Gary W. LaVigna and Thomas J. Willis, Institute for Applied Behavior Analysis, Los Angeles, CA
A version of this paper was presented at the Annual Conference of the Association for Behavior Analysis, San Francisco, CA, May, 1992. (This article appeared in Positive Practices, Volume I Number 1, October 1995 and is copyrighted (1995) by the Institute for Applied Behavior Analysis. All rights are reserved. To receive permission to reprint this article, e-mail IABA giving all details of the reprint and information on contacting you.)
A major value associated with the recent movement toward community integration for people with a developmental disability has been the opportunity for social integration and interaction with the general population. Major barriers remain, however, for those disabled individuals who exhibit significant challenging behavior. These barriers may include both the behavior challenges the person presents as well as the support strategies that have traditionally been employed to remediate the challenges. They are barriers because neither may be accepted by society-thus limiting the person's opportunity to benefit from the community integration movement. Present models for providing support have not proven fully adequate to the task of breaking these barriers to social and community integration for individuals who have severe and challenging behavior. In the following paragraphs, we present a model of support that we feel may go a long way toward "Breaking the Barriers."
The foundation of the model is an expanded view of the outcome criteria by which support strategies can be evaluated (see Figure 1 below). Traditionally, the success of a support plan has been measured by how quick and how much the plan has reduced problem behavior (i.e., the speed and degree of effects). We suggest that you must go beyond simple speed and degree of effects to conclude that a support plan has been effective. Support strategies should be evaluated in terms of the durability and generalization of their effects, the side effects they produce, and their social and clinical/educational validity (Favell et al., 1982; Evans & Meyers, 1985). This last outcome requirement is perhaps the most important, for it keeps us focused on the major point of a support plan. That is, not to eliminate the target behavior, per se, but to contribute to the overall quality of the person's life. This most critical measure says that a support plan has clinical/educational validity if, as a result and through the process of bringing the behavior itself under control, the person has a better quality of life, that the person has such things as more access, opportunity, choice and control, competencies and nurturing, caring and mutually gratifying relationships.
This complex array of critical outcomes makes it unlikely that any one strategy will produce all the desired results. Rather, full results are likely to require multielement support plans whose various components, in combination, address the full range of outcome requirements.
Figure 1: A Multielement Model for Breaking the Barriers to Social and Community Integration
The components of our multielement support plan are illustrated in Figure 1. The first major distinction within a multielement support plan is between proactive strategies and reactive strategies. Proactive strategies are those designed to produce changes over time. Reactive strategies, on the other hand, are those designed to manage the behavior at the time it occurs. Included within the category of proactive strategies are ecological changes, positive programming, and focused support. These three categories of proactive strategies, and their intended contributions to outcomes, are described below:
Ecological Changes. As the ABA Task Force report on "the right to effective treatment" acknowledges (Van Houten et al., 1988), behaviors occur within a context and often are a function of the person's physical, interpersonal and programmatic environment. Environmental or setting events and characteristics (i.e., the ecological context for behavior) provide an important area of analysis and offer significant opportunities for change as part of a support plan. For instance, some challenging behaviors could be a reaction to the crowded or noisy conditions in which a person must work, or could be a reflection of simple boredom. If this is the case, then the challenging behavior may be impacted by simple ecological changes in which crowding and noise are reduced and the environment is made more exciting. Some examples of ecological changes include changing the person's setting (Horner, 1980); changing the number and quality of interactions (Egel, Richman & Koegel, 1981; Strain, 1983); changing the instructional methods that are being used (Koegel, Dunlap & Dyer, 1980; Winterling & Dunlap, 1987); changing instructional goals; and/or removing or controlling environmental pollutants such as noise or crowding (Adams, Tallon & Stangle, 1980; Rago, Parker & Cleland, 1978). Generally speaking, ecological changes attempt to "smooth the fit" between the person and his or her environment by modifying the environment (Rhodes, 1967).
Behavior challenges may reflect a poor match, i.e., a conflict between the person's needs, characteristics and aspirations and that person's physical, interpersonal and programmatic environments. Resolution of those conflicts may require a change in those environments. For example, if the assessment concludes that the challenging behavior is a reaction to a barren and unstimulating living environment, it may ultimately be necessary for that person to have a home that provides more stimulation.
This may take some time, however. In the meantime, while a more suitable living arrangement is being pursued, strategies may be needed to reduce or manage the challenging behavior in the current location. Focused support strategies are designed to meet this need. The person may be reinforced for the absence or lesser occurrence of the problem; antecedents that set off the behavior may be eliminated to reduce the likelihood of the behavior (i.e., antecedent control strategies may be employed); etc.
Ecological changes do not always produce an immediate improvement in behavior. For example, while most individuals might show improvement in moving from an institutional setting into the community, some might show an increase in challenging behavior. Such an environmental change might still be pursued, however, if it is in a normal home environment that the person can learn, through positive programming, to be successful and enjoy living in a real home. If such a goal has validity, and if such a goal is most realistically achievable with a change in environment, the transitional increase in challenging behavior may have to be addressed with appropriate focused support and reactive strategies.
There are other ways in which ecological changes may have to be balanced with other elements of the framework. For example, it is often true that giving the person increased choice and control over their day to day life is a necessary change in the interpersonal and programmatic environments. However, it may be that the person exercises choices primarily to avoid participating in most activities and/or to avoid learning new skills. If the right to choose were taken as an absolute, the person may end up not having the best quality of life. It is important for support staff to acknowledge their responsibility to teach the person how to make increasingly informed choices. How are support staff to balance their responsibility to respect the right of the person to choose and their responsibility to teach the person new skills and to teach them to make increasingly informed choices? The following anecdote shows how one support team struck this balance.
A young, adult man with the challenges associated with autism engaged in frequent self injurious behavior. Assessment and analysis disclosed that most of this behavior was his way of saying "no," his way of saying that he didn't want to do what he was being asked to do. Accordingly, his support staff developed a positive program to teach him how to say "no" by holding up a wooden symbol. The instructional program was successful and self injury was avoided by staff backing off from their request whenever he held up the symbol. The quandary that they found themselves in, however, was that, in this fashion, he avoided most opportunities to learn new skills, even a recreational skill such as ping pong and the like. Whenever staff would begin instruction, he would "choose" not to participate by holding up his signal.
In response to these circumstances, staff then developed another positive program to teach coping and tolerance for this activity. They initially withheld the availability of the wooden "escape" symbol for a few seconds. This delay was not long enough to provoke an episode of self injury, but it did allow some initial seconds of instruction. When the symbol was available and held up by the person, staff responded by terminating the activity. Very gradually, the availability of the symbol was delayed for increasingly longer periods of time, still with self injury being avoided. This continued until the availability of the symbol was being delayed for a five minute period of instruction. This was accomplished while still avoiding self injury.
At this point, the symbol was made available from the beginning of instruction. It was observed that this young man would tolerate 30 seconds of ping pong instruction before he asked to stop, using his wooden symbol. Staff always complied with this request by terminating the instructional session. However, for any session that lasted for 30 seconds or less, they terminated the session with a sincere "...Nice game. Let's play again tomorrow." For any session that lasted for more than 30 seconds, they terminated the session with "...Nice game. Let's play again tomorrow. Why don't we go get a snack." Through this differential reinforcement, and with a gradual increase in the criterion for reinforcement, this young man eventually got to the point where he could volley back and forth a 100 times, successfully, missing no more frequently than his opponent. More to the point, he began to seek staff out with the ping pong paddles in an effort to get them to play with him.
This example provides one illustration of how staff balanced the important ecological strategy of increasing a person's choice and control with a positive program teaching tolerance for learning a new recreational skill. This was accomplished in such a way that challenging behavior was brought under control while enriching the person's quality of life, by giving him a new recreational skill that he now has the opportunity to enjoy on a regular basis. The model reminds us that ecological strategies hold a position of primacy in our support plans, but that these strategies may need to be balanced by the other strategies to produce outcomes that have the highest clinical/educational validity, that is, result in the best quality of life possible for the person.
Positive Programming. If Ecological changes can be described as changes in the environmental context, to smooth the fit between the environment and the individual, positive programming can be described as changes in the person's skills to deal better with the environment. Positive programming is defined as systematic instruction designed to give the individual greater skills and competencies which will contribute to social integration (LaVigna, Willis and Donnellan, 1989). There are four variations of positive programming involving the development of general, functionally equivalent, functionally related and coping/tolerance skills.
General skill development across the domestic, vocational, recreational, and general community domains facilitates the reduction of challenging behavior by increasing the person's repertoire of socially acceptable responses. "The increase in more adaptive and socially adequate behaviors will no doubt result in a concurrent decrease in maladaptive behaviors" (Lovaas & Favell, 1987, p. 312) (e.g., Wong et al., 1987). The opportunity to learn and engage in a wide variety of activities thereby provides a fundamental basis for other instructional efforts.
Challenging behavior occurs in certain situations because they can serve useful functions (Carr & Durand, 1985; Durand, 1990). What is much needed is an analysis of these functions and the incorporation of positive programming which teaches functionally equivalent but more socially acceptable responses, or responses that are otherwise functionally related to the identified reinforcers. (Donnellan, Mirenda, Mesaros, and Fassbender, 1984; Favell, McGimsey & Schell, 1982).
Along with ecological change, positive programming has the primary goal of producing durable, generalized outcomes, with good social and clinical/educational validity. In contrast with ecological change, positive programming involves systematic instruction while the former has to do with availability and opportunity. For example, ecological change could involve having access to a kitchen in one's home, having choices about what to do and having a day planner in which to schedule one's day. Positive programming might include teaching the person how to cook a meal independently, teaching the person how to make choices and teaching the person how to use a day planner to schedule a full day of interesting and desirable activities.
LaVigna, Willis and Donnellan (1989) describe in more detail the different variations of positive programming. We believe that among the most important functionally related skills is the ability to cope with and tolerate naturally occurring aversive events. This last category of positive programming deserves to be highlighted because it is often overlooked in support plans and because of its critical need for anyone who is living a full life in the real world.
Life's texture includes being told such things as "later," "no," and "good-bye." It includes such things as failure, frustration, criticism, being teased, being sick and performing nonpreferred tasks. While we would want to help anybody find a set of life circumstances that keeps these naturally occurring events to a minimum, anybody who has a life, has these experiences.
The rub is that these events are often the antecedents to challenging behavior. Ecologically, we may try to minimize them and it may be important to teach the person to learn how to communicate the key messages that let us know what she or he wants or what he or she is upset about. For truly durable outcomes, however, and for the best quality of life possible, support staff may need to take the responsibility to systematically teach the person how to cope with and tolerate these events, and not just rely on the sink or swim approach or rely on the natural consequences to teach life's lessons. If the individuals we are concerned about were so able to learn from natural consequences, such an elaborate framework for addressing their behavior challenges would not be necessary. In fact, their serious behavior challenges probably would not even have developed.
Focused Support. Ecological changes, depending on their difficulty, may take time to arrange, and positive programming may require some time before new skills and competencies are mastered. It may therefore be necessary to include focused support strategies for more rapid effects. Hence the inclusion of these strategies in our approach (see Figure 1).
There are alternatives to punishment in addition to differential schedules of reinforcement which can produce this rapid effect (LaVigna and Donnellan, 1986). These include, but are not limited to, certain antecedent and instructional control strategies (Touchette et al., 1985; Touchette, 1983; Carr, Newsom, & Binkoff, 1976) and stimulus satiation Rast, Johnston, Drum, & Conrin, 1981; Ayllon, 1963). A comprehensive support plan could also include nonbehavioral strategies such as neurophysiological techniques, medication adjustments, and dietary changes.
Within the multielement model, the purpose of a focused support strategy is to produce the most rapid effects possible, to reduce the risks associated with the behavior and to reduce the need for reactive strategies. The model emphasizes the use of nonaversive focused support strategies, since punishment brings a greater risk of negative side effects and itself may detract significantly from the person's quality of life. Further, the use of some punishment procedures may preclude the person from having access to certain environments, because of the relative lack of social validity of such strategies.
The use of nonaversive strategies is also dictated by the outcome requirement of speed and degree of effects, which is the primary reason for using focused support strategies. Punishment, by definition, is an after-the-fact procedure. The behavior occurs and then the punishing consequence is provided. In contrast, stimulus satiation and antecedent control may, conceptually and procedurally, preclude the occurrence of the challenging behavior altogether (LaVigna & Donnellan, 1986). Schedules of reinforcement may further strengthen the ability of a support plan to avoid or minimize the occurrence of challenging behavior.
For those support staff who favor an emphasis on an ecological approach to challenging behavior and who have a strong appreciation for the individual's rights and dignity, there may be an aversion to using focused support strategies, since such strategies are often artificial and contrived. There may also be an aversion to any procedure, such as a schedule of reinforcement, that is so blatantly "behavioral." This is of significant concern, since such strategies may be necessary for rapid control and necessary to keep the person and others free from the risks associated with the challenging behavior, including the risk of further exclusion. This "anti technology" sentiment may be understood within the context of a history in which many believe "behavior modification" has been used with a behavior, program or research focus rather than a focus on the person and her or his quality of life. However, this framework proposes to harness behavioral technology toward the end of supporting human values and dignity. (See the discussion of clinical/educational validity elsewhere in this article.)
A person who is physically challenged may need a physical prosthesis, such as a wheelchair, to gain independence and full community access. Support staff would advocate for the individual's right to the wheelchair, even though it may represent an "artificial" means by which the person would have mobility in the community, and may in fact elicit negative attention from the community. Similarly, a person who is behaviorally challenged may need a behavioral prosthesis, such as a formal schedule of reinforcement, to gain temporary control over behavior and to enjoy full community presence and participation, as more permanent solutions are being sought. This would suggest that support staff should be equally comfortable in advocating for the individual's right to the schedule of reinforcement, if needed, even though it may represent an "artificial" means of behavior control, and may in fact elicit negative attention from the community.
To summarize, proactive support strategies are those designed to produce changes over time and to improve the person's overall quality of life. Although there is some inter relatedness and overlap, our model delineates three categories of proactive strategies, (ecological changes, positive programming and focused support), each of which makes its own contribution to a complex array of desired outcomes. While proactive support strategies are included to produce changes over time, reactive strategies are included for the narrow but important purpose of situational management.
The need for situational management is unavoidable when you are supporting a person whose behavior can be challenging. For those support staff who have been resistant to using strictly non-punitive strategies, it may be partly because many advocates of a nonaversive approach have not explicitly described what to do when a challenging behavior occurs.
Generally, nonaversive strategies create a reactive vacuum. Ecological strategies, positive programming and focused support strategies do not describe what to do when a behavior occurs; they are proactive, not reactive. Punishment, in contrast, is by definition a reactive strategy and prescribes exactly how to react when the behavior occurs. Given this critical need, in lieu of other suggestions, it is no wonder that some people have held on to their use of punishment.
As shown in Figure 1, the multielement model calls for the explicit inclusion of reactive strategies as a component of a support plan. The outcome requirement that is being addressed by a reactive strategy is a subset of speed and degree of effects. While the proactive strategies address speed and degree of effects over time, reactive strategies address the speed and degree with which individual episodes of behavior can be brought under control, with the least amount of risk of injury to the person, to support staff and to others in the environment. The role of a reactive strategy is not to produce changes in the future, but rather to keep people safe in the here and now.
The model's liberation of reactive strategies from the need to produce future effects allows more options for the rapid resolution of an episode of behavior than more traditional approaches have provided. This is because the reactive strategy is planned within the context of a powerful proactive plan that does focus on the future. If we have ecological changes on track, if we are actively engaged in positive programming, and if we have our focused support strategies in place, it is less likely that the reactive strategy will produce a counter therapeutic effect. The following anecdote illustrates this point.
A classroom student was engaging in tantrums, which included disruptive screaming and scratching herself, an average of 40 minutes a day, despite the use of a corner time-out procedure for the previous year and a half. Based on a thorough assessment, a comprehensive support plan was designed. For example, ecological changes included an improved curriculum and a rearranged classroom. Positive programming included teaching her a relaxation response and to communicate using a communication board, with which she could ask to get a drink of water or to go to the bathroom, ask for a break, ask for a magazine, ask for assistance, etc. Focused support included a differential reinforcement schedule of low rates of responding. However, rather than continuing to use the corner time out procedure as a reactive strategy, at the earliest sign of a tantrum or a known precursor to tantrums, she was handed a magazine. This was selected because support staff knew that when she had physical access to a magazine, she compulsively and immediately stopped whatever she was doing, even tantrums, and removed the staples from the middle of the magazine. Once she completed the removal of the staples, it was quite easy to redirect her back to her educational activities.
From a traditional perspective, such a reactive strategy would be criticized for its potentially counter therapeutic effects. The fear would be that handing her a magazine, with which she engages in a high probability behavior, as a reaction to her challenging behavior, would reinforce and strengthen tantrums. The framework allows the inclusion of such strategies, however, relying on a fully developed proactive plan to overcome the potential counter therapeutic effects of the reactive strategy, that might occur without the context of the proactive strategies.
In the example, what actually happened was that with the initiation of the full multielement plan, tantrums were immediately reduced to an average of less than five minutes a day, a direct result of the effectiveness of the reactive strategy to rapidly establish control over each episode and to prevent its continuation and escalation. Further, her time on-task, engaging in productive instructional activities gradually increased and the daily rate of tantrums gradually decreased. It has now been more than two years since any tantrums have occurred.
We believe that certain reactive strategies, which are in many ways, counter-intuitive, such as the one described above, may contribute rapid and safe ways of resolving individual episodes of challenging behavior, if certain guidelines are followed (Willis and LaVigna, in press). This may represent a novel contribution of the proposed multielement model to the field. It also represents a new area of much needed research, to enable us to understand how multielement plans operate and to investigate their possible synergistic capabilities.
The components of this multielement model, which provides for both proactive and reactive strategies, is dictated by a focus on all six outcome requirements. The design of many of these components requires specific information which only can be gathered through a comprehensive assessment, including the possible influence that neurological, medical or other organic variables may have on the challenging behavior and its meaning to the person, i.e., the function it serves or the message it conveys. The purpose of an assessment process is to determine this meaning.
One strategy for this person centered approach to assessment is to use personal profiling and positive futures planning (Mount & Zwernik, 1988; Patterson, Mount, & Tham, 1988; O'Brien & Lovett, 1992). We have found futures planning to be particularly useful as a way of understanding how the person's ecology may be affecting behavior and what ecological changes may be helpful in trying to support the person.
Personal profiling and positive futures planning is a two step process designed to provide an understanding of a person's life and what they have experienced from their point of view and to develop a plan that helps them reach their goals and aspirations for the future. As is the multielement model, this approach is based on five quality of life values: (1) presence and participation in the community; (2) fulfilling valued roles and gaining social respect; (3) maintaining satisfying personal relationships with friends and family; (4) expressing personal preferences and making choices; and (5) gaining skills and competencies. Participating in the process are the focus person and the "stakeholders" in that person's life, i.e., a circle of support that includes family, friends, past and present support staff, and/or any others that may be able to make a contribution. If this process does not provide a sufficient understanding of the behavior and its meaning for the person, a specific process of behavioral assessment and functional analysis should be employed.
The fundamental role of behavioral assessment and functional analysis in providing behavioral services represents a hallmark in the field of applied behavior analysis (Kanfer & Saslow, 1969; Schwartz, Goldiamond & Howe, 1975). Assessment methods, information, and materials are considered to have utility if they have been demonstrated to contribute to beneficial outcomes (Hayes, Nelson & Jarrett, 1987). More specifically, the utility of assessment is defined insofar as it bears relevance for developing a support plan (Hayes, Nelson & Jarrett, 1989). Utility research is in its infancy in the area of challenging behavior (Ballmaier, 1992).
As shown in Figure 1, our framework provides for three aspects of assessment as having possible utility. The first of these is the method or process of assessment. Traditionally, the treatment of challenging behavior has relied almost exclusively on direct, naturalistic observation. Increasingly, however, interviewing, records review and analog situations are being utilized (Durand, 1990; Iwata, Dorsey, Slifer, Bauman, & Richman, 1982; O'Neill, Horner, Albin, Storey, & Sprague, 1990; Willis, LaVigna, & Donnellan, 1991). The second aspect of assessment that bears on utility is the information gathered by the assessment process (Ballmaier, 1992). Some main may seem to have obvious utility, for example, knowing the controlling antecedents. Other information may still be of questionable value to some practitioners, for example, knowing the history of the person and of the specific challenging behavior. Finally, the framework reminds us that assessment materials and devices are subject to exploration for their possible utility, that is, their contribution to the development of effective support plans (Ballmaier, 1992; Durand, 1990; O'Neill, Horner, Albin, Storey, & Sprague, 1990; Willis, LaVigna, & Donnellan, 1993).
An inclusive framework for breaking the barriers to integration caused by challenging behavior must also address a variety of mediator issues (Durand & Kishi, 1987; LaVigna, Willis, Shaull, Abedi, and Sweitzer, 1994). Hence their inclusion as illustrated in Figure 1. No support plan, regardless of its comprehensiveness and elegance, will produce the desired outcomes, unless it is fully and consistently implemented. Our model delineates a number of dimensions that relate to this issue. Firstly, three categories of social change agents are identified who may participate on the support team. These include natural mediators such as parent, siblings, regular education teachers, supervisors at work, and others whose relationship to the person is a natural one and has nothing to do with the person's disability or challenging behavior. Also included are professional staff whose relationship to the person is a function of their disability, such as special education teachers, job coaches, and domestic and community living support staff. Finally, included would be specialized staff whose relationship to the person is a function of the challenging behavior. These might include the behavior consultant, the one-to-one support staff, or others who are involved specifically because of the challenging behavior.
Secondly, the model delineates three aspects of training, as they may relate to the three categories of mediators. These include teaching the general skills that such support people may need to support the person, teaching the specific skills that are necessary to implement the procedures incorporated into the plan and quality assurance systems to assure full compliance with the support plan. Such quality assurance systems include clear and operational definitions of what exactly needs to be done, socially valid monitoring of implementation, feedback based on the results of monitoring to improve and maintain full and consistent implementation, and outcome evaluation (LaVigna, Willis, Shaull, Abedi & Sweitzer, 1994).
We may also need to consider what is reasonable to expect of a person providing support, particularly parents or parent surrogates, regardless of training. Some support strategies may be so involved or some situations so deteriorated that they require professional or even specialized staff. For this reason, we have developed an intensive support approach that allows the provision of specialized services without placing the person in a more restrictive setting or other "challenging behavior unit" (Donnellan, LaVigna, Zambito & Thvedt, 1985).
By design and definition, good research isolates independent and dependent variables and seeks to determine the effect of the former on the latter. The variables not under study are removed or otherwise controlled. In stark contrast, while individual elements may be based on a specific study or group of studies, a person centered support plan has an array of elements, is based on a comprehensive assessment, and is aimed at producing a broad range of outcomes. We suggest that because this broad context is often lacking, research findings may be misinterpreted and misapplied. Additionally, we suspect that the narrow interpretation of research findings has led to practices that many outside the field have perceived as an overuse, misuse and, in some cases, abuse of the punishment technology.
The model we have proposed is a framework for generating research questions, for discussing research findings, and for incorporating those findings into multielement, comprehensive, person centered support plans. It also provides a model for guiding behavior analysts in understanding the difference between a person centered support plan and the experimental investigation of isolated variables. If our strength has been in the latter, our weakness may be in the former. By adopting a model such as the one proposed here, we can only enhance the field of applied behavior analysis.
The multielement model is fundamentally derived from the outcomes desired when supporting a person who has the reputation of having challenging behavior. Speed and degree of effects has received most of the focus in the field, but this is only one of the outcomes that require our attention. The others include the durability and generalization of effects, minimizing negative side effects, social validity, that is, the acceptability of our strategies to the individual receiving treatment, to his or her family, to support staff, and to the community, and clinical/educational validity.
In this way, the proposed framework provides a values base for addressing challenging behavior. Effectiveness is ultimately measured by clinical/educational validity, that is, by the effects of the support plan on the person's quality of life, on the person's increased independence and competence, social and community presence and participation, productivity, personal empowerment and choice, and relationships and support network (O'Brien, & O'Brien, 1991). It is to these valued outcomes that this Multielement model is dedicated.
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