Severe Behavior Problems
Wendy K. Berg, Senior Research Assistant, Applied Behavior Science.
David P. Wacker, Ph.D., Professor, Applied Behavior Science,
University Hospital School, University of Iowa.
Children who repeatedly injure themselves, hurt others, or destroy property pose a unique challenge to care providers. Traditionally these behaviors have been attributed to such conditions as autism or severe mental retardation. Treatment recommendations, usually based on the specific behavior, produced inconsistent results, with some children demonstrating rapid improvements in behavior while others worsened. An extensive body of research conducted over the past 12 years indicates that severe behavior problems such as self-injury, aggression, and destruction often serve a purpose. Identifying the function of that behavior is the first step in developing an effective treatment plan.
Escape and gain
Initially, it may appear that a problem behavior occurs randomly throughout the child's day and, in some cases, throughout the night. Careful observation of the child, however, often reveals that severe problem behavior is more probable in specific situations, and that it predictably leads to specific consequences. We refer to these situations as social events -- situations in which certain behaviors have specific functions. The situations and consequences associated with severe problem behavior are unique for each child, but the functions of behavior can usually be placed within two broad categories:
Between 70% and 95% of children evaluated in the Biobehavior Clinic at University Hospital School display problem behavior to accomplish
one of these functions.
An escape function is accomplished when problem behavior results in the termination of, or a reduction in, a nonpreferred activity. In this situation, problem behavior occurs when the child is required to perform disliked or difficult activities, such as grooming, picking up toys, or completing an arduous learning task. By engaging in the problem behavior, the child escapes from the activity.
Other children engage in problem behavior when they want something -- a desired item or, often, attention. Attention may come in the form of comforting, scolding, or redirection to another, more appropriate activity. Or preferred items, such as a favorite toy or snack, may be provided to calm the child. In either case, the child gains a desired outcome as a consequence of engaging in severe problem behavior.
The specific function of a problem behavior is identified through a two-part behavior assessment (see Insert, page 2). The first phase consists of an Antecedents-Behavior-Consequences (A-B-C) analysis, which is used to develop hypotheses regarding the function of the behavior. The A-B-C analysis is conducted through direct observation of the child, interviews with the child and the child's parents or teachers, or through information gathered using checklists that are completed by the child's parents or teachers. The purpose of the A-B-C assessment is to identify:
- The situation immediately before, or antecedent to, the problem behavior.
- The specific problem behavior of the child.
- The consequences that follow the behavior.
Once the antecedents, behaviors, and consequences are identified, hypotheses are developed to explain the function of the behavior.
The hypotheses developed through the A-B-C assessment are tested using analog assessment sessions, arranged to allow analysis of the problem behavior. The antecedent events (nonpreferred activities; absence of attention) that appear to trigger and maintain problem behavior are systematically introduced and removed. The child is observed to evaluate how this affects behavior. These assessments are called functional analyses of problem behavior.
The results of the functional analysis guide treatment. The goals of treatment are to:
- Reduce the occurrence of problem behavior.
- Increase positive behavior.
Both goals are met by teaching the child new, acceptable behaviors that produce the desired outcomes identified during the functional analysis. For example, one child may be taught to use a manual sign to request a short break from a nonpreferred task. Another child may be taught to wait briefly (for example, first for 10, then 20, then 30 seconds) for a parent to attend to them. When the child engages in problem behaviors, the desired outcome is withheld.
Teaching the child an acceptable behavior that quickly produces a desired outcome, and withholding the desired outcome when problem behavior occurs, can be very effective. Research suggests that both elements are necessary for treatment to be effective. Initially, problem behavior may increase while the child is learning to use appropriate behavior to receive reinforcement, and consistent treatment often must continue for some time.
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