Resurgence as Choice: Basic and Clinical Studies

Children with intellectual disabilities often display severe destructive behaviors that pose
significant risk to self or others and represent barriers to community integration. These
destructive behaviors are often treated with behavioral interventions derived from a
functional analysis (FA), which is used to identify the environmental antecedents and
consequences that occasion and reinforce (i.e., reward) the target response. One such
treatment is called differential reinforcement of alternative behavior (DRA), which involves
extinction (i.e., removal of rewards) of destructive behavior and reinforcement of an
alternative communication response with the consequence that previously reinforced
destructive behavior. Results from review studies indicate that interventions based on an FA,
like DRA, typically reduce problem behavior by 90% or more.

One commonly used DRA intervention is functional communication training (FCT). During FCT,
clinicians withhold reinforcement for destructive behavior and teach the individual a
functional communication response to access reinforcement. For instance, a clinician may
teach the child to exchange communication cards to express their wants and needs. However,
DRA interventions reported in the literature have typically been evaluated by experts in
controlled research settings, and treatment relapse often occurs in the natural environment
when a caregiver is unable reinforce the DRA response every time that the response occurs due
to competing responsibilities. Accordingly, a recent investigation of 25 applications of DRA
found that relapse of problem behavior occurred in 76% of cases.

Resurgence as Choice Theory helps to explain why treatment relapse occurs under these
circumstances and also provides mathematical equations that can be used to predict the
variables that increase and decrease the likelihood that treatment relapse will occur. In
this project, the investigators have used these equations to identify refinements to DRA that
are likely to decrease the probability that treatment relapse will occur when the DRA
response is not reinforced. In some cases, these refinements are at odds with what is
recommended in the clinical literature on DRA. Therefore, it is important to compare these
refinements that are derived from Resurgence as Choice Theory with current clinical practice
in order to determine the best way to implement DRA, so that treatment remains effective when
it is implemented with less than perfect precision by caregivers in the natural environment.

The two predictions that are most relevant to our project are (a) resurgence of destructive
behavior will decrease with increased DRA treatment duration, and (b) reinforcement schedule
thinning show included slow, small decreases in reward deliveries (smaller than those
previously reported in the literature). Accordingly, our project will examine the effects of
different durations of DRA on resurgence and the effects of adjusting the schedule of
reinforcement for each session to include slow and small decreases to avoid resurgence.
Findings from this project could have vast clinical implications in that the investigators
will demonstrate that time in treatment affects relapse and that schedule thinning can be
accomplished without recurrence of destructive behavior. The investigators will compare
short, moderate, and extended durations of treatment with DRA to identify the optimal
duration of treatment to reduce the extent of relapse of destructive behavior. The
investigators will demonstrate that the degree of relapse may depend on the length of
treatment with DRA.

The investigators will use measurements of destructive behavior, appropriate behavior, and
reinforcer deliveries during each treatment session to inform the number of reinforcers that
will be available during upcoming treatment sessions, informed by both the Resurgence as
Choice (RaC) Theory and on the results of a coordinated study with nonhuman animals. The
investigators will demonstrate that this schedule thinning progression is efficacious at
maintaining an 85% reduction in problem behavior (i.e., relative to baseline) during each
treatment session.

Inclusion Criteria:

1. males and females between the ages of 3 and 18;

2. problem behavior (e.g., aggression, property destruction, self-injurious behavior)
that has been the focus of outpatient behavioral and pharmacological treatment but
continues to occur, on average, more than once per hour;

3. problem behavior reinforced by social consequences (i.e., significantly higher and
stable rates of the behavior in one or more social test conditions of a functional
analysis [e.g., attention, escape] relative to the control condition [play] and the
test condition for automatic reinforcement [alone or ignore]);

4. IQ and adaptive behavior scores between 35 and 70 (i.e., mild to moderate intellectual
disability);

5. on a stable psychoactive drug regimen (or drug free) for at least 10 half-lives of
each medication with no anticipated changes;

6. stable educational plan and placement, with no anticipated changes during the study.

Exclusion Criteria:

- Exclusion criteria.

1. children not meeting the inclusion criteria above;

2. children currently receiving intensive (i.e., 15 or more hours per week),
function-based, behavioral treatment for their problem behavior through the school or
another program;

3. DSM-V diagnosis of Rett syndrome or other degenerative conditions (e.g., inborn error
of metabolism);

4. presence of a comorbid health condition (e.g., blindness) or major mental disorder
(e.g., bipolar disorder) that would interfere with participation in the study (e.g.,
requiring frequent hospitalizations);

5. children with self-injurious behavior who, based on the results of the risk
assessment, cannot be exposed to baseline conditions without placing them at risk of
serious or permanent harm (e.g., detached retinas);

6. children requiring changes in drug treatment (but such children will be invited to
participate after they meet the above criteria for a stable drug regimen).