Extensions of Resurgence as Choice: Basic and Clinical Studies

Preliminary Procedures

Functional Analysis. As part of our standard clinical practice, the investigators will conduct a functional analysis of each participant's problem behavior. Functional analyses identify the consequences (e.g., access to attention) that maintain problem behavior. Prior to conducting a functional analysis, the investigators routinely conduct a risk assessment to ensure that it is safe to conduct a functional analysis with each patient using the procedures developed in our program and described most recently by Saini et al. (2021). The investigators also will conduct preference assessments with each participant to determine a preference hierarchy (e.g., of toys, foods). The investigators will use this information to individualize each condition of the functional analysis for each participant. The investigators will extend session duration when indicated (e.g., if it appears that problem behavior begins to occur near the end of a 5-min session). The functional analysis will include at least three test conditions (social attention, demand, and monitored alone/ignore) and one control condition (play) that the investigators conduct within a multielement design. The investigators will interview the caregivers prior to the functional analysis to determine the relevant stimuli (e.g., types of attention, preferred items, demands) to program within each condition. In accordance with best clinical practice, the investigators will include an additional test condition (tangible) if the caregiver reports providing, or is observed to provide, preferred tangible items following problem behavior. For some participants who do not display problem behavior during standard test conditions, the investigators may evaluate other test conditions relevant to their case to determine idiosyncratic sources of reinforcement (e.g., social control, where adult compliance with child requests functions as reinforcement for problem behavior). The investigators will program a uniquely colored surgical smock for each condition to facilitate discrimination between test and control conditions.

In the attention condition, the therapist will provide the participant with high-quality attention for 1 min prior to the session. Then, the therapist will withdraw attention and pretend to read a magazine while the participant has an opportunity to play with a moderately preferred toy. If the participant emits problem behavior, the therapist will deliver 20 s of vocal (e.g., "Stop that, you'll hurt yourself") and physical (e.g., rubbing the participant's back) attention. In the demand condition, the therapist will deliver non-preferred demands (e.g., "Write your name") using sequential verbal, model, and physical prompts every 5 s. Compliance will produce praise (e.g., "Nice job writing your name!"), noncompliance will result in physical guidance (e.g., hand-over-hand prompting the participant to write their name) and no praise, and problem behavior will produce a 20-s break from demands. In the monitored alone condition, the participant will be alone in a treatment room without any toys or materials, but a therapist will monitor the participant from behind a one-way observation window. If the participant displays aggression toward others, the investigators will conduct a monitored ignore condition instead of an alone condition, during which a therapist will monitor the participant from inside the therapy room but will not interact with the participant or respond to the participant's problem behavior. In the tangible condition, the therapist will provide the participant access to a highly preferred toy for 1 min prior to the start of the session. The therapist will then withdraw the toy at the beginning of the session and return it to the participant for 20 s following problem behavior. In the control condition (play), the therapist will provide continuous access to the participant's highly preferred toy from the tangible condition and will deliver attention every 20 s for the absence of problem behavior (e.g., "Nice job playing with your blocks"). The investigators will conduct at least three sessions in each condition or until the investigators verify that problem behavior is maintained by social positive reinforcement (e.g., access to attention or tangible items) using the ongoing visual inspection criteria developed and validated by our research team.

Evaluation of differential reinforcement of alternative behavior (DRA). As part of our standard clinical practice, the investigators first teach an alternative response, called the functional communication response (FCR), to the child and evaluate its effectiveness following the functional analysis. The purpose of this DRA evaluation is to ensure that DRA effectively suppresses problem behavior and increases the child's use of the FCR when each FCR is reinforced. The investigators often teach the child an FCR modality that therapists can physically guide, such as a card exchange or card touch because our prior research has shown that it is critically important to minimize exposure to the establishing operation for problem behavior during the early stages of DRA (i.e., limiting the time the child does not have access to the functional reinforcer). Typically, the investigators create a laminated index card with a photograph of the child consuming the reinforcer (e.g., the child playing with an iPad) and then teach the child to either exchange or touch the FCR card to gain access to the reinforcer maintaining problem behavior. Caregiver input (e.g., preference for a vocal response) and participant-specific factors (e.g., low vision) are also considered when selecting the FCR for each patient. The investigators typically progress through the DRA evaluation in the following manner: (1) baseline, (2) DRA pretraining, (3) DRA, (4) baseline, and (5) DRA to demonstrate DRA's efficacy within a reversal design.

Baseline. Baseline for the DRA evaluation is identical to the functional-analysis test condition related to problem behavior. The therapist restricts access to the functional reinforcer (e.g., by removing access to the iPad) until problem behavior occurs, at which time the therapist delivers 20-s access to the functional reinforcer (e.g., 20 s of access to the iPad). The investigators conduct at least three baseline sessions or until response rates stabilize or increase in a countertherapeutic direction. Baseline sessions last 5 min.