Behavioral Interventions
Behav. Intervent. 22: 69–82 (2007)
Published online in Wiley InterScience
(www.interscience.wiley.com) 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: hserve@aol.com
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
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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
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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
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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 Ned engage in contingent
movement in the school’s hallways.
RESULTS
In Figure 1, the six major targeted behaviors, aggression, self-injury, dangerous
behavior, disruptive behavior, induced vomiting, and inappropriate toileting have
been combined into a single category, severe behavior. Figure 1 shows that severe
behavior increased over the 4-month baseline to over 110 instances per day. Although
severe behavior decreased dramatically in Phase 2, it began to increase in April 2004
and was trending upward. Virtually all of this increase was the result of aggressive
behavior which meant that a decrease in instructional time, change in location, and
great increase in reinforcement were not affecting it. In Phase 3, the daily rate of
severe behavior decreased quickly when aggression was treated by negative
Copyright # 2007 John Wiley & Sons, Ltd.
Behav. Intervent. 22: 69–82 (2007)
DOI: 10.1002/bin
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Treatment of severe behavior
120
Baseline
Phase 2
Phase 4
Phase 3
100
80
60
Ned
40
20
0
Se
pt
-03
N
ov
-03
Fe
b-0
Ap 4
r-0
Ju
4
ne
-04
Au
g-0
4
O
ct
-04
D
ec
-04
Fe
b-0
Ap 5
r-0
Ju
5
ne
-05
Au
g-0
5
O
ct
-05
D
ec
-05
Fe
b-0
Ap 6
r-0
6
Severe behavior in classroom:
mean daily rate
Severe behavior in classroom
Months
Figure 1. The average daily rate of six severe behaviors (aggression, SIB, dangerous behavior,
disruptive behavior, induced vomiting, and inappropriate toileting) per month in the classroom during
baseline, Phase 2 (home and community based), Phase 3 (community based) and Phase 4 (public school)
conditions.
consequences and it later reached and remained at near zero levels when all other
forms of severe behavior received negative consequences. These reductions
continued during Phase 4 when Ned was moved to a self-contained classroom
at a public school. Overall, Ned’s severe behavior has been at or near zero for
14 consecutive months.
As noted earlier, the number of hours of instructional time varied across phases.
Table 1 presents the hourly rates of the six-targeted severe behaviors so that
meaningful comparisons can be made across phases. It shows that all severe behaviors
other than aggression were greatly reduced in Phase 2 and that these reductions
continued through Phase 4. Aggression showed the same pattern beginning in Phase 3.
Table 2 shows that in Phase 2 these reductions ranged from 68% for SIB to 98% for
induced vomiting and averaged 86%. In Phase 3, all six severe behaviors were
reduced to an average of 96% of baseline (range 88–100%). Three behaviors were
reduced by 100% and aggression, which had increased in Phase 2, was reduced to
95% of baseline. In Phase 4, all six behaviors were reduced by greater than 95%, five
by greater than 98% and three remained at zero.
Acquisition of New Behaviors
Educational
The true measure of a successful program is that a treated individual acquires new
skills as inappropriate behaviors are being decreased. This was the case in the present
Copyright # 2007 John Wiley & Sons, Ltd.
Behav. Intervent. 22: 69–82 (2007)
DOI: 10.1002/bin
78
R. M. Foxx and J. Garito
Table 1. Severe behaviors per hour across conditions.
Condition # of school
days
Baseline
Phase 2
Phase 3
Phase 4
Average Aggression SIB Dangerous Disruptive Induced Inappropriate
behavior behavior vomiting
toileting
time in
school (h)
70
88
332
65
6.0
3.6
6.25
6.25
1.27
2.03
0.06
0.01
3.77
1.22
0.32
0.09
1.52
0.15
0
0
1.97
0.3
0.23
0.07
7.4
0.13
0
0
0.08
0.01
0
0
Table 2. Percent of change from baseline in severe behaviors.
Condition
Phase 2
Phase 3
Phase 4
Aggression
SIB
Dangerous
behavior
Disruptive
behavior
Induced
vomiting
Inappropriate
toileting
þ60%
95%
99%
68%
92%
98%
90%
100%
100%
85%
88%
96%
98%
100%
100%
88%
100%
100%
intervention. Consider that during the 4 months of Phase 1 or baseline, 24% of Ned’s
individualized education plan (IEP) was completed. The selected goals had been
designed to be non-challenging and focused more on compliance to the Our Way/
Your Way protocol than to academics. This IEP was discontinued in Phase 2 and Ned
mastered 47% of his new IEP in the remaining 5 months of the school year. This new
IEP contained over 50 goals. The ones that were completed focused on expressive and
receptive language and math and writing. This IEP was continued in Phase 3 for
3 months. At this point, a new 90 goal IEP was written because Ned was rapidly
acquiring new skills. It included goals from the previous plan as well as reading goals,
leisure goals, and social skills training. At present Ned has mastered almost 75% of
his new IEP. Mastered skills included nine expressive goals, seven reading goals,
three writing goals, three math, and two science goals.
Anecdotal Reports
Several anecdotal reports reveal high social validity (Wolf, 1978). During Phase 1,
at least five lengthy IEP meetings took place over a 4-month period. In Phase 3, only
one meeting was held per academic year and the focus of the meeting was to agree on
new objectives. Both Ned’s parents and school staff report high levels of satisfaction
Copyright # 2007 John Wiley & Sons, Ltd.
Behav. Intervent. 22: 69–82 (2007)
DOI: 10.1002/bin
Treatment of severe behavior
79
with his progress. This agreement was important given that the parents and school
district had been through some contentious due process hearings. Members of Ned’s
church asked the second author to provide several training sessions to volunteers who
watched him during services. Therapists (TSSs) from an outside agency and Ned’s
father were trained by the second author to apply some of the treatment techniques in
the home.
When Phase 3 was implemented, Ned’s overall behavior had improved to the point
that same age peers from his church were brought into the classroom to help with his
social skills training. Ned began attending recess at a local primary school several
times a week. In Phase 4 Ned is in a self-contained classroom with another student at
that primary school.
There have been a number of other positive developments. Prior to treatment Ned
avoided social situations, used gestures or very simple language to convey his wishes
and disliked appropriate physical contact such as hugs. He now has become more
social, uses more elaborate language in the form of sentences to convey his wishes,
enjoys activities with other children and likes appropriate physical contact with others
including rough housing on a mat. He has displayed some surprising splinter skills
that no one knew he had. For example, when he was asked to identify a river in a
picture he noted that there was debris on the shoreline.
DISCUSSION
The results showed that Ned’s severe behaviors were successfully treated and that
this success has been maintained for 2 years even though he has received and
mastered increasing educational challenges. This success appears note worthy
because his severe behavior (a) had been resistant to a variety of treatments and
settings, (b) had caused him to be removed from a number of educational placements,
and (c) had prevented him from learning new skills. When he is not in school, Ned
attends camps, takes vacations with his family, and participates in community
outings.
The success of the program can be attributed to numerous factors. One, severe
behaviors no longer produced escape from educational and social demands. Two, Ned
learned to display alternate and appropriate behaviors in order to access preferred
reinforcers. Three, the complexity of social reinforcement and tasks were increased as
Ned’s behavior became more appropriate (Foxx, 1985; Foxx & McMorrow, 1983) as
did the density of naturally occurring positive reinforcement. The complexity and
relevance of tasks also were increased. Four, choice-making (Foxx, Faw, Taylor,
Davis, & Fulia, 1993) and problem solving (Foxx & Bittle, 1989) were emphasized.
Copyright # 2007 John Wiley & Sons, Ltd.
Behav. Intervent. 22: 69–82 (2007)
DOI: 10.1002/bin
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R. M. Foxx and J. Garito
And choice-making opportunities were increased for both tasks and reinforcement.
Choice making is a first step in teaching of self-control (Foxx, 1990) because granting
someone choices is giving them control and ultimately patience. Five, Ned’s parents
participated in every treatment decision and offered valuable insight into their son’s
routines. His parents and family were excellent and valuable sources of information
because they knew his learning history, reinforcer preferences, communications
skills, and history of severe behavior. Six, Ned’s pre-existing skills were heavily
reinforced and shaped so that they could be displayed more frequently and with more
variety. Seven, a skill-building strategy was employed wherein Ned was taught new
behaviors to serve the same function as his severe behavior and which would be more
efficient in obtaining reinforcement. This was why teaching him to communicate was
so heavily emphasized and his treatment team was expected to respond consistently
and rapidly to his requests and be knowledgeable about his communication system.
Eight, arrangements were made to insure that the stimuli that could, at times, control
appropriate behavior were present before, during and after the severe behavior was
treated. For example, it was well known that Ned was fascinated by snakes. As a
result, snake stickers were used as the reinforcement system for earning community
trips. One of his favorite places to visit was a store that sold snakes. In a similar
fashion, we had his parents purchase a small boa which Ned could earn access to with
good behavior. Nine, the least restrictive treatment model was followed (Foxx, 1982b)
wherein the least intrusive but effective procedure for severe behavior was selected.
Special attention was paid to selecting treatments, documented in the literature, that
were successful with individuals similar to Ned in terms of age, diagnosis and who
displayed their severe behavior in comparable situations or environments. Careful
consideration was also given to the intensity, severity, frequency, and topography of
Ned’s severe behavior. Ten, the school district provided continuous support
throughout the program. Eleven, maintenance and generalization of effects were
actively planned. Current data show no re-emergence of behavior when the on-site
behavior analyst is absent and the teacher is the primary change agent.
Given Ned’s history and behavioral repertoire, it was critical to have someone with
him on a daily basis that could carry out complex and intrusive programs. This is why
the greatest levels of success were achieved when the second author became involved
with the program. In effect, the most important contributor to long-term success was
the presence of a board-certified behavior analyst on-site. His presence in the
classroom assured treatment integrity, reliability, flexibility, and accountability and
assured the senior author that his program was being run by someone with the
necessary skills, training, and background to make daily decisions and observations.
The authors initially spoke by phone every day and then weekly. Treatment data are
sent to the senior author weekly and he visits Ned’s program at least once per month.
Other phone calls or visits are made on an as needed basis.
Copyright # 2007 John Wiley & Sons, Ltd.
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DOI: 10.1002/bin
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