Factor structure of the Treatment Evaluation Inventory: Implications for measurement of treatment acceptability

The Treatment Evaluation Inventory (TEI), a frequently used measure of treatment acceptability, was used by 164 undergraduates to rate the acceptability of each of the following treatments: differential reinforcement of other behavior, exclusionary time-out, overcorrection, medical restraint, contingent electric shock, and physical restraint. TEI ratings of each treatment type were grouped separately, variance-covariance matrices were formed and compared, and data were subjected to factor analysis. The results indicated that the factor structure of the TEI varied with the treatment it was used to evaluate. Item analysis of the TEI indicated a high degree of internal consistency, although item-total correlations varied between rated treatments. The findings suggest that although the TEI is a reliable instrument, sensitive assessment of the treatment acceptability construct probably requires multidimensional measurement.     

Personality traits in eating-disordered patients with and without self-injurious behaviors

Although there is a high comorbidity of eating disorder and self-injurious behavior (SIB), no systematic research has focused on personality trait differences in patients with and without SIB. In this study, a Dutch adaptation of the NEO-FFI (Costa & McCrae, 1985, 1992) was completed by 178 female, eating-disordered (ED) patients of whom 46.5% showed at least 1 form of SIB (e.g., cutting, burning, hair pulling). A subsample of 41 patients also completed the NEO-PI-R. Compared to patients without SIB, ED patients with SIB scored significantly higher on the Neuroticism scale and significantly lower on the Extraversion scale; on subtraits (facet scores) they appeared to be more anxious, more willing to please and less cheerful, efficient and ambitious. Personality traits were not associated with frequency or form of SIB or subtype of ED (except for impulsiveness). We also did not find a significant interaction effect between ED subtype and presence/absence of SIB.     

Treatment Acceptability

The present study assessed mothers' and fathers' acceptance of six interventions frequently used to alter children's problem behavior. This is the first study to assess fathers' perceptions of behavioral interventions for children. Positive reinforcement, response cost, medication, room timeout, chair timeout and spanking were rated by parents using the Treatment Evaluation Inventory (TEI). In addition, parents' perceptions of their children's behavior and own marital adjustment were measured using standardized checklists. Parents' acceptability ratings differed significantly across treatment conditions depending on parent gender, child behavior problems, and marital adjustment. Treatment preference order was equivalent for all groups.     

Development of a modified treatment evaluation inventory

Kazdin's (1980a) Treatment Evaluation Inventory (TEI) is the major instrument used to assess parents' acceptance of procedures for behavior problem children. The length of the TEI, however, as well as problems with its scaling and wording limits its value as a clinical research instrument. In the present study, three experiments were conducted to develop a modified TEI. In Experiment 1, 153 parents completed the TEI to evaluate a behavioral treatment for noncompliant and oppositional children. A factor analysis of the data was used to obtain a reliable factor structure for the TEI and to construct a 9-item TEI-Short Form (TEI-SF) with a 5-point scale, consistent anchors on the scale, and simplified text and instructions. Experiment 2 evaluated the psychometric characteristics of the TEI and the TEI-SF. These data indicated the TEI-SF is a sound alternative to the original TEI. Experiment 3 compared the readability and completion time of the two instruments.     

Functional analysis and treatment of self-injury associated with transitions.

We applied functional analysis methodology to the assessment and treatment of 2 individuals' self‐injurious behavior (SIB), which was reported to be occasioned by transitions from one activity or location to another. A structural (task) analysis of activity transitions identified at least three separate components that might influence behavior either alone or in combination: (a) termination of a prechange activity, (b) initiation of a postchange activity, and (c) movement from one location to another. Results of preference and avoidance assessments were used to identify activities to which participants were exposed in varying arrangements during transitions in a functional analysis. Results of 1 participant's functional analysis indicated that his SIB was maintained by avoidance of having to change locations, regardless of the activity terminated prior to the change or the activity initiated following it. The 2nd participant's analysis revealed the same function but also an additional one: avoidance of certain task initiations. This information was used to identify transition contexts during intervention and to design treatment procedures appropriate for a given context and behavioral function. A procedure involving advance notice of an upcoming transition had no effect on SIB, and differential reinforcement of alternative behavior (DRA) had limited effects in the absence of extinction. Sustained decreases in SIB were observed when DRA was combined with extinction and response blocking. Further extensions of functional analysis methodology to the assessment of problem behavior in situations characterized by multiple or protracted stimulus changes are discussed.     

ARTIFACTUAL EFFECTS OF SENSORY-INTEGRATIVE THERAPY ON SELF-INJURIOUS BEHAVIOR

Three individuals who exhibited self-injurious behavior (SIB) were exposed to sensory-integrative therapy. Prior to treatment, a functional analysis baseline was conducted to identify the motivational features of their SIB. One subject's SIB appeared to be an attention-getting response (maintained by positive reinforcement), which varied subsequently as a function of attention being either withheld or provided noncontingently during sensory-integration sessions. The 2nd subject displayed a pattern of responding suggestive of stereotypic SIB (maintained by automatic reinforcement), which paradoxically increased during sensory-integration sessions. The 3rd subject's SIB appeared to function as an escape response (maintained by negative reinforcement), and his behavior during sensory-integration sessions was similar to that observed during baseline sessions in which demands were not present. The SIB of all 3 subjects later was reduced when behavioral interventions were applied. The data presented raise questions about the active components of sensory-integrative therapy and the functional types of SIB for which it might be appropriate.     

Perceptions of Cognitive-Behavioral Therapy and Antidepressant Medication for Depression After Brief Psychoeducation: Examining Shifts in Attitudes

The majority of people with depression in the United States either never seek treatment or gravitate exclusively to antidepressant medication (ADM), despite the existence of other effective treatments, such as cognitive-behavioral therapy (CBT). Reluctance to use psychotherapy is partly due to lack of appropriate mental health literacy and perceptions of low treatment acceptability (appropriateness for a given problem) and credibility (treatment logicalness, and whether the patient expects improvement). In the current investigation, we examined whether providing psychoeducation about CBT for depression would change participant perceptions of the treatment’s acceptability and credibility. We recruited 554 (female n = 314; 57%) participants across two online studies, and assessed their baseline perceptions of CBT and ADM using modified Treatment Acceptability (TAAS) and Treatment Credibility and Expectancy (CEQ) scales. Participants were subsequently presented with evidence-based, expert-vetted psychoeducational materials describing CBT and ADM, and were asked to recomplete the TAAS and CEQ. In Study 1, participants endorsed significantly higher CBT-CEQ (credibility/expectancy) scores postpsychoeducation. In Study 2, participants endorsed significantly lower CBT-TAAS (acceptability), and among those with no exposure to depression treatments, endorsed significantly higher CBT-CEQ scores postpsychoeducation. In both studies, there were no perceptual changes of ADM after the psychoeducation. Finally, in Study 2, endorsement of a biological model of depression and depressive symptoms were negatively predictive of CBT’s acceptability and credibility and expectancy postpsychoeducation. Perceptions of credibility and expectancy of CBT for depression appear malleable even after exposure to brief psychoeducation, whereas shifting perceptions of CBT’s acceptability may require more extensive intervention.     

WHAT MAKES EXTINCTION WORK: AN ANALYSIS OF PROCEDURAL FORM AND FUNCTION

We examined methods for determining how extinction should be applied to different functions of self-injurious behavior (SIB). Assessment data indicated that the head banging of 3 children with developmental disabilities was maintained by different reinforcement contingencies: One subject's SIB was positively reinforced by attention from adults, the 2nd subject's SIB was negatively reinforced by escape from educational tasks, and the 3rd subject's SIB appeared to be automatically reinforced or “self-stimulatory” in nature. Three functional variations of extinction—EXT (attention), EXT (escape), and EXT (sensory)—were evaluated, and each subject was exposed to at least two of these variations in reversal or multiple baseline designs. Reductions in SIB were observed only when implementation of “extinction” involved the discontinuation of reinforcement previously shown to be responsible for maintaining the behavior. These results highlight important differences among treatment techniques based on the same behavioral principle (extinction) when applied to topographically similar but functionally dissimilar responses, and further illustrate the practical implications of a functional analysis of behavior disorders for designing, selecting, and classifying therapeutic interventions.     

THE FUNCTIONS OF SELF-INJURIOUS BEHAVIOR: AN EXPERIMENTAL-EPIDEMIOLOGICAL ANALYSIS

Data are summarized from 152 single-subject analyses of the reinforcing functions of self-injurious behavior (SIB). Individuals with developmental disabilities referred for assessment and/or treatment over an 11-year period were exposed to a series of conditions in which the effects of antecedent and consequent events on SIB were examined systematically by way of multielement, reversal, or combined designs. Data were collected during approximately 4,000 experimental sessions (1,000 hr), with the length of assessment for individuals ranging from 8 to 66 sessions (M = 26.2) conducted over 2 to 16.5 hr (M = 6.5). Differential or uniformly high responding was observed in 145 (95.4%) of the cases. Social-negative reinforcement (escape from task demands or other sources of aversive stimulation) accounted for 58 cases, which was the largest proportion of the sample (38.1%). Social-positive reinforcement (either attention or access to food or materials) accounted for 40 (26.3%) of the cases, automatic (sensory) reinforcement accounted for 39 (25.7%), and multiple controlling variables accounted for 8 (5.3%). Seven sets of data (4.6%) showed either cyclical or inconsistent patterns of responding that were uninterpretable. Overall results indicated that functional analysis methodologies are extremely effective in identifying the environmental determinants of SIB on an individual basis and, subsequently, in guiding the process of treatment selection. Furthermore, an accumulation of assessment data from such analyses across a large number of individuals provides perhaps the most rigorous approach to an epidemiological study of behavioral function.     

Functional analysis of self‐injury maintained by automatic reinforcement: exposing masked social functions

Two functional analyses for self‐injurious behavior (SIB) exhibited by a child diagnosed with mental retardation and autism were conducted. Responding was high and undifferentiated in the first functional analysis, indicating that SIB was maintained by automatic reinforcement. During the second functional analysis, the client wore a padded helmet and all SIB was blocked. SIB decreased in all conditions except attention, suggesting that SIB was multiply controlled (social positive and automatic reinforcement). Copyright © 2001 John Wiley & Sons, Ltd.     

Consumers' and clients' pretreatment acceptability ratings of classroom group contingencies

Group contingencies are popular with teachers and have been demonstrated to be effective for managing children's classroom behavior. Children's views of the acceptability of such techniques, however, have not been assessed systematically and may have important consequences for long-term treatment effectiveness. In addition, little is known about psychologists' sense of the acceptability of such techniques. The present analog study investigated fifth graders', teachers', and school psychologists' assessment of the acceptability of three types of group contingencies (dependent, independent, and interdependent) that entail a consequence of positive reinforcement for appropriate behavior. Variables of treatment type, sex of rater, and the severity of a hypothetical classroom problem were examined to determine their influence on intervention acceptability scores on a child's and an adult's version of the Intervention Rating Profile. Fifth graders rated all three types of group contingencies mildly acceptable. Teachers and school psychologists rated the dependent form of the group contingency unacceptable, and the independent and interdependent forms acceptable.     

A COMPARISON OF NONCONTINGENT REINFORCEMENT AND SENSORY EXTINCTION AS TREATMENTS FOR SELF-INJURIOUS BEHAVIOR

We compared the effects of two treatments, noncontingent reinforcement (NCR) and sensory extinction (EXT), on the self-injurious behavior (SIB) exhibited by 3 individuals with developmental disabilities. Results of a functional analysis indicated that their SIB was not maintained by social reinforcement, as indicated by undifferentiated responding across assessment conditions or higher rates of responding in the alone condition. Prior to treatment, leisure probes were conducted to identify highly preferred items for use in the NCR condition, and equipment probes were conducted to identify devices that produced the greatest behavioral suppression for use in the EXT condition. Following baseline, treatment was implemented in a multiple baseline across subjects design, and the effects of NCR and EXT were compared in a multielement format. During NCR sessions, participants had continuous access to a highly preferred item. During EXT sessions, participants wore equipment (gloves or protective sleeves) that seemed to attenuate stimulation directly produced by their SIB, while still allowing the behavior to occur. Results indicated that both procedures were effective in reducing SIB, although NCR was associated with either more rapid or greater overall response suppression.     

Functional analysis and treatment of self-injurious behavior in young children a summary of 30 cases

The assessment and treatment of self-injurious behavior (SIB) has received much attention in the literature; however, few studies have focused on early intervention for this behavior. In the current study, functional analyses with developmentally appropriate modifications were conducted in an outpatient clinic with 30 children (aged 10 months to 4 years 11 months) to assess SIB and problem behavior in its early stages. The reported mean age of SIB onset was 17 months, and head banging was the most prevalent topography. Functional analyses identified sources of reinforcement for SIB in 62.1% of cases; with the inclusion of all forms of problem behavior, sources of reinforcement were identified for 87.5% of cases. Function-based treatments were developed for 24 cases, with functional communication training prescribed most often (70.8% of cases). Implications of these findings for the development of early intervention programs for SIB are discussed.     

Self-injurious behavior in institutionalized,severely/profoundly retarded adults—Prevalence data and staff agreement

Staff agreement on the identification of 18 different types of self-injurious behavior (SIB) and the prevalence of SIB were assessed in a population of 91 severely and profoundly retarded residents in a large facility for mentally retarded people in West Germany (FRG). The survey included 27 direct care staff; groups of three to five rated the behavior of 8 to 27 residents from their own wards. Agreement was calculated with two different formulas for multiple raters. The data suggest that the standard definition of SIB [Tate, B. G.,& Baroff, G. S. (1966).Behavior Research and Therapy, 4, 281–287], together with a list of the most common SIB topographies, yields variable and generally low staff agreement. The data for the prevalence statistics were derived from cases in which at least 50% of the staff had indicated the occurrence of an SIB topography in a resident. Sixty of the 91 residents exhibited some form of SIB; of these, 15 demonstrated only one type, 12 two, and 33 three or more SIB topographies. The data corroborate the notion of the two taxonomic classes of social and nonsocial SIB. Contrary to other classifications the data indicate that ruminative vomiting belongs to the social SIB class.The author wishes to express his gratitude to Dr. Udo Lück, chief psychologist of the Diakoniezentrum Hephata, who made this study possible by his interest and support. The help of Walter Edlinger in collecting the data and of Prof. Hartmann Scheiblechner in giving methodological advice is also greatly appreciated.     

Self-injurious behavior and the efficacy of naltrexone treatment: a quantitative synthesis

People with mental retardation, autism, and related developmental disabilities who self-injure are treated with a wide array of behavioral techniques and psychotropic medications. Despite numerous reports documenting short-term and some long-term changes in self-injury associated with the opiate antagonist naltrexone hydrochloride, no quantitative review of its efficacy has been reported. We conducted a quantitative synthesis of the peer-reviewed published literature from 1983 to 2003 documenting the use of naltrexone for the treatment of self-injurious behavior (SIB). Individual-level results were analyzed given subject and study characteristics. A sample of 27 research articles involving 86 subjects with self-injury was reviewed. Eighty percent of subjects were reported to improve relative to baseline (i.e., SIB reduced) during naltrexone administration and 47% of subjects SIB was reduced by 50% or greater. In studies reporting dose levels in milligrams, males were more likely than females to respond. No significant relations were found between treatment outcomes and autism status or form of self-injury. Results are discussed with respect to future efficacy work related to study outcomes and the pharmacological treatment of self-injury.     

Psychometric appraisal of the Scale for Interpersonal Behavior (SIB) in France.

The present study was carried out in France to evaluate the reliability and validity of the Scale for Interpersonal Behavior (SIB), a multidimensional measure of difficulty and distress in assertiveness that was originally developed in The Netherlands. This appraisal was conducted with a clinical sample (N = 166) and a general population sample (N = 150). The clinical series comprised 115 patients with social phobia and 51 patients with personality disorder, 28 of whom were of the avoidant type. Support was found for internal consistency and test-retest reliability of the French SIB. Compared to controls, both social phobics and patients with an avoidant personality disorder had significantly lower mean scores on all performance scales and significantly higher ones on all distress scales, with the social phobics occupying a position in between. Findings in relation to convergent and divergent validity were quite satisfactory. Sensitivity of the French SIB for detecting change was demonstrated in a subgroup of the clinical Ss who had undergone 15 sessions of cognitive-behavioral group therapy for underassertiveness.     

AN ANALYSIS OF REINFORCER SUBSTITUTABILITY USING OBJECT MANIPULATION AND SELF-INJURY AS COMPETING RESPONSES

The concept of reinforcer substitutability proposes a continuum of interactions among reinforcers in a given situation. At one end of this continuum, reinforcers are substitutable, with one reinforcer being readily traded for another. We conducted an analysis of reinforcers that were substitutable with those produced by self-injurious behavior (SIB). Three individuals with profound developmental disabilities, whose SIB appeared to be maintained by automatic reinforcement, participated. Results of three experiments showed that (a) object manipulation and SIB were inversely related when leisure materials and SIB were concurrently available, with participants showing almost complete preference for object manipulation; (b) attempts to reduce SIB using the preferred objects as reinforcers in differential reinforcement contingencies were unsuccessful for all 3 participants; and (c) participants' preferences for SIB or object manipulation systematically changed when reinforcer cost (the amount of effort required to obtain the object) was varied. Results of the three experiments illustrate the importance of examining interactions among concurrently available reinforcers when conducting reinforcer assessments.     

Acceptability of positive and reductive behavioral interventions: Factors that influence teachers'' decisions

Treatment acceptability refers to individuals' judgments as to whether psychological treatment procedures are appropriate, fair, and reasonable for a given problem. In the present two-experiment study, experienced teachers' ratings of acceptability for positive (i.e., praise, home-based reinforcement, and token economy) and reductive (i.e., ignoring, response-cost lottery, and seclusion time-out) behavioral interventions were investigated. Using the Intervention Rating Profile (IRP) and a case study methodology to manipulate variables of intervention complexity and problem behavior severity, it was established that (a) teachers' acceptability ratings of both positive and reductive interventions varied with the severity of a target behavior, (b) the complexity of an intervention influenced teachers' ratings of acceptability, less complex or time-consuming interventions being rated generally more acceptable, and (c) mean acceptability ratings were significantly more favorable for positive than reductive treatments. These findings are discussed in the context of previous acceptability research and future investigations.     

EXPERIMENTAL ANALYSIS AND TREATMENT OF MULTIPLY CONTROLLED SELF-INJURY

A functional analysis of the self-injurious behavior (SIB) of 3 adults with profound developmental disabilities showed that each engaged in SIB in more than one assessment condition. Such outcomes may result from a failure to isolate the variable maintaining SIB, or they may reflect multiple sources of control over SIB. In order to identify more clearly the determinants of SIB, each subject was exposed to a series of treatments appropriate to one or both of the apparent functions of SIB. These treatments, applied sequentially on baselines appropriate to each behavioral function, identified the maintaining variables for SIB through differential outcomes across baselines. Results indicated that the SIB of 2 subjects was multiply controlled, confirming the outcomes of the functional analysis. However, the SIB of the 3rd subject was eliminated using a treatment designed for a single function, suggesting spurious results of the original assessment. Alternative interpretations of undifferentiated assessment data are discussed, as are analysis and treatment issues related to multiply determined behavior disorders.