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JOURNAL OF APPLIED BEHAVIOR ANALYSIS 2010, 43, 569–589 NUMBER 4 (WINTER 2010)

AN INVESTIGATION OF DIFFERENTIAL REINFORCEMENT OF ALTERNATIVE BEHAVIOR WITHOUT EXTINCTION

ELIZABETH S. ATHENS

MARCUS AUTISM CENTER

AND

TIMOTHY R. VOLLMER

UNIVERSITY OF FLORIDA

We manipulated relative reinforcement for problem behavior and appropriate behavior using differential reinforcement of alternative behavior (DRA) without an extinction component. Seven children with developmental disabilities participated. We manipulated duration (Experiment 1), quality (Experiment 2), delay (Experiment 3), or a combination of each (Experiment 4), such that reinforcement favored appropriate behavior rather than problem behavior even though problem behavior still produced reinforcement. Results of Experiments 1 to 3 showed that behavior was often sensitive to manipulations of duration, quality, and delay in isolation, but the largest and most consistent behavior change was observed when several dimensions of reinforcement were combined to favor appropriate behavior (Experiment 4). Results suggest strategies for reducing problem behavior and increasing appropriate behavior without extinction.

Key words: attention deficit hyperactivity disorder, autism, concurrent schedules, differential reinforcement, extinction, problem behavior

Differential reinforcement is a fundamental principle of behavior analysis that has led to the development of a set of procedures used as treatment for problem behavior (Cooper, Heron, & Heward, 2007). One of the most frequently used of these procedures is the differential reinforcement of alternative behav- ior (DRA). DRA typically involves withholding reinforcers following problem behavior (extinc- tion) and providing reinforcers following ap- propriate behavior (Deitz & Repp, 1983). Pretreatment identification of the reinforcers that maintain problem behavior (i.e., functional analysis) permits the development of extinction procedures, which, by definition, must match

We thank Brian Iwata, Lise Abrams, and Stephen Smith for their comments on an earlier draft of this manuscript. Portions of this manuscript were included as part of the dissertation of the first author at the University of Florida.

Address correspondence concerning this article to Elizabeth Athens, who is now at ABA Learning Centre, #100–21320 Gordon Way, Richmond, British Columbia V6W 1J8, Canada (e-mail: [email protected]).

doi: 10.1901/jaba.2010.43-569

the function of problem behavior (Iwata, Pace, Cowdery, & Miltenberger, 1994). In addition, the reinforcer maintaining problem behavior can be delivered contingent on the occurrence of an alternative, more appropriate response. Under these conditions, DRA has been success- ful at reducing problem behavior (Dwyer- Moore & Dixon, 2007; Vollmer & Iwata, 1992).

Although extinction is an important and powerful component of DRA, it is, unfortu- nately, not always possible to implement it (Fisher et al., 1993; Hagopian, Fisher, Sullivan, Acquisto, & LeBlanc, 1998). For example, a caregiver may be physically unable to prevent escape with a large or combative individual, leading to compromises in integrity of escape extinction. It would also be difficult to withhold reinforcement for behavior maintained by attention in the form of physical contact if physical blocking is required to protect the individual or others. For example, if an individual’s attention-maintained eye gouging

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570 ELIZABETH S. ATHENS and TIMOTHY R. VOLLMER

is a threat to his or her eyesight, intervention is necessary to protect vision.

Several studies have found that DRA is less effective at decreasing problem behavior when implemented without extinction (Volkert, Ler- man, Call, & Trosclair-Lasserre, 2009). For example, Fisher et al. (1993) evaluated func- tional communication training (FCT; a specific type of DRA procedure) without extinction, with extinction, and with punishment contin- gent on problem behavior. Results showed that when FCT was introduced without an extinc- tion or punishment component for problem behavior, the predetermined goal of 70% reduction in problem behavior was met with only one of three participants. FCT was more effective at reducing problem behavior when extinction was included, and the largest and most consistent reduction was observed when punishment was included.

Hagopian et al. (1998) conducted a replica- tion of the Fisher et al. (1993) study and found that a predetermined goal of 90% reduction in problem behavior was not achieved with any of 11 participants exposed to FCT without extinction. When FCT was implemented with extinction, there was a 90% reduction in problem behavior for 11 of 25 applications, with a mean percentage reduction in problem behavior of 69% across all applications.

McCord, Thomson, and Iwata (2001) found that DRA without extinction had limited effects on the self-injurious behavior of two individu- als, one whose behavior was reinforced by avoidance of transition and another whose behavior was reinforced by avoidance of transition and avoidance of task initiation. In both cases, DRA with extinction and response blocking produced sustained decreases in self- injury. These examinations of research on DRA without extinction have shown a bias in responding toward problem behavior when the rate and immediacy of reinforcement of problem and appropriate behavior are equiva- lent.

When considering variables that contribute to the effectiveness (or ineffectiveness) of DRA without extinction as a treatment for problem behavior, it is helpful to conceptualize differ- ential reinforcement procedures in terms of a concurrent-operants arrangement (e.g., Fisher et al., 1993; Mace & Roberts, 1993). Concurrent schedules are two or more schedules in effect simultaneously. Each schedule independently arranges reinforcement for a different response (Ferster & Skinner, 1957). The matching law provides a quantitative description of respond- ing on concurrent schedules of reinforcement (Baum, 1974; Herrnstein, 1961). In general, the matching law states that the relative rate of responding on one alternative will approximate the relative rate of reinforcement provided on that alternative. Consistent with the predictions of the matching law, some studies have reported reductions in problem behavior without extinc- tion when differential reinforcement favors appropriate behavior rather than problem behavior (Piazza et al., 1997; Worsdell, Iwata, Hanley, Thompson, & Kahng, 2000).

For example, Worsdell et al. (2000) exam- ined the effect of reinforcement rate on response allocation. Five individuals whose problem behavior was reinforced by social positive reinforcement were first exposed to an FCT condition in which both problem and appro- priate behavior were reinforced on fixed-ratio (FR) 1 schedules. During subsequent FCT conditions, reinforcement for problem behavior was made more intermittent (e.g., FR 2, FR 3, FR 5), while appropriate behavior continued to be reinforced on an FR 1 schedule. Four of the participants showed shifts in response allocation to appropriate behavior as the schedule of reinforcement for problem behavior became more intermittent. There were several limita- tions to this research. For example, reinforce- ment rate was thinned in the same order for each participant such that reductions in prob- lem behavior may have been due in part to sequence effects. In addition, the reinforcement

571 DIFFERENTIAL REINFORCEMENT

schedule was thinned to FR 20 for two individuals. For these two participants, problem behavior rarely contacted reinforcement. The schedule in these cases may have been func- tionally equivalent to extinction rather than intermittent reinforcement. Nevertheless, these results suggest that extinction may not be a necessary treatment component when the rate of reinforcement favors appropriate behavior rather than problem behavior.

In another example of DRA without extinc- tion, Piazza et al. (1997) examined the effects of increasing the quality of reinforcement for compliance relative to reinforcement associated with problem behavior. Three individuals whose problem behavior was sensitive to negative reinforcement (break from tasks) and positive reinforcement (access to tangible items, attention, or both) participated. Piazza et al. systematically evaluated the effects of reinforc- ing appropriate behavior with one, two, or three of the reinforcing consequences (a break, tangible items, attention), both when problem behavior produced a break and when it did not (escape extinction). For two of the three participants, appropriate behavior increased and problem behavior decreased when appro- priate behavior produced a 30-s break with access to tangible items and problem behavior produced a 30-s break. The authors suggested that one potential explanation for these findings is that the relative rates of appropriate behavior and problem behavior were a function of the relative value of the reinforcement produced by escape. It is unclear, however, whether the intervention would be effective with individuals whose problem behavior was sensitive to only one type of reinforcement.

Together these and other studies have shown that behavior will covary based on rate, quality, magnitude, and delay of reinforcement. Re- sponding will favor the alternative associated with a higher reinforcement rate (Conger & Killeen, 1974; Lalli & Casey, 1996; Mace, McCurdy, & Quigley, 1990; Neef, Mace, Shea,

& Shade, 1992; Vollmer, Roane, Ringdahl, & Marcus, 1999; Worsdell et al., 2000), greater quality of reinforcement (Hoch, McComas, Johnson, Faranda, & Guenther, 2002; Lalli et al., 1999; Neef et al.; Piazza et al., 1997), greater magnitude of reinforcement (Catania, 1963; Hoch et al., 2002; Lerman, Kelley, Vorndran, Kuhn, & LaRue, 2002), or more immediate delivery of reinforcement (Mace, Neef, Shade, & Mauro, 1994; Neef, Mace, & Shade, 1993; Neef, Shade, & Miller, 1994).

Although previous research suggests that extinction may not always be a necessary component of differential reinforcement treat- ment packages, as described above there were certain limitations inherent in previous investi- gations. In addition, there has not been a comprehensive analysis of several different reinforcement dimensions both singly and in combination. The current study sought to extend this existing research by examining the influence of multiple dimensions of reinforce- ment and by incorporating variable-interval (VI) reinforcement schedules.

Interval schedules are less likely than ratio schedules to push response allocation exclusively toward one response over another. Under ratio schedules, reinforcer delivery is maximized when responding favors one alternative (Herrn- stein & Loveland, 1975). Under interval schedules, reinforcer delivery is maximized by varying response allocation across alternatives (MacDonall, 2005). If responding favors one response alternative over another under an interval schedule, this would indicate a bias in responding that is independent of the schedule of reinforcement. This bias would not be as easily observable during ratio schedules of reinforcement. In the current application, an interval schedule allowed us to identify poten- tial biases in responding that were independent of the reinforcement schedule. In addition, the application of a VI schedule mimics, to a degree, the integrity failures that could occur in the natural environment.

572 ELIZABETH S. ATHENS and TIMOTHY R. VOLLMER

In the natural environment, caregivers may not always implement extinction procedures accurately. They also may fail to implement reinforcement procedures accurately (Shores et al., 1993). Therefore, it may be important to identify a therapeutic differential reinforcement procedure that is effective despite intermittent reinforcement of both appropriate and problem behavior. The use of concurrent VI schedules in the current experiments allowed the examina- tion of the effects of failure to withhold reinforcement following every problem behav- ior and failure to reinforce every appropriate behavior in a highly controlled analogue setting.

We evaluated several manipulations that could be considered in the event that extinction either cannot or will not be implemented. In Experiments 1 to 3, we manipulated a single dimension of reinforcement such that reinforce- ment favored appropriate behavior along the lines of duration (Experiment 1), quality (Experiment 2), or delay (Experiment 3). In Experiment 4, we combined each of these dimensions of reinforcement such that rein- forcement favored appropriate behavior.

GENERAL METHOD

Participants and Setting

Seven individuals with developmental disor- ders who engaged in severe problem behavior participated. These were the first seven individ- uals who engaged in problem behavior sensitive to socially mediated reinforcement (as identified via functional analysis) and were admitted to an outpatient clinic (Justin, Henry, Corey, Ken- neth, Lana) or referred for behavioral consulta- tion services at local elementary schools (George, Clark). (See Table 1 for each partic- ipant’s age, diagnosis, problem behavior, and appropriate behavior.) We selected the targeted appropriate behavior for each participant based on the function of problem behavior. For example, if an individual engaged in problem behavior to access attention, we selected a mand for attention as the appropriate behavior.

Targeted response forms were in the partici- pants’ repertoires, although the behavior typi- cally occurred at low rates.

Session rooms in the outpatient clinic (3 m by 3 m) were equipped with a one-way observation window and sound monitoring. We conducted sessions for George and Clark in a classroom at their elementary schools. The rooms for all participants contained materials necessary for a session (e.g., toys, task materi- als), and the elementary school classrooms contained materials such as posters and tables (George and Clark only). With the exception of the final experimental condition assessing generality, no other children were in the room during the analyses with George and Clark.

Trained clinicians served as therapists and conducted sessions 4 to 16 times per day, 5 days per week. Sessions were 10 min in duration, and there was a minimum 5-min break between each session. We used a multielement design during the functional analysis and a reversal design during all subsequent analyses.

Response Measurement and Interobserver Agreement

Observers were clinicians who had received training in behavioral observation and had previously demonstrated high interobserver agreement scores (.90%) with trained observ- ers. Observers in the outpatient clinic sat behind a one-way observation window. Observers in the school sat out of the direct line of sight of the child. All observers collected data on desktop or laptop computers that provided real-time data and scored events as either frequency (e.g., aggression, disruption, self- injury, and screaming) or duration (e.g., delivery of attention, escape from instructions; see Table 1 for operational definitions of behavior). Observations were divided into 10-s bins, and observers scored the number (or duration) of observed responses for each bin. The smaller number (or duration) of observed responses within each bin was divided by the larger number and converted to agreement

573 DIFFERENTIAL REINFORCEMENT

Table 1

Participants’ Characteristics

Name Age (years) Diagnosis Problem behavior Appropriate behavior

Justin 7 Attention deficit hyperactivity disorder instructional (ADHD)

Aggression: forcefully hitting, kicking, biting others’ body parts, pinching skin between fingers, scratching others with nails, forceful pushing, and head head butting others. Behavior drew blood or caused bruises on his victims. Disruption: forcefully throwing objects and hitting walls. Inappropriate sexual behavior: touching himself or the therapist in a sexual way by contact of the hand to the torso, bottom, or genitals.

Compliance with demands such as ‘‘fold the clothing’’ or ‘‘pick up the trash.’’

Henry 8 Autism Aggression: forcefully hitting and kicking others resulting in bruising his victims. Disruption: forcefully throwing objects.

Exchange of a picture card

Corey 9 Autism and ADHD Aggression: forcefully hitting, biting, spitting, and kicking resulting in bruising or bleeding of victims. Disruption: forcefully throwing objects around room and at people, tearing paper materials.

Vocal request (‘‘May I have my toy please?’’)

Kenneth 6 Autism Aggression: forcefully hitting, scratching, and pinching resulting in bleeding or bruising of victims. Disruption: throwing objects around room and at people.

Exchange of a picture card

Lana 4 Autism Aggression: forcefully hitting, kicking, and scratching resulting in bruising or bleeding in victims.

Sign language (sign for ‘‘play’’)

George 10 Autism Aggression: forcefully hitting, kicking, and biting resulting in bruising or bleeding victims. Disruption: throwing objects around the room and at people.

Exchange of a picture card

Clark 12 Autism Aggression: hitting, kicking, and scratching resulting in bruising or bleeding of victims.

Vocal request (‘‘toy please’’)

percentages for frequency measures (Bostow & Bailey, 1969). Agreement on the nonoccurrence of behavior within any given bin was scored as 100% agreement. The agreement scores for bins were then averaged across the session.

Two independent observers scored the target responses simultaneously but independently during a mean of 37% of functional analysis sessions (range, 27% to 49%) and 29% of experimental analysis sessions (range, 25% to 32%). We assessed interobserver agreement for problem behavior (aggression, disruption, inap- propriate sexual behavior) and appropriate behavior (compliance and mands) of all partic- ipants and for the therapist’s behavior, which included therapist attention, delivery of tangible items, and escape from demands.

For Justin, mean agreement was 98% for aggression (range, 87% to 100%), 96% for disruption (range, 85% to 100%), 100% for inappropriate sexual behavior, and 98% for compliance (range, 86% to 100%). For Henry, mean agreement was 100% for aggression, 99.9% for disruption (range, 99.7% to 100%), and 97% for mands (range, 95% to 99%). For Corey, mean agreement was 100% for aggression and disruption and 97% for mands (range, 95% to 100%). For Kenneth, mean agreement was 98% for aggression (range, 94% to 100%), 99% for disruption (range, 97% to 100%), and 99% for mands (range, 95% to 100%). For Lana, mean agreement was 99% for aggression (range, 99% to 100%) and 100% for mands. For George, mean agreement

574 ELIZABETH S. ATHENS and TIMOTHY R. VOLLMER

was 99% (range, 98% to 100%) for aggression, 99% for disruption (range, 98% to 100%), and 93% for mands (range, 88% to 99%). Mean interobserver agreement scores for 39% of all sessions was 100% for therapist attention, 99.9% for access to tangible items (range, 99% to 100%), and 100% for escape from instructions.

Stimulus Preference Assessment

We conducted a paired-stimulus preference assessment for each participant to identify a hierarchy of preferred items for use in the functional analysis (Fisher et al., 1992). In addition, for those participants whose problem behavior was reinforced by tangible items (Corey, Lana, and Clark), a multiple-stimulus- without-replacement (MSWO) preference as- sessment (DeLeon & Iwata, 1996) was con- ducted immediately prior to each session of the treatment analyses. We used informal caregiver interviews to select items used in the preference assessments, and a minimum of six items were included in the assessments.

Functional Analysis

We conducted functional analyses prior to the treatment evaluation. Procedures were similar to those described by Iwata, Dorsey, Slifer, Bauman, and Richman (1982/1994) with one exception to the procedures for George. His aggression was severe and primarily directed toward therapists’ heads; therefore, a blocking procedure was in place throughout the functional analysis for the safety of the therapist. Blocking consisted of a therapist holding up his arm to prevent a hit from directly contacting his head. During the functional analysis, four test conditions (atten- tion, tangible, escape, and ignore) were com- pared to a control condition (play) using a multielement design.

Figure 1 shows response rates of problem behavior during the functional analyses for Justin, Corey, Kenneth, and Henry. We collected data for aggression and disruption

separately and obtained similar results for each topography for all participants; therefore, both topographies were combined in these data presentations. We obtained similar results for inappropriate sexual behavior for Justin, which we combined with aggression and disruption.

Justin engaged in the highest rates of problem behavior in the escape condition. Although the overall trend in the escape condition is downward, inspection of the data showed that he was becoming more efficient in escape behavior by responding only when the therapist presented demands. Corey engaged in the highest rates of problem behavior during the tangible condition. Kenneth engaged in the highest rates of aggression and disruption during the attention and escape conditions. Henry displayed the highest rates of aggression and disruption in the escape condition.

Figure 2 shows the results of the functional analyses for Lana, Clark, and George. Lana and Clark displayed the highest rates of aggression during the tangible condition. George engaged in the highest rates of aggression and disruption during the attention condition.

Baseline

During baseline and all subsequent condi- tions of Experiments 1 to 4, equal concurrent VI schedules of reinforcement (VI 20 s VI 20 s) were in place for both problem and appropriate behavior. A random number generator selected intervals between 1 s and 39 s, with a mean interval length of 20 s, and the programmed intervals for each session were available on a computer printout. A trained observer timed intervals using two timers set according to the programmed intervals. The first instance of behavior following availability of a reinforcer resulted in delivery of the reinforcer for 30 s (for an exception, see Experiment 1 involving manipulations of reinforcer duration). When reinforcement was available for a response (i.e., the interval elapsed) and the behavior occurred, the observer discreetly tapped on the one-way window from the observation room (clinic) or

575 DIFFERENTIAL REINFORCEMENT

Figure 1. Response rates during the functional analysis for Justin, Corey, Kenneth, and Henry.

briefly nodded his head (classroom) to prompt the therapist to reinforce a response. After 30 s of reinforcer access (or the pertinent duration value in Experiment 1), the therapist removed the reinforcer and reset the timer for that response. The VI clock for one response (e.g., appropriate behavior) stopped while the partic- ipant consumed the reinforcer for the other response (e.g., problem behavior). The therapist reinforced responses regardless of the interval of time since the last changeover from the other

response alternative. The reinforcer identified for problem behavior in the functional analysis served as the reinforcer for both responses during baseline. In Experiments 2 and 4, which involved manipulations of quality, participants received the same high-quality toy contingent on appropriate or problem behavior during baseline.

We conducted each baseline in the experi- ment as described but labeled them differently in order to highlight the dimensions of

576 ELIZABETH S. ATHENS and TIMOTHY R. VOLLMER

Figure 2. Response rates during the functional analysis for Lana, Clark, and George.

reinforcement that varied across experiments. For example, in Experiment 1 we manipulated duration of reinforcement, and baseline is labeled 30-s/30-s dur to indicate that reinforce- ment was provided for 30 s (duration) following problem and appropriate behavior. In Experi- ment 2, we manipulated quality of reinforce- ment, and baseline is labeled 1 HQ/1 HQ to indicate that a high-quality reinforcer was delivered following appropriate and problem behavior. In Experiment 3, we manipulated delay to reinforcement, and baseline is labeled 0-s/0-s delay. In Experiment 4 we manipulated duration, quality, and delay in combination, and baseline is labeled 30-s dur 1 HQ 0-s delay/ 30-s dur 1 HQ 0-s delay.

EXPERIMENT 1: DURATION

Method The purpose of Experiment 1 was to examine

whether we could obtain clinically acceptable changes in behavior by providing a longer dura- tion of access to the reinforcer following appro- priate behavior and shorter duration of access to the reinforcer following problem behavior.

30-s/10-s dur. Justin and Lana participated in the 30-s/10-s dur condition. For Justin, appro- priate behavior produced a 30-s break from instructions. Problem behavior produced a 10-s break from instructions. For Lana, appropriate behavior produced access to the most preferred toy for 30 s, and problem behavior produced access to the same toy for 10 s.

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Figure 3. Justin’s and Lana’s response rates during the duration analysis for problem behavior and appropriate behavior.

45-s/5-s dur. Justin participated in the 45-s/5- s dur condition during which the duration of reinforcement was more discrepant across response alternatives. Appropriate behavior produced a 45-s break from instructions, and problem behavior produced a 5-s break from instructions.

Results and Discussion

Figure 3 shows the results for Justin and Lana. For Justin, during the 30-s/30-s dur baseline condition, problem behavior occurred at higher rates than appropriate behavior. In the 30-s/10-s dur condition, there was a slight decrease in the rate of problem behavior, and some appropriate behavior occurred. Because

problem behavior still occurred at a higher rate than appropriate behavior, we conducted the 45-s/5-s dur condition. In the last five sessions of this condition, problem behavior decreased to low rates, and appropriate behavior in- creased. In a reversal to the 30-s/30-s dur baseline, problem behavior returned to levels higher than appropriate behavior. In the subsequent return to the 45-s/5-s dur condition, the favorable effects were replicated. Respond- ing stabilized in the last five sessions of this condition, with problem behavior remaining low and appropriate behavior remaining high. In a reversal to the 30-s/30-s dur baseline, however, there was a failure to replicate previous baseline levels of responding. Instead, low rates

578 ELIZABETH S. ATHENS and TIMOTHY R. VOLLMER

of problem behavior and high rates of appro- priate behavior occurred.

During the 30-s/30-s dur baseline, Lana’s problem behavior occurred at higher rates than appropriate behavior. During the 30-s/10-s dur condition, appropriate behavior occurred at higher rates, and problem behavior decreased to zero. The effects of the 30-s/30-s dur baseline and the 30-s/10-s dur condition were replicated in the final two conditions.

In summary, the duration analysis indicated that for both participants, the relative rates of problem behavior and appropriate behavior were sensitive to the reinforcement duration available for each alternative in four of the five applications in which duration of reinforcement was unequal. This finding replicates the findings of previous investigations on the effects of reinforcement duration on choice responding (Catania, 1963; Lerman et al., 2002; Ten Eyck, 1970).

There were several limitations to this exper- iment. For example, the participants did not show sensitivity to the concurrent VI schedules

when both the rate and duration of reinforce- ment were equal. Under this arrangement, the participants would have collected all of the

available reinforcers had they distributed their responding roughly equally between the two response options. The failure to distribute

responding across responses indicates a bias toward problem behavior. Additional research into this failure to show sensitivity to the

concurrent VI schedules is warranted but was outside the scope of this experiment.

With Justin, we were unable to recapture baseline rates of problem and appropriate behavior in our final reversal to the 30-s/30-s dur baseline. This failure to replicate previous rates of responding may be a result of his recent history with a condition in which reinforcement favored appropriate behavior (i.e., the 5 s/45-s dur condition). Nevertheless, this lack of replication weakens the demonstration of experimental control with this participant. With

both participants, there was a gradual change in responding in the condition that ultimately produced a change favoring the alternative behavior, which is not surprising given that extinction was not in place. Responding under intermittent schedules of reinforcement can be more resistant to change (Ferster & Skinner, 1957).

EXPERIMENT 2: QUALITY

The purpose of Experiment 2 was to examine whether we could obtain clinically acceptable changes in behavior by providing a higher quality reinforcer following appropriate behav- ior and lower quality reinforcer following problem behavior.

Method

Reinforcer assessment. We conducted a rein- forcer assessment using procedures described by Piazza et al. (1999) before conducting the quality analysis with Kenneth. The assessment identified the relative efficacy of two reinforcers (i.e., praise and reprimands) in a concurrent- operants arrangement. During baseline, the therapist stood in the middle of a room that was divided by painter’s tape and provided no social interaction; toy contact (e.g., playing with green or orange blocks on either side of the divided room) and problem behavior resulted in no arranged consequences. Presession prompt- ing occurred prior to the beginning of the initial contingent attention phase and the reversal (described below). During presession prompt- ing, the experimenter prompted Kenneth to make contact with the green and orange toys. Prompted contact with green toys resulted in praise (e.g., ‘‘Good job, Kenneth,’’ delivered in a high-pitched, loud voice with an excited tone). Prompted contact with the orange toys resulted in reprimands (e.g., ‘‘Don’t play with that,’’ delivered in a deeper pitched, loud voice with a harsh tone). Following presession prompting, we implemented the contingent attention phase. The therapist stood in the

579 DIFFERENTIAL REINFORCEMENT

middle of a room divided by painter’s tape and delivered the consequences to which Kenneth had been exposed in presession prompting. The therapist delivered continuous reprimands or praise for the duration of toy contact and blocked attempts to play with two different- colored toys simultaneously.

During the second contingent attention phase, we reversed the consequences associated with each color of toys such that green toys were associated with reprimands and orange toys with praise. The different-colored toys were always associated with a specific side of the room, and the therapist ensured that they remained on that side. Kenneth selected the colored toy associated with praise on a mean of 98% of all contingent attention sessions.

1 HQ/1 LQ. For Justin, problem behavior produced 30 s of escape with access to one low- quality tangible item identified in a presession

MSWO. Appropriate behavior produced 30 s of escape with access to one high-quality tangible

item identified in a presession MSWO. Al- though the variable that maintained his prob- lem behavior was escape, we used disparate

quality toys as a way of creating a qualitative difference between the escape contingencies for appropriate and problem behavior.

For Kenneth, problem behavior produced reprimands (e.g., ‘‘Don’t do that, I really do not like it, and you could end up hurting someone’’), which the reinforcer assessment identified as a less effective form of reinforce- ment than social praise. Appropriate behavior produced praise (e.g., ‘‘Good job handing me the card; I really like it when you hand it to me so nicely.’’), which was identified as a more effective form of reinforcement in the reinforcer assessment.

3 HQ/1 LQ. For Justin and Kenneth, problem behavior did not decrease to therapeu- tic levels in the 1 HQ/1 LQ condition. For Justin, within-session analysis showed that as sessions progressed during the 1 LQ/1 HQ condition, he stopped playing with the toy and

showed decreases in compliance, possibly due to reinforcer satiation. Unfortunately, we did not have access to potentially higher quality toys that Justin had requested (e.g., video game systems). Given this limited access, we increased the number of preferred toys provided contin- gent on appropriate behavior as a way of addressing potential satiation with the toys. We provided three toys selected most frequently in presession MSWO assessments. Therefore, for Justin, in the 3 HQ/1 LQ condition, appropriate behavior produced 30 s of escape with access to three high-quality toys. Problem behavior produced 30 s of escape with access to one low-quality tangible item.

For Kenneth, anecdotal observations be- tween sessions showed that he frequently requested physical attention in the forms of hugs and tickles by guiding the therapist’s hands around him or to his stomach. Based on this observation, we added physical attention to the social praise available following appropriate behavior. Therefore, during the 3 HQ/1 LQ condition, appropriate behavior produced praise and the addition of physical attention (e.g., ‘‘Good job handing me the card,’’ hugs and tickles). Problem behavior produced reprimands.

Results and Discussion

During the 1 HQ/1 HQ baseline condition, Justin (Figure 4, top) engaged in higher rates of problem behavior than appropriate behavior. In the 1 HQ/1 LQ condition, rates of problem behavior decreased, and appropriate behavior increased. However, toward the end of the phase, problem behavior increased, and appro- priate behavior decreased. Lower rates of problem behavior than appropriate behavior were obtained in the 3 HQ/1 LQ condition. During the subsequent 1 HQ/1 HQ baseline reversal, there was a failure to recapture previous rates of problem and appropriate behavior. Instead, problem behavior occurred at a lower rate than appropriate behavior. Despite this, problem behavior increased relative to what was

580 ELIZABETH S. ATHENS and TIMOTHY R. VOLLMER

Figure 4. Response rates for Justin and Kenneth during the quality analysis for problem behavior and

appropriate behavior.

observed in the immediately preceding 3 HQ/1 LQ condition. Problem behavior de- creased, and appropriate behavior increased to high levels during the return to the 3 HQ/1 LQ condition.

Kenneth (Figure 4, bottom) engaged in higher rates of problem behavior than appro- priate behavior in the 1 HQ/1 HQ baseline. In the 1 HQ/1 LQ condition, rates of problem behavior decreased, and appropriate behavior increased. During the last five sessions, re- sponding shifted across response alternatives across sessions. During a replication of 1 HQ/1 HQ baseline, we observed high rates of problem behavior and relatively lower rates of appropri-

ate behavior. During a subsequent replication of the 1 HQ/1 LQ condition, slightly higher rates of problem behavior than appropriate behavior were obtained, with responding again shifting across response alternatives across sessions. In a replication of 1 HQ/1 HQ baseline, high rates of problem behavior and lower rates of appropriate behavior were obtained. Following this replication, we conducted the 3 HQ/1 LQ condition, and problem behavior decreased to rates lower than observed in previous conditions and appropriate behavior increased to high rates. The effects of the 1 HQ/1 HQ baseline and the 3 HQ/1 LQ condition were replicated in the final two conditions.

581 DIFFERENTIAL REINFORCEMENT

In summary, results of the quality analyses indicated that for both participants, the relative rates of both problem behavior and appropriate behavior were sensitive to the quality of reinforcement available for each alternative. These results replicate the findings of previous investigations on the relative effects of quality of reinforcement on choice responding (Conger & Killeen, 1974; Hoch et al., 2002; Martens & Houk, 1989; Neef et al., 1992; Piazza et al., 1997).

One drawback to this study was the manipulation of both magnitude and quality of reinforcement with Justin. Given the cir- cumstances described above, a greater number of higher quality toys were provided contingent on appropriate behavior relative to problem behavior prior to obtaining a consistent shift in response allocation.

As in Experiment 1, the failure to replicate prior rates of appropriate behavior in our final reversal to the 1 HQ/1 HQ baseline weakened experimental control with Justin. Again, base- line levels of behavior were not recaptured after an intervening history in which the reinforce- ment quality and magnitude favored appropri- ate behavior.

EXPERIMENT 3: DELAY

Method

The purpose of Experiment 3 was to examine whether we could produce clinically acceptable changes in behavior by providing immediate reinforcement following appropriate behavior and delayed reinforcement following problem behavior.

0-s/30-s delay. Corey and Henry participated in the 0-s/30-s delay condition. For Corey, appropriate behavior produced 30-s immediate access to a high-quality toy (selected from a presession MSWO). Problem behavior pro- duced 30-s access to the same high-quality toy after a 30-s unsignaled delay. For Henry, appropriate behavior produced an immediate 30-s break from instructions. Problem behavior

produced a 30-s break from instructions after a 30-s unsignaled delay. With both participants, once a delay interval started, additional instanc- es of problem behavior did not reset the interval. When problem behavior occurred, the data collector started a timer and signaled the therapist to provide reinforcement when the timer elapsed by a discreet tap on the one-way window. If a participant engaged in appropriate behavior during the delay interval for problem behavior, the therapist immediately delivered the reinforcer for appropriate behavior (as programmed), and the delay clock for problem behavior temporarily stopped and then resumed after the reinforcement interval for appropriate behavior ended.

0-s/60-s delay. When the initial delay interval did not result in therapeutic decreases in problem behavior for Corey, we altered the delay interval such that problem behavior produced 30-s access to a high-quality toy (selected from a presession MSWO) after a 60-s unsignaled delay. Appropriate behavior contin- ued to produce 30-s immediate access to the same high-quality toy. For Henry, problem behavior produced a 30-s break from instruc- tions after a 60-s unsignaled delay, and appropriate behavior continued to produce an immediate 30-s break.

Results and Discussion

During the 0-s/0-s delay baseline, Corey (Figure 5, top) engaged in higher rates of problem behavior than appropriate behavior. In the 0-s/30-s delay condition, problem behavior continued to occur at a higher rate than appropriate behavior. Given this, the 0-s/ 60-s delay condition was implemented, and a gradual decrease in problem behavior and increase in appropriate behavior was obtained. During a reversal to the 0-s/0-s delay baseline, there was an increase in problem behavior and a decrease in appropriate behavior. In the final reversal to the 0-s/60-s delay condition, Corey became ill with strep throat. His caregiver continued to bring him to the clinic and did not

582 ELIZABETH S. ATHENS and TIMOTHY R. VOLLMER

Figure 5. Corey’s and Henry’s response rates during the delay analysis for problem behavior and appropriate behavior.

inform us until after he began treatment. (We have indicated this period on the graph.) Following his illness, problem behavior ceased, and appropriate behavior increased to high, steady rates.

During the 0-s/0-s delay baseline, Henry (Figure 5, bottom) engaged in higher rates of problem behavior than appropriate behavior. In the 0-s/30-s delay condition, Henry continued to engage in a higher rate of problem behavior than appropriate behavior. In a reversal to 0-s/ 0-s delay baseline, there was a slight increase in problem behavior from the previous condition and a decrease in appropriate behavior. During the 0-s/60-s delay condition, there was a decrease in problem behavior to zero rates and

an increase in appropriate behavior to steady rates of two per minute (perfectly efficient responding given 30-s access). These results were replicated in the reversals to 0-s/0-s delay baseline and 0-s/60-s delay condition.

In summary, results of the delay analysis indicate that the relative rates of problem behavior and appropriate behavior were sensi- tive to the delay to reinforcement following each alternative. These results replicate the findings of previous investigations on the effects of unsignaled delay to reinforcement (Sizemore & Lattal, 1978; Vollmer, Borrero, Lalli, & Daniel, 1999; Williams, 1976). For example, Vollmer et al. showed that aggression occurred when it produced immediate but small rein-

583 DIFFERENTIAL REINFORCEMENT

forcers even though mands produced larger reinforcers after an unsignaled delay. In their study, participants displayed self-control when therapists signaled the delay to reinforcement.

It is important to note that the programmed delays were not necessarily those experienced by the participant. The occurrence of problem behavior started a timer that, when elapsed, resulted in delivery of reinforcement. Additional problem behavior during the delay did not add to the delay in order to prevent extinction-like conditions. It was therefore possible that prob- lem behavior occurred within the delay interval and resulted in shorter delays to reinforcement. This rarely occurred with Henry. By contrast, Corey’s problem behavior sometimes occurred in bursts or at high rates. In these cases, problem behavior was reinforced after delays shorter than the programmed 30 s or 60 s. Nevertheless, the differential delays to reinforcement following inappropriate and appropriate behavior eventu- ally shifted allocation toward appropriate re- sponding. One way to address this potential limitation would be to add a differential reinforcement of other behavior (DRO) compo- nent with a resetting reinforcement interval. The resetting feature would result in the occurrence of problem behavior during the interval resetting the interval and therefore delaying reinforce- ment. With high-rate problem behavior, this DRO contingency would initially result in very low rates of reinforcement, making the condition similar to extinction. We did not add a DRO component in the current experiment because our aim was to evaluate treatments without extinction.

Another potential limitation to the current experiment was the possibility of adventitious reinforcement of chains of problem and appropriate behavior. For example, when appropriate behavior occurred during the delay interval for problem behavior and the VI schedule indicated reinforcement was available for that response, there was immediate rein- forcement of appropriate behavior. This rein-

forcement could have strengthened a chain of problem and appropriate behavior. Although this did not seem to be a concern in the current experiment, one way to control for this limitation would be to add a changeover delay (COD). A COD allows a response to be reinforced only if a certain interval has passed since the last changeover from the other response alternative. The COD could prevent adventitious reinforcement of problem and appropriate behavior and result in longer periods of responding on a given alternative and thus greater control by the relative reinforcement available for those alternatives (Catania, 1966).

EXPERIMENT 4: DURATION, QUALITY, AND DELAY

The purpose of Experiment 4 was to evaluate the effects of delivering immediate, longer duration access to high-quality reinforcement following appropriate behavior and delayed, shorter duration access to low-quality reinforce- ment following problem behavior. We observed gradual treatment effects in the previous experiments. This was to be expected, because both types of responding were reinforced, but is not an ideal clinical outcome. In addition, experimental control was not clear in several of the cases, and none of the experiments clearly demonstrated how reinforcement that favored appropriate behavior could be used in a practical manner as a treatment for problem behavior. The focus of Experiment 4, therefore, was to combine all the variables and examine whether clinically acceptable changes in behav- ior could be produced by making reinforcement for appropriate behavior greater along several dimensions. We also assessed the maintenance and generality of treatment effects. George and Clark participated in Experiment 4.

Method

Reinforcer assessment. Before conducting the experimental analyses with George, we con-

584 ELIZABETH S. ATHENS and TIMOTHY R. VOLLMER

ducted a reinforcer assessment using procedures similar to those described in Experiment 2. We compared the reinforcing efficacy of praise (e.g., ‘‘Good job, George’’) and physical contact (e.g., high fives, pats on the back) with reprimands (e.g., ‘‘Don’t do that’’) and physical contact (e.g., therapist using his hands to block aggression from George for safety reasons). George allocated a mean of 96% of his responses to the colored toys that resulted in praise and physical contact.

30-s dur HQ 0-s delay/5-s dur LQ 10-s delay. As in previous experiments, equal concurrent VI schedules of reinforcement (VI 20 s VI 20 s) were in place for both problem and appropriate behavior throughout the experiment. For George, appropriate behavior immediately pro- duced 30 s of high-quality attention in the form of social praise and physical attention (e.g., high fives, pats on the back). Problem behavior produced 5 s of low-quality attention in the form of social disapproval and brief blocking of aggression after a 10-s unsignaled delay. For Clark, appropriate behavior produced 30 s of immediate access to a high-preference toy. Problem behavior produced 5 s of access to a low-preference toy after a 10-s unsignaled delay. The therapist timed delays to reinforcement in the same manner as described in Experiment 3. We assessed maintenance of treatment effects and extended treatment across therapists with both participants. George’s participation con- cluded with a 1-month follow-up to evaluate the maintenance of treatment effects. His teacher conducted the final three sessions of this condition. Clark’s participation concluded with a 2-month follow-up during which his teacher conducted sessions. Teachers received written descriptions of the protocol, one-on-one training with modeling of the procedures, and feedback after each session regarding the accuracy of their implementation of the procedures.

Results and Discussion

During the 30-s dur 1 HQ 0-s delay/30-s dur 1 HQ 0-s delay baseline, George (Figure 6, top)

engaged in higher rates of problem behavior than appropriate behavior. In the 30-s dur HQ 0-s delay/5-s dur LQ 10-s delay condition, there was a decrease in problem behavior and an increase in appropriate behavior. In a reversal to baseline, there was an increase in problem behavior and a decrease in appropriate behavior. In the final reversal to the 30-s dur HQ 0-s delay/5-s dur LQ 10-s delay condition, there was a further decrease in problem behavior and an increase in appropriate behavior. At the 1- month follow-up, no problem behavior oc- curred, and appropriate behavior remained high.

During the 30-s dur 1 HQ 0-s delay/30-s dur 1 HQ 0-s delay baseline, Clark (Figure 6, bottom) engaged in higher rates of problem behavior than appropriate behavior. In the initial 30-s dur HQ 0-s delay/5-s dur LQ 10-s delay condition, there was a decrease in problem behavior and an increase in appropri- ate behavior. In a reversal to baseline, there was an increase in problem behavior and a decrease in appropriate behavior. In a reversal to the 30-s dur HQ 0-s delay/5-s dur LQ 10-s delay condition, there was a further decrease in problem behavior and an increase in appropri- ate behavior. At the 2-month follow-up, no problem behavior occurred, and appropriate behavior remained high.

In summary, results of the combined analyses indicate that for these participants the relative rates of problem behavior and appropriate behavior were sensitive to a combination of the quality, delay, and duration of reinforce- ment following each alternative. Compared to the first three experiments, Experiment 4 resulted in clear experimental control; there were rapid changes in response allocation across conditions and consistent replications of re- sponding under previous conditions, despite the fact that we did not include an extinction component.

There were several limitations to this exper- iment. We did not conduct within-subject

585 DIFFERENTIAL REINFORCEMENT

Figure 6. George’s and Clark’s response rates for problem behavior and appropriate behavior.

comparisons of manipulating single versus multiple dimensions of reinforcement. In addition, the response blocking included in George’s case limits conclusions regarding efficacy of treatments that do not include extinction because response blocking may function as either extinction or punishment (Lerman & Iwata, 1996). Unfortunately, George’s aggression tended to cause substantial harm to others and warranted the use of the briefest sufficient block to prevent harm. The blocking used during treatment was the same as that used in the functional analysis. The blocking response did not serve to suppress

aggression in the functional analysis, and it is doubtful that it exerted any such suppressive effects during the intervention. We did attempt to control for the addition of physical contact required following problem behavior by adding physical contact contingent on appropriate behavior.

A potential strength of this investigation was that we assessed both maintenance and gener- ality of the procedures in a 1-month follow-up, with George’s and Clark’s teachers serving as therapists in several of the sessions. George’s teacher reported that he had a history of attacking peers, making his behavior too severe

586 ELIZABETH S. ATHENS and TIMOTHY R. VOLLMER

to ignore. His teacher also indicated that the presence of four other children in the room limited the amount of attention she could deliver following appropriate behavior. Clark’s behavior was so severe that prior to this investigation, he had been moved to a classroom in which he was the only student; he returned to a small-size (four peers) classroom following this investigation. The current procedure iden- tified an effective treatment in which teachers delivered a relatively long duration of high- quality reinforcement immediately following some appropriate behavior and brief, low- quality reinforcement after a short delay following some problem behavior. Our specific recommendation to both teachers was to follow the procedures in Experiment 4 to the best of their abilities, with the caveat that each should immediately intervene for aggression that was directed toward peers or was likely to cause severe harm.

GENERAL DISCUSSION

The current experiments attempted to identify differential reinforcement procedures that were effective without extinction by manipulating several dimensions of reinforce- ment. We sought to extend prior research that focused solely on multiply maintained problem behavior (Piazza et al., 1997) and examined only single manipulations of reinforcement (Lalli & Casey, 1996; Piazza et al.). The present studies showed the effectiveness of DRA that provided some combination of more immediate, longer duration, or higher quality of reinforcement for appropriate behavior relative to reinforcement for problem behavior. In cases in which extinction is not feasible, the current studies offer a method of decreasing problem behavior and increasing appropriate behavior without the use of extinction. For example, if problem behavior is so severe (e.g., severe aggression, head banging on hard surfaces) that it is not possible to withhold or even delay reinforcement, it may be possible to

manipulate other parameters of reinforcement such as duration and quality to favor appro- priate behavior. If attention maintains problem behavior in the form of severe self-injury, for example, problem behavior could result in brief social attention and appropriate behavior could result in a longer duration of attention in the form of praise, smiles, conversation, laughter, and physical attention such as hugs and tickling.

One potential contribution of the current experiments was procedural. The use of inter-

mittent schedules of reinforcement in the treatment of problem behavior had several benefits. For example, these schedules likely mimic to a degree the schedules of reinforce- ment in the natural environment. It is unlikely

that at home or school, for example, each instance of behavior produces reinforcement. It is likely, however, that variable amounts of appropriate and problem behavior are rein- forced or that varying amounts of time pass

between reinforced episodes. Further, concur- rent VI arrangements allow comparisons to and translations from experimental work on the matching law.

One limitation of these experiments is the brevity and varying length of the conditions. In a laboratory, it may be possible to conduct conditions until meeting a stability criterion (e.g., a difference of less than 5% between data points); however, in a clinical setting, it is not always possible to bring each condition to stability before exposing behavior to another condition (i.e., Corey and Kenneth).

A second potential limitation to the current experiment is the difference in obtained versus programmed schedules of reinforcement. VI schedules of reinforcement involve delivery of a reinforcer for the first response after an average length of time has passed since the last reinforcer. Participants did not always respond immediately after the required length of time elapsed, resulting at times in a less dense

587 DIFFERENTIAL REINFORCEMENT

reinforcement schedule than programmed. The differences in obtained versus programmed reinforcement schedules were neither large nor consistent, however.

Our study suggests several areas for future research. These experiments included concur- rent schedules of VI 20-s reinforcement for problem and appropriate behavior. Future research may involve similar analyses using concurrent-schedules arrangements based on naturalistic observations. The extent to which relative response allocation is similar under descriptive and experimental arrangements may suggest values of reinforcement parameters that may increase both the acceptability and integ- rity of treatment implementation by caregivers. For example, researchers could conduct descrip- tive analyses (Bijou, Peterson, & Ault, 1968) with caregivers and analyze the results using reinforcers identified in a functional analysis with procedures similar to those described by Borrero, Vollmer, Borrero, and Bourret (2005). If descriptive analysis data show that problem behavior is reinforced on average every 15 s and appropriate behavior is reinforced on average every 30 s, treatment might involve reinforcing appropriate behavior every 15 s and problem behavior every 30 s.

Investigations similar to the current exper- iments could further explore the dimensions of quality, duration, and delay with more participants and with additional values of these dimensions. In addition, future research- ers could investigate the effect of concurrent manipulations of the dimensions of reinforce- ment as treatment for problem behavior. For example, when it is not possible to withhold reinforcement for problem behavior, it may be that the rate of reinforcement can continue to favor problem behavior if several dimensions of reinforcement, such as magnitude, quality, and duration, favor appropriate behavior. This area of research may result in the development of more practical and widely adopted inter- ventions for problem behavior.

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Received December 30, 2008 Final acceptance November 18, 2009 Action Editor, Rachel Thompson

Research in Developmental Disabilities 30 (2009) 409–425

Contents lists available at ScienceDirect

Research in Developmental Disabilities

Review

A review of empirical support for differential reinforcement of alternative behavior

Erin S. Petscher a,*, Catalina Rey b, Jon S. Bailey b

a University of Florida, United States b Florida State University, United States

A R T I C L E I N F O A B S T R A C T

Article history: Received 16 July 2008 Received in revised form 12 August 2008 Accepted 30 August 2008

Keywords: Differential reinforcement of alternative behavior Functional communication training Empirically supported treatments Destructive behavior Problem behavior Aberrant behavior Behavior analysis

Differential reinforcement of alternative behavior (DRA) is one of the most common behavior analytic interventions used to decrease unwanted behavior. We reviewed the DRA literature from the past 30 years to identify the aspects that are thoroughly researched and those that would benefit from further emphasis. We found and coded 116 empirical studies that used DRA, later grouping them into categories that met APA Division 12 Task Force criteria. We found that DRA has been successful at reducing behaviors on a continuum from relatively minor problems like prelinguistic communication to life-threatening failure to thrive. DRA with and without extinction is well established for treating destructive behavior of those with developmental disabilities, and to combat food refusal.

� 2008 Elsevier Ltd. All rights reserved.

Contents

1. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411 1.1. Inclusion and exclusion criteria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411 1.2. Experimental design. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411 1.3. Participant and setting characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411 1.4. Behavior topography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411 1.5. Assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 412 1.6. Procedural manipulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 412 1.7. Generalization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 412

* Corresponding author. Tel.: +1 850 322 1797. E-mail address: [email protected] (E.S. Petscher).

0891-4222/$ – see front matter � 2008 Elsevier Ltd. All rights reserved. doi:10.1016/j.ridd.2008.08.008

410 E.S. Petscher et al. / Research in Developmental Disabilities 30 (2009) 409–425

1.8. Task Force criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 412 1.9. Inter-rater reliability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 412

2. Results and discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 412 2.1. Experimental design. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413 2.2. Participants and settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 414 2.3. Behavior topography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 416 2.4. Assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417 2.5. Procedural variations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417

2.5.1. Schedule thinning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417 2.6. Generalization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 418 2.7. Empirically supported treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 418

2.7.1. DRA with extinction is a well-established treatment for destructive behavior . . . 419 2.7.2. DRA without extinction is a well-established treatment for destructive behavior . . . 419 2.7.3. DRA with extinction is well established for the treatment of food refusal. . . . . . . 419 2.7.4. DRA plus NCR is an experimental treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 419

3. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 420 Acknowledgements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 420 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 420

Differential reinforcement is the withholding of reinforcers for one behavior and delivering them for another. Through the years many specific variations of differential reinforcement have emerged to demonstrate impressive behavior reductions with difficult clients (see Vollmer & Iwata, 1992). In fact, Lennox, Miltenberger, Spengler, and Efanian (1988) found that differential reinforcement (DR) procedures are among the most frequently used to suppress unwanted behaviors.

In recent years the field of behavior analysis has moved toward the use of function-based treatments to reduce unwanted behaviors. Function-based treatments are considered to be among the most efficient and effective behavioral interventions (Beare, Severtson, & Brandt, 2004; Iwata, Dorsey, Slifer, Bauman, & Richman, 1982/1994). Differential reinforcement is particularly appropriate today as the extinction component requires the assessment of maintaining variables, helping it meet the definition a function-based treatment.

Extinction alone may produce more unwanted side effects than when it is combined with another intervention (Lerman, Iwata, & Wallace, 1999; Petscher & Bailey, 2008). Differential reinforcement of alternative behavior (DRA) withholds the reinforcer for unwanted behavior while simultaneously reinforcing a specific, alternative response (Cooper, Heron, & Heward, 2007; Vollmer, Roane, Ringdahl, & Marcus, 1999). DRA may be the ideal intervention in many cases because it reduces behavior without the concern of extinction-induced side effects and provides an appropriate option for the clients to earn valuable reinforcers once they are no longer provided for unwanted behaviors (Rolider & Van Houten, 1990).

Some DRA literature has been reviewed for specific client types. For example, Mirenda reviewed the use of functional communication training through augmentative alternative communication devices (1997). Matson, Dixon and Matson (2005) reviewed treatment of aggressive behaviors among those with developmental disabilities, finding that a variation of DRA, functional communication training (FCT), is one of the most common interventions. However, a comprehensive review of DRA has not yet been performed. The authors of the current study feel that demonstrating the empirical support of DRA to those outside of applied behavior analysis is important for the dissemination of the field. Therefore, in addition to summarizing the status of DRA literature, the current study also utilizes the model offered by Severtson, Carr, and Lepper (2008) by coding articles according to the Task Force criteria.

Since 1995, The Division 12 Task Force on the Promotion and Dissemination of Psychological Procedures (Task Force) has been identifying treatments that meet the criteria they set to demonstrate empirical validation. Members of the Task Force publish lists of interventions found to meet their standards as well established, probably efficacious, or experimental (Chambless et al., 1996; Task Force, 1995). Unfortunately, while many behavioral interventions may be effective and efficacious, few have been included in the Task Force lists (see Chambless & Hollon, 1998).

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The purposes of the current study are to review the published studies on DRA in the past 30 years, report the characteristics that meet criteria for being well established or probably efficacious, and to identify the variants that need further research.

1. Methods

The articles selected were each evaluated by the first or second author, and some were also reviewed by a second, independent observer who was trained to search for the relevant elements. Observers coded information about the participants, variables, interventions, results and follow-up.

1.1. Inclusion and exclusion criteria

Peer-reviewed journal articles that reported data on an intervention with DRA since 1977 were reviewed for this paper. The search terms, ‘‘differential reinforcement of alternative behavior’’, and ‘‘functional communication training’’, ‘‘DRA’’, and ‘‘FCT’’, were used within the search engines PsychInfo and Educational Resources Information Center (ERIC), Journal of Applied Behavior Analysis abstracts and Journal of the Experimental Analysis of Behavior abstracts. Reference lists of the articles obtained were also scanned for interventions that matched the definition but did not actually report it as DRA or FCT (e.g., Coe et al., 1997; Riordan, Iwata, Finney, Wohl, & Stanley, 1984). Search criteria permitted all dates through the end of 2007 and only the English language. Eliminations were made for those who either did not present data or used non-human subjects. Review articles and group designs that did not present individual participants’ data were excluded.

1.2. Experimental design

Experimental design was tracked by participants rather than studies. The designs were matched by definitions given by Bailey and Burch (2002). AB designs were listed if intervention just followed baseline. A multielement design involved the rapid alternation between at least two conditions. A reversal design required that at least two conditions were introduced twice. Variations of reversal designs, such as an ABCBA, where additional conditions were added to the design, were included. A multiple baseline was marked if two or more baselines of different durations were followed by the intervention. Those that added other conditions without replication, such as an ABCDE were categorized as additive designs. Changing criterion designs involved the stepwise progression of behavior requirements. Finally, if the participants were introduced to designs with multiple characteristics, this was tracked as a combination.

The experimenter who implemented the intervention was recorded as staff, parents or family members, teachers, therapist, or a behavior analyst. When not specified or the data collectors were trained observers or interns, these were considered behavior analysts.

1.3. Participant and setting characteristics

The number and age of participants was recorded, along with the first two diagnoses reported for each. Participants were grouped as children (up to 18 years old), or adults (19 and over). If a participant was diagnosed with an intellectual or physical disability that could be considered a developmental disability other than autism this was also recorded. Autism was tracked separately to show any distinction, although it was combined with developmental disabilities when studies were evaluated for Task Force criteria. The settings were inpatient facilities, clinics, schools, home, and vocational programs.

1.4. Behavior topography

The topographies of alternative behavior and problem behaviors were reported. Aggression, self- injurious behavior, property destruction, and disruptions were later grouped to encompass destructive behavior (Fisher, Thompson, Hagopian, Bowman, & Krug, 2000). The article reviewers

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also tracked whether the individual data were presented for problem behavior, replacement behavior or both.

1.5. Assessments

Articles were scanned for reports and results of preference, reinforcer, and functional assessments. Functional assessments were tracked as descriptive, indirect, antecedent-behavior-consequence, motivation assessment scale (Durand, 1990), functional analysis or as a modified experimental analysis.

1.6. Procedural manipulations

While all studies included in this paper involved the use of DRA, some could be further distinguished as differential negative reinforcement of alternative behavior (DNRA) and FCT. DNRA specifies that the alternative behavior is negatively reinforced by the removal of an aversive stimulus. FCT requires that the presumed function of the unwanted behavior is made contingent upon the alternative response, rather than utilizing any or several arbitrary reinforcers. The specific style of DRA used was coded by reviewers.

Many studies manipulated antecedents and consequences in addition to the DRA intervention. Some were combined with DRA and these modifications were tracked as function-based or arbitrary. In addition, recorders reported the schedule thinning techniques that were utilized.

1.7. Generalization

When experimenters reported a generalization or follow-up condition these and the data trend were monitored. In addition, if side effects were reported, the perceived value of them was tracked as desired or undesired.

1.8. Task Force criteria

The criteria set by the Task Force for single subject designs require that the intervention is compared to a control or other acceptable treatment, has a treatment manual or other specific instructions, appropriate design and practically significant results, participants with details reported and similar characteristics, and at least two different investigators performed the studies (Chambless et al., 1996; Task Force, 1995). It is well established if at least 10 single subject cases meet criteria.

The Task Force criteria were used to group studies along identical interventions and similar participant characteristics and target behaviors. Reversal, multielement, some combinations and concurrent multiple baselines were all considered appropriate experimental designs if the first author found visually significant differences in trend, level, and variability (Bailey & Burch, 2002). However, a multiple baseline differed from the previous definition as a minimum of three panels were required to have the possibility of demonstrating control (Chambless & Hollon, 1998).

1.9. Inter-rater reliability

A trained, second reader independently analyzed 35% of the articles to determine inter-rater agreement on the evaluation of the studies. Agreement was calculated by an item-by-item comparison of data sheets. The number of item agreements was divided by the total number of agreements plus disagreements and multipled by 100 (Hanley, Iwata, & McCord, 2003). Average inter- rater agreement was 93% (range 82–100%).

2. Results and discussion

The initial search identified 538 articles and 116 remained after the exclusionary criteria were applied. These articles were each reviewed multiple times, and are all denoted in the reference list.

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Table 1 Experimental design and experimenter type for all reviewed studies

Number Percent

Design AB 5 4.3 Additive 8 6.9 Combination 32 27.6 Multielement 7 6.0 Multiple baseline 29 25.0 Other 10 8.7 Reversal 25 21.6

Experimenter Behavior analyst 70 60.3 Combination 3 2.6 Parent/family 11 9.5 Staff 13 11.2 Teacher 8 6.9 Therapist 11 9.5

Although the findings and designs of all 116 did not meet Task Force criteria, many still offered substantial contributions to the DRA body of literature, so were included in the sample of articles used for Tables 1–4.

2.1. Experimental design

Table 1 displays the experimental design and experimenter type for 116 articles that utilized DRA. Many research designs replicated variables in order to properly demonstrate experimental control (Ringdahl et al., 2002; Roberts, Mace, & Daggett, 1995; Vollmer, Iwata, Smith, & Rodgers, 1992). Some authors selected experimental designs that involved no or limited opportunity to demonstrate experimental control (Beare et al., 2004; Dura, 1991; Earles & Myles, 1994; Walsh, 1991). As the control is demonstrated by the replication of the findings in single subject designs, such findings

Table 2 Age of participants, different settings, and first two diagnoses for participants

Characteristic Number Percent

Age category Child 277 82.4 Adult 59 17.6

Total participants 336 100

Diagnosis Autism 116 27.4 Developmental disability 271 64.1 Gastroesophageal reflux 6 1.4 None 3 0.7 Other 27 6.4

Total diagnoses 423 100

Setting Clinic 17 14.7 Home 21 18.1 Hospital 36 31.0 Multiple 4 3.4 Other 3 2.6 School 32 27.6 Vocational 3 2.6

Total studies 116 100

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Table 3 Topography of alternative and unwanted behaviors

Number Percent

Problem behavior Aggression 31 9.2 Destruction/combination 160 47.6 Disruption 9 2.7 Food rejection/packing 15 4.5 Not specified/unclear 11 3.3 Other 26 7.7 Self-Injury 74 22.0 Vocalizations 10 3.0

Alternative behavior Communication 287 85.4 Compliance 8 2.4 Exchange cigarette 4 1.1 Food acceptance 18 5.4 Play/social 4 1.1 Task engagement 13 3.9 Transitions 2 0.6

should be replicated either across participants, settings, behaviors, or intervention phases. The AB and most additive designs alone, therefore, added little to indicate that the interventions were responsible for any behavior changes.

Most studies used a combination of at least two designs, which often were needed to evaluate multiple components of interventions. For example, in one study a reversal design was used first with full implementation of DRA compared to baseline. Next, modified versions of DRA were alternated to demonstrate the effects of partial DRA implementation on problem and alternative behavior (Vollmer et al., 1999). Other combination designs did not provide the opportunity to display experimental control, but still suggested interventions for further inquiry. For example, Fisher et al. (2005) combined a reversal and multielement design for Kim. However, the baseline conditions were too short to indicate a trend. These data suggested a positive response to the intervention and indicated that further study could be beneficial.

Behavior analysts typically performed the interventions. Such studies are likely to produce consistent results and treatment fidelity (Vollmer et al., 1999). However, those studies in which parents or staff implemented the intervention were programmed for generalization from the beginning. For example, Bird, Dores, Moniz, and Robinson (1989) performed their study in a classroom and the teacher enforced the intervention. This should increase consumer’s confidence that the intervention would continue successfully after the study ended. Unfortunately, it can be especially difficult to train teachers or parents to perform interventions while they are also held responsible for their typical duties. It can also confound the intervention and cause confusion if it does not sufficiently produce behavior change. Therefore, an approach commonly employed is to implement the intervention first with a trained experimenter, then transfer the training to someone who naturally interacts with the participant in the absence of a study. For example, after Goh, Iwata, and Kahng (1999) successfully reduced cigarette pica, they reportedly transferred the intervention to multiple settings and therapists.

2.2. Participants and settings

The number, first two diagnoses and age of participants are reported in Table 2. Over 80% of the participants were children, which corresponded with a similarly high percent of studies located in schools. Wright-Gallo et al. (2006) performed one such study, in which they achieved their goal of performing classroom-based functional analyses and DRA treatments for students diagnosed with emotional/behavioral disorders. Furthermore, their findings support the use of function-based interventions in the actual classroom, rather than an empty treatment room at a school or other location.

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Table 4 Studies that demonstrated DRA with extinction as a well-established treatment of destructive behavior for children and adults with developmental disabilities

Study Participant Problem behaviora Alternative behaviorb Function

Children Bowman et al. (1997) Ben PD, SIB, AGG COM Compliance from

others Carr and Durand (1985) Jim AGG, TAN, OP Academic tasks Attention Carr and Durand (1985) Eve AGG, SIB, OP Academic tasks Attention Carr and Durand (1985) Tom AGG, TAN, OS Academic tasks Attention Carr and Durand (1985) Sue AGG, TAN, SIB Academic tasks Attention DeLeon et al. (2000) Jake AGG COM Tangible Derby et al. (1998) Lana SIB COM Attention Durand (1999) Allison Crying, screaming COM Tangible Durand (1999) Mike SIB, PD COM Tangible Durand (1999) Ron AGG COM Attention Durand (1999) David SIB COM Escape Durand (1999) Matt SIB, screaming COM Escape Durand and Carr (1991) Hal SIB Correct responses Escape Durand and Carr (1991) Ben AGG Correct responses Attention, escape Durand and Carr (1991) Tim SIB, AGG Correct responses Escape Durand and Carr (1992) Sam TAN, PD Correct responses Attention Durand and Carr (1992) Ted TAN, PD, OP Correct responses Attention Durand and Carr (1992) Ian TAN, PD, OP Correct responses Attention Durand and Carr (1992) Ray AGG, TAN, PD Correct responses Attention Durand and Carr (1992) Mike TAN Correct responses Attention Durand and Carr (1992) Jaynie OP, TAN Correct responses Attention Fisher, Adelinis, Thompson, Tina AGG COM Escape

Worsdell, and Zarcone (1998) Fisher, Adelinis, et al. (1998) Ike AGG COM Escape Fisher, Kuhn, et al. (1998) Ned AGG, PD COM Attention Fisher, Kuhn, et al. (1998) Amy SIB, AGG, PD COM Tangible, attention Fisher et al. (2000) Ken AGG, SIB, PD COM Attention Fyffe, Kahng, Fittro, and Russell Matt ISB COM Attention

(2004) Hagopian et al. (1998) Case 17 SIB, AGG, DIS COM Tangible Hagopian et al. (1998) Case 19 SIB, AGG, DIS COM Attention, escape Hagopian, Kuhn, Long, and Rush Stephen SIB, AGG, DIS COM Attention

(2005) Hagopian et al. (2005) James SIB, AGG, DIS COM Attention Hagopian et al. (2005) Matt AGG COM Tangible Hanley et al. (1997) Tony AGG, DIS COM Attention Hanley et al. (1997) Carla DIS, AGG COM Attention Kahng, Hendrickson, and Vu (2000) Ashby SIB, AGG, DIS COM Tangible Kelley, Lerman, and Van Camp Gary AGG COM Escape

(2002) Lalli et al. (1995) Joe SIB COM Escape Lalli et al. (1995) Jen SIB COM Escape Lalli et al. (1995) Kim AGG COM Escape Mancil et al. (2006) Scott TAN COM Tangible Marcus and Vollmer (1996) CJ SIB, AGG, DIS COM Tangible Piazza et al. (1999) Ike TAN COM Attention Roane et al. (2004) Carl AGG COM Tangible Roberts et al. (1995) Mary SIB Tasks Escape Sigafoos and Meikle (1996) Pete AGG, SIB, DIS COM Attention, tangible Sigafoos and Meikle (1996) Dale AGG, SIB, DIS COM Attention, tangible Thompson, Fisher, Piazza, Ernie AGG COM Attention

and Kuhn (1998) Vollmer et al. (1999) Rachel SIB, AGG Compliance, COM Escape Vollmer et al. (1999) Todd SIB Compliance, COM Tangible Vollmer et al. (1999) Kyle AGG Compliance, COM Escape

Adults Bird et al. (1989) Jim AGG, SIB COM Multiple Fisher et al. (2000) Glen SIB, AGG, PD COM Tangible

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Table 4 (Continued )

Study Participant Problem behaviora Alternative behaviorb Function

Hanley, Iwata, and Thompson Karen SIB COM Attention (2001)

Hanley et al. (2001) Jake SIB COM Tangible Hanley et al. (2001) Julie SIB, AGG COM Attention Kahng, Iwata, DeLeon, and Todd SIB COM Escape

Worsdell (1997) Kahng et al. (1997) Lynn SIB COM Attention Kahng et al. (1997) Bob SIB COM Escape Lindauer et al. (2002) Sam SIB COM Attention Vollmer et al. (1992) Bob SIB Compliance Escape, attention

a AGG = aggression; SIB = self-injurious behavior; DIS = disruption; ISB = inappropriate sexual behavior; TAN = tantrum; PD = property destruction; OP = oppositional behavior; OS = out of seat. b COM = communication.

Adults exhibiting behavior problems may pose additional challenges as their longer learning histories and physical size is difficult when aggression or escape-maintained behaviors are present. In one study, a 24-year old with a developmental disability was treated in a multielement design comparing baseline and two forms of FCT. Although one form of FCT improved communication, both still resulted in variable rates of aggression (Bailey, McComas, Benavides, & Lovascz, 2002).

Most studies were performed in inpatient hospitals, where clients typically have severe and urgent needs for interventions that work quickly. The choice to utilize DRA in these cases indicates that experimenters are confident of its efficacy. Schools housed many studies as well, supporting the use of FCT as an instructional technique necessary for successful school behavior.

The vast majority of participants in DRA studies were diagnosed with autism or another developmental disability. Considering the impressive overall findings of this literature, the preference for clients with developmental disabilities over other diagnoses may suggest that they are the best fit for DRA interventions. However, some authors also utilized DRA to improve problem behavior of those with other diagnoses. Wilder and colleagues used DRA to decrease bizarre vocalizations for a 43-year old diagnosed with Schizophrenia (2001). The impressive behavior reduction indicated that DRA may be effective with similar clients and aberrant behavior in the future.

2.3. Behavior topography

Table 3 lists the unwanted and alternative behavior topographies that were targeted during DRA studies. Destruction included a combination of aggressive and disruptive behaviors, and was the most common presenting problem. Many authors published data on several of their clients’ destructive behaviors (e.g., LeBlanc, Hagopian, Marhefka, & Wilke, 2001; Piazza et al., 1999), while others opted to demonstrate how DRA improved specific topographies (e.g., McCord, Thomson, & Iwata, 2001). In one study, authors tracked changes in aggression and self-injury separately, demonstrating that the behavior frequencies varied based on the corresponding reinforcer schedule (Lindauer, Zarcone, Richman, & Schroeder, 2002).

In addition to reducing destructive behaviors, DRA has been effective in treating severe behaviors for children diagnosed with a failure to thrive (Kahng, Tarbox, & Wilke, 2001; Peck, Wacker, Berg, & Cooper, 1996). In these cases it may be vital for effective interventions to be provided immediately, and the data show that DRA satisfies the requirements.

Some behaviors targeted by authors are less severe but can lead to more restrictive placements if left untreated. For example, inappropriate vocalizations are often targeted in schools and many produce positive results (e.g., Dixon et al., 2004; Keen, Sigafoos, & Woodyatt, 2001; Lee, McComas, & Jawor, 2002). Alternative behaviors ranged from task completion to cigarette exchanges, with appropriate communication being the most frequent. It is an obvious target with DRA because conceptually the need is to improve client’s repertoires by adding appropriate ways for them to obtain reinforcers. When these reinforcers become available for other behaviors, those that require the least response effort will be utilized. In a fascinating display, the DRA intervention was provided as baseline

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in which responses already in the participant’s repertoire were reinforced. During a Lag 1 DRA phase, only appropriate novel responses were reinforced. When reinforcers were provided for appropriate responses, novel (i.e., more difficult) behaviors rarely occurred. However, when the reinforcers were contingent upon appropriate and novel responses, participants exhibited many more of these (Lee et al., 2002).

2.4. Assessments

It may be important to perform functional analyses even if the function of behavior appears clear, as an incorrect hypothesis could waste time and other resources (Vollmer et al., 1992). The studies reviewed in this article provide further support for the use of functional analysis in developing high- quality treatments. Seventy-nine of the studies reported the use of an experimental analysis of maintaining variables prior to the intervention. Out of the 27 studies with at least one data set meeting Task Force criteria for reducing destructive behavior of children, 85% performed some type of functional analysis, and only one study did not specify methods to identify the function. This indicates that the articles that used functional analyses were more likely to produce good data and designs. However, it is also possible that those researchers who designed studies with the good validity and reliability needed to produce good results were those that included a functional analysis prior to training.

Since 1982, Iwata and colleagues have suggested that function-based treatments may be more beneficial than those based on arbitrary reinforcers (Iwata et al., 1982/1994). Apparently the authors of DRA studies agreed as 84% of the articles utilized the hypothesized maintaining variable during DRA. However, some of the studies that employed functional analyses did not use the maintaining reinforcer for the intervention. Two studies used a functional analysis and concluded that multiple reinforcers maintained the behavior. Thus, they provided a preferred item for appropriate behavior but the interventions did not yield adequate results until response cost was added for problem behavior (Bowman, Fisher, Thompson, & Piazza, 1997; Ross, 2002).

2.5. Procedural variations

The DRA intervention in over 70% of the studies would be considered FCT. The emphasis on many of these designs is on the increase of appropriate communication rather than the reduction of unwanted behavior. As such, several experimenters used FCT without extinction to increase appropriate communication (Fisher, Kuhn, & Thompson, 1998; Johnson, McComas, Thompson, & Symons, 2004; Koegel, Stiebel, & Koegel, 1998; Schindler & Horner, 2005).

Many studies used a DNRA intervention successfully, supporting the use of DRA among various functions of problem behavior. For example, Fisher and colleagues demonstrated nice results of a DNRA intervention in which the alternate behavior resulted in the termination of prompts that interfered with their preferred activities.

Most studies used extinction to reduce target behaviors, but other techniques were also examined. In some cases DRA was paired with another intervention such as demand fading (Piazza, Moes, & Fisher, 1996), punishment (Fisher et al., 2000), or time out (Derby et al., 1997). In other situations, the experimenters compared DRA to approaches other than no-treatment baseline like noncontingent reinforcement (Goh et al., 1999), differential reinforcement of other behavior (Wacker, Steege, Northup, & Sasso, 1990), and escape-extinction (McConnachie & Carr, 1997). Many variables were combined with or compared to DRA.

2.5.1. Schedule thinning Some authors altered the schedules of reinforcement for unwanted or alternative behaviors. In a

few studies, reinforcer delivery was incrementally delayed for the alternative behavior (Fisher et al., 2000; Hagopian, Fisher, Sullivan, Acquisto, & LeBlanc, 1998). Others increased the fixed ratio of delivery from continuous to more reasonable frequencies (Lalli, Casey, & Kates, 1995). Finally, Roane et al. (2004) restricted access to the operandum needed for the participant to perform the response. Such schedule thinning techniques have resulted in appropriate levels of replacement behaviors without the high cost of excessive reinforcer delivery.

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In some cases, the reinforcer rate for problem behavior was manipulated until an appropriate level of both targeted behaviors occurred (Deleon, Fisher, Herman, & Crosland, 2000; Vollmer et al., 1999). Another approach to this was the addition of noncontingent reinforcement, which was faded over time (Goh, Iwata, & Deleon, 2000; Marcus & Vollmer, 1996).

Reinforcer magnitude was also studied for the alternative behavior in a DRA intervention. The experimenters monitored post-reinforcement pauses and response frequency to discover that the duration of access to reinforcers did not affect overall response rates (Lerman, Kelley, Vorndran, Kuhn, & LaRue, 2002).

2.6. Generalization

Almost 20% of the studies included a generalization phase after the conclusion of the primary intervention. For example, Jensen, McConnachie, and Pierson (2001) demonstrated that the intervention generalized across locations. Similarly, Mancil, Conroy, Nakao, and Alter (2006) discovered that the treatment successfully generalized from the experimenter to the participant’s mother.

Twenty-eight studies reported results of follow-up data collection. Koegel et al. (1998) collected encouraging evidence that the intervention maintained as much as 1 year after the intervention had ended. Even when demonstrated by a few probe data points, the application of this technique adds considerably to the quality of such studies. The follow-up data collected by many authors provide evidence that the results of DRA are longstanding rather than being produced by either reactivity or novelty effects.

Seventeen of the studies reported some type of side or collateral effects, and eight of these used data to illustrate the phenomena. The desirable collateral effects varied from necessary weight gain (Kahng et al., 2001), to less teacher stress (McConnachie & Carr, 1997), and attention to tasks (Sisson, Hersen, & Van Hasselt, 1993). Only two of the studies mentioned the presence of unwanted side effects. Roane et al. (2004) reported that the participant tried harder to obtain the reinforcer when it was unavailable, while Carr and Carlson (1993) found that participants performed the alternative response too frequently.

2.7. Empirically supported treatments

The 116 articles using DRA were grouped by participant diagnosis and problem behavior to identify those that had sufficient empirical support according to Task Force criteria. As most participants were diagnosed with a developmental disability, most of the findings involved this type of client. Task Force criteria require that participant characteristics such as age and gender are described in the studies but do not specify that the treatments are only applied by these

Table 5 Studies that demonstrate FCT without extinction is a well-established intervention for persons with developmental disabilities

Study Participant Problem behaviora Alternative behavior Function

Fisher, Kuhn, et al. (1998) Amy SIB, PD, aggression Communication Tangible Johnson et al. (2004) Abe Aggression Communication Escape Koegel et al. (1998) Child 1 Aggression Communication Multiple Koegel et al. (1998) Child 2 Aggression Communication Multiple Koegel et al. (1998) Child 3 Aggression Communication Multiple Roane et al. (2004) Juan Aggression Communication Attention Schindler and Horner (2005) Neal Pinch, whine Communication Activity Schindler and Horner (2005) Ellie Scream Communication Escape Schindler and Horner (2005) Kit Scream, whine, Communication Avoid transition

noncompliance Worsdell, Iwata, Hanley, Thompson, Jedb SIB Communication Tangible

and Kahng (2000) a SIB = self-injurious behavior; PD = property destruction. b Adult participant.

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Table 6 Students that demonstrate DRA is a well-established treatment for food refusal

Study Participant Diagnosisa

Kahng, Boscoe, and Byrne (2003) Clara Speech delay, possible PDD Najdowski, Wallace, Doney, and Ghezzi (2003) Jack Autism Patel et al. (2002) Alex Congenital heart disease, GER Patel et al. (2002) Sunshine GER, DD Patel et al. (2002) Jarred GER, DD Piazza et al. (2003) Chris Feeding disorder, FTT Piazza et al. Cameron Feeding disorder, FTT Piazza et al. Zane Feeding disorder, FTT Piazza et al. Zack Feeding disorder, FTT Riordan et al. (1984) Joan Cerebral palsy Riordan et al. (1984) Nancy Chromosomal aberration Riordan et al. (1984) Jerry Seizures, left hemiplegia Riordan et al. (1984) Holly FTT, hydrocephalus

a PDD = pervasive developmental disorder; GER = gastroesophageal reflux; DD = developmental disabilities; FTT = failure to thrive.

characteristics. Therefore, since so many studies demonstrated visually significant results, in Table 4 the studies are grouped into child and adult participants. In Tables 5 and 6 the participants are all children except when noted.

Tables 4–6 display the lists of studies that met Task Force criteria to determine that DRA with and without extinction is well established for treating destructive behaviors of children and adults with developmental disabilities. It is also well established for the treatment of food refusal. DRA with noncontingent reinforcement meets criteria of an experimental approach.

2.7.1. DRA with extinction is a well-established treatment for destructive behavior Table 4 shows the studies that contributed to our finding that DRA with extinction is a well-

established treatment for destructive behavior of both adults and children with developmental disabilities. The participants in the list all showed marked behavior improvements when DRA with extinction was compared to either a baseline or other treatment. In all these cases, graphs displayed problem behavior but it was not required that they reported data for the alternative. In a specific case, Roberts et al. (1995) reported positive results on the presence of self-injury, but compliance data were not included in the report.

2.7.2. DRA without extinction is a well-established treatment for destructive behavior DRA without extinction is a well-established treatment for destructive behavior of persons with

developmental disabilities. These studies are listed in Table 5. It is important to note that, while the Task Force criteria were met for this intervention, several other participants were exposed to it in a similar way and it failed to produce sufficient behavior change. For example, Fisher et al. (2000) introduced Ken to FCT without extinction but his destruction remained with high variability until extinction was added to the intervention. Therefore, when extinction can be performed in conjunction with DRA, it will likely produce more rapid and complete behavior changes.

2.7.3. DRA with extinction is well established for the treatment of food refusal Table 6 lists the participants who refused food prior to treatment and accepted more as a result of

the DRA intervention. In 1984, Riordan and colleagues ignored food expulsion and received praise for bites accepted. The intervention improved food accepted in four severe cases.

2.7.4. DRA plus NCR is an experimental treatment The studies that used DRA with NCR to treat destructive behavior for persons with developmental

disabilities showed promise. Some authors were concerned about the presence of side effects that could have resulted from DRA, so added NCR to their intervention. Two participants were found who had visually significant results from this intervention (Hagopian, Wilson, & Wilder, 2001; Marcus & Vollmer, 1996). In another study, two adult participants with self-injurious behavior improved with

420 E.S. Petscher et al. / Research in Developmental Disabilities 30 (2009) 409–425

DRA plus NCR (Goh et al., 2000). However, the multiple baseline design did not meet Task Force criteria as a third participant would have been required.

3. Conclusion

DRA has been successful at reducing severe behaviors for many participants, while replacing the unwanted response with appropriate behaviors that can enhance participants’ quality of life. It rarely produced unwanted side effects but instead commonly resulted in positive collateral changes. However, in those cases where the alternative behavior rate would be difficult to maintain, schedule thinning has been shown to successfully reduce the rate to acceptable levels.

DRA has been performed in many studies and is a well-established treatment for food refusal and participants with developmental disabilities exhibiting destructive behavior. The published studies with participants otherwise diagnosed, such as Schizophrenia (Wilder, Masuda, O’Connor, & Baham, 2001) were generally positive and warrant further study.

Many studies were identified whose data were promising but the designs did not meet Task Force criteria. Most often the design did not replicate findings appropriately, such as the ABCD design in Derby et al. (1997), and multiple baselines whose lengths were not varied enough in Durand (1993). While they were commonly successful at answering their research questions, the data could not be used for the current review. Over time this can cause problems because the interventions cannot demonstrate empirical validity accepted by mainstream psychology. If behavior analysts desire to increase such awareness, we suggest that designs are tweaked when possible to meet the Task Force criteria.

Future research should focus on DRA with NCR for the treatment of destructive behavior of persons with developmental disabilities in order for it to be considered a well-established treatment. Additional directions of interest would include participants without diagnoses or with those other than developmental disabilities, and with behaviors other than destruction and food refusal. Other promising areas include the studies manipulating response effort and reinforcer magnitude.

Acknowledgements

This paper includes some information submitted as a qualifying examination by the first author in partial fulfillment of the PhD degree at the Florida State University. We thank committee members Barbara and Mark Licht, Bruce Thyer, and Tom Welsh for their input and review of the original manuscript. Our gratitude extends to David Lee and Kellyn Johnson for their collection of inter-rater reliability data, and to Gregory Hanley and his anonymous reviewers for their comments on an earlier version of this manuscript.

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student with autism. Research in Developmental Disabilities, 26, 77–85. +Buckley, S., Strunck, P., & Newchok, D. (2005). A Comparison of two multicomponent procedures to increase food

consumption. Behavioral Interventions, 20, 139–146. +Campbell, R., & Lutzker, J. (1993). Using functional equivalence training to reduce severe challenging behavior: A case

study. Journal of Developmental and Physical Disabilities, 5, 203–216. +Carr, E., Levin, L., McConnachie, G., Carlson, J., Kemp, D., Smith, C., et al. (1999). Comprehensive multisituational

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problem behavior and mands. Education & Treatment of Children, 29, 23–50. +Drasgow, E., Halle, J., Ostrosky, M., & Harbers, H. (1996). Using behavioral indication and functional communication

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