1. of Young Children: A Focus on Teaching Delay Tolerance
Treating Problem Behavior
of Young Children: A Focus on
Teaching Delay Tolerance
Gregory P. Hanley. Ph.D., BCBA-D
For more information go to:
Please use the workbook for taking notes. Write down questions. There are two times scheduled for Q&A.
Let me be frank. I hope to convince you today that despite the buffets of functional assessment options and the larger buffet of treatment options that…. its not all good. That there are better, faster, and safer ways to conduct assessments and that some treatments are geared better than others for yielding socially meaningful outcomes.
I have been conducting functional assessments and function-based treatments for 25 years. I only started being comfortable and confident in the process over the last 4 or so years.
Utah Neuropsychiatric Institute
Autism Intervention Program for Professionals
November, 2016

2. IISCA-Based Treatment
Process has led to comprehensive treatments with large, generalized effects
Treatment relies on strengthening:
functional communication delay/denial toleration
compliance
With
Intermittent & unpredictable reinforcement

3. Problem behavior no longer yields the reinforcers (escape to child-directed play and teacher attention)
A simple response
(button press: “ My way please”)
is prompted and reinforced with
(escape to child-directed play & teacher attention)

4. A more interactional response
(shoulder tap,
wait for teacher acknowledgement,
two-button press:
May I have / My way please”)
is prompted and reinforced

5. Now, FCRs are reinforced half the time.
The other half, the teacher denies the bid (e.g., says’s no, do your work without me, please)
Responses to disappointment
are prompted and reinforced:
(Take a breath and nodding yes)
Cues of disappointment,
Delays to reinforcement, and
unpredictable outcomes
have now been introduced!

6. Now, FCRs are reinforced 1/3 of the time.
TRs are reinforced 1/3 of the time.
And compliance with progressively longer and more challenging instructions is reinforced

7. Treatment is now implemented by all his teachers, session length is extended across the school day. At the end, he is communicating, tolerating, complying and having his way about half the time. All without problem behavior.

8. Intermittent and unpredictable reinforcement of life skills:
What is the treatment????
Intermittent and unpredictable reinforcement of life skills:
Functional Communication
Delay/denial toleration
Compliance
Similar outcomes were achieved for all childen.

9. Meltdowns and aggression
“Play with me”
“Excuse me,” waits for acknowledgement from parent, then says, “Will you play with me, please” with appropriate tone and volume
This bridge study involved 3 children…the first three served by our severe problem behavior clinic two years ago. They ranged in age from 3 to 11, were all on the autism spectrum, and all engaged in severe problem behavior in the form of meltdowns, aggression towards parents and siblings, screaming, and property destruction.
Saying, “okay” while glancing at parent who just said “No,” Wait,” “Hold on,” or “in a minute”

10. Reinforcement: Time with Mom’s undivided attention and preferred toys
Compliance: Doing whatever Mom asked her to do quickly and completely
This bridge study involved 3 children…the first three served by our severe problem behavior clinic two years ago. They ranged in age from 3 to 11, were all on the autism spectrum, and all engaged in severe problem behavior in the form of meltdowns, aggression towards parents and siblings, screaming, and property destruction.

11. Treatment relies on set of reinforcers identified via the IISCA
Reinforcement is:
Function-based Sr
Examples:
Access to attention and toys
Escape from instructions to access preferred activities
Escape from parent instructions to access preferred activities and to have people comply with his requests
Termination of non-preferred conversations and access to preferred conversations
Access to ritualistic behaviors
Escape from discrete-trial work to child-led play with the teacher
It is hard to communicate the essentials of the treatment in this short amount of time, so let me return to the treatment one more time prior to making my closing remarks.
First point: The reinforcement we are using is function-based, meaning it is the same reinforcer we determined was maintaining problem behavior. And for us it is almost always a synthesis of multiple reinforcers.
Here are some examples of common reinforcers identified through our functional assessment process.

12. Reinforcement is:
Function-based
Differential
Problem Behavior Sr
Simple FCR Sr
Complex FCR Sr
Complex FCR
“No”
Tolerance response Sr
Second: We are relying on differential reinforcement in that neither problem behavior nor simple communication responses yield reinforcement; they are placed on extinction.
*Reinforcement is provided only for complex communication, tolerance responses, or compliance with instructions or expectations.
Complex FCR
“No”
Tolerance response
Instruction
Compliance Sr

13. Functional Communications
Reinforcement is:
Function-based
Differential
Intermittent
Complex
Functional Communications
Compliance
30%
50%
Tolerance
responses
It is important to understand that reinforcement in this treatment is intermittent. We immediately reinforce communication responses about 30% of the time. We immediately reinforce tolerance responses about 20% of the time. And we reinforce various amounts of compliance 50% of the time.
So reinforcement is intermittently provided for the important behaviors of communication, toleration, and compliance.
20%

14. Compliance Complex Functional Communications Compliance Tolerance
Reinforcement is:
Function-based
Differential
Intermittent
10%
Compliance
Complex
Functional Communications
Compliance
10%
Compliance
30%
10%
Compliance
Tolerance
responses
Because children sometime need to be without their reinforcers for short or extended amounts of time or said another way, children need to do various amounts of work, we end delays or reinforce when a child complies with very little demands, such as have a seat, lets do some work. And we sometimes don’t reinforce until a lot of work has been done.
20%
20%

15. Reinforcement is: Function-based Differential Intermittent
Complex FCR Sr
Complex FCR Sr
Complex FCR Sr
Complex FCR
“No”
Tolerance response Sr
Complex FCR
“No”
Tolerance response Sr
Complex FCR
This is a schematic of the various chains of behavior that yield reinforcement; schematic also indicates the relative probability each is reinforced.
Take note of how often communication is always part of the chains of responses that yield reinforcement and how often tolerance responses will be practiced and reinforced as part of the interactional chains.
“No”
Tolerance response
Instruction C Sr
Complex FCR
“No”
Tolerance response
Instruction
Compliance Sr
Complex FCR
“No”
Tolerance response
Instruction
Compliance Sr
Complex FCR
“No”
Tolerance response
Instruction
Compliance Sr
Complex FCR
“No”
Tolerance response
Instruction
Compliance Sr

16. Reinforcement is: Response requirement is: Function-based Variable
Differential Unpredictable
Intermittent
Complex FCR
“No”
Tolerance response Sr
Complex FCR Sr
Complex FCR
“No”
Tolerance response
Instruction
Compliance Sr
Complex FCR
“No”
Tolerance response Sr
Complex FCR
“No”
Tolerance response
Instruction
Compliance Sr
Complex FCR
This last schematic illustrates the treatment during implementation.
It is important to understand that there is a variable and unpredictable response requirement. The child never knows which behavior will be reinforced because the response requirement for reinforcement, or how long the chain of behavior will be prior to reinforcement, is purposely unpredictable. This prepares children for the ambiguities of the real world, and as mentioned earlier, children seem to prefer conditions that retain this unpredictability or what we might call hope, hope that the things they have to do will be over at any second so that they can do what they would rather be doing.
“No”
Tolerance response
Instruction C Sr
Complex FCR Sr
Complex FCR
“No”
Tolerance response
Instruction
Compliance Sr
Complex FCR
“No”
Tolerance response
Instruction
Compliance Sr
Complex FCR Sr

17. Reinforcement is: Response requirement is: Function-based Variable
Differential Unpredictable
Intermittent
Variable in duration
Complex FCR
“No”
Tolerance response Sr
Complex FCR Sr
Complex FCR
“No”
Tolerance response
Instruction
Compliance Sr
Complex FCR
“No”
Tolerance response Sr
Complex FCR
“No”
Tolerance response
Instruction
Compliance Sr
Complex FCR
Finally, we make the reinforcement duration variable as well. This then is a schematic of the final treatment.
“No”
Tolerance response
Instruction C Sr
Complex FCR Sr
Complex FCR
“No”
Tolerance response
Instruction
Compliance Sr
Complex FCR
“No”
Tolerance response
Instruction
Compliance Sr
Complex FCR Sr

18. Reinforcement is: Response requirement is: Function-based Variable
Differential Unpredictable
Intermittent
Variable in duration
Complex FCR
“No”
Tolerance response Sr
Complex FCR Sr
Complex FCR
“No”
Tolerance response
Instruction
Compliance Sr
Complex FCR
“No”
Tolerance response Sr
Complex FCR
“No”
Tolerance response
Instruction
Compliance Sr
Complex FCR
Look how much practice of the skills there are each time an EO is presented!
We think it is these characteristics of the reinforcement program* that have led to the general and meaningful effects of our treatments.
Seems complicated right?
“No”
Tolerance response
Instruction C Sr
Complex FCR Sr
Complex FCR
“No”
Tolerance response
Instruction
Compliance Sr
Complex FCR
“No”
Tolerance response
Instruction
Compliance Sr
Complex FCR Sr

19. Treatment Implementation
Put these in your pocket
Pull one out while child is experiencing their reinforcers
Keep it to yourself
Require that behavior next time
Spin it!
Keep it to yourself
Require that behavior next time
*Materials not needed:
Laminate
Laminating machine
Glue guns
Vis a vis markers
Velcro
Tokens
Token boards
Timers
Stickers
Candies
Anything that was not already in
the child’s environment!
Based on the schematics I just showed, this sort of treatment may seem complicated to implement. But it isn’t. There are several strategies to ensure implementation with integrity. I prefer this low tech system. *
You write the behaviors down that will yield the reinforcers, put them in your pocket, pull one out while the child is experiencing their reinforcers, keep the information to yourself please, and simply require that amount of behavior the next time the child initiates communication.
Please appreciate that which is not required to implement this function-based treatment.

20. App called “Names in a Hat”
Based on the schematics I just showed, this sort of treatment may seem complicated to implement. But it isn’t. There are several strategies to ensure implementation with integrity. I prefer this low tech system. *
You write the behaviors down that will yield the reinforcers, put them in your pocket, pull one out while the child is experiencing their reinforcers, keep the information to yourself please, and simply require that amount of behavior the next time the child initiates communication.
Please appreciate that which is not required to implement this function-based treatment.

21. App called “Roundom”
Based on the schematics I just showed, this sort of treatment may seem complicated to implement. But it isn’t. There are several strategies to ensure implementation with integrity. I prefer this low tech system. *
You write the behaviors down that will yield the reinforcers, put them in your pocket, pull one out while the child is experiencing their reinforcers, keep the information to yourself please, and simply require that amount of behavior the next time the child initiates communication.
Please appreciate that which is not required to implement this function-based treatment.

22. Time Assessment
Taking into account the going rates of the behavior analysts working together during this process, the projected cost for these outcomes is between 6 and 9000 us dollars.
Considering the much higher costs of inpatient psychological services (which is about $8000 per day), out-of-district educational placements (which cost between 80 and 130,000 per year), or long-term supported care for individuals with autism, which was estimated to be 3.2 million dollars across their lifetime, proper assessment and treatment of these problem behaviors while children with autism are young seems a reasonable investment.
This process costs about the same as a family of 4 week long vacation in Disneyworld, about the same as smoking 2 packs a day in Massachusetts, or about the same as getting the navigation, moon roof package, and wood paneling package in an SUV.

23. Cost Assessment
Taking into account the going rates of the behavior analysts working together during this process, the projected cost for these outcomes is between 6 and 9000 us dollars.
Considering the much higher costs of inpatient psychological services (which is about $8000 per day), out-of-district educational placements (which cost between 80 and 130,000 per year), or long-term supported care for individuals with autism, which was estimated to be 3.2 million dollars across their lifetime, proper assessment and treatment of these problem behaviors while children with autism are young seems a reasonable investment.
This process costs about the same as a family of 4 week long vacation in Disneyworld, about the same as smoking 2 packs a day in Massachusetts, or about the same as getting the navigation, moon roof package, and wood paneling package in an SUV.

24. IISCAs have led socially-validated outcomes
The procedures, treatments, amount of behavior change, and overall consultation process were also socially validated by the families of the children participating in the process.
I never asked these questions when doing standard analyses and basing treatments off of the standard analyses because I knew the unfortunate truth, that despite measurable improvements, the amount of behavior change and resulting treatments were often not satisfactory.
from Hanley et al., 2014

25. Personalized Social validity Data
When asked about their comfort level with presenting the specific situations that were initially reported to evoke problem behavior, ratings improved for all parents between the initial and their last meeting with the behavior analyst and the parents reported being very comfortable with presenting evocative situations after being trained on the treatment.

26. Some open-ended responses from the Social Acceptability Questionnaire

27. These are two of the more legible responses to open-ended questions.

28. Ten Unique Aspects of our Approach (continued)
Our function-based treatments are always skill-based
NO EXT only, DRO, or NCR
Published in Behavior Analysis in Practice in 2008
(available for free at PubMed Central)

29. Ten Unique Aspects of our Approach
We always explicitly teach delay/denial tolerance
This takes up most of our time with children and families (not the functional assessment or teaching the FCRs)
First teach an explicit response to a variety of disappointment signals, then to make treatment practical:
Chain important behavior to the tolerance response
(there is always a progressive component—a gradual increase in time, stakes, or both)

30. With only Progressive Reinforcement Delay:
As delay increases, FCR weakens & probability of PB increases
As the delay increases, the newly acquired alternative response starts to diminish and, in this case, self-injury re-emerges.

31. Time-based vs. Contingency-based Progressive Delay (Lead Author: Mahshid Ghaemmaghami)
2 to 3 min delay

32. Time-based vs. Contingency-based Progressive Delay (Lead Author: Mahshid Ghaemmaghami)
2 to 3 min delay

33. Time-based vs. Contingency-based Progressive Delay (Lead Author: Mahshid Ghaemmaghami)
2 to 3 min delay

34. 5 Critical Aspects of Delay/Denial Tolerance Training
Always provide immediate sr for some FCRs
Teach an appropriate response to multiple cues of delay, denial, or disappointment
Progressively increase the average amount of behavior (not just time) required to terminate the delay
Terminate the delay for various amounts of behavior (sometimes expect very little behavior sometimes request larger or more complex types of behavior during the delay)
Probably best to not signal how much behavior is required to terminate the delays
How do we achieve high social acceptability ratings?

35. A final message
With Autism, there is a higher likelihood of problem behavior
Meltdowns
Aggression
Self-injury
References: Baghdadli, Pascal, Grisi, & Aussilloux, 2003; Horner et al., 2002; Kim et al., 2000; Murphy, Healy, & Leader, 2009; Thompson, 2009
One final message:
Recall that with Autism, there is a higher likelihood of problem behavior

36. is attainable from these behaviors
freedom
from these behaviors
for persons with Autism and their caregivers
is attainable
Although these problem behaviors are highly prevalent among those diagnosed with autism, freedom from these behaviors for persons with Autism and their caregivers is attainable. This is an important take home message to share with any parent of a child with autism, regardless of the child’s age or abilities.

37. It is attainable for most
without drugs
without hospitalization
without harsh punishment
without candies, stickers, and token boards
Be sure to tell them that freedom from problem behavior is attainable for most without

38. understanding can be realized quickly, safely, and analytically
It is attainable
by first understanding* why the child is engaging in the problem behavior
Freedom is attainable by first understanding why the child is engaging in the problem behavior.
And my main point today was that this understanding can be and should be realized quickly, safely, and analytically.
understanding can be realized quickly, safely, and analytically

39. *Communication and toleration
It is attainable
when children are taught skills* to help them navigate our complex social world
*Communication and toleration
Sorry that I could not get into the details this morning, but I also believe that this freedom is only attainable when children are taught the skills of communication and toleration to help them navigate our complex social world.

40. It is attainable
when the skills are maintained via unpredictable and intermittent reinforcement
which is probably the same arrangement that maintained the various forms of problem behavior
It is important to acknowledge also that freedom is attainable when children are taught the skills of communication and toleration to help them navigate our complex social world.
There is a massive treatment buffet out there with options that are cold, old, and tasteless, and some options that will leave kids hungry, or make them sick.
We have the skills and tools to prepare a well seasoned healthy meal for children with autism that will make them more fit than ever. Serve it up…..no one else can like you….serve it up.

41. Good luck with all that you do for all who you teach and provide care
For more information go to:
Contact info.:
Gregory P. Hanley, Ph.D., BCBA-D
Psychology Department
Western New England University
1215 Wilbraham Road
Springfield, Massachusetts 01119
Thank you very much.
Most of these changes to #/length of sessions, measures, etc. are like putting racing stripes on a big old Cadillac, that Cadillac will move but it is still going to guzzle up your time, the brakes don’t work so well and it never had seat belts to begin with, so you may lose control and it may get dangerous, but ultimately the problem is that, more times than not, that old Cadillac is not going to get you where you want to go.