Comparisons of synthesized and individual reinforcement contingencies during functional analysis

The Challenges Ahead: Concepts, Analytics, and Ethics of Value-Based Care in Applied Behavior Analysis

Value-based care has incrementally increased its footprint across healthcare over the past 2 decades. Several organizations in ABA have begun experimenting with various components of value-based care specific to the delivery of ABA services and it seems likely that this trend will continue into the future. For those new to value-based care, this article reviews the main conceptual components as well as common myths and misconceptions about value-based care. Though conceptually straightforward, practically pulling off value-based care in ABA will require significant advancements in data collection, analytics, sharing, and transparency that follow from broad field-wide collaboration. Further, many ethical questions will likely arise as ABA providers begin thinking about and assessing their clinical and business operations through a value-based care lens. Though value-based care will likely roll out slowly and incrementally over many years, ABA providers interested in participating or leading these conversations will likely benefit from focusing collaborative efforts around: normalizing data sharing and self-analysis; defining and developing quality and cost measures; identifying patient risk variables; addressing challenges at the intersection of public health ethics and clinical ethics; and addressing challenges at the intersection of AI ethics and clinical ethics. Most probably agree that optimizing patient outcomes is the goal of ABA services. However, doing it in an objective, measurable, and consistent manner that can be validated by third-parties will require overcoming significant challenges.

Synthesized alternative reinforcement and resurgence

In treatments based on differential reinforcement of alternative behavior, applied researchers and clinicians often provide multiple, qualitatively different reinforcers (i.e., synthesized reinforcement) rather than a single reinforcer (i.e., isolated reinforcement) contingent on alternative behavior. Some research shows that providing synthesized reinforcement for alternative responses within such treatments produces more rapid and complete suppression of target behavior; however, there is limited research evaluating the durability of these effects during treatment disruptions. Conceptual explanations of resurgence (e.g., resurgence as choice, context theory) suggest that treatments that include synthesized alternative reinforcement may lead to more resurgence of target behavior when alternative reinforcement is disrupted relative to treatments using isolated reinforcement. We evaluated this hypothesis within a three-phase resurgence evaluation. We exposed rats to isolated or synthesized reinforcement for alternative responding in the second phase, and we exposed rats to extinction in the third phase. Synthesized alternative reinforcement produced more rapid and complete suppression of target behavior than did isolated reinforcement in the second phase; however, exposure to extinction following synthesized reinforcement produced more resurgence. We discuss these results in terms of their implications for applied research and their support for current conceptual explanations for resurgence.

Protective procedures in functional analysis of self-injurious behavior: An updated scoping review

Despite the efficacy of functional analyses in identifying the function of challenging behavior, clinicians report not always using them, partly due to safety concerns. Understanding how researchers employ safeguards to mitigate risks, particularly with dangerous topographies like self-injurious behavior (SIB), is important to guide research and practice. However, the results of a scoping review of functional analyses of self-injurious behavior conducted by Weeden et al. (2010) revealed that only 19.83% of publications included protections. We extended the work of Weeden et al. to determine whether reporting has improved. We observed increases in all but two types of protections reviewed by Weeden et al. Additionally, we included new protections not reported by Weeden et al. In total, 69.52% of the studies included at least one protective procedure and 44.39% specified that the protections were used for safety. It appears that reporting has increased since Weeden et al. called for improved descriptions of participant protections.

Retrospective consecutive controlled case series of outcomes for functional analyses of severe destructive behavior

Functional analysis methods allow clinicians to determine the variable(s) that maintain destructive behavior. Previous reviews of functional analysis outcomes have included large samples of published and unpublished data sets (i.e., clinical samples). The purpose of this review was to conduct a large retrospective consecutive controlled case series of clinical functional analyses. We sought to identify the prevalence of differentiation, procedural modifications for undifferentiated and differentiated cases, and identified function(s) of destructive behavior. In addition, we extended the existing literature by determining whether functional analysis differentiation and function varied when single or multiple behavior topographies were consequated in the functional analysis. We discuss our findings considering previously published functional analysis reviews, provide avenues for future research, and offer suggestions for clinical practice.

Long-term effectiveness and generality of practical functional assessment and skill-based treatment

There are several considerations to address when conducting functional communication training for challenging behavior in a school setting, such as the need for schedule thinning and maintenance across staff and the need to establish a variety of appropriate classroom skills. There are several strategies for conducting schedule thinning following functional communication training and for transferring effects across people or settings. However, there are few examples of these processes in natural settings with relevant caregivers and with long-term maintenance of effects. We implemented a functional assessment and skill-based treatment process with six children with autism in a specialized school setting and extended treatment until challenging behavior was reduced to near-zero levels across multiple staff and settings. Follow-up data indicate that effects were still observed 1 year posttreatment and the use of crisis procedures (e.g., physical restraint) was eliminated for all participants.

A Discussion of Positive Behavior Support and Applied Behavior Analysis in the Context of Autism Spectrum Disorder in the UK and Ireland

This article addresses the relationship between applied behavior analysis (ABA) and the emergence of positive behavior support (PBS) in context of autism spectrum disorder (ASD) in the UK and Ireland. Two overarching issues that are salient in this discussion are professional training and certification. To date, there has been a lack of standardized training or statutory requirements to practice PBS despite proponents insisting that its practice should be grounded in behavior analytic principles. Furthermore, there is an undercurrent of anti-ABA bias fueled by misinterpretation and unsubstantiated anecdotal claims used to promote an alternative "value based" approach to managing behavior.

Toward Maximizing Assessment Efficiency: A Synthesized Trial-Based Functional Analysis and Competing Stimulus Assessment

Despite the success of the standard functional analysis (FA), some limitations to conducting an FA in practice include time, resources, ecological relevance, and safety, which have led to the development of procedural adaptations such as trial-based and synthesized FA formats. The purpose of this case study was to identify the function(s) of self-injurious behavior (SIB) for a 3-year-old female with developmental disabilities using a brief trial-based FA with ecologically relevant synthesized contingencies, based on caregiver input, to minimize opportunities for SIB. We identified that positive physical attention likely functioned, at least in part, as a reinforcer for SIB, in less than 42 min. Overall harm to the child as a result of the synthesized trial-based FA was minimal, and the caregiver viewed the modified conditions favorably. We then assessed the role of competing stimuli on SIB rates with the child's mother and identified two potential items that may compete with attention as a reinforcer for SIB. Our findings highlight the utility and importance of individualized assessment as the first step in the safe treatment of severely challenging behavior.

Description and evaluation of a function-informed and mechanisms-based framework for treating challenging behavior

Individualization and iterative design are essential components of the assessment and treatment of challenging behavior. Currently, there are few validated frameworks for engaging in iterative processes. Due to the nature of single-case design, empirically rigorous evaluations of decision-tree processes are particularly prohibitive. Notwithstanding, evaluations are needed. In this paper we first describe a function-informed and mechanisms-based (FIMB) framework for selecting treatment components employed by a university-based practicum experience designed to expose pre-service practitioners to a valid treatment process for challenging behavior. Then, we share a completed retrospective consecutive case series across a 6-year period in which we conducted a technique analysis to identify which procedures were most commonly selected in the practicum, and the impact of those choices on client outcomes. The results suggest that the model can be highly effective for some, but not all, cases. Implications are discussed.

Conducting Translational Research in the Context of Patient Care

Although much has been written on the importance of translational research for bridging the continuum of basic science to clinical practice, few authors have described how such work can be carried out practically when working with patient populations in the context of ongoing clinical service delivery, where the priorities for patient care can sometimes conflict with the methods and goals of translational research. In this article, we explore some of the considerations for conducting this type of work while balancing clinical responsibilities that ensure high-quality patient care. We also discuss strategies we have found to jointly facilitate translational research and improve routine, clinical service delivery. A primary goal of this article is to encourage others working in applied settings to contribute to the increasingly important role that translational research plays in our science and practice by helping to better characterize and potentially lessen or remove barriers that may have impeded such investigations in the past.

Further evaluation of functional analysis screening methods in early autism intervention

A goal of some functional analysis (FA) variations is to reduce assessment time while still maintaining efficacy. This may be especially important when conducting FAs in early intervention programs, where time is a crucial commodity. To that end, we evaluated a model for using the results of the no-interaction condition as a screening for behavioral function and to guide selection of FA test conditions with 20 participants (22 assessments) aged 3 to 7 years old. We used the no-interaction condition to develop hypotheses for both automatic reinforcement and socially mediated reinforcement. The outcome of the no-interaction condition guided the selection of test conditions for the remainder of the FA. We also incorporated methods from prior FA studies (e.g., divided attention) to modify the test conditions. We obtained differentiated results in 91% of assessments, all within 70 min and, as such, extended evidence that an FA can be completed in little time without sacrificing efficacy.

On the Reliability and Treatment Utility of the Practical Functional Assessment Process

Saini et al. (2019) urged caution with respect to the use of practical functional assessment (PFA) procedures to inform behavioral treatment when they found that responses to an open-ended caregiver interview were only somewhat reliable and showed moderate to weak correspondence with analog functional analyses. Because the practitioner's goal in conducting any functional assessment process is to inform the successful treatment of problem behavior, we replicated and extended Saini et al. by (a) evaluating the reliability of hypotheses gleaned from two independent PFA processes for each of four children, (b) conducting treatment informed by a randomly assigned PFA, and (c) determining the extent to which potentially different levels of reliability impacted the treatment utility of the PFA process. Results indicated that the reliability of the PFA process varied depending on the stringency with which it was evaluated. However, treatments developed from randomly determined PFA processes produced efficacious outcomes on problem behavior and targeted social skills that transferred to the context designed from the other PFA process in all evaluations, suggesting that the PFA has strong treatment utility despite parts of the process having ambiguous levels of reliability. We discuss implications for practitioners tasked with treating severe problem behavior.

Further comparison of isolated and synthesized contingencies in functional analyses

Recent research on functional analyses (FAs) has examined the extent to which problem behavior is maintained by single (isolated) or combined (synthesized) reinforcement contingencies. Outcomes of these analyses might differ depending on the sources of information that are used to inform contingencies included in test conditions. The purpose of the current study was to compare the outcomes of isolated FAs and synthesized contingency analyses (SCAs) with 3 participants. Conditions in both analyses were informed by interviews and both unstructured and structured observations. Problem behavior for all 3 participants was maintained by 1 or 2 isolated reinforcers. Results suggested false-positive SCA results for 2 participants. For 1 participant, a second isolated reinforcer was identified following the SCA, indicating the induction of a novel function. Implications for the use of isolated and synthesized consequences are discussed, as well as the predictive validity of the assessments that are used to inform them.

Evaluating the Potential for Correspondence Between Brief Functional Analysis and Interview-Informed Synthesized Contingency Analysis Procedures

School Psychologists regularly conduct Functional Behavior Assessment (FBA), though, most FBA are completed using indirect procedures, which are inadequate for creating function-based interventions relative to experimental measures, such as functional analysis (FA). However, traditional FA may be considered arduous in the school setting. Alternative procedures like brief functional analysis (BFA) and interview informed synthesized contingency analysis (IISCA), may be as effective and more efficient than FA. Limited research exploring the correspondence of these procedures exists. The current study used an alternating treatment design across eight school aged children to compare control and test conditions for each measure. A within subjects approach was also used to compare the results of BFA and IISCA. Correspondence across the two measures was 54.17%. With average correspondence yielding just over half, the results indicate the two FA methods did not reliably identify the same function. Implications for practice are discussed.

An Evaluation of "Balance": a Home-Based, Parent-Implemented Program Addressing Emerging Problem Behavior

Programs that prevent the development of severe problem behavior in young children with autism spectrum disorder (ASD) are critically needed. We describe a program designed to do this, and we report on a preliminary evaluation of its effects with four 3- and 4-year-old children with ASD. Parents served as the primary implementers, with twice-weekly coaching from a Board Certified Behavior Analyst. Direct measures and Aberrant Behavior Checklist scores reflected decreases in emerging problem behavior. Direct measures also reflected increases in child communication, social, and cooperation skills, and parents rated the process as highly acceptable. A randomized controlled trial will be required to evaluate the extent to which the program prevents the development of problem behavior in young children with ASD.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40617-020-00490-3.

A comparison of function- and nonfunction-based extinction treatments for inappropriate mealtime behavior

Previous literature supports the use of functional analyses to prescribe treatments for children with feeding disorders (Bachmeyer et al., 2009). Nevertheless, clinicians often train caregivers to use healthy contingencies, independent of whether those contingencies are function based. However, it is unclear whether including nonfunction-based contingencies differentially affects inappropriate mealtime behavior. In the current investigation, the caregivers of 3 children with feeding disorders provided escape from bites and drinks and attention following inappropriate mealtime behavior. Results of a functional analysis showed escape from bites or drinks, but not attention, reinforced inappropriate mealtime behavior. We then tested the effects of escape extinction when the feeder either provided or withheld attention following inappropriate mealtime behavior. Inappropriate mealtime behavior decreased and acceptance increased when the feeder implemented escape extinction independent of whether they provided or withheld attention. We discuss the implications of including nonfunction-based components in the treatment of pediatric feeding disorders.

Does teaching an omnibus mand preclude the development of specifying mands?

When problem behavior is controlled by a synthesized reinforcement contingency, a simple omnibus mand that yields access to all reinforcers simultaneously has been shown to effectively replace problem behavior. The question arises as to whether teaching an omnibus mand will preclude the acquisition of specifying mands for each of the combined reinforcers. In this study, after 3 students diagnosed with autism acquired an omnibus mand ("My way, please") that yielded all identified reinforcers simultaneously, specifying mands (e.g., "All done," "May I have my toys?" "Play with me") were taught to yield each individual reinforcer (e.g., escape, tangibles, attention). Problem behavior was immediately eliminated for all children, and the omnibus mand was acquired quickly. Teaching an omnibus mand did not preclude acquisition of specifying mands for any learner and instead allowed for the acquisition of specifying mands once problem behavior had been effectively reduced.

A Preliminary Evaluation of Interrater Reliability and Concurrent Validity of Open-Ended Indirect Assessment

Indirect assessments are a commonly used component of functional behavior assessment by behavior analysts in practice who work with individuals with severe behavior disorders. Although used frequently, closed-ended indirect assessments have repeatedly been shown to have low to moderate interrater reliability and poor concurrent validity with functional analysis. Recently, the use of open-ended interviews has become more commonly adopted in applied clinical practice, despite no studies evaluating the psychometric properties of such assessments. In the present study, we evaluated the interrater reliability and concurrent validity of an open-ended functional assessment interview. We compared the results of two open-ended indirect assessments conducted with a common caregiver and subsequently conducted functional analyses in an attempt to validate hypotheses generated from the interviews. Interrater agreement for the open-ended interviews was higher than previous research on closed-ended interviews (75%); however, concurrent validity with functional analysis was relatively poor (50%). We discuss these findings in the context of assessment and treatment for severe behavior disorders, as well as best practice methods during functional behavior assessment.

Resurgence following differential reinforcement of alternative behavior implemented with and without extinction

In the clinic, differential reinforcement of alternative behavior (DRA) often involves programming extinction for destructive behavior while reinforcing an alternative form of communication (e.g., a functional communication response); however, implementing extinction can be unsafe or impractical under some circumstances. Quantitative theories of resurgence (i.e., Behavioral Momentum Theory and Resurgence as Choice) predict differences in the efficacy of treatments that do and do not involve extinction of target responding when reinforcement conditions maintaining alternative responding worsen. We tested these predictions by examining resurgence following two DRA conditions in which we equated rates of reinforcement. In DRA without extinction, target and alternative behavior produced reinforcement. In DRA with extinction plus noncontingent reinforcement, only alternative behavior produced reinforcement. We conducted this study in a reverse-translation sequence, first with participants who engaged in destructive behavior (Experiment 1) and then in a laboratory setting with rats (Experiment 2). Across both experiments, we observed proportionally lower levels of target responding during and following the DRA condition that arranged extinction for the target response. However, levels of resurgence were similar following both arrangements.

On the Standardization of the Functional Analysis

The functional analysis procedures described in the seminal Iwata et al. (1982/1994) study are prominent in the applied behavior analytic literature, having been replicated hundreds of times over the past 30 years (Beavers, Iwata, & Lerman, 2013; Hanley, McCord, Iwata, 2003). However, the extent to which particular components of this functional analysis model have become more or less prominent over time is not clear from these literature reviews. We therefore conducted a review of the functional analysis literature between the years of 1965 and 2016 to determine the trends in the usage of particular components over time and to determine if the published literature reflects a standardization of the manner in which functional analyses of problem behavior are conducted. Furthermore, we discuss whether or not this standardization of a functional analysis model is currently necessary.

Interview-Informed Synthesized Contingency Analysis (IISCA): Novel Interpretations and Future Directions

The functional analysis (FA) methodology was developed to provide an empirical basis for understanding the reinforcers contributing to the maintenance of problem behavior. Previous research has demonstrated that multiple formats have been established to address some areas, such as practicality, efficiency, and safety. We reviewed the research on a new replication and extension of the standard FA format, the interview-informed synthesized contingency analysis (IISCA) and its subsequent treatment. We discuss the efficiency and effectiveness of the IISCA across various populations, settings, topographies of problem behaviors, and maintaining functions across 17 studies. Common treatment trends, novel developments, and other critical intervention components are also reviewed. We provide suggestions for future directions and guidelines for practitioners when considering the use of the IISCA.

Comparisons of standardized and interview-informed synthesized reinforcement contingencies relative to functional analysis

We compared the functions of problem behavior identified by (a) a functional analysis (FA), (b) an interview-informed synthesized contingency analysis (IISCA) that was informed by the results of an open-ended interview and a structured observation, and (c) a standardized-synthesized contingency analysis (SSCA) in which we synthesized three common functions of problem behavior across 12 individuals in a controlled consecutive case series. We then compared outcomes across assessments. The FA was sufficient in identifying the variables maintaining problem behavior for 11 of the 12 participants, replicating the findings of Fisher, Greer, Romani, Zangrillo, and Owen (2016). Error type (i.e., false positives, false negatives) and error prevalence were similar across functions identified by the IISCA and the SSCA, calling into question the utility of the open-ended interview and the structured observation that informed the IISCA.

Evaluation of an Omnibus Mand in the Treatment of Multiply Controlled Destructive Behavior

Functional communication training is a commonly used and effective treatment for socially reinforced destructive behavior. However, when a functional analysis suggests that destructive behavior is multiply controlled (e.g., by attention, tangibles, and escape), teaching and evaluating separate functional communication responses (FCRs) can be time-consuming or only partially effective when failing to address multiple establishing operations that may occur simultaneously. We evaluated the use of an omnibus FCR or mand that produced access to attention, tangibles, and escape within each functional-analysis test condition for two boys with autism spectrum disorder who displayed multiply controlled destructive behavior. The omnibus-FCR treatment produced low rates of destructive behavior and high percentages of independent FCRs within each condition for both children, suggesting that such a treatment option may reduce destructive behavior and teach communication skills quickly prior to introducing other treatment components, such as teaching individual FCRs to address each unique function of destructive behavior.

Evaluation of a trial-based interview-informed synthesized contingency analysis

We evaluated the viability of an interview-informed synthesized-contingency analysis (IISCA) conducted in a trial-based format with 3 children with autism spectrum disorders who engaged in problem behavior. We compared results to those from typical trial-based and traditional functional analyses and found high degrees of correspondence. The trial-based IISCA format took the least amount of time to conduct and was associated with the lowest frequencies of problem behavior. Results are discussed in terms of merits of each of the 3 types of functional analysis arrangements and directions for future research.

A translational evaluation of potential iatrogenic effects of single and combined contingencies during functional analysis

Recent research suggests that combining putative reinforcers for problem behavior into a single, synthesized contingency may increase efficiency in identifying behavioral function relative to traditional functional analysis (FA). Other research suggests potential shortcomings of synthesized contingency analysis (SCA), such as the potential for false-positive outcomes. In prior comparisons of traditional FAs and SCAs, investigators could not ascertain with certainty the true function(s) of the participants' problem behavior for use as the criterion variable. We conducted a translational study to circumvent this limitation by training a specific function for a surrogate destructive behavior prior to conducting a traditional FA and SCA. The traditional FA correctly identified the previously established function of the target response in all six cases and produced no iatrogenic effects. The SCA produced differentiated results in all cases and iatrogenic effects (i.e., an additional function) in three of six cases. We discuss these findings in terms of the mechanisms that may promote iatrogenic effects.

Efficiency in functional analysis of problem behavior: A quantitative and qualitative review

Originating in the mid-1960s, functional analysis (FA) has become the gold standard method for understanding the environmental variables that come to shape and maintain problematic behaviors such as aggression, self-injury, and property destruction. Over the decades, a number of studies have refined FA methods, attempting to improve the overall efficiency of the analysis through experimental design and procedural modifications. In the present review, we used ongoing visual-inspection criteria and basic probability theory to compare and analyze levels of efficiency across FA types. The multielement design and synthesized contingency analyses were about equally efficient with respect to the mean number of sessions conducted per function tested, and the trial-based and synthesized contingency analyses were the 2 most efficient with respect to the mean duration per function tested. We discuss the implications of these findings in the broader context of efficiency and provide recommendations for maximizing efficiency during an FA. We also discuss other qualitative procedural details that may influence the overall efficiency of an FA.

Evaluating competing activities to enhance functional communication training during reinforcement schedule thinning

Arranging periods in which requests for reinforcement are denied in a multiple schedule may result in increased destructive behavior during these periods for individuals who receive functional communication training (FCT) as treatment for severe destructive behavior. Providing access to competing activities during periods of reinforcer unavailability has been shown to minimize destructive behavior. We evaluated methods to identify effective competing activities for use when thinning reinforcement availability in a multiple schedule and compared competing activities embedded within the multiple schedule using an alternating-treatments design. Results suggested at least one competing activity facilitated favorable treatment outcomes for each participant. We discuss building on this empirical approach to identify effective competing activities for use during reinforcement schedule thinning.

Identifying predictive behavioral markers: A demonstration using automatically reinforced self-injurious behavior

Predictive biomarkers (PBioMs) are objective biological measures that predict response to medical treatments for diseases. The current study translates methods used in the field of precision medicine to identify PBioMs to identify parallel predictive behavioral markers (PBMs), defined as objective behavioral measures that predict response to treatment. We demonstrate the utility of this approach by examining the accuracy of two PBMs for automatically reinforced self-injurious behavior (ASIB). Results of the analysis indicated both functioned as good to excellent PBMs. We discuss the compatibility of this approach with applied behavior analysis, describe methods to identify additional PBMs, and posit that variables related to the mechanisms of problem behavior and putative mechanism of treatment action hold the most promise as potential PBMs. We discuss how this technology could guide individualized treatment selection, inform our understanding of problem behavior and mechanisms of treatment action, and help determine the conditional effectiveness of clinical procedures.

Further evaluation of differential exposure to establishing operations during functional communication training

Recent research findings (DeRosa, Fisher, & Steege, ) suggest that minimizing exposure to the establishing operation (EO) for destructive behavior when differential reinforcement interventions like functional communication training (FCT) are introduced may produce more immediate reductions in destructive behavior and prevent or mitigate extinction bursts. We directly tested this hypothesis by introducing FCT with extinction in two conditions, one with limited exposure to the EO (limited EO) and one with more extended exposure to the EO (extended EO) using a combined reversal and multielement design. Results showed that the limited-EO condition rapidly reduced destructive behavior to low levels during every application, whereas the extended-EO condition produced an extinction burst in five of six applications. We discuss these findings in relation to the effects of EO exposure on the beneficial and untoward effects of differential reinforcement interventions.