1. Treating Severe Problem Behavior: A Focus on Strengthening
Socially Important Behavior
of Persons with Autism
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 informs comprehensive treatments yeilding large effects
Treatment relies on strengthening:
functional communication delay/denial toleration
compliance
Via
Intermittent and
unpredictable reinforcement
The study I mentioned earlier shows that this process of interview and analysis leads to comprehensive treatments with large effects.
The treatment relies on strengthening:
functional communication delay/denial toleration
compliance

3. Functional Assessment and Treatment Model
Steps (expanded) 1
Interview 2
Functional Analysis 3
Simple Functional Communication Training 4
Complex FCT 5
Tolerance Response Training 6
Easy Response Chaining 7
Difficult Response Chaining 8
Treatment Extension
So at this point, we have come to some understanding as to why problem behavior occurs and have taught a replacement behavior but we are far from being done because this is not a treatment that can be handed off to parents at this point. The real challenging part of the process is that which follows. Due to time constraints, I will describe it in detail only for Dale.

4. 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”

5. 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.

6. Treatment Results
from Hanley et al., JABA, 2014
Similar results were obtained with all three children
Similar results were replicated in home and schools settings
(Santiago, Hanley, Moore, & Jin, under review, JADD)
All this talk of speed and analytic control is unimportant relative to the extent to which this approach leads to effective treatment outcomes. Again the bottom line is whether an approach allows for more effective action and this approach has allowed us to develop integrated and comprehensive treatments that produce large effects. In baseline, the data shown in black, there was problem behavior and little to no functional communication, tolerance, or compliance for the participants in our recent JABA study, but these skills were well developed at the end of treatment and the baselines from the interview informed synthesized contingency analyses provided the properly motivating conditions for these skills to be developed.

7. Discuss with your neighbor.
Take a moment to reflect on this particular treatment process. How is it similar to and different than the treatment you implement?
Discuss with your neighbor.
Before I summarize what the process should look like, let’s hit another mistake of mine. I used to think that all functional analyses required 5 or more conditions, but that is not the case.
The defining features of a functional analysis are **direct observation of behavior under at least two conditions in which some event is manipulated
The two conditions** can be thought of as test and control conditions where there is one fundamental difference between the two: the Test conditions contains the contingency thought to maintain severe problem behavior, whereas the Control condition does not.
You don’t need 5 or more conditions. A good front end interview and brief observation should lead you to a hunch that you can test out with only two conditions. Here is an example.

8. 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.

9. 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.

10. 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

11. 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.

12. Ten Unique Aspects of our Approach (continued)
7. 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)

13. Ten Unique Aspects of our Approach
8. We always increase the complexity, flexibility, and/or interactional nature of the FCR before teaching delay/denial tolerance
Simple FCR: (“My way” or “My way, please”)
Complex FCR:
“Excuse me”
After a second or two, “Yes, Billy”
“May I have my way, please?”
“Will you play my way, please?”
After a second or two, “Sure, Billy”
Don’t need extinction here, could provide more immediate, longer, and higher quality reinforcers for complex FCR and delayed shorter and lower quality functional reinforcers for the simple FCR.

14. Shape the complex response
We have a very specific and emprically validated approach to teaching kids to handle disappointment. I am sorry I cannot review each of these in detail, most are

15. Differentiate the complex response
NO EXT only, DRO, or NCR

16. Implementation questions regarding FCT?
Tips:
Teach a simple omnibus mand rather than try to teach specific mands for different reinforcers at first.
Specific mands can be taught once problem behavior is zero and the omnibus mand is occurring independently.
Rely on a novel mand rather than a pre-existing mand.
Do everything possible to avoid chaining problem behavior with the target mand.
For instance, be careful of prompting the novel mand after emission of pb
Either let extinction of pb occur via time out or use an errorless prompting tactic such as most to least prompting
Start out fast and sweaty; end slow and cool.

17. Come up with at least one question relevant to implementing Functional Communication Training (FCT)

18. Ten Unique Aspects of our Approach
9. 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)

19. 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.

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

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

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

23. 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?

24. Nominate the critical features of programming to teach children to tolerate delays to the reinforcers maintaining their problem behavior.
once compliance chains are acquired, always delay the reinforcer following a functional communication response
teach an appropriate response to delay and denial cues by providing preferred candy when the child does not meltdown following a delay or denial cue
end the delay when the amount of time determined prior to sessions has expired
reinforce the functional communication response immediately at least some of the time
end delays when the child has engaged in a sufficient amount of an appropriate activity

25. Nominate the critical features of programming to teach children to tolerate delays to the reinforcers maintaining their problem behavior.
once compliance chains are acquired, always delay the reinforcer following a functional communication response
teach an appropriate response to delay and denial cues by providing preferred candy when the child does not meltdown following a delay or denial cue
end the delay when the amount of time determined prior to sessions has expired
reinforce the functional communication response immediately at least some of the time
end delays when the child has engaged in a sufficient amount of an appropriate activity

26. In this skill-based program, reinforcement is:
function-based as opposed to arbitrary
differentially delivered as opposed to noncontingent
continuous as opposed to intermittent
consistent as opposed to variable in duration
fairly unpredictable as opposed to highly predictable

27. In this skill-based program, reinforcement is:
function-based as opposed to arbitrary
differentially delivered as opposed to noncontingent
continuous as opposed to intermittent
consistent as opposed to variable in duration
fairly unpredictable as opposed to highly predictable

28. Nominate the critical aspects of delay and denial tolerance training.
progressively increase the average amount of behavior required to terminate the delay
teach an appropriate response to multiple cues of delay, denial, or disappointment
always provide immediate reinforcement for some functional communication responses
do not signal how much behavior is required to terminate the delays
terminate the delay for various amounts of behavior

29. Nominate the critical aspects of delay and denial tolerance training.
progressively increase the average amount of behavior required to terminate the delay
teach an appropriate response to multiple cues of delay, denial, or disappointment
always provide immediate reinforcement for some functional communication responses
do not signal how much behavior is required to terminate the delays
terminate the delay for various amounts of behavior

30. Come up with at least one question relevant to implementing Delay/Denial Tolerance Training

31. Let’s review.
Often, children, especially those diagnosed with autism, will engage in problem behavior and extended bouts of crying and tantrumming in order to retain or gain access to reinforcers. At best, some children repeatedly request their reinforcers when they are unavailable.
Children will learn developmentally advanced mands (requests) best if they are highly motivated. Therefore, the success of this process relies on identifying powerful reinforcers.
It is time to both prove the accuracy of your hunches described above as well as develop a motivating teaching context for the child.
To accomplish these goals, describe either your functional analysis or mand analysis that will demonstrate the response-reinforcer relation and serve as your baseline from which to teach the tolerance repertoire. These both involve two distinct conditions.
These both involve two distinct conditions.
In the control condition, provide the reinforcers the whole time (do not remove them) during a 5 min session. In the test condition, attempt to remove the reinforcers, but give them back for 30 seconds immediately following any problem behavior or its precursors (functional analysis) or following any sort of mand for the reinforcers (mand analysis). Repeat removal and contingent reinstatement throughout the 5 min session. Alternate between control and test sessions until there is a reliable difference in the target behaviors (problem behavior and its precursors or mands) across conditions.

32. 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.

33. 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

34. 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%

35. 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%

36. 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

37. 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

38. 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

39. 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

40. 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.

41. 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.

42. Come up with at least one question relevant to implementing the function-based treatment as described.

43. 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.

44. 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

45. *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.

46. 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.

47. 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.