INCREASING COMPLIANCE WITH MEDICAL PROCEDURES: APPLICATION OF THE HIGH-PROBABILITY REQUEST PROCEDURE TO A TODDLER

The effects of high-probability (high-p) requests on compliance with low-probability (low-p) responses have received increased attention from applied investigators. This study examined the effects of a high-p procedure on a toddler's compliance with medical procedures. Compliance to low-p requests occurred more frequently following compliance to high-p requests, suggesting that this procedure may be useful across different topographies of compliance.     

Effects of High-Probability Request Sequences on Preschoolers' Compliance and Disruptive Behavior

A high-probability request sequence was implemented with three preschool children with developmental delays within their classroom during typical activities. A multiple baseline design across subjects was used to evaluate the effects of the high-probability request sequence on compliant responding to low-probability requests and the occurrence of disruptive behavior. Results of the study indicate that the use of the high-probability request sequence was effective in increasing compliant responding to low-probability requests delivered by two different trainers for all children. No increases in disruptive behavior were noted as a result of using the high-probability request sequence. When the high-probability request sequence was withdrawn, compliant responding to low-probability requests was maintained for all children across time and in different settings.     

An evaluation of the high-probability instruction sequence with and without programmed reinforcement for compliance with high-probability instructions

We assessed the effects of reinforcement and no reinforcement for compliance to high-probability (high-p) instructions on compliance to low-probability (low-p) instructions using a reversal design. For both participants, compliance with the low-p instruction increased only when compliance with high-p instructions was followed by reinforcement. These results suggest that providing reinforcement for high-p instructions may result in increased compliance to low-p instructions.     

BEHAVIORAL MOMENTUM IN THE TREATMENT OF NONCOMPLIANCE

Behavioral momentum refers to the tendency for behavior to persist following a change in environmental conditions. The greater the rate of reinforcement, the greater the behavioral momentum. The intervention for noncompliance consisted of issuing a sequence of commands with which the subject was very likely to comply (i.e., high-probability commands) immediately prior to issuing a low-probability command. In each of five experiments, the high-probability command sequence resulted in a “momentum” of compliant responding that persisted when a low-probability request was issued. Results showed the antecedent high-probability command sequence increased compliance and decreased compliance latency and task duration. “Momentum-like” effects were shown to be distinct from experimenter attention and to depend on the contiguity between the high-probability command sequence and the low-probability command.     

An evaluation of differential reinforcement with stimulus fading as an intervention for medical compliance

Individuals with autism spectrum disorder (ASD) often exhibit noncompliance during medical exams. One intervention used to address this concern is differential reinforcement. Although differential reinforcement includes extinction, it may not be feasible or safe to implement extinction during medical exams. In the current study, we evaluated differential reinforcement without extinction and differential reinforcement without extinction plus stimulus fading, for increasing compliance during routine medical exams exhibited by 4 individuals with ASD. An indirect assessment identified problematic medical procedures, and a functional analysis showed that participants' disruptive behavior was maintained by escape from medical tasks. Differential reinforcement without extinction was insufficient in increasing medical compliance with 3 of 4 participants. The addition of a modified stimulus fading procedure that involved gradually introducing smaller components of problematic exam steps was effective in increasing medical compliance with all exam steps.     

Evaluation of stimulus intensity fading on reduction of rapid eating in a child with autism

This study assessed the effects of a vibrating pager on reduction of rapid eating. The study also evaluated two strategies for fading the pager, by intensity and by frequency. The pager was successful in decreasing the pace of eating to an appropriate level and the pager prompt was successfully faded. Fading by frequency was ineffective in maintaining an appropriate pace of eating while intensity fading was successful.     

Reinforcement of probe responses and acquisition of stimulus control in fading procedures

Stimulus control of pigeons' key pecking was transferred from colors to lines by the method of stimulus fading. Fading was conducted with the addition of probes consisting of the line stimuli presented alone at each fading level. Probe responding was used to measure stimulus-control acquisition by the lines. Effects of reinforcement and nonreinforcement of probe responding upon acquisition of stimulus control were assessed using a single-organism repeated-acquisition design in which three fades were conducted serially. Probe responding was not reinforced in the first and third fade but was in the second. Reinforcement of probe responding substantially reduced the number of fading levels needed to complete fading. The outcome of a control experiment ruled out the possibility of accounting for these results in terms of the specific stimuli used in each fade or in terms of the sequential exposure to the three discriminations. Although probes permitted measurement of stimulus-control acquisition in fading, a measurement/acquisition interaction was also present.     

Reinforcement of compliance with respiratory treatment in a child with cystic fibrosis.

An 8-year-old boy with cystic fibrosis (CF), mental retardation, and autism exhibited noncompliance with respiratory treatments that were essential for the management of his CF. A treatment involving shaping cooperation while still allowing escape for aggression and avoidance behavior resulted in increases compliance with respiratory treatments and decreases in problem behavior. Treatment gains were maintained over 3 months.     

Effects of d-amphetamine, cocaine, and phencyclidine on the acquisition of response sequences with and without stimulus fading.

In each of three components of a multiple schedule, monkeys were required to emit a different sequence of four responses in a predetermined order on four levers. Sequence completions produced food on a fixed-ratio schedule. Errors produced a brief timeout. One component of the multiple schedule was a repeated-acquisition task where the four-response sequence changed each session (learning). The second component of the multiple schedule was also a repeated-acquisition task, but acquisition was supported through the use of a stimulus-fading procedure (faded learning). In a third component of the multiple schedule, the sequence of responses remained the same from session to session (performance). At higher doses, d-amphetamine, cocaine, and phencyclidine decreased the overall rate of responding and increased the percent errors in all three components. At lower doses, however, the three drugs produced selective effects on errors. Errors were increased in the learning component at lower doses than those required to disrupt the behavior in the faded-learning component. The performance component tended to be the least sensitive to disruptive drug effects. The data are consistent with the view that stimulus fading can modulate the effects of drugs on acquisition.     

Behavioral momentum in college basketball

Three classes of events were scored from videotapes of 14 college basketball games during the 1989 National Collegiate Athletic Association tournament: reinforcers (such as points and favorable turnovers), adversities (such as missed shots, unfavorable turnovers, and fouls), and responses to adversities (favorable or unfavorable outcomes of the first possession of the ball following an adversity). Within-game and within-team analyses of these data supported three findings. First, a team's favorable response to an adversity generally increased as the rate of reinforcement increased 3 min preceding the adversity. Second, basketball coaches called time-out from play when being outscored by their opponents an average of 2.63 to 1.0. Third, calling time-outs from play appeared to be an effective intervention for reducing an opponent's rate of reinforcement. Rates of reinforcement during the 3 min immediately after a time-out were nearly equal for both teams. Results are discussed within a behavioral momentum framework.     

A method to establish stimulus control and compliance with instructions

We evaluated a unique procedure to establish compliance with instructions in four young children diagnosed with autism spectrum disorder (ASD) who had low levels of compliance. Our procedure included methods to establish a novel therapist as a source of positive reinforcement, reliably evoke orienting responses to the therapist, increase the number of exposures to instruction–compliance–reinforcer contingencies, and minimize the number of exposures to instruction–noncompliance–no reinforcer contingencies. We further alternated between instructions with a high probability of compliance (high‐p instructions) with instructions that had a prior low probability of compliance (low‐p instructions) as soon as low‐p instructions lost stimulus control. The intervention is discussed in relation to the conditions necessary for the development of stimulus control and as an example of a variation of translational research.     

The momentum of compliance

Compliance with demanding requests that are normally ineffective may be increased by presenting a series of easy or high-probability (high-p) requests before the more demanding requests. Mace and his colleagues have discussed the effectiveness of the high-p procedure in relation to behavioral momentum—the tendency for behavior, once initiated and reinforced, to persist in the face of a challenge. The high-p procedure differs in several ways from that employed in laboratory research on momentum, and the methods and findings of basic research may not be relevant to applied work on compliance. This article reviews some laboratory procedures used in research on behavioral momentum, summarizes the major findings of that research, and discusses its relevance to the high-p procedure and its outcomes. Increased compliance with demanding requests following the high-p procedure can be understood in relation to the procedures and findings of basic research, but some questions arise in the process of translating research into application via the metaphor of momentum. These questions suggest some new directions for both experimental and applied behavior analysis.     

Establishing compliance with liquid medication administration in a child with autism

Children with autism often display difficulty with swallowing pills and liquid medications. In the current study, stimulus fading and positive reinforcement established compliance with liquid medication administration in a young boy with autism. The boy's mother eventually administered liquid medication on her own.     

Behavioral momentum in sports: a partial replication with women's basketball

Previous research has applied the behavioral momentum metaphor to men's college basketball. In the current investigation, the relative rate of reinforcement prior to and following adversities (e.g., turnovers, fouls) and periods of time-out were examined in a subset of women's college basketball games.     

Replication of a high-probability request sequence with varied interprompt times in a preschool setting

An intervention for noncompliance consisting of a series of requests promoting a high probability of compliance followed either 5 s or 20 s later by a request with a low probability of compliance was implemented with a preschool child with autism. Results indicated that applications of the request sequence with a shorter interprompt time resulted in higher rates of compliance, and longer interprompt times resulted in near-baseline rates of compliance.     

Behavioral momentum theory: equations and applications

Behavioral momentum theory provides a quantitative account of how reinforcers experienced within a discriminative stimulus context govern the persistence of behavior that occurs in that context. The theory suggests that all reinforcers obtained in the presence of a discriminative stimulus increase resistance to change, regardless of whether those reinforcers are contingent on the target behavior, are noncontingent, or are even contingent on an alternative behavior. In this paper, we describe the equations that constitute the theory and address their application to issues of particular importance in applied settings. The theory provides a framework within which to consider the effects of interventions such as extinction, noncontingent reinforcement, differential reinforcement of alternative behavior, and other phenomena (e.g., resurgence). Finally, the theory predicts some counterintuitive and potentially counterproductive effects of alternative reinforcement, and can serve as an integrative guide for intervention when its terms are identified with the relevant conditions of applied settings.     

The effects of a high-probability instruction sequence and response-independent reinforcer delivery on child compliance

We compared the effects of a high-probability (high-p) instruction sequence and a fixed-time (FT) schedule of reinforcement on the compliance of 2 typically developing children. A multielement experimental design with a reversal component was implemented according to a multiple baseline across participants arrangement. Both the high-p and FT conditions resulted in increased compliance for both participants during the multielement sessions. These results suggest that it may be possible to increase compliance without a response requirement of the type arranged in the high-p instruction sequence.     

Aversive-Nonaversive Issue: Tip of the Iceberg

ABSTRACT

This article addresses the lack of communication between child behavior analysis (CBA) and what has been referred to as “mainstream clinical child psychology” (MCCP). It is suggested that the emotionality of the aversive-nonaversive debate is attributable in part to a lack of information exchange among these two sub-specialties. Distinct contributions of CBA and MCCP are examined in each of the following four areas: population, assessment, research, and treatment. Recommendations are made for enhancing child clinical psychology by (a) promoting constructive communication, and (b) integrating components of the two approaches.     

Increasing compliance with medical examination requests directed to children with autism: effects of a high-probability request procedure

The purpose of this study was to evaluate the effectiveness of a high-probability (high-p) request sequence as a means of increasing compliance with medical examination tasks. Participants were children who had been diagnosed with autism and who exhibited noncompliance during general medical examinations. The inclusion of the high-p request sequence effectively increased compliance with medical examination tasks. In addition, the procedure was efficient, could be implemented by parents and medical professionals, and did not involve aversive procedures.