Rethinking paradigms in geriatric ethics

This paper calls for a shift away from autonomy as the central value in geriatric ethics. In treatment and experimental settings, differences between older and younger adults are easily attributed to deficiencies on the part of the elderly when autonomy is the central value. Overemphasis on the concept of autonomy skews our understanding of human relationships toward excessively rational models, distracts attention from important physical and social characteristics of aged persons, and results in ethics by default. This paper describes several principles that would be more useful starting points than autonomy in developing a geriatric ethic.     

DEVELOPING A TECHNOLOGY FOR THE USE OF OPERANT EXTINCTION IN CLINICAL SETTINGS: AN EXAMINATION OF BASIC AND APPLIED RESEARCH

Extinction of operant behavior, which involves terminating the reinforcement contingency that maintains a response, is important to the development, generalization, and reduction of behavior in clinical settings. We review basic and applied research findings on variables that influence the direct and indirect effects of extinction and discuss the potential value of a general technology for the use of extinction. We suggest that current research findings are not sufficient for the development of a comprehensive, applied technology of extinction and provide extensive guidelines for further studies on factors that may affect the course of extinction in clinical settings.     

A METHODOLOGY FOR DISTINGUISHING BETWEEN EXTINCTION AND PUNISHMENT EFFECTS ASSOCIATED WITH RESPONSE BLOCKING

We present one method for distinguishing between extinction and punishment effects. The proportion of responses that produced a consequence (blocking) was varied while hand mouthing was treated in a man diagnosed with profound mental retardation. Response patterns across the schedule changes suggested that the blocking procedure functioned as a punishing event.     

COMBINING NONCONTINGENT REINFORCEMENT AND DIFFERENTIAL REINFORCEMENT SCHEDULES AS TREATMENT FOR ABERRANT BEHAVIOR

Research has shown that noncontingent reinforcement (NCR) can be an effective behavior-reduction procedure when based on a functional analysis. The effects of NCR may be a result of elimination of the contingency between aberrant behavior and reinforcing consequences (extinction) or frequent and free access to reinforcers that may reduce the participant's motivation to engage in aberrant behaviors or mands. If motivation is momentarily reduced, behavior such as mands may not be sensitive to positive reinforcement. In this study, for 3 children with aberrant behavior maintained by tangible positive reinforcement, differential-reinforcement-of-alternative-behavior schedules were superimposed on NCR schedules to determine if mands could be strengthened. Results for the participants indicated that NCR did not preclude reinforcement of mands.     

Direct assessment of quality of care in a geriatric nursing home

Direct observation was used to examine multiple aspects of care provided in a proprietary nursing home. The samples were taken at random intervals, 7 days per week for 5 weeks, across several categories of environmental and resident conditions as well as staff and resident activity. Results showed a high degee of compliance with predefined standards (based on current federal regulations) for environmental and resident conditions. Overall distributions of resident and staff activity showed results similar to those found in previous studies, with residents spending most of their time engaged in nonsocial activity and staff spending the majority of their time engaged in nonresident work. When data were analyzed across areas of the facility, times of day, and weekdays versus weekends, some differences were noted. Weekend versus weekday comparisons showed higher resident:staff ratios on weekends and more resident inactivity, but no significant differences in environmental or resident conditions. In addition, more frequent resident care, resident interaction, and resident activity were observed in Medicare units than in non-Medicare units. Results are discussed in terms of federal requirements for monitoring the quality of care in nursing homes and the potential use of time sampling expressly for this purpose.     

NONCONTINGENT ESCAPE AS TREATMENT FOR SELF-INJURIOUS BEHAVIOR MAINTAINED BY NEGATIVE REINFORCEMENT

We extended research on the role of noncontingent positive reinforcement following a functional analysis of attention-maintained self-injurious behavior to self-injury maintained by negative reinforcement in 2 young males with developmental disabilities. During a pretreatment functional analysis, each participant's self-injury was shown to be differentially sensitive to escape from instructional activities as negative reinforcement. During noncontingent escape, escape from learning activities was provided on a fixed-time schedule that was not influenced by the participant's behavior. One participant was also exposed to differential negative reinforcement of other behavior. During this condition, escape from instructional activities was provided contingent on the omission of self-injury for prespecified intervals. Results showed that the provision of escape, even when noncontingent, resulted in significant reductions in self-injury. These results are particularly interesting in light of the experimental history of noncontingent reinforcement as a control rather than as a therapeutic procedure. Noncontingent escape is discussed as a form of extinction that may be less likely than other forms of extinction to produce severe side effects.     

DOES FUNCTIONAL COMMUNICATION TRAINING COMPETE WITH ONGOING CONTINGENCIES OF REINFORCEMENT? AN ANALYSIS DURING RESPONSE ACQUISITION AND MAINTENANCE

We examined the effectiveness of functional communication training (FCT) in reducing self-injurious behavior (SIB) and in shaping an alternative (communicative) response while SIB continued to be reinforced. Following a functional analysis of 3 individuals' SIB, we attempted to teach an alternative response consisting of a manual sign to each individual, using the reinforcer that maintained SIB. When FCT was implemented without extinction, SIB remained at baseline rates for all participants, and none of the participants acquired the alternative response. When extinction was added to the training procedure, SIB decreased and manual signing increased for all participants. To determine if signing, when established, would compete with SIB when both were reinforced, extinction was then withdrawn. Signing was maintained and SIB occurred at low rates for 2 individuals, but SIB returned to baseline rates for the 3rd individual, necessitating the reimplementation of extinction. These results suggest that it may be difficult to establish alternative behaviors if inappropriate behavior continues to be reinforced, but that, when established, alternative behavior might compete successfully with ongoing contingencies of reinforcement for inappropriate behavior.     

NEGATIVE SIDE EFFECTS OF NONCONTINGENT REINFORCEMENT

Noncontingent reinforcement (NCR) has emerged as a treatment package for severe behavior problems. Although concerns about potential side effects (such as incidental reinforcement) have been raised, there have been few reported negative side effects in published studies to date. In this article, we report an NCR treatment evaluation for severe aggression that produced (a) an extinction burst and (b) incidental reinforcement. These side effects were evaluated by examining within-session response patterns and response distributions. As a solution, a brief omission contingency was added to the reinforcement schedule. The omission contingency resulted in decreased aggression rates.