Journal Article Critique


Question Description

Journal Article Critique

For this assignment, read the article by Richard Foxx and Jeffrey Garito: The Long Term Successful Treatment of the Very Severe Behaviors of a Preadolescent with Autism. This is a peer reviewed article published in the journal, Behavioral Interventions. As you read this article, you will notice how the principles of operant conditioning are applied to a 12 year old boy with autism who exhibits severe behavioral problems.

After reading the article you are to write a critique on how operant conditioning techniques have been applied in this situation to reduce inappropriate behaviors of aggression. This article will provide you with insight into how a behavioral program is developed and implemented. In fact, this article should assist you with your Behavior Management Project.It is advisable that you first skim the article to obtain a general overview and then read it critically. Use APA style with the following reference: Publication Manual of the American Psychological Association (Sixth Edition). The critique must include a title and reference page, page numbers, statement of the problem or issue discussed, as well as the author’s purpose, methods, hypothesis, and major conclusions. In addition to the title and reference page, this assignment should contain a minimum of three double-spaced pages.

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Behavioral Interventions Behav. Intervent. 22: 69–82 (2007) Published online in Wiley InterScience ( DOI: 10.1002/bin.232 THE LONG TERM SUCCESSFUL TREATMENT OF THE VERY SEVERE BEHAVIORS OF A PREADOLESCENT WITH AUTISM Richard M. Foxx1* and Jeffrey Garito2 2 1 Penn State University, Middletown, PA, USA Lancaster Lebanon IU 13, East Petersberg, PA, USA A program was developed for reducing the severe behavior (aggression, self-injury, dangerous behavior, disruptive behavior, induced vomiting and inappropriate toileting) of a 12-year-old boy with autism. The boy was a Romanian orphan who was adopted by American parents at age 2. All previous interventions had been ineffective including prolonged hospitalization. The program included a high density of positive reinforcement, tokens, choice making, contingent exercise, and overcorrection. Treatment occurred across three sites, home, a community-based site, and a self-contained classroom in a public school. All of the boy’s severe behaviors were reduced to at or near zero levels and these effects have been maintained for 2 years. He has made excellent progress in a number of academic areas and his social skills have increased dramatically. Copyright # 2007 John Wiley & Sons, Ltd. A great deal of controversy has existed regarding the appropriate and effective treatment of the severe behaviors such as self-injury and aggression exhibited by individuals with autism and developmental disabilities (Foxx, 2005a,b). Most of the current research literature focuses on the use of functional analysis, positive reinforcement and antecedent-based techniques to treat these behaviors (Foxx, 2005b; Johnston, Foxx, Jacobson, Green, & Mulick, 2006). However, the vast majority of this research has targeted much less severe forms of these behaviors including ones that would be considered mild by most practitioners (Foxx, 2005b). As result, the more severe forms of behavior have remained untreated in part because they typically do not respond to protocols that do not contain negative consequences (Foxx, 2003). This is especially true when the individual’s severe behavior is motivated by escape/avoidance. For these individuals, research has repeatedly shown that effective comprehensive treatment programs feature functional *Correspondence to: Richard M. Foxx, Psychology Program, Penn State Harrisburg, 777 West Harrisburg Pike, Middletown, PA 17057-4898, USA. E-mail: Copyright # 2007 John Wiley & Sons, Ltd. 70 R. M. Foxx and J. Garito analysis, antecedent changes, reinforcement, and negative consequences or inhibitory techniques (Foxx, 1990, 1991, 1996, 2003, 2005b; Foxx, Bittle, & Faw, 1989; Foxx, Zukotynski, & Williams, 1994). Yet, the use of a well-designed program that includes negative consequences is often not considered or sanctioned in inclusive school settings. This is true even when the severe behavior is dangerous to the child or his peers and teachers. The conundrum becomes that the individual’s behavior requires a comprehensive empirically based treatment program that the site is unwilling or unable to provide. In many cases, it takes a crisis combined with a number of failed educational placements and treatments to create the necessary conditions for parents and school districts to become amenable to approving a comprehensive behavioral program that includes the use of negative consequences. Often the crisis is precipitated by legal and economic factors such as due process or considering the child for residential placement in an expensive private facility. At this point, all parties become united in their efforts to seek effective treatment that will help the child and resolve the crisis. This paper describes just such a situation. Its purpose is to demonstrate how a comprehensive behavioral program, when implemented and overseen by qualified behavior analysts, can be successful in a child’s home school district. Furthermore, the paper will show that this program was instrumental in reducing severe behaviors so that the child could learn both academically and socially and have greater access to his community. METHOD Subject Ned is a 12-year-old male with the diagnoses of autism, mental retardation, and attention deficit hyperactivity disorder (ADHD). He previously suffered from seizures and impaired vision but these conditions have been corrected. Ned is somewhat verbal but can be difficult to understand due to several speech deficits. He has a long history of aggression, self-injury, and property destruction that have resulted in injuries to himself, his family, staff, and peers. He currently lives at home with his parents and older sisters. Ned was adopted by his American parents from a Romanian orphanage when he was 2 years old. No record exists of his years at the orphanage. It is known that he was kept in a cage-like enclosure and fed from a communal baby bottle. Initially, he showed no response to verbal stimuli. At age 3, he was diagnosed with autism and ADHD. Ned’s father, a neuropsychologist, used behavioral techniques to teach Ned to make eye contact, communicate verbally, and exhibit some social behavior. Copyright # 2007 John Wiley & Sons, Ltd. Behav. Intervent. 22: 69–82 (2007) DOI: 10.1002/bin Treatment of severe behavior 71 Over the years Ned’s severe behaviors resulted in him being enrolled and demitted from a number of specialized school programs designed for children with behavioral excesses and deficits. In 2003, Ned was admitted to a renowned inpatient severe behavior treatment unit where a number of functional analyses were conducted. They revealed that the variables maintaining his aggressive destructive behavior included attention, access to tangibles, sensory reinforcement, and escape from demands (Linscheid, Iwata, & Foxx, 1996). A mands analysis suggested a correlation between destructive behavior and the ignoring of his requests by bystanders. The facility’s treatment of Ned’s destructive behavior consisted of discrimination training and extinction. Differential reinforcement of alternative behavior (DRA) and other behavior (DRO) as well as facial screening were found to be ineffective components and physical restraint caused an escalation in the intensity and frequency of inappropriate behavior. Positive treatment effects achieved during concentrated one and half hour sessions conducted by senior therapists in a special room did not generalize to the facility’s inpatient unit. Both Ned’s family and his local school district teachers visited the inpatient unit in order to be trained in the treatment protocols. After 9 months of inpatient treatment, Ned was discharged with an overall recommended program that consisted of 1:1 discrete trial instruction using three-step guided compliance, an augmentative communication device, and sensory-based occupational therapies. At discharge, he exhibited the following target behaviors per 1 h intervals: 6 disruptive behaviors, 6 aggressive behaviors, and 32 self-injurious behaviors. The treatment program Ned was sent home with consisted of a two-part program: Ned’s Way and Our Way. Each part was signaled by a timer and a card that indicated the condition. During Ned’s way, which lasted 5 min, Ned was allowed to engage in any behavior he chose. During Our Way, which lasted 10 min, he was expected to comply with all requests made by the educational staff or his parents. This program was in effect both in Ned’s self-contained classroom and home when the senior author became involved in the case. Ned received Risperdal, Depakote, Clonadine, and Stratera during baseline and throughout all treatment phases. Settings The time period from Ned’s release from the inpatient facility to the present is separated into four phases. The phases are based on the treatment delivered at the time. Phase 1 represents baseline and details the school district’s implementation of the inpatient facility’s recommendations. Phase 2 represents the senior author’s initial involvement and the implementation of a home and community-based program using antecedent management, skills building, and reinforcement contingencies. Phase 3 describes the continuation of the program with the addition of the junior author and Copyright # 2007 John Wiley & Sons, Ltd. Behav. Intervent. 22: 69–82 (2007) DOI: 10.1002/bin 72 R. M. Foxx and J. Garito negative consequences. Phase 4 presents the current treatment program being conducted in a classroom setting at a public school. Phase 1: Baseline Treatment was carried out in a classroom, 20 ft by 15 ft, located at a primary school in Ned’s local school district. Ned was the only student in the classroom. The staff consisted of a teacher, teacher’s aide, a teacher’s aide assigned to record data and a therapeutic support staff (TSS) person from a human services wrap-around agency. Ned’s behavior was considered so severe that his family had been authorized to receive up to 75 h per week of 1:1 (TSS) therapeutic support services. Phase 2 Due to the severity of his behavior, Ned did not return to the classroom after the winter holiday break. A program designed by the first author was implemented at Ned’s home. Later, the program was transferred to a 20 ft by 25 ft room located at Ned’s church. A special education teacher, teacher’s aide, and a TSS delivered treatment. Phase 3 The program continued at the church. Staffing changes included a different special education teacher and the second author, a master’s level Board-certified behavior analyst (BCBA). The same TSS participated. Phase 4 The program was moved to a 30 ft by 15 ft classroom at a primary school in Ned’s home district. It was not the school he had attended in Phase 1. Staff remained the same. Response definition and recording Data were collected using event recording on a standard data sheet across each condition. In Phase 2 and subsequent phases, event recording was done within 15-min intervals across the school day. The data sheets included sections for functional assessment information. Ned’s target behaviors were defined as follows: Copyright # 2007 John Wiley & Sons, Ltd. Behav. Intervent. 22: 69–82 (2007) DOI: 10.1002/bin Treatment of severe behavior 73 Self-injurious behavior (SIB): head-banging, hitting his chin or nose or any part of his body with his fist, arm, or knee or with an object and forcefully contacting surfaces with his body (e.g., throwing himself against a wall or floor). Aggression: Head butting, hitting, kicking, pulling hair, pinching, slapping, biting, and throwing objects within 2 ft of someone. Dangerous behaviors: unfastening car seatbelts in moving autos, standing on furniture, turning over furniture, tipping chairs backwards while seated, and attempting to touch electrical outlets. Disruptive behaviors: breaking, tearing, or striking objects, swiping objects off surfaces, and throwing objects further than 2 ft from another person. Induced vomiting: putting fingers down his throat and inducing gagging or vomiting. Inappropriate toileting: urinating or defecating anywhere other than the toilet. Ned was completely toilet trained. Reliability No assessments of interobserver reliability were conducted in the baseline other than a single video recording. Reliability was periodically assessed in the remaining phases by comparing the records of staff who had simultaneously recorded instances of behavior during the same time period. These comparisons revealed high agreement between the recorders. Procedure Phase I: Baseline Ned’s school day was divided into 15-min segments consisting of 5 min of ‘Ned’s way’ followed by 10 min of ‘Our Way.’ ‘Ned’s way’ was paired with an orange card as the SD and allowed Ned access to reinforcers for 5 min. He was required to choose the reinforcer via a picture book. If the reinforcer was not listed in the picture book, he was denied the item. ‘Our way’ was paired with a green card as the S^ for access to reinforcers and Ned was expected to comply with all demands for 10 min. A three-step guided compliance (verbal/gestural/physical prompting) procedure was applied if he did not respond within 10 s. Compliance to either verbal or gestural prompting received praise. A standard daily picture schedule was used in conjunction with the time schedule protocol. Highly preferred items were brought on-site and referenced in his picture book. Two scheduled snack times were provided in addition to lunch. No more than two sessions of direct instruction were recommended per day. Copyright # 2007 John Wiley & Sons, Ltd. Behav. Intervent. 22: 69–82 (2007) DOI: 10.1002/bin 74 R. M. Foxx and J. Garito Staff ignored all inappropriate behaviors at all times unless Ned was endangering himself or others in which case he was isolated. This program was ineffective. During the first 4 months of the school year, Ned attacked peers in 11 separate events. These attacks occurred in hallways since he was the only student in his classroom. He caused several injuries to staff. He destroyed furniture. He began to disrobe and flush his clothing down the toilet. He urinated and had bowel movements in the classroom in order to escape demands. He induced vomiting in order to be sent home. He was eventually forbidden to enter the nurse’s office. Ned also removed 11 of his teeth including three permanent ones. Ned’s mother was frequently called to remove him from the school. After 4 months, Ned’s inappropriate behavior had escalated to a point where the first author was asked to evaluate him and his program. The author’s recommendation was that Ned be schooled at home. Phase 2: Home and Community-Based Program Treatment began at Ned’s home and was later moved to a 25 ft by 25 ft room at his church. Parental permission was obtained for all treatment procedures in this phase and all subsequent phases after each was explained and demonstrated. A number of reinforcement programs were created. They included a differential reinforcement of appropriate behaviors program on an initially very rich schedule and a token economy program for compliance with classroom rules. At the end of each instructional day, Ned could exchange his tokens for either a community-based trip to visit a highly preferred location or activity or buy a highly reinforcing item. Attenuation of reinforcement to leaner schedules was included in the protocol. A response cost program was incorporated into the token program. Crisis intervention went into effect whenever aggression or SIB occurred that could lead to physical damage. If redirection was ineffective and the episode was intense, physical restraint was employed. A main treatment component was to reduce the amount of instructional time from 6 to 2.5 h. Daily instructional time was gradually increased in 15 min increments as Ned’s behavior improved. All instructional activities were designed to be interesting, challenging, and highly reinforcing (Foxx, 1982a). Phase 3: Community-Based Program Treatment was delivered across the school day at multiple settings. These included Ned’s 25 ft by 25 ft classroom at his family’s church, other areas of the church and grounds, various locations in the community, and later, a playground at a local Copyright # 2007 John Wiley & Sons, Ltd. Behav. Intervent. 22: 69–82 (2007) DOI: 10.1002/bin Treatment of severe behavior 75 primary school. The duration of his daily attendance was increased so that he was attending for a full school day by the 5th month of the phase. The reinforcement system from Phase 2 continued with a more detailed token system added during instructional sessions. Each token was paired with a single response. A predetermined number of tokens (usually 3–5) were set in front of Ned. When all the tokens were earned, he received a break. If he did not engage in target behaviors and completed his tasks, he also received tokens to exchange for an end of the day reinforcer such as a trip to a pet store. The Premack principle, verbal communication training, and errorless learning were implemented consistently. Finally, because Ned was experiencing poor sleep patterns his in-school nap durations were increased. (They have since been decreased). Although he was in a highly reinforcing and less demanding environment, Ned continued to display some of the targeted behaviors. To treat them effectively, several procedures were added to the program. This was possible because the second author was now working full time in Ned’s program. Contingent Physical Exercise Contingent exercise (Luce, Delquadri, & Hall, 1980) was initially applied as a consequence for aggressive behavior. Whenever he aggressed, Ned was escorted to an area free of objects where he was given a series of verbal commands to engage in gross motor actions (e.g., touch your head, touch your stomach, and touch your toes.). If he did not comply with an instruction, he immediately received graduated guidance (Foxx & Bechtel, 1983) to complete it. The amount of guidance was in proportion to the non-compliance. The duration of the exercise was 15 min. When Ned aggressed during the exercise, he was required to complete another exercise period when the current one was completed. At the end of the consequence, Ned lost any reinforcers he had earned and retuned to the task in which he had aggressed. Aggression on a break resulted in his returning to direct instruction once the exercise period ended. This consequence was later applied to SIB. Overcorrection Dangerous and disruptive behaviors induced vomiting, inappropriate toileting, and non-compliance to tasks received an overcorrection consequence (Foxx, 1982b). Both components of overcorrection, positive practice and restitution were used when applicable. Any event that disturbed the environment would result in extended cleaning of the environment. Any event that included mishandling of objects was followed by a guided appropriate handling of them for an extended period of time (usually 5 min). Inappropriate toileting resulted in the standard toileting Copyright # 2007 John Wiley & Sons, Ltd. Behav. Intervent. 22: 69–82 (2007) DOI: 10.1002/bin 76 R. M. Foxx and J. Garito overcorrection (Foxx & Azrin, 1973). Non-compliance to tasks resulted in repeated correct practice of them with no reinforcement. If Ned engaged in aggression or SIB during overcorrection, he would receive the consequence for those more serious behaviors before resuming the overcorrection procedure. Contingent Movement Contingent movement was a less intensive contingent exercise program for loud or prolonged noises during instruction and for non-compliance to task. It involved taking Ned to the hallway outside the classroom and having him run back and forth using guided compliance when necessary. Duration was based on a distance of approximately 100 m. Intensity varied from a brisk walk to a fast jog depending on Ned’s compliance, that is, the greater the compliance the slower the pace. The duration was extended if he dropped to the ground. If Ned engaged in a targeted behavior that received contingent exercise or overcorrection, the order in which he would receive these consequences was determined by the severity of the behavior such that the most serious behavior was treated first. Following the consequence Ned was required to complete the contingent movement. Phase 4: Transition to Public School Classroom The program was moved to a 30 ft by 15 ft self-contained classroom at Ned’s home primary school. He attends school for the same number of hours each day as all other students. All treatments continued to be employed. The only change was that the use of contingent movement was replaced with a modified response cost program. We made this change because it would be stigmatizing to have Ne ...
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Journal Article Critique
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Journal Article Critique

The Statement of Problem
According to Foxx & Garito (2007), no attention has been given to design of programs in
public schools to address more severe bhaioral forms of behavior among students with disorders
that do exhibit positive consequences. As such, more severe behaviors such as aggression and
self-injury are still issues that affect the life of students at school. It becomes worse for these
students with health disorders that are characterized by these severe behaviors because the
behaviors are stimulated by avoidance or escape. For example, Ned was not initially admitted in
a specialized school that could address his Attention Deficit Hyperactivity Disorder (ADHD).
Another issue that the authors have raised is the environment in which the affected students are
living. Having no programed school settings in public schools that enables placement as well as
treatment of students with very severe behavioral disorders is an issue.
The Authors’ Purpose
One of the authors’ purpose of the article is to create awareness of what the current

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