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DIFFERENTIAL REINFORCEMENT
1
DIFFERENTIAL REINFORCEMENT OF OTHER
BEHAVIOR (DRO) IN AN ADULT WITH SMITHMAGENIS SYNDROME
By
Tanya M. Hough
A thesis submitted in partial fulfillment of the requirements
for the degree of
Master of Science in Psychology
Kaplan University
2013
UMI Number: 1541043
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KAPLAN UNIVERSITY
Abstract
Differential Reinforcement of Other Behavior (DRO) in Adult with Smith Magenis Syndrome
By Tanya M. Hough
The effectiveness of differential reinforcement of other behavior (DRO) with an extinction
component was evaluated with two target behaviors with an adult with Smith Magenis Syndrome
(SMS) residing in the community who displayed elopement and physical aggression. The
intervention included DRO using a fixed-time schedule of reinforcement, paired with extinction
when elopement and physical aggression occurred. DRO was demonstrated to be effective in
reducing the target behaviors of elopement and physical aggression, resulting in a 79% reduction
of elopement and 100% decrease in physical aggression in the group home. Currently, there is a
significant need for research using behavioral interventions to decrease challenging behaviors in
adults diagnosed with SMS, as very little has been published on this topic.
Keywords: Keywords: Physical Aggression, Elopement, Differential Reinforcement of
Other Behavior, Extinction, Smith Magenis Syndrome
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Table of Contents
List of Tables and Figures ..................................................................................................................... 4
Introduction ........................................................................................................................................... 6
Literature Review............................................................................................................................ 6
Hypotheses/Research Questions ................................................................................................... 13
Method ................................................................................................................................................. 13
Participants .................................................................................................................................... 13
Procedures ..................................................................................................................................... 18
Results ................................................................................................................................................. 19
Discussion............................................................................................................................................ 25
Findings ......................................................................................................................................... 25
Limitations .................................................................................................................................... 27
References ........................................................................................................................................... 30
Appendix A: FAST Structured Interview Form................................................................................. 33
Appendix B: FAST Rating Scale and Scoring Summary .................................................................. 36
Appendix C: Direct Observation Forms ............................................................................................. 38
Appendix D: Data Sheets .................................................................................................................... 41
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List of Tables and Figures
Number
Page
1. Table 1 ..................................................................................................................................... 21
2. Table 2 ..................................................................................................................................... 21
3. Figure 1 ................................................................................................................................... 23
4. Figure 2 ................................................................................................................................... 24
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Acknowledgments
The author wishes to express sincere appreciation to my BCBA supervisor, Alfred Brewin, for his
support throughout the thesis writing process. The author also wishes to thank her thesis adviser, Dr.
Edward Cumella, for his wisdom, wonderful insight, and mentoring, as well as her Thesis Committee-Dr. Natasha Chung and Dr. Jessica Tischner. The author is very thankful to the community provider that
allowed her to review client records to extract data for analysis in this thesis. Without their support and
willingness, this thesis would not exist
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Smith-Magenis Syndrome (SMS) is a genetic disorder caused by the deletion of the 17p11.2
chromosome as a result of haploinsufficiency, where part of the diploid cell is inactive due to
mutation and affects one genes, the retinoic acid-induced 1 (RAI1). This syndrome affects
multiple aspects of the individual’s life that include behavioral, intellectual, emotional, and
social functioning. It occurs in 1 of 25,000 births (Elsea & Girirajan, 2008; Finucane & HaasGivler, 2009; Laje, Bernert, Morse, Pao, & Smith, 2010; Taylor & Oliver, 2008). SMS manifests
as a complicated neurobehavioral disorder that is characterized by mild to moderate intellectual
disability and delays in speech and language development (Sloneem, Oliver, Udwin, &
Woodcock, 2011).
Dykens, Finucane, and Gayley (1997) developed a cognitive and behavior profile of
SMS. A cognitive and behavioral profile is imperative in understanding the behavioral
phenotype of this neurobehavioral disorder and developing effective interventions addressing the
problem behavior(s). This is the first study to examine distinctive cognitive and behavioral
features of adolescents and adults with SMS (Dykens, Finucane, & Gayley, 1997). The study
consisted of ten participants, two male and eight female, between 14 and 51 years-old with
moderate to mild intellectual disabilities and residing in institutional settings. A variety of
assessments were conducted with each participant to determine their cognitive functioning and
behaviors, both adaptive and maladaptive. Results demonstrated cognitive limitations with
specific abilities such as sequential processing. Results also identified maladaptive behavior
unique to this complex chromosomal disorder.
People with SMS share common physical features consisting of small stature and short
fingers, flattened facial features with flat mid-face and head shape, and a broad nasal bridge.
Some other physical facial features include a down-turned mouth and prominent jaw. These
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physical features become more distinctive as the person transitions into adulthood (Dykens,
Finucane, & Gayley, 1997; Finucane & Haas-Givler, 2009; Martin, Wolters, & Smith, 2006).
Individuals with SMS tend to have an engaging and outgoing personality. These
individuals socialize with others easily and usually make friends quickly (Finucane & HaasGivler, 2009). However, these individuals also present challenging behaviors that are
characteristic of SMS. Challenging behaviors include self-injurious behavior, temper tantrums,
physical aggression, hyperactivity, disruptive behavior, and sleep disturbances. These behaviors
occur throughout the affected individual’s life (Finucane & Haas-Givler, 2009; Martin, Wolters,
& Smith, 2006; Taylor & Oliver, 2008). Martin, Wolters, and Smith (2006) offered the first
study providing an in-depth account of the relationship between cognitive functioning and
adaptive and maladaptive behaviors displayed by children with SMS. This was also the first
study where information was gathered using objective, valid assessment procedures (Martin,
Wolters, & Smith, 2006).
Dykens and Smith (1998) was comprised of two studies that compared maladaptive
behaviors in children and adolescents with SMS to problem behavior in children and adolescents
with both Prader-Willi Syndrome and nonspecified intellectual disabilities. The first study
examined the rate of different problem behaviors in the three groups. The second study assessed
distinctive behavioral patterns in the SMS group. A total of 105 participants, 45 males and 60
females, were enrolled in the first study. Only the SMS group was used in the second study.
Participants ranged from four to 20 years-old and resided at home with their families (Dykens &
Smith, 1998). In the first study, parents completed a child behavior checklist, which consisted of
112 problem behaviors. In the second study, parents of participants with SMS completed a
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stereotypy checklist, self-injury checklist, sleep history checklist, and the child behavior
checklist used in the first study.
Results indicated that children and adolescents with SMS showed significantly higher
rates of problem behavior compared to the other groups. Although there was some overlap in
problem behavior between the three groups, the behavior patterns varied clearly between the
groups. Participants with SMS slept less, demonstrated higher rates of hyperactivity and greater
demand for attention, and were more emotionally labile compared to their counterparts (Dykens
& Smith, 1998).
Behavioral and pharmacological interventions are two approaches to treating the
challenging behaviors of individuals diagnosed with SMS. Laje, Bernert, Morse, Pao, and Smith
(2010) investigated the use of psychotropic medication on disruptive behavior in children with
SMS. The authors used retrospective data from 62 participants diagnosed with SMS. Medication
that had been prescribed to these individuals included stimulants, anti-depressants, antipsychotics, mood stabilizers, alpha 2 agonists, and benzodiazepines. Results indicated that
medication taken for challenging behaviors varied widely. The authors concluded that
psychotropic medication, sleep aides, mood stabilizers, and other types of medications did not
appear to provide consistent effectiveness in reducing problem behaviors in children with SMS
(Laje, Bernert, Morse, Pao, & Smith, 2010).
An individual diagnosed with SMS will present challenging behaviors that create high
levels of familial stress and often a pessimistic outlook in the family (Hodapp, Fidler, & Smith,
1998). Despite the severe behavioral challenges this population presents, there are currently no
studies examining the effectiveness of applied behavior analysis (ABA) techniques in addressing
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the problem behavior of adults with SMS. The lack of research in this area makes it more
difficult to design an effective treatment plan utilizing ABA.
Taylor and Oliver (2008) examined the functional relationship between the social
environment and maladaptive behaviors of children and adolescents with SMS. This is one of the
first studies employing components of a functional behavior assessment to investigate the
association between the environment and problem behavior in children and adolescents with
SMS. The authors looked at the impact of social interaction on disruptive, aggressive, and selfinjurious behaviors. Participants were comprised of five children, three female and two male,
diagnosed with SMS, between three and 13 years-old, with moderate to severe intellectual
disability. Direct observations were conducted in the participants’ school setting to record
environmental events, frequency and duration of the three target behaviors. No behavioral
intervention was introduced to address the variables maintaining the problem behavior (Taylor &
Oliver, 2008). A co-occurrence analysis was completed to evaluate the connection between
environmental conditions and frequency of target behaviors. Results of the study demonstrated
that a decrease in attention led to participant’s exhibiting the problem behavior that resulted in
adult attention. That is, results established a functional relationship between adult attention and
problem behavior with children and adolescents with SMS. The authors recommended the need
for more studies using ABA techniques to gain a better comprehension of the function(s) of
problem behaviors in people with SMS (Taylor & Oliver, 2008).
Sloneem, Oliver, Udwin, and Woodcock (2011) extended this research on the functional
relationship between the environment and problem behavior in children and adults with SMS.
Participants consisted of 40 children and adults with SMS between four and 39 years-old. Most
of the participants resided at home with their families, and a small percentage received
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residential care. This study employed several assessment tools measuring the maladaptive
behaviors of the participants and under which environmental conditions the subjects were more
likely to display the behaviors. Testing procedures were carried out along with structured
interviews and assessment techniques with the participants’ parents, guardians, or caregivers.
The authors explored five environmental functions of aggressive behavior that included
attention, escape, self-stimulation, tangible, and pain and discomfort. Rating scales used to assess
the functions indicated that attention was the highest ranking variable (Sloneem, Oliver, Udwin,
& Woodcock, 2011). This remains preliminary research, and clearly the need remains for
additional research in this area.
Differential reinforcement is where reinforcement is only provided for a response that is
part of a larger response class and meets a specified criterion, which includes topography,
frequency, and/or duration of the target behavior (Cooper, Heron, & Howard, 2007). Differential
reinforcement is a widely used technique for decreasing undesired behavior, such as physical
aggression or elopement. Differential Reinforcement of Other Behavior (DRO) is one type of
differential reinforcement where reinforcement is provided for the absence of the target behavior
for a specified time interval. For example, the person could be watching television, coloring, or
cleaning, but still earn contingent on the absence of the target response (Cooper, Heron, &
Howard, 2007). DRO is an ABA intervention commonly used to address the variable
maintaining the problem behavior. There is little empirical research investigating the
effectiveness of DRO with SMS, despite the widespread use of this intervention in various
settings with other individuals who have developmental disabilities.
Vollmer, Iwata, Zarcone, Smith, and Mazaleski (1993) evaluated the effectiveness of
Noncontingent Reinforcement (NCR) and DRO in reducing attention-maintained self-injurious
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behavior, a problem behavior common in SMS. The authors initially hypothesized that NCR
would be more effective in decreasing participants’ problem behavior. However, results
demonstrated that DRO was as effective as NCR in reducing self-injury (Vollmer, Iwata,
Zarcone, Smith, & Mazaleski, 1993)
Mazaleski, Iwata, Vollmer, Zarcone, and Smith (1993) examined the reinforcement and
extinction components of DRO, which was comprised of two studies. The first experiment
examined the role of the reinforcement element of DRO and explored preferred versus nonpreferred arbitrary stimuli used to reinforce the absence of the problem behavior. The second
study was later added to investigate the role of the extinction component of DRO. Both studies
consisted of three female participants between 32 and 42 years-old, diagnosed with profound to
severe developmental disability and residing in a long-term institutional setting. Results of the
first study indicated that preference of different stimuli had little significance when attention was
the primary function of the target behavior. Identifying the variables maintaining the behavior is
critical for DRO to be effective. Results of the second study demonstrated that extinction is an
essential factor in DRO with this population (Mazaleski, Iwata, Vollmer, Zarcone, & Smith,
1993).
Heard and Watson (1999) measured the efficacy of a social contingency in treating
wandering behavior in adults diagnosed with dementia. Participants consisted of four females
between 79 and 83 years-old residing in a nursing home. The DRO consisted of an extinction
component contingent on the maladaptive behavior occurring. Direct observations and
Antecedent-Behavior-Consequence (ABC) tracking was used to determine the function of
wandering behavior. Results of the study demonstrated that the social contingency in the DRO
was effective in decreasing wandering in all four participants (Heard & Watson, 1999).
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Differential Reinforcement of Lower Response Rate (DRL) is another type of differential
reinforcement. DRL is where reinforcement is contingent on the target response occurring at a
lower rate than a pre-set criterion for a specified time interval. The goal is to gradually decrease
the number of responses during a specified time period (Cooper, Heron & Howard, 2007). Singh,
Dawson, and Manning (1981) examined the efficacy of spaced responding DRL to address
pervasive stereotypic responding, a behavior that is often seen in persons with SMS. Spaced
responding DRL is where reinforcement is contingent on a minimum timeframe where there is
an absence of the target behavior from the previous response to next response (Cooper, Heron, &
Howard, 2007). Participants consisted of three adolescents females between 15 and 18 years-old
with profound intellectual disabilities and residing institutional settings most of their lives.
Results demonstrated that an incremental spaced responding DRL was effective in decreasing
stereotypic responding in all three participants (Singh, Dawson, & Manning, 1981).
In summary, the peer-reviewed literature contains very few studies of ABA techniques
with SMS children and adolescents, none with SMS adults, and a few studies of similar
behaviors in persons with other diagnoses. Thus, there is an immense need for research using
behavioral interventions to decrease severe and challenging behaviors in adults diagnosed with
SMS. The lack of research using ABA interventions to address socially inappropriate and unsafe
behaviors makes it challenging for caregivers and direct care staff to work with this population.
These severe challenging behaviors are dangerous and can lead to increased risks for the person
and others.
As such, the present study provides a unique contribution to expanding research on
effective ABA interventions addressing the variables that maintain problem behavior in adults
with SMS in a community setting. The purpose of this present study is to evaluate the
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effectiveness of a DRO in decreasing attention maintained elopement and physical aggression in
an adult with SMS. It is hypothesized that the intervention will be demonstrated as effective in
reducing the target behaviors.
Method
Participant
To meet the age criteria for this study, the individual had to be 21 years or older
diagnosed with SMS. To meet the inclusion criteria for an intellectual disability, the individual
had to be diagnosed by a licensed medical or psychological practitioner with an intellectual
disability that originated before the age of 18 years old. To be diagnosed with an intellectual
disability the person would need an intellectual quotient (IQ) of 70 or below and significant
deficits in adaptive behavior. Adaptive behavior consists of conceptual, social, and practical
skills (American Association on Intellectual and Developmental Disabilities, 2012). The
participant’s IQ was determined by the Wechsler Adult Intelligence Scale-III (WAIS-III, 1997)
(Indiana University-Purdue University Indianapolis). The final inclusion criterion is severe
challenging behavior consisting of elopement and physical aggression documented for six
months prior to this study and including behavior interventions that have been unsuccessful in
decreasing the problem behavior.
The participant selected for this study is Edna (a pseudonym), a 36 year-old female
diagnosed with SMS and a mild intellectual disability. Edna has been displaying severe
challenging behaviors in her group home. The participant currently resides in a private
community-based group home and attends a day program in the Northeast US. Prior to
transitioning into a community based group home, the participant resided in an institutional
setting for 16 years. The facility delivered services using an Intermediate Care Facilities for
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Individuals with Mental Retardation (ICF/MR) Model. The ICF/MR is a Medicaid benefit that
enables the state to provide individualized and multi-faceted health care and rehabilitation
services encouraging development and growth of the person’s functional status and
independence (Centers for Medicare & Medicaid, n.d.). Consequently, the participant’s
adjustment into a private group home in the community has been difficult.
Information on Edna’s overall adaptive functioning level was obtained from the
Inventory for Client and Agency Planning (ICAP; Pyo, 2012) that was conducted at her previous
placement. The ICAP can be used to assess the frequency and perceived severity of maladaptive
behavior (Pyo, 2012). The ICAP is a widely used instrument that measures five domains of
functioning; areas assessed consist of motor skills, social skills, communication skills, personal
and community living ability, and broad independence. Edna functions at approximately six
years-old for social skills, communication skills, and broad independence; seven years-old for
motor and community living skills; and nine years-old for personal living skills. Edna’s ICAP
scores indicate that she needs regular personal care and close supervision.
Edna was admitted to an institutional setting as a child due to severe challenging
behaviors at home and the need for a more structured environment. At her previous placement,
she had a behavior support plan in place that addressed four target behaviors. The challenging
behaviors targeted for reduction were physical aggression; property destruction; refusing to
complete her daily routine; and disruptive behavior. Physical aggression was defined as Edna
hitting and kicking others. Property destruction was defined as destroying property such as
throwing objects at another person and/or ripping the mirror of vehicles. Non-compliance was
defined as Edna refusing to complete her daily routine, which included refusing to listen to
directions from direct care staff or completing chores. Disruptive behavior was defined as
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pestering and teasing others, starting fights, cursing, and/or yelling at others. The behavior plan
consisted of differential reinforcement of alternative behavior (DRA) for compliance to her daily
schedule, prompts prior to activity change, verbal redirection, and extinction. Her challenging
behaviors decreased over time at her prior placement.
However, physical aggression, disruptive behavior, property destruction, and noncompliance significantly increased following Edna’s community integration. Elopement was a
behavior that emerged following her admission to the group home. Elopement consisted of Edna
running out of the group home, leaving the yard, and running down the street away from staff.
Elopement appears to be a historical behavior that occurred long before her move to the group
home. Edna may have a history of running away from staff, but the behavior was not socially
significant because she resided on a campus setting and had built-in safety boundaries regarding
where she could run to. It is also possible that elopement is an emerging behavior that was
reinforced over time following her move into the community. Elopement in the community is a
socially significant behavior that poses a detrimental risk to the personal safety of the participant
and staff working with the participant.
The significant increase in frequency and severity of physical aggression, disruptive
behavior, property destruction, non-compliance, and elopement may perhaps be attributed to the
quick transition from the institutional setting to the community based group home. The
integration process into the community occurred rapidly, without a slow transition from the
institution to the privately operated group home. The environment and levels of restriction
between residing in the institution and living in the community are dramatically different.
Behavior strategies addressing problem behaviors were developed following her move
into the group home. A behavior support plan for the group home was developed to address
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physical aggression, disruptive behavior, property destruction, non-compliance, and elopement.
Behavioral interventions included DRO, extinction, and redirection. The DRO consisted of a
three opportunities to earn a chip throughout the day when she went a period of time without
engaging in the target behaviors. The criteria for earning the chip included keeping her hands to
herself, staying on group home property, and following her daily schedule. This behavior plan
was ineffective at reducing problem behaviors.
This DRO program may have been ineffective due to the long intervals between
opportunities to earn. Another limitation of this treatment program was the protracted time
between earning the chip, indicating that she had met the criteria to earn, and having the ability
to exchange the chip in for the reinforcer. An additional limitation of this intervention was
starting the plan with the criteria set too high. Edna was unsuccessful in meeting the criteria on a
consistent basis; thus, problem behaviors increased in the home.
Response Measurement and Interobserver Agreement
Structured interviews and rating scales were completed with direct care staff in the
participant’s group home. Observations were conducted in the group home. Edna lives in a
single-level home with four other peers. Three staff members are on duty for all three shifts and
are all engaged in activities with those in the home, as well as the maintenance of the home.
During the day, Monday through Friday, Edna attends another agency for day program services.
Baseline and treatment measures were collected on a daily basis using a data sheet to
track physical aggression, elopement, and non-compliance. Data was collected using a partialinterval recording in hour intervals to track the occurrence of the four target behaviors--physical
aggression, non-compliance, elopement, and disruptive behavior. An Antecedent-BehaviorConsequence (A-B-C) format was used to track disruptive behavior. ABC data collection is a
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component of a descriptive functional behavior assessment. ABC data collection involved
continuous recording of disruptive behavior, where staff documented the antecedent events
occurring immediately before the behavior, the topography of the disruptive behavior, and
consequential events immediately following the target response (Cooper, Heron, & Howard,
2007); see Appendix D for data recording sheets.
Interobserver agreement was collected once a week in the group home along with another
behaviorist. Staff was provided feedback on accurate treatment implementation following the
observations. Interobserver agreements for the rates of the four target behaviors were computed
using the total count interobserver agreement formula (Cooper, Heron, & Heward, 2007). The
total count percentage of agreement for each observation session was calculated by taking the
smaller amount of intervals, dividing it by the larger amount, and multiplying by 100.
Physical Aggression was defined as the participant spitting, punching, biting, swinging at
others, kicking, and/or hitting others with an open/closed hand. It also includes using objects as a
weapon. Elopement was defined as the participant running out of the group home, leaving the
yard, and running down the street away from staff.
Differential Reinforcement of Other Behavior (DRO) will include opportunities to earn
throughout the day. Earning time will start at every hour that Edna does not elope from the group
home, when she will have the opportunity to engage in one-to-one activity of her choice with
staff for 10 minutes. A timer will be used to indicate when she has met the criteria for earning for
that hour. At the end of 10 minutes, staff will reset the timer and let Edna know that when she
stays in the group home, she can earn the one-to-one activity with staff. Activities can include a
game of Uno, Go Fish, other card game, coloring, board game, and/or having a one-to-one
conversation on a topic that Edna chooses. When the criterion is met for not eloping from the
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group home for seven days, the criterion will expand to include physical aggression. Time
between earning will increase as Edna continues to meet the established criterion. Interventions
also consist of a structured schedule where Edna’s day was broken down into set time intervals
outlining what day looked like. A structured schedule allows Edna to know what her day looks
like so she's prepared for the various tasks and activities that occurs.
Procedure
A descriptive assessment was conducted to determine the function of the problem
behaviors. Target behaviors were assessed using the Functional Assessment Screening Tool
(FAST; Dunlap & Kincaid, 2001); see Appendices A and B. The FAST is an indirect assessment
tool used to gain more information on a behavior of interest. The FAST is comprised of a
structured interview and rating scales. The structured interview was conducted with direct care
staff working with the participant to gain information on the topography of the behavior, the
environmental condition when the behavior is least and most likely to occur, and what occurs
immediately before and following the behavior (Dunlap & Kincaid, 2001). The FAST rating
scale is a 16-item Likert scale measuring four conditions: attention/preferred item; escape from
demand; self-stimulation; and pain attenuation. Direct observations were conducted in the
participant’s natural environment; see Appendix C for observation form. A behavior support
plan was developed to address the severe challenging behavior in the group home.
Staff was trained on the SMS personality, distinctive physical characteristics, and SMS
behavioral phenotype. The SMS training also consisted of how to manage problem behaviors.
Recommendations included a highly structured schedule to create a consistent routine for the
person, keeping the person engaged, minimal attention to maladaptive behaviors, maintaining
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positive interactions, providing clear instructions and expectations, and not negotiating/arguing
with the person.
A multiple baseline across behaviors design was used to measure the DRO. The
intervention was progressive in nature where after seven days of no occurrence of elopement, the
criterion increased to include physical aggression. Edna had the opportunity to earn access to
one-to-one attention from staff for ten minutes on an hourly basis throughout the day in the
group home. After seven days of absence in physical aggression and elopement, the criterion of
the DRO was increased to include non-compliance. Staff working in the group home were
trained how to implement the initial steps of the DRO. The last behavior addressed was
disruptive behavior where reinforcement was contingent on the behavior occurring at a lower
rate than the set criterion.
Results
Functional Behavior Assessment (FBA)
Results of the behavior interview were used to develop the operational definition for
elopement and physical aggression. The FBA assisted in identifying antecedent and
consequential environmental events of the target behaviors. Responses on the behavior interview
indicated elopement and physical aggression occurred to elicit staff attention. Respondents also
identified elopement and physical aggression as the primary behaviors of concern. Responses of
physical aggression consisted of spitting, punching, biting, swinging at others, kicking, and/or
hitting others with an open/closed hand. This also included using objects around the house as
weapons. All respondents reported that Edna would display disruptive and non-compliant
behavior prior to both physical aggression and elopement from the group home. Group home
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staff members implementing the intervention were trained to engage the participant in a positive
manner when reminding her of the contingencies to earn.
Responses from the behavior interview and analysis on the A-B-C data indicated that the
most common antecedents included the participant wanting to engage in an activity at the time,
staff attention not being immediately available to her, or participant being asked to do something.
The participant’s responses varied depending on what was going on in the environment. For
example, she was more likely to display disruptive and non-compliant behaviors when asked to
do something; however, she would often engage in disruptive behavior that would escalate to
physically aggressive or elopement behaviors when staff attention was not available
immediately. Consequential events consisted of staff telling her to display appropriate behavior,
trying to engage her in an ongoing activity, ignoring the problem behavior, telling her to stop,
and/or trying to redirect her. Responses indicated there was not a consistent consequential pattern
following the occurrences of physical aggression and elopement.
According to the FAST results for elopement listed in Table 1, attention/preferred items
was the primary function of elopement, with a total score of 3.5. This was followed by sensory
stimulation, with a total score of 2.5, then escape from task, with a total score of 2.0. The results
suggested that Edna was more likely to elope from the group home to gain attention from staff or
when access to attention/preferred activity/item was not immediately available.
According to the results for FAST for physical aggression listed in Table 2,
attention/preferred items and sensory stimulation were the primary functions, each with a total
score of 3.0. This was followed by escape from task, with a total score of 2.0. Disruptive
behaviors, where the participant made verbal threats towards others, cursed at others, or
threatened to run away or leave the group home, usually occurred prior to the more severe
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behaviors where the participant became physically aggressive toward others or left the group
home property.
Table 1
FAST Results for Elopement
Attention/
Escape
Preferred Items
Sensory
Pain
Stimulation
Attenuation
Staff 1
3
1
3
1
Staff 2
4
3
2
0
Mean
3.5
2.0
2.5
0.5
Escape
Sensory
Pain
Stimulation
Attenuation
Table 2
FAST Results for Physical Aggression
Attention/
Preferred Items
Staff 1
4
3
3
0
Staff 2
2
1
3
0
Mean
3.0
2.0
3.0
0
The behavior chain tended to begin with the participant screaming at staff to “shut up” or
“leave me alone, you b*&^$!” When staff made verbal comments to the participant, she tended
to continue to exhibit disruptive behavior. She might be trying to gain the attention a particular
staff member when that staff member was engaged with another client. If attention was not
immediately available in the environment, Edna was more likely to display non-compliance with
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the other staff. When staff did not provide verbal attention to the behavior, she might walk away
from staff or threaten to leave and go out onto the porch, follow staff around, or slam doors
within the home. At times, she would leave the group home property, where staff had to follow
her as she ran down the street. At times she attacked staff from behind or became physically
aggressive to the point where she met the criteria of physical restraint or the incident resulted in a
911 call.
Observations in the participant’s natural environment supported results of the structured
behavior interview and the analysis of the A-B-C data, both of which suggested that the
identified target behaviors were maintained by attention. The outcome of the descriptive
assessment supported using a DRO to address physical aggression and elopement. Because
results of the assessment indicated behavior was maintained by attention, staff members were
trained not to provide attention when the participant was displaying physical aggression or when
she had eloped from the group home. Staff members were instructed to periodically remind the
participant in a positive manner about the criteria to earn.
Treatment Implementation
The intervention was selected based upon the results of the FBA. Results from the FBA
indicated that the selected target behaviors were primarily maintained by attention. The behavior
support plan was only implemented in the group home. The intervention was comprised of
planned ignoring, redirection, and the DRO. Prior to the implementation of the treatment, staff
members were trained on the intervention techniques of the behavior support plan at a staff
meeting. Staff members were instructed to follow the participant when she eloped from the
group home, but not to talk to her when she was engaging in elopement behavior.
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23
The DRO used a fixed-interval schedule for delivery of reinforcement. For every hour
that the participant did not display elopement from the group home, she had the opportunity to
engage in a limited activity of her choice with one staff member for 10 minutes. A timer was
used to indicate when she met the criteria for earning for that interval. At the end of the10
minutes, staff reset the timer and let the participant know that when she stayed in the group home
and kept her hands to herself, she could earn the activity with staff. Activities selected were of
the participant’s choosing. When the criterion was met for absence of elopement, physical
aggression, and non-compliance for seven days, time between earning increased as the
participant continued to meet the established criteria. Data were collected in the group home
setting to determine if elopement and physical aggression would decrease. In the group home
setting, dependent measures included a data sheet with half-hour intervals using partial interval
recording to measure the rate of elopement and physical aggression. Staff also indicated on the
data sheet whether the participant met the criterion for the specified interval and the activity
selected by the participant.
Treatment Outcomes
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24
15
14
Baseline
DRO
13
12
Occurrences of Elopement
11
10
9
8
7
6
5
4
3
2
1
0
Feb-13
Mar-13
Apr-13
May-13
Dates
Figure 1: Baseline and DRO on the occurrence of elopement
Elopement occurred at an average of 4.8 episodes per month during the baseline
condition. The occurrence of elopements decreased to three occurrences following the
implementation of the intervention (Figure 1). This was a 38% decrease in the eloping behavior
during the first month of the intervention condition. There was an increase in the occurrence of
elopement the following month. Elopement increased by 100%, doubling, which was attributable
to two days during the month where there was a major disruption in the participant’s structured
routine and during which the incidents of elopement occurred. Once this issue was addressed,
eloping behavior significantly decreased the following month, by 83% (Figure 1). Overall, from
baseline to month four of the intervention, elopement behaviors decreased from 4.8 to 1.0 per
month, a decrease of 79%.
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25
35
Baseline
DRO
Occurrences of Physica Aggression
30
25
20
15
10
5
0
Feb-13
Mar-13
Apr-13
May-13
Dates
Figure 2: Baseline and DRO on the occurrence of physical aggression
Physical aggression occurred at an average of 2.9 episodes per month during the baseline
condition. The participant met the first criterion within the first week. The criterion for the DRO
was then increased to include physical aggression. The number of physical aggression episodes
increased to 19 occurrences per month in the first month following the implementation of the
intervention (Figure 2). This can be attributed to a change in how data was collected. Data was
initially collected using an A-B-C format, but was switched to a data sheet using one hour
intervals and partial interval recording to measure the occurrences of elopement and physical
aggression. The method of data collection was changed to increase accuracy as partial interval
recording is an easier method for direct care staff. Moreover, A-B-C data were initially collected
to establish a function of the participant’s aggressive and eloping behavior. In the third month,
however, even using the new and more accurate method of data collection, there was a
significant decrease in the occurrences of physical aggression, by 68%. Physical aggression
DIFFERENTIAL REINFORCEMENT
26
continued to significantly decrease during the final month, with 0 episodes, representing an
overall decrease from baseline to month four of the intervention of 100% (Figure 2).
Discussion
It was hypothesized that a DRO intervention would be demonstrated as effective in
reducing the target behaviors of elopement and physical aggression in an adult with SMS.
Results appear to confirm this hypothesis, as elopement was decreased by 79% and aggression
by 100% between baseline and the end of intervention.
Results of the functional behavior assessment conducted in this study supported previous
findings indicating a functional relationship between the participant’s behavior and the social
environment (Sloneem, Oliver, Udwin, & Woodcock, 2011; Taylor & Oliver, 2008). The results
of this study were also consistent with previous studies using differential reinforcement as an
effective intervention to address problem behavior (Heard &Watson, 1999; Mazaleski, Iwata,
Vollmer, Zarcone, and Smith, 1993; Singh, Dawson, & Manning, 1981; Vollmer, Iwata,
Zarcone, Smith, & Mazaleski, 1993).
Currently, there is an immense need for research using behavioral interventions to
decrease challenging behaviors in adults diagnosed with SMS. This study is the first study
known to this author that uses ABA techniques to address socially significant problem behaviors
in this population. This study also provided a unique opportunity to expand research on SMS to
include an ABA intervention addressing problem behavior in an adult with SMS residing in the
community.
Elopement and physical aggression were selected because they were socially significant
behaviors that posed a risk of injury to staff, peers, and the participant. Factors in this study that
promoted decreases in elopement and physical aggression included staff training on the behavior
support plan prior to the implementation of the intervention. Staff members were retrained on the
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27
intervention following an increase in elopement after initial implementation of the intervention.
The group home also increased communication with the day program, which improved
consistency in addressing the target behaviors. However, it must be noted that the intervention
was not generalized to the day program because the participant attended a day program operated
by an outside agency, so we were unable to collect any data from the day program.
Results of this study supported the results from Taylor and Oliver (2008) on a functional
relationship between attention and problem behavior in someone with SMS. Taylor and Oliver
(2008) demonstrated that a decrease in attention led to participants exhibiting the problem
behavior that resulted in adult attention. That is, results established a functional relationship
between adult attention and problem behaviors with children and adolescents with SMS. The
authors had recommended the need for more studies using ABA techniques to gain a better
understanding of the function(s) of problem behaviors in adults with SMS (Taylor & Oliver,
2008).
The extinction component of the DRO seemed to play a critical role in the effectiveness
of the intervention used in the present study. The results of the present study were consistent
with Mazaleski, Iwata, Vollmer, Zarcone, and Smith (1993), where results demonstrated that
extinction is an essential factor in the DRO. Because the participant’s behavior in the present
study was maintained by attention, it was essential that attention was not provided during times
when the participant was engaging in eloping or physically aggressive behaviors.
This study used a DRO to address attention maintained elopement and physical
aggression. Findings were also consistent with Vollmer, Iwata, Zarcone, Smith, and Mazaleski
(1993). These authors evaluated the effectiveness of an NCR and DRO in reducing attentionmaintained self-injurious behavior, a problem behavior common in SMS. Results demonstrated
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28
that the DRO was as effective as the NCR in reducing self-injurious behavior (Vollmer et al.,
1993). Thus, future research should compare the effects of NCR and DRO within the adult SMS
population. It would also be interesting to compare the effects of an NCR, DRO, and Momentary
DRO (MDRO). Since the present study used a fixed-time schedule for the DRO, it would be
useful to compare whether a fixed-time or variable-time schedule is more effective for the DRO.
There are limitations of the current study which should be considered when interpreting
the results and planning future research. First, the intervention was carried out in the group
home only. Treatment was not generalized to the day program since the participant attended a
day program operated by an outside agency to which it was not possible to have access. Future
research should look at generalizing treatment to multiple settings. Future research could also
focus on an extended study that assesses long term generalization effects of a DRO on problem
behavior.
Second, this treatment was only used with one individual. It should be noted that this is
the first study known to this author using a behavioral intervention with an adult with SMS
residing in a community setting. Future research should focus on replicating this design and
comparing the differences between treatment implementation, with and without the extensive
measures taken, across multiple subjects.
A third limitation to this study is that treatment was carried out in the group home. It was
impossible to control for extraneous variables that could have influenced changes in the target
behaviors, such as staff turnover. Future research should focus on using more extensive measures
to control for extraneous variables. It would be useful to know the impact that staff training has
on the effectiveness of the treatment. Staff members were trained prior to the intervention being
implemented, when the criterion was increased, and following an increase in elopement. It would
DIFFERENTIAL REINFORCEMENT
29
be helpful to assess if the initial training along with integrity checks with or without immediate
feedback and/or modeling techniques would increase accuracy of treatment implementation.
A fourth limitation is that maintaining a continuous schedule of reinforcement could lead
to satiation of the reinforcer. In order to maintain the effectiveness of treatment, it is necessary to
fade the continuous schedule of reinforcement over time to match the schedule of reinforcement
in the natural environment. In the present study, the DRO used a fixed time schedule where the
participant had the opportunity to earn an activity with staff at the end of every hour she met the
criterion. Criterion was increased by adding in additional target behaviors, rather than increasing
the time between earning opportunities. It would be useful to examine the long-term effects of
continually increasing the criterion by the number of target behaviors compared to increasing the
criterion by increasing time between earning. It would also be useful to assess the effects of
simultaneously increasing the time between earning and adding additional behaviors to the
criterion to earn. Future research could focus on the effects of fading out the criterion through
extending the time between earning versus adding additional target behaviors.
There were sources of potential bias when recording response measures and
implementing treatment in the present study. It is important to note that extensive measures were
taken to decrease the probability of the internal validity of this study being compromised.
Although extensive measures were taken to train group home staff on treatment implementation,
there were still risks for attention to be provided following physical aggression or when the
participant eloped from the group home. There were also transient staff members who
occasionally worked in the group home or worked in the home for the first time. Transient staff
did not attend the training on proper implementation of the plan.
DIFFERENTIAL REINFORCEMENT
30
Overall, the DRO intervention was demonstrated as effective in reducing the target
behaviors of elopement and physical aggression in an adult with SMS. Results also suggest the
benefits of using a DRO with an extinction component. Yet future research might evaluate the
effectiveness of the DRO to the MDRO. As such, this remains a preliminary study using an ABA
intervention to address severe challenging behaviors in an adult with SMS. The need remains for
additional research using behavioral interventions with individuals with SMS.
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31
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Appendix A: FAST Structured Interview Form
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Appendix B: FAST Rating Scale and Scoring Summary
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Appendix C: Direct Observation Forms
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Appendix D: Data Sheets
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