Reducing problem behaviors in a residential unit using structural analysis and staff management procedures: A preliminary study

A structural analysis of the problem behaviors of 32 adults with mental retardation living together in a residential facility showed that a disproportionate number of these behaviors were associated with a period of time scheduled for leisure activities. A staff management program was implemented during this time which included activity and staff scheduling, staff inservice training, and staff performance monitoring and feedback. The results showed an 83% decrease in problem behaviors when the program was implemented during the leisure period and no decrease in problem behaviors during adjacent time periods where the program was not utilized. Follow-up assessments indicated maintenance of these decreased levels of behavior at 3 and 6 months. It was concluded that this approach of combining a structural analysis with staff management procedures was effective in reducing a high level of problem behavior in a residential setting. The results are discussed with regard to pragmatic strategies for the pretreatment analysis of problem behaviors in residential settings, and the role of organizational behavior management techniques in habilitative programing for individuals with behavior disorders.     

Behavioral Pediatrics: A Team-Based Interprofessional Approach

An interprofessional approach to pediatric behavioral care is increasingly important in the care of pediatric patients, who present to healthcare settings with a wide variety of concerns ranging from potty training to depression. Previously, much of the care of these patients have focused on a narrow approach to the problem, based on the expertise of the professional providing care. Faculty from three disciplines: Social Work, Psychology, and Medicine collaborated to design a course for students from these three disciplines to collaborate in attaining three goals: (1) reinforce the importance of multidisciplinary collaboration, (2) share clinical techniques and skills in a simulated interprofessional setting, and (3) practice collaboration within interprofessional teams. We detail the course goals and design and topics covered and discuss implementation of this course. Suggested module content and pedagogical design are discussed, and case examples are detailed with the goal of encouraging the adoption of similar courses.

     

An Empirically Supported Framework for Addressing Pediatric Nonalcoholic Fatty Liver Disease in Outpatient Care

In the wake of the pediatric obesity epidemic, the prevalence of nonalcoholic fatty liver disease (NAFLD) has been rising. Standard care for pediatric NAFLD includes dietary and physical activity guidelines, but such recommendations are difficult for families to implement. Clinicians in medical settings may be called upon to address NAFLD; cognitive behavioral techniques that have been effectively used for pediatric obesity are likely applicable. However, given the unique circumstances surrounding NAFLD, it may be helpful also to incorporate community-based and telehealth strategies when assisting families. This treatment development report offers a framework for integrating cognitive behavioral techniques within a community-based, telehealth approach to treating NAFLD within a medical setting. A series of illustrative cases is presented to depict exemplary considerations for implementing this intervention.     

A Brief Alcohol Intervention During Inpatient Psychiatric Hospitalization for Suicidal Adolescents

Alcohol use and suicide-related thoughts and behaviors are common in psychiatrically hospitalized adolescents and each problem can exacerbate the other. Despite knowledge about the functional relationship between alcohol use and suicide-related thoughts and behaviors, inpatient psychiatric units only cursorily address alcohol use because suicide risk is considered primary. In this paper we provide theoretical and empirical rationale for the inclusion of brief motivational interventions for alcohol use in inpatient treatment settings for suicidal adolescents. We give a case example of the brief intervention in practice, including when and how to use specific techniques. Following the case example, we discuss the flexibility of this intervention and how it can be adapted for adolescents with varying risk profiles. We conclude with recommendations for future research, including the development and testing of technology-based boosters following hospital discharge.     

Implementing Cognitive Behavioral Therapy in Specialty Medical Settings

This article is an introduction to the second issue of a two-part special series on integrating cognitive behavioral therapy (CBT) into medical settings. The first issue focused on integrating CBT into primary care, and this issue focuses on implementing CBT in other specialty medical settings, including cancer treatment, HIV care, and specialized pediatric medical clinics. Models for treatment delivery to improve ease of implementation are also discussed, including telehealth and home-delivered treatment. The six articles in this series provide examples of how to transport CBT techniques that are largely designed for implementation in outpatient mental health settings to specialized medical settings, and discuss unique considerations and recommendations for implementation.     

The consistency of a class of coercive child behaviors across school settings for individual subjects

This study addressed the problem of the intraindividual consistency of a class of coercive child behaviors across two school settings. Observational data were collected on eight coercive behaviors of 53 boys in classrooms and on the playground. Previous Guttman scale analyses had shown that these eight coercive behaviors constituted a response class. The rates of the eight coercive responses in the response class were rank ordered separately for each of the 53 subjects in each of the two settings. The intraindividual rank order correlations were all positive, and 37 were statistically reliable. This number of significant correlations was further shown to be significantly greater than chance. It was concluded that there is a substantial amount of crosssituational consistency if intraresponse class analyses are done for individuals.This study was supported by the National Institute of Mental Health, through Grants l RO1 MH 31017 and 1 ROI MH 33067. The authors wish to thank all of the people at the Oregon Social Learning Center for their support. Particular appreciation is given for the continued help and encouragement received from Gerald R. Patterson.     

基于气质视角的情绪调节与儿童问题行为

问题行为作为儿童期的异常行为妨碍儿童正常的社会适应, 通常包括内化和外化问题行为。儿童情绪调节功能的异常被认为是其主要影响因素, 相关成因亦源于儿童自身的气质特征。在对国内外相关研究梳理的基础上, 从气质的四个维度出发(积极情感/接近、恐惧/行为抑制、愤怒/烦躁、努力控制)分析了情绪调节与常见调节策略对儿童问题行为的影响及相应的情绪调节训练干预。未来研究应结合儿童气质特征, 深入探讨气质各维度之间的交互作用与儿童情绪调节以及问题行为之间的关系, 并在纵向研究中加入神经生理相关技术, 考察三者在儿童发展过程中的关系, 此外还应开展国内本土化研究, 开发适合我国问题行为儿童的实践干预方案, 促进儿童情绪社会化的健康发展。     

Promoting Nurturing Environments in Afterschool Settings

Given the rise in dual-career and single-parent families, and the need for monitoring and supervision during out-of-school time, afterschool settings are becoming important contexts for the prevention of problem behaviors and the promotion of the positive development of youth. Research indicates that high-quality afterschool programs can have positive effects on children’s academic, socio-emotional, and behavioral outcomes. But less is known about how these influences occur and potential mechanisms involved in this nurturing and promotion process. This paper draws upon the current theoretical and empirical literature in school settings and beyond to examine ways in which afterschool settings can be leveraged as a potential nurturing environment. We apply the conceptualization of nurturing environments put forth by Biglan et al. (Am Psychol 67(4):257–271, 2012. doi: 10.1037/a0026796), which attends to the minimization of toxic social and biological conditions, reinforcement of diverse prosocial behaviors, limiting opportunities and influences for problem behavior, and promoting psychological flexibility in the pursuit of one’s values and goals. This paper concludes by identifying potential future research directions and practice implications regarding afterschool settings as nurturing environments for all youth.     

Multiple reinforcement contingencies to reduce aggression,self-injury and dysfunctional verbal behaviors in an adult who is sensory impaired

Differential reinforcement of other behavior (DRO) and differential reinforcement of low rates of responding (DRL) have been effective techniques in reducing maladaptive behaviors in therapeutic settings. Reported studies of these reinforcement-based procedures indicate that they are usually implemented in isolation, targeting only a single behavior or class of behaviors. In this study, multiple DRO and DRL contingencies were utilized concurrently in reducing two distinct classes of behaviors with a 26 year-old blind man with moderate retardation. One class of behaviors included socially inappropriate verbalizations, while the other included aggressive, self-injurious and environmentally destructive behaviors. Distinct contingencies were established according to the functions of the targeted behaviors and their severity and separate schedules of reinforcement were derived from baseline frequencies. Over a period of 20 months, the differential reinforcement interventions resulted in rapid reduction of behaviors in both classes to near-zero rates and frequencies were maintained at this low level while contingency schedules were systematically lengthened. Collateral effects are discussed including performance in functional academics and participation in community integration activities.     

Parents, infants, and day-care teachers: Interrelations and implications for better child care

Many young children are reared today in both family and child-care settings. The relation that exists between these two settings has important implications for child care. Bronfenbrenner's (1979) ecological model is used as a way to view the interrelations among children, families, and child-care programs. Data from a study of infants in day care provide information on the time infants spend in family and day-care contexts, how parents and caregivers view children's behavior in these two settings, and rates of otitis media (ear infections) and other illnesses for these children. Results show that infants spend about twice as many hours per day awake with parents as in day care. Regarding child behaviors, parents and caregivers seem to have similar behaviors they like and dislike, but they each see particular children quite differently with respect to these behaviors. Finally, infants in this sample were diagnosed with illnesses 60% to 70% of the time. Findings are discussed in terms of the ecological model with particular attention given to relations between parents and caregivers.     

Setting up inpatient behavioral treatment programs: The staff needs assessment

Despite the success that behavior therapy has demonstrated in treating severely mentally ill adults, widespread impact of behavioral treatments on this population has been limited because the staff of many inpatient settings do not routinely utilize these strategies. Surveying staff regarding their perception of programatic and organizational needs is proposed as a valuable first step for selecting behavioral strategies to be introduced in these settings. Goldfried and D'Zurilla (1969) developed a behavioral assessment survey that is especially useful for identifying staff needs vis-à-vis behavioral rehabilitation. Using these strategies, survey questions addressed five problem areas: Administrative, Staff, Patient, Resource, and Programatic. Results using this survey with 40 clinicians on the extended care unit of a state hospital showed that staff members had greatest concern with the Patient Problem Area (i.e., aversive patient behaviors that are not sufficiently addressed by treatment plans). Further analyses showed staff members were interested in addressing Patient concerns using incentive procedures. The needs assessment in this study not only provided useful information that might be generalized to other treatment settings, but also showcased a reliable survey approach that program developers might implement prior to designing training curricula for behaviorally naive staff in inpatient settings.     

The structure of self-reported aggression, drug use, and delinquent behaviors during early adolescence

Examined the structure of self-report scales designed to assess the frequency of adolescent problem behaviors. Urban (n = 988) and rural (n = 1,895) middle school students completed the Problem Behavior Frequency Scale (Farrell, Danish, & Howard, 1992a) and measures of other relevant constructs. Confirmatory factor analyses supported a model that included specific factors related to aggression, drug use, and delinquent behaviors, and a higher order problem behavior factor. Findings did not support a distinction between physical and nonphysical aggression. Results were generally consistent across settings (i.e., urban vs. rural) and gender. Other relevant constructs, including peer pressure for drug use and attitudes favoring aggression, had both specific associations with relevant first-order factors and more general associations with the second-order factor. These findings support the construction of separate scales assessing specific domains of problem behaviors in studies of adolescents' problem behaviors.     

SOME STRUCTURAL ASPECTS OF DEVIANT CHILD BEHAVIOR1

Covariation within behavior repertoires of problem children were examined. Two boys, referred for psychological help, were observed both at school and at home for about 3 yr. A coded observation system permitted scoring of 19 child-behavior categories and six social-environment categories. After a two-month baseline, behavior categories were intercorrelated, demonstrating that each child showed a group of behaviors that covaried. These groupings were specific to the home and school settings. Contingency management procedures were then applied to each child's problem behaviors in one setting. Next, a reversal phase was instituted, followed by resumption of the initial contingency management phase. These three phases lasted seven months, until the end of the children's public school terms. Results showed that the baseline group of covarying behaviors continued to covary over the three experimental phases. The children then entered a remedial education setting for three summer months, and then returned to schools and were observed in follow-up for 2 yr. The baseline group of behaviors continued to covary during both phases. The behavior covariations could not be accounted for on the basis of temporal relationships between the behaviors and social environment categories. Although no behavior covariations extended across either child's home and school settings, contingency management procedures produced across-setting effects.     

CHARACTERISTICS AND TRENDS IN APPLIED BEHAVIOR ANALYSIS1

Characteristics and trends in applied behavior analysis were examined by evaluating the contents of the Journal of Applied Behavior Analysis (JABA) from 1968 to 1974. Investigations were categorized according to the settings, populations, target behaviors, and research methodology employed. The analyses, completed separately for each dimension, revealed a relatively high proportion of investigations conducted in classrooms, with children and adolescents, and for problematic-disruptive behaviors. Although research in each of these areas did not constitute the majority of JABA investigations, only two categories across each content dimension were required to constitute the majority. The majority of JABA research has been conducted in classrooms and institutional settings, with children and adolescents and retardates of all ages, and for problematic-disruptive and academic behaviors. Despite the relatively restricted focus, the proportion of investigations conducted in naturalistic or open-field settings (e.g., movie theaters, parks, zoos, busses) and, to a lesser extent, day-care facilities has increased in recent years. Also, the focus upon academic responses, training individuals to employ behavior modification, and community relevant behaviors (e.g., employment, littering) has increased. As expected, examination of research design and evaluation techniques revealed extensive reliance upon intrasubject replication designs. Indeed, the majority of investigations have employed reversal (ABAB) designs. Interestingly, the use of multiple-baseline and between-group designs has increased in recent years. Finally, the use of statistical tests, not at all a rarity in JABA investigations, has not systematically increased since the inception of JABA.     

Evaluating Treatments for Functionally Equivalent Problem Behavior Maintained by Adult Compliance with Mands During Interactive Play

A primary goal of behavioral interventions is to reduce dangerous or inappropriate behavior and to generalize treatment effects across various settings. However, there is a lack of research evaluating generalization of treatment effects while individuals with functionally equivalent problem behavior interact with each other. For the current study, the severe problem behavior of two participants with developmental disabilities was targeted for assessment and treatment. Results of a functional analysis indicated that for both participants, problem behaviors occurred when destructive behavior produced reinforcement of participant mands . The use of a multiple schedule that alternated between differential reinforcement of other behaviors and differential reinforcement of alternative behavior (mands) was sufficient to produce a significant reduction in problem behavior for one participant; the addition of differential reinforcement of alternative behaviors via compliance was necessary for the second participant. Extended treatment sessions, which focused on interaction between the two participants, involved one therapist concurrently implementing each participant’s treatment while they were directed to play with one another (a situation that previously evoked problem behavior). Results show that each participant’s treatment produced low to zero rates of problem behavior even during extended interactions.     

Development and Application of an Innovative Transdiagnostic Treatment Approach for Pediatric Irritability

Recent work has drawn attention to the previously underrecognized role that irritability plays in childhood psychopathology. Despite increased recognition of the clinical importance of pediatric irritability as a transdiagnostic symptom dimension, there is a lack of evidence-based treatments for this population that simultaneously and equitably addresses both child and contextual (e.g., parental) factors implicated in the development and maintenance of associated emotional and behavioral difficulties. In the current pilot study, we adapted the Unified Protocol for Transdiagnostic Treatment of Emotional Disorders in Children (UP-C) for the treatment of pediatric irritability in a sample of 19 children (ages 8 to 12) with primary presenting concerns of irritability and/or disruptive behaviors. Results supported the feasibility and acceptability of this treatment and provided preliminary evidence that such an approach may yield improved outcomes for symptoms of pediatric irritability and disruptive behaviors. Implications of these findings for future research and clinical interventions for pediatric irritability are discussed.     

Using the picture exchange communication system (PECS) with children with autism: assessment of PECS acquisition,speech, social-communicative behavior,and problem behavior

The picture exchange communication system (PECS) is an augmentative communication system frequently used with children with autism (Bondy & Frost, 1994; Siegel, 2000; Yamall, 2000). Despite its common clinical use, no well-controlled empirical investigations have been conducted to test the effectiveness of PECS. Using a multiple baseline design, the present study examined the acquisition of PECS with 3 children with autism. In addition, the study examined the effects of PECS training on the emergence of speech in play and academic settings. Ancillary measures of social-communicative behaviors and problem behaviors were recorded. Results indicated that all 3 children met the learning criterion for PECS and showed concomitant increases in verbal speech. Ancillary gains were associated with increases in social-communicative behaviors and decreases in problem behaviors. The results are discussed in terms of the provision of empirical support for PECS as well as the concomitant positive side effects of its use.     

Predicting Kindergarten Peer Social Status from Toddler and Preschool Problem Behavior

The aim of this study was to investigate the toddler and preschool predictors of early peer social preference. Behavioral and social functioning were examined in a sample of children across the toddler and preschool years from parent and teacher observations. Kindergarten social behavior and peer social preference were assessed in the children's kindergarten classrooms using standard sociometric techniques. Results indicated that parent report of toddler externalizing behavior and teacher report of preschool problem behavior, as indexed by aggressive behavior, social skills, and emotional regulation, were predictive of peer liking in kindergarten. However, this relation was mediated by specific behaviors evidenced in the kindergarten classroom. For boys, overt aggression mediated these relations. For girls, sharing and engaging in sneaky behavior in kindergarten mediated the relation between preschool problem behaviors and peer status. These results indicate that specific behaviors displayed in the peer group account for the relation between early problem behavior and peer status. Moreover, these data point to the importance of considering gender when examining developmental trajectories and outcomes.     

Dialectical Behavior Therapy for Adolescents: Theory, Treatment Adaptations, and Empirical Outcomes

Dialectical behavior therapy (DBT) was originally developed for chronically suicidal adults with borderline personality disorder (BPD) and emotion dysregulation. Randomized controlled trials (RCTs) indicate DBT is associated with improvements in problem behaviors, including suicide ideation and behavior, non-suicidal self-injury (NSSI), attrition, and hospitalization. Positive outcomes with adults have prompted researchers to adapt DBT for adolescents. Given this interest in DBT for adolescents, it is important to review the theoretical rationale and the evidence base for this treatment and its adaptations. A solid theoretical foundation allows for adequate evaluation of content, structural, and developmental adaptations and provides a framework for understanding which symptoms or behaviors are expected to improve with treatment and why. We first summarize the adult DBT literature, including theory, treatment structure and content, and outcome research. Then, we review theoretical underpinnings, adaptations, and outcomes of DBT for adolescents. DBT has been adapted for adolescents with various psychiatric disorders (i.e., BPD, mood disorders, externalizing disorders, eating disorders, trichotillomania) and problem behaviors (i.e., suicide ideation and behavior, NSSI) across several settings (i.e., outpatient, day program, inpatient, residential, correctional facility). The rationale for using DBT with these adolescents rests in the common underlying dysfunction in emotion regulation among the aforementioned disorders and problem behaviors. Thus, the theoretical underpinnings of DBT suggest that this treatment is likely to be beneficial for adolescents with a broad array of emotion regulation difficulties, particularly underregulation of emotion resulting in behavioral excess. Results from open and quasi-experimental adolescent studies are promising; however, RCTs are sorely needed.