1. Linda Heitzman-Powell University of Kansas Medical Center Rachel White Integrated Behavioral Technologies, Inc. Data-Based Decisions: Using Data to Determine the Effects of an Intervention with an Aggressive Adolescent male

2.  Despite the efficacy of employing function- based treatments, non-specific strategies designed to decrease challenging behaviors are implicated under certain conditions: ◦ when maintaining variables cannot be identified or controlled, ◦ when the challenging behavior must be reduced rapidly, ◦ when function based treatment is not sufficient enough (Lerman & Vorndran, 2002), or ◦ when the target behaviors are unresponsive to reinforcement techniques (Luiselli, 1984). Introduction

3.  Jonathan received a diagnosis of Autism when he was four years old. Jonathan has a history of severe aggression, observed both in home and at school. He also has a history of chronic ear infections. His aggression appears to escalate when he is experiencing an infection in his ears. His school aggression was severe enough to warrant a placement in LakeMary Center, an alternative placement for children whom are not able to be served in their home school setting. His home aggression was severe enough that a case manager recommended therapeutic foster-care placement. In June, his current case manager began the reintegration process with in-home behavioral supports. Jonathan currently is on multiple medications to manage his aggressions. Meet Jonathan

4.  Interview ◦ Parent ◦ Caregivers ◦ School  Observation ◦ School ◦ Home  Real-time data collection  Frequency  Duration  Intensity  ABC data

5.  Operational Definitions  Intensity Scale  Defining Data

6.  Jonathan engages in a series of behaviors that disrupt his, and others, environments. These behaviors include repetitive vocalizations, hitting, spitting, self-injury, injury to others and property destruction. An event will be considered over when Jonathan has exhibited a quiet body (hands, feet, mouth, and voice) for at least 5 minutes. A new event will be recorded if at least 5 minutes have passed since the end of a previous event.

7.  1 = pacing or perseverative statements (“moo moo”)  2 = crying or whining  3 = jumping or stomping  4 = screaming or yelling  5 = kicking or tripping  6 = property damage or slamming objects  7 = hitting, grabbing or pushing  8 = scratching or pinching  9 = biting  10 = self-injurious behavior Intensity Scale

8.  Frequency ◦ Number per day  Intensity ◦ Based on scale with behavioral anchors  Duration ◦ Based on time

9. Frequency per Day

10. Average Intensity per Day

11.  Function-based Intervention ◦ Possible functions (suggested by observation and ABC data)  Escape from non-preferred activities  Access to tangible reinforcers

12.  Functional Communication Training ◦ Escape  “No thank you” for immediate removal of non- preferred activities ◦ Access  “Water (or any other item he might want) please” ◦ However, escape and access to reinforcers were not always plausible (e.g., activities regarding personal hygiene, access to dangerous materials)

13. Frequency per Day

14. Ave. Intensity

15.  Access to reinforcers not contingent upon any particular behavior – delivered on a continuous schedule  No-demand

16. BL FCT NCR/No Demand Frequency per Day

17. Ave. Intensity

18. Frequency per Day

19. Ave. Intensity

20. BL FCT NCR/No Demand In-Patient Schedule Extinction Quiet Room

21. Frequency per Day BL FCT NCR/No Demand In-Patient Schedule Extinction Quiet Room

22.  One of the more acceptable and less aversive procedures to de-escalate challenging behavior is contingent effort (Luce, Delquadri, & Hall, 1980).  Several studies demonstrated the effectiveness of contingent effort in decreasing challenging behavior beyond or in the absence of reinforcement based intervention. (Experiment I; Luce et al., 1980).  Additionally, contingent effort (stacking rings) significantly decreased aggression in both residential and classroom settings (Jackson, Tyminski, Frederick, Neary, & Luce, 2005). Contingent Effort

23.  Despite successful uses of de-escalation procedures, these studies were conducted at residential or school settings and the extent to which the effectiveness and utility of contingent effort as a de- escalation procedure at home setting has not been well reported.  Therefore, the present study examined the effectiveness of an existing de-escalation procedure (Jackson et al., 2005) modified for use in the home. Contingent Effort (cont.)

24.  Intervention was conducted at home and during family community outings  Materials: ◦ 1 ring stacking base ◦ 5 color rings Setting and Materials

25.  Design ◦ Baseline (non-effective contingency management & FCT)  Alternating Treatments ◦ Treatment  Changing Criterion  Initially, during the treatment phase, on the first occurrence of aggression, the child was: ◦ Prompted to move to a designated room by parents or staff ◦ Instructed to sit down and engage in a de- escalation contingent effort (i.e., stacking rings). ◦ Required to complete the task calmly (no incidents of aggression) for a period of two minutes. Procedures

26.  As aggression began to decrease, the criterion for contacting “ring stacking” changed: ◦ Pre-cursor behaviors were targeted  1 st criterion change targeted 3 instances of verbal escalation  2 nd criterion change targeted 2 instances of verbal escalation  3 rd criterion change targeted 1 instance of verbal escalation  If any incidents of aggression occurred during all criterion phases, the task was re-presented until he completed the task with no aggressive incidents for two minutes.  Rings and the stacking base were available when the child went on an outing Procedures (cont.)

27.  An Antecedent-Behavior-Consequence (ABC) chart was filled out by parents or staff upon the occurrence of aggression.  Aggression was defined as any attempt to hit, scratch, pinch, bite, kick, grab or push a person. ◦ Intensity of each aggressive episode was scored on a scale of 1 to 10 ◦ Duration data was also recorded Data Recording

28. All Recorded Incidents

29. Functional Analysis  Behaviors ◦ Silliness ◦ Non-compliance ◦ Inappropriate Language  Conditions ◦ Access  Contingent upon expression of the behavior, the student was given the item for 15s ◦ Escape  Contingent upon expression of the behavior, the materials were removed and the student was given escape from the task 15s ◦ Play  No demands; free access to reinforcers

30. Intervention  Attention ◦ Noncontingent Reinforcement  Timer set for 20m  When the timer goes off, Mom/Dad spend 2-3 minutes ◦ Functional Communication  Teaching  Teach phrases such as “look at me”, “play with me” etc.  In the presence of a NO-demand situation (free-time)  Model functional communication  Require an imitative response  Escape ◦ Extinction  In the presence of a demand:  Do not attend or respond  Continue to present demand

31. Frequency Function-based Intervention

32.  Reduced overall number of aggressive behaviors from around 4 episodes per month to 0-6 (first month only) by the end of the reporting period.  The intervention also reduced pre-cursor behaviors from between 10 and 14 to between 0 and 4 per month. Results – Function-based Intervention

33.  Contingent effort can be effectively implemented in a home setting even when trained staff are not readily available.  The same procedure has been successfully implemented at his school given the success at home.  As the challenging behavior is decreasing, the focus of the intervention needs to shift from decreasing challenging behavior to function-based interventions. Discussion

34.  Staffing needs ◦ 2004-2005  1:1 25+ hours per week  8-10+ hours per month from consultant ◦ 2005-2006  1:1 15-25 hours per week  4-6 hours per month from consultant ◦ 2007  1:1 10-15 hours per week  2-4 hours per month from consultant ◦ 2008-2009  1:1 <10 hours per week  As needed (approximately 2 visits in 2 years) Discussion (cont.)

35.  Jackson, A., Tyminski, J., Frederick, L., Neary, P., & Luce, S. (2005, May). Decreasing aggressive behavior: Utilization of contingent effort as a de-escalation procedure. Poster session presented at the annual meeting of the Association for Behavior Analysis, Chicago, IL.  Lerman, D. C. & Vorndran (2002). On the status of knowledge for using punishment: Implications for treating behavior disorders. Journal of Applied Behavior Analysis, 35, 431-464.  Luce, S. C., Delquadri, J., & Hall, R.V. (1980). Contingent exercise: A mild but powerful procedure for suppressing inappropriate verbal and aggressive behavior. Journal of Applied Behavior Analysis, 13, 583-594.  Luiselli, J. K. (1984). Therapeutic effects of brief contingent effort on severe behavior disorders in children with developmental disabilities. Journal of Clinical Child Psychology, 13, 257-262. References

36. Contact Information Linda Heitzman-Powell lhpowell@ku.edu University of Kansas Medical Center 3901 Rainbow Blvd. Phone (913) 945-6604 Rachel White rachelwhite@ibt-inc.org