of SIB could not be made due to inconsistent rates of responding. For these latter individuals, extensions to functional analysis methodology may be necessary to determine the function of aberrant behavior (Carr, 1994).

Bowman, Fisher, Thompson, and Piazza (1997) examined an experimenter's compliance with participants' requests as a possible reinforcer for problem behavior in two children diagnosed with developmental disabilities. For both participants, a functional analysis was inconclusive due to low rates of problem behaviors across experimental conditions. In a subsequent assessment, the experimenter complied with the participants' requests contingent upon targeted problem behaviors during the test condition. For both participants, rates of problem behavior were consistently higher in the test condition relative to the control condition. These results led to the development of a function-based treatment consisting of functional communication training (FCT) and extinction for problem behaviors.

DeLeon, Kahng, Rodriguez-Catter, Sveinsdottir, and Sadler (2003) evaluated the effects of a similar treatment on aggression maintained by wheelchair movement. In the functional analysis, an additional experimental condition was included during which the participant was pushed in his wheelchair contingent on problem behavior. Results from this assessment suggested that the participant engaged in the majority of aggressive responses during the contingent wheelchair movement condition relative to other experimental conditions. These data served as the basis for a function-based treatment in which the participant was taught to communicate for access to being pushed in his wheelchair, while all problem behaviors were placed on extinction.

Murphy, Macdonald, Hall, and Oliver (2000) investigated the termination of ritualistic behavior as a possible maintaining variable for the aggressive behavior of an individual diagnosed with severe developmental disabilities. Anecdotal reports suggested that this participant's aggressive responses were occasioned by blocking her from engaging in ritualistic behaviors (e.g., flushing items down the toilet). A functional analysis was conducted to isolate the maintaining environmental variables for the aggressive behavior. Experimental conditions were compared where the participant's ritualistic behaviors were blocked or permitted with both flushable (paper) and unflushable (polystyrene) materials. Although the participant engaged in relatively low levels of aggression throughout the different experimental conditions, the probability of engaging in aggressive responses was highest in the flushable materials with blocking condition. These data suggest that, for this participant, aggressive behavior may have been maintained by terminating the prevention of ritualistic behaviors by caregivers.

These studies highlight the potential importance of identifying strategies that extend the Iwata et al. (1982/1994) functional analysis protocol to alternative, less common functions of problem behavior. In particular, Murphy et al. (2000) examined a problematic ritualistic behavior, which may be somewhat common among certain individuals with developmental disabilities (e.g., individuals with autism). The purpose of this study is to examine whether or not an idiosyncratic (1) variable such as access to ritualistic behaviors may function as a reinforcer for problem behavior.

Method

Participant and Setting

Maria was a 9-year-old female diagnosed with autism, moderate mental retardation, and cerebral palsy. She was admitted to an inpatient pediatric hospital for the assessment and treatment of SIB, aggression, property destruction, and ritualistic behaviors. Maria used vocal speech to communicate and had good receptive and expressive language skills.

All assessments were conducted on the inpatient unit of the pediatric hospital. Initially, functional analysis sessions were conducted in a 2 m x 2 m padded session room. These sessions were then moved to the main living unit.

Response Definitions

Data were collected on problem behaviors and communication during the treatment evaluation. Problem behaviors included SIB, aggression, and property destruction. SIB was defined as hitting head on hard surfaces (i.e., headbanging), self-biting, hitting knee to head, and/or hitting self with hand or objects. Aggression was defined as hitting, kicking, scratching, and/or head-butting others. Property destruction was defined as throwing objects, ripping/tearing/breaking objects, banging on surfaces, and/or kicking walls or other surfaces. Ritualistic behavior was defined as repeatedly opening and closing doors to different rooms, refrigerators, and microwaves. Communication was defined as Maria handing the therapist a picture card while emitting in the vocal response, "My way, please."

Data Collection and Interobserver Agreement

Data were collected on laptop computers using the Behavioral Data Analysis and Collection System (BDACS; Lieving, 2005). Overall frequency was recorded for each topography of problem behavior, which was then converted into a rate measure (responses per minute). A second, independent observer collected data during 40% of the functional analysis sessions and 40% of all sessions during the ritualistic behavior assessment and treatment evaluation. Sessions were divided into 10-s intervals and data from both observers were compared. Interobserver agreement was calculated according to the exact agreement method (# of scoring agreements/ total # intervals multiplied by 100%). An agreement was defined as both observers reporting the same number of responses within a 10-s interval. For all target behaviors, interobserver agreement averaged 99.6% (range, 98.8% to 100%) during the functional analysis and 94.3% (range, 76.3% to 99.7%) during the ritualistic behavior assessment and treatment evaluation.

Experimental Design

The initial functional analysis was conducted using a multielement design. An A-B-A-B reversal design was then used to demonstrate experimental control during the subsequent assessment of ritualistic behavior and treatment evaluation. Within the first baseline phase of the assessment of ritualistic behavior, the test (i.e., baseline) and control conditions were evaluated using a multielement design.

Functional Analysis

A functional analysis (Iwata et al., 1982/1994) consisting of the toy play, social attention, and demand conditions was initially conducted. Due to the severity of Maria's SIB, a fourth condition, ignore, was substituted for an alone condition (2). All sessions were 10 min in duration and were conducted in the padded session room. During the toy play condition, Maria was given access to highly preferred toys and noncontingent attention was provided every 30 s. In the social attention condition, the therapist pretended to engage in an activity (e.g., reading a magazine) and provided attention in the form of a verbal reprimand contingent upon targeted problem behaviors. During the demand condition, a 3-step, least-to-most prompting procedure was used to present Maria with a variety of academic and domestic demands. Maria was given 30 s of escape from demands contingent upon targeted problem behaviors. During the ignore condition, a therapist was present to block any instances of SIB, but did not otherwise interact with Maria.

Assessment of Ritualistic Behavior

Due to low levels of problem behaviors across all conditions of the functional analysis, an assessment of ritualistic behavior was conducted to examine another, more idiosyncratic function of Maria's problem behaviors. Anecdotal observations and parental report suggested that Maria would engage in intense bursts of problem behavior when blocked from engaging in ritualistic behaviors, which were occasioned by others opening and/or closing doors in Maria's presence. The ritualistic behavior assessment was conducted on the main living unit. All sessions were 5 min in length. For both the test and control conditions, Maria had 2-min pre-session access to open and close the door prior to session. During the test condition, the therapist manipulated the position of the door every 30 s. For example, if the door was open, the therapist would close it. If it were closed, the therapist would open it. Contingent on problem behaviors, Maria was allowed to engage in ritualistic behaviors (e.g., opening the door and propping it open with a doorstop). In the control condition, the therapist did not manipulate the position of the door. That is, the door was left in whatever position Maria had put it in during the pre-session access period. The test condition of this assessment served as the baseline for the subsequent treatment evaluation.

Functional Communication Training

Prior to conducting the treatment evaluation phase, functional communication training (FCT) trials were initiated (Carr & Durand, 1985). Functional communication is a specific type of differential reinforcement of alternative behavior (DRA) procedure commonly used with individuals diagnosed with developmental disabilities. This procedure is designed to teach the individual to appropriately ask for identified functional reinforcers in the naturalistic environment and is commonly paired with other components such as extinction for problem behaviors. The purpose of FCT was to teach Maria to appropriately communicate for access to ritualistic behaviors. Least-to-most prompting was used to teach Maria to hand the therapist a picture card and simultaneously emit the vocal response, "My way, please." Ten trial sessions were conducted and data were collected on level of independent communication on each trial. Maria was able to access her ritualistic behavior following communication. Maria acquired the appropriate communicative response within 3 sessions, independently communicating for "my way" during an average of 87% of trials.

Ritualistic Behavior Treatment Evaluation

Following the completion of the FCT trials, the ritualistic behavior treatment evaluation was initiated with Maria. All treatment sessions were 5 min in length. The test condition, described previously under Assessment of Ritualistic Behaviors, served as the initial baseline for this treatment evaluation. During treatment, Maria continued to receive 2-min pre-session access to re-position the door. The therapist manipulated the position of the door every 30 s, similar to the test condition in the ritualistic behavior assessment. During treatment sessions, all problem behaviors were placed on extinction (i.e., access to ritualistic behaviors was no longer provided contingent upon targeted problem behaviors). Maria was given access to ritualistic behaviors contingent upon communication on a fixed-ratio (FR) 1 schedule.

Results

Low rates of problem behaviors were observed across all conditions during the initial functional analysis (Figure 1), making any conclusions about behavioral function impossible. Additionally, Maria did not engage in ritualistic behavior during the initial functional analysis. Maria would close the door upon entering the room and the door was left closed throughout each session.

[FIGURE 1 OMITTED]

Clear differentiation was observed between the test and control conditions of the ritualistic behavior assessment (initial baseline, Figure 2). During this assessment, Maria engaged in no problem behaviors during the control condition and an average of 4.3 problem behaviors per min during the test condition (problem behavior, Figure 2) when the door was manipulated by the therapist. Thus, it appeared that Maria's problem behaviors may be maintained, in part, by access to ritualistic behaviors.

[FIGURE 2 OMITTED]

In the subsequent ritualistic behavior treatment evaluation (Figure 2), rates of problem behaviors were lower than in the baseline (i.e., test condition). Rates of problem behaviors averaged 1.3 per min during the initial treatment phases and communication averaged 1.0 per min. In the subsequent return to baseline (i.e., test condition), problem behaviors increased to 5.6 per min. Finally, in the return to treatment, problem behaviors decreased to 0.3 per min and communication increased to an average of 1.5 per min. The introduction of treatment, consisting of communication for access to ritualistic behaviors combined with extinction for all problem behaviors, resulted in an 80% reduction in rates of problem behaviors as compared to baseline.

Discussion

A functional analysis using conditions described by Iwata et al. (1982/1994) was inconclusive due to low rates of problem behavior. Anecdotal observations and parental report led to the development of a ritualistic behavior assessment to explore more idiosyncratic functions of Maria's problem behaviors, specifically the possibility that Maria's problem behaviors may have been occasioned by blocking access to ritualistic behaviors. Results obtained from the subsequent ritualistic behavior assessment suggested that the problem behavior exhibited by this participant was maintained by access to ritualistic behavior in the form of manipulating the position of doors in close proximity.

These findings extend the previous research on the importance of examining more idiosyncratic functions of problem behaviors in individuals diagnosed with developmental disabilities. Although in most cases, functional analysis of problem behaviors as described by Iwata et al. (1982/1994) are sufficient to determine behavioral function, additional assessment may be necessary to identify more idiosyncratic behavioral functions as the problem behaviors of some individuals with developmental disabilities may not be sensitive to social attention, escape from academic tasks, or serve to provide sensory stimulation. Iwata et al. (1994) reported that for the vast majority of their participants, a clear behavioral function (i.e., access to attention or tangible items, escape from demands, and/or automatic reinforcement) was identified. However, conclusions could not be made about the function of SIB due to cyclical patterns in the data or other unclear patterns of responding in 4.6% of the sample. Although a functional analysis based on Iwata et al. (1982/1994) is still the most efficient and powerful means of identifying behavioral function, it may be necessary to explore alternative, less common functions of problem behaviors for this small subset of the population should the initial functional analysis be inconclusive.

For practical reasons, it would be difficult for clinicians to test for these very idiosyncratic functions of problem behaviors by including multiple additional experimental conditions within an initial functional analysis. In these cases, it may be beneficial to conduct subsequent functional assessments to determine these nontraditional functions of problem behavior in an effort to develop and empirically validate function based treatments (Carr, 1994; Iwata, 1994). To aid in the development of these additional functional assessments, it may be beneficial to utilize anecdotal observations and caregiver reports to formulate hypotheses as to the more idiosyncratic maintaining variables for an individual's problem behaviors.

Iwata et al. (1982/1994,1994) identified five conditions, free play, attention, tangible, escape, and automatic reinforcement, which correspond to variations on positive and negative reinforcement. In this case, it is possible that access to ritualistic behaviors served as either positive or negative reinforcement for problem behavior. That is, it may have been the case that Maria was previously denied access to manipulating the door, thus this period of deprivation served as a motivating operation (Laraway, Snycerski, Michael, & Poling, 2003)-more specifically establishing operation - for problem behavior. Alternatively, the position of the door may have served as an establishing operation that had an evocative effect on problem behavior. Future research should examine methods of conducting additional analyses to further elucidate the functional relationship between ritualistic and problem behaviors.

One limitation to this study may be the practicality of providing reinforcement for communication on a dense schedule of reinforcement. Communication was continuously reinforced throughout this treatment evaluation. It may be impractical to allow ritualistic behaviors such as these to occur whenever requested in the naturalistic environment for a variety of safety reasons. Although the schedule of reinforcement was not thinned during the treatment evaluation, anecdotal reports from treatment generalization did suggest that Maria would tolerate her requests for access to ritualistic behaviors being denied by her therapists or caregivers. Another limitation may be that Maria was permitted to engage in the ritualistic behavior. Given the long history of problem behaviors, Maria's mother reported that she would allow Maria to engage in ritualistic behaviors upon her return to the home. Thus, the behavioral intervention focused on teaching Maria a more appropriate means of accessing ritualistic behaviors. Finally, future studies should evaluate these behaviors among a larger group of participants. Although these data do suggest a viable approach to the assessment and treatment of problem behaviors that are maintained by gaining access to ritualistic behaviors, this study was only conducted with a single participant.

Notes

(1) For the purposes of this study, the idiosyncratic function of behavior refers to a function of problem behavior not typically tested for in the Iwata et al. (1982/1994) functional analysis methodology. These types of ritualistic behaviors are not uncommon among individuals diagnosed with some types of developmental disabilities such as autism. That is, the termination or blocking of stereotyped patterns of behaviors (i.e., rituals) may occasion problem behaviors. The reported prevalence of these complex, ritualistic patterns of behavior in the developmentally disabled population have varied from 3.5% to 96% (Vitiello, Spreat, & Behar, 1989; McDougle et al., 1995).

(2) During intake interviews, Caregivers did not report that Maria had a history of gaining access to tangible items contingent on problem behaviors. Therefore, a tangible condition was not included in the initial functional analysis due to the potential for inadvertently creating a tangible function.

References

Bowman, L. G., Fisher, W. W., Thompson, R. H., & Piazza, C. C. (1997). On the relation of mands and the function of problem behavior. Journal of Applied Behavior Analysis, 30, 251-265.

Carr, E. G. & Durand, V. M. (1985). Reducing behavior problems through functional communication training. Journal of Applied Behavior Analysis, 18, 111-126.

Carr, E. G. (1994). Emerging themes in the functional analysis of problem behavior. Journal of Applied Behavior Analysis, 27, 393-399.

Carr, E. G., Yarbrough, S. C., & Langdon, N. A. (1997). Effects of idiosyncratic stimulus variables on functional analysis outcomes. Journal of Applied Behavior Analysis, 30, 673-686.

DeLeon, I. G., Fisher, W. W., & Marhefka, J. (2004). Decreasing self-injurious behavior associated with awakening in a child with autism and developmental delays. Behavioral Interventions, 19, 111-119.

DeLeon, I. G., Kahng, S., Rodriguez-Catter, V., Sveinsdottir, I., & Sadler, C. (2003). Assessment of aberrant behavior maintained by wheelchair movement in a child with developmental disabilities. Research in Developmental Disabilities, 24, 381-390.

Iwata, B. A., Dorsey, M. F., Slifer, K. J., Bauman, K. E., & Richman, G. S. (1982/1994). Toward a functional analysis of self-injury. Journal of Applied Behavior Analysis, 27, 197-209. (Reprinted from Analysis and Intervention in Developmental Disabilities, 2, 3-20, 1982).

Iwata, B. A., Pace, G. M., Dorsey, M. F., Zarcone, J. R., Vollmer., T. R., Smith, R. G., et al. (1994). The functional analysis of self-in-jurious behavior: An experimental-epidemiological analysis. Journal of Applied Behavior Analysis, 27, 215-240.

Laraway, S., Snycerski, S., Michael, J., & Poling, A. (2003). Motivating operations and terms to describe them: Some further refinements. Journal of Applied Behavior Analysis, 36, 407-414.

Lieving, G. A. (2005). Behavioral Data Analysis and Collection System (Version 1.1.1) [Computer software and manual]. Baltimore, MD: Kennedy Krieger Institute.

McDougle, C. J., Kresch, L. E., Goodman, W. K., Naylor, S. T., Volkmar, F. R., Cohen, D. J., et al. (1995). A case-controlled study of repetitive thoughts and behaviour in adults with autistic disorder and obsessive-compulsive disorder. American Journal of Psychiatry, 152, 772-777.

Murphy, G., Macdonald, S., Hall, S., & Oliver, C. (2000). Aggression and the termination of "rituals": a new variant of the escape function for challenging behavior? Research in Developmental Disabilities, 21, 43-59.

Vitiello, B., Spreat, S., & Behar, D. (1989). Obsessive-compulsive disorder in mentally retarded patients. Journal of Nervous and Mental Disease, 177, 232-236.

Nicole Hausman

Kennedy Krieger Institute

SungWoo Kahng

Kennedy Krieger Institute and the Johns Hopkins University School of Medicine

Ellen Farrell and Camille Mongeon

Kennedy Krieger Institute

Correspondence to: SungWoo Kahng, Ph.D., Department of Behavioral Psychology, Kennedy Krieger Institute, 707 N. Broadway, Baltimore, MD 21205; email: Kahng@kennedykrieger.org.
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Author:Hausman, Nicole; Kahng, SungWoo; Farrell, Ellen; Mongeon, Camille
Publication:Education & Treatment of Children
Article Type:Clinical report
Geographic Code:1USA
Date:Feb 1, 2009
Words:3528
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