We Can Prevent Behavior/Emotional Disorders by Teaching Communication Skills

Ooh Ooh Ooh, They Finally Did It!

I am going to discuss some ideas I had after reading a useful meta-analysis about how to intervene with students referred for intervention or special education for Behavior and/or Emotional Disorders (B/ED).

The article is Practices Reflecting Functional Communication Training for Students With or At-Risk for Emotional and Behavioral Disorders: Systematically Mapping the Literature by Alexandra Hollo and Jonathan Burt and published in the journal Behavioral Disorders. If you cannot get access, please send me an email, and I will send you a copy.

An additional resource is Unidentified Language Deficits in Children With Emotional and Behavioral Disorders: A Meta-Analysis also by Hollo, Wehby, and Oliver.

This manuscript reviewed the use of communication-based interventions for students with B/ED. Hollo and Burt found that there is a lot of disagreement in the field and spotty implementation fidelity, but when functional communication skills are taught to students to get their needs met, challenging behaviors are dramatically reduced. Often these reductions in problem behaviors are great enough that the at-risk student no longer requires intensive interventions or special education (cf., here).

I specifically am avoiding discussing functional communication training in autism. In my experience, when dealing with autistic students, teachers and interventionists rely on ABA-flavored methods too highly and reduce the efficacy of communication training.

This blog post will evaluate the consequences and presentation of SLI in students with B/ED.  Solutions and intervention strategies discussed in the literature will then be unpacked, and a review of functional communication as an evidence-based solution will be undertaken. Finally, future directions and policy solutions will be discussed.

Speech and Language Impairments in Students with Behavioral or Emotional Disorders

Speech and language impairments (SLI) have been demonstrated to result in a wide range of behavioral and educational deficits (here, here). Often, these students can be referred to intervention for dangerous or challenging behaviors as a first step; with these referrals happening before interventions or evaluation for the SLI being considered (here). Further, teacher reports of student communication skills do not correlate with standardized assessment, with teachers assuming higher communication skills than the students possess (here).

Looking at it from the other side, there is a proportionally higher quantity of SLI in students receiving services for B/ED – including those students that legitimately have social and emotional learning deficits and behavioral disorders (here). Although at present the repercussions of this oversight have not been fully evaluated, data suggest that interventions addressing SLI and communication deficits greatly benefit students with B/ED in the K-12 educational setting.

Richman and Wacker stated:

The correlation between speech and language disorders and psychiatric disorders has been noted by numerous research teams and with a variety of methodological techniques (Benasich, Curtis, & Tallal, 1993; Glassberg, Hooper, Mattison, 1999; Griffiths, 1969; Hogan & Quay, 1984; Piancentini, 1987). These cumulative findings provide a rationale for the provision of early intervention services to children with speech and language problems in an attempt to decrease the probability of their developing behavioral difficulties. It also makes intuitive sense to assist young children with language difficulties to learn how to respond appropriately to parental requests and to assist the parents of these children how to deliver requests effectively.

Furthermore, it has been reported since the 1980s that K-12 students with B/ED show impairments for semantics and pragmatics of speech with relatively spared syntax (cf.here). In layman’s terms, students with B/ED struggle with word meanings but are okay with sentence structure. They also struggle with how to use language in social situations; which is called pragmatics–should be no surprise there. Access to a speech-language pathologist to work with the student on semantics and pragmatics has positive effects on students at risk for B/ED (see here, here, and here).

Functional Communication

To best describe Functional Communication Training, I refer to the following paper: Functional Communication Training: A Review and Practical Guide by Tiger, Hanley, and Bruzek.

Functional communication training (FCT) is a differential reinforcement (DR) procedure in which an individual is taught an alternative response that results in the same class of reinforcement identified as maintaining problem behavior. Problem behavior is typically placed on extinction (i.e., reinforcement no longer follows problem behavior). Functional communication training differs from other function-based DR procedures in that the alternative response is a recognizable form of communication (e.g., a vocalization, manual sign).

For those that read this blog, it may be a bit surprising I propose a method touted as being developed by ABA practitioners. I do this because functional communication training is just good teaching. And, frankly, like many other things, functional communication, under different titles, has been used extensively before the development of ABA as a field. What ABA has contributed is a unification and parameterization of methods.

Functional Communication Methods

Based on the manuscripts reviewed and meta-analyzed by Hollo and Burt, there appears to be a relative consensus among practitioners as to the form functional communication training takes when used as to intervene with students with B/ED.

The steps undertaken in the majority of the literature surveyed are as follows:

  • The behavior of interest is identified by interviewing stakeholders (e.g., teachers, paraeducators, parents, student) and by direct observation and data collection.
    • At this stage, it is essential to use objective descriptions or the behavior and avoid adjective use as much as possible.
    • Any severity or magnitude measurements need to be provided on a Likert scale rather than in a narrative description.
    • Data collection should be done across environments to ascertain if there are similar or different triggers for behavior in each setting.
  • A functional analysis is undertaken using an interview/observational approach. This means that an observer collects data regarding the antecedent leading to the behavior, the behavior itself, and the consequence that maintains the behavior (this is called the A-B-C method).
    • The observational and interview focus here is important as it is noninvasive to the student and does not require the individual collecting data to have a rapport with the child (cf., link).
    • An experimental functional assessment (like this that I described before) is not recommended for students with potential B/ED because they already demonstrate trust issues with authority, so intentionally triggering behaviors and recording the student responses can escalate into a dangerous situation for both assessor and student very quickly.
  • Taking the data from the A-B-C analysis, the team ascertains the function of the behavior, or what motivates and maintains the behavior.
    • In an educational context, the functions are most often simplified to the following: to gain attention, to escape or avoid a task or situation, or access to a tangible.
    • I disagree with limiting our analysis to these simplified categories, but this simplification can be used within an educational context for teaching communication skills.
  • Using the data from the above two steps, a replacement behavior is chosen, in functional communication, this is always a communication strategy. Importantly, this communication must result in the student meeting the same need as the problem behavior being targeted for intervention.
    • This takes the form, initially, of a script that can be easily remembered and recited by an agitated student
    • If a student struggles to speak when agitated, provide communication cards or hand signals that can be used as the communication. I have had numerous students that wrote: “I need a break” on a card while they were in crisis because they were beyond words. I accepted this as volitional communication and provided reinforcement.
    • If a student needs some kind of adaptive technology or additional supports to achieve communication, provide it as quickly as possible and teach how to use it.
    • A simple button programmed to say, “I need a break” or to request attention is often sufficient (inexpensive option here).
    • PECS or other picture communication systems are also useful for this purpose
  • The communication strategy is explicitly taught using direct or explicit instruction. This includes modeling correct and incorrect behaviors to the student so they understand what is required for them to get their needs met.
    • The explicit instruction method I describe is based on Anita Archer’s work and uses her methods.
    • Basically, the strategy is task analyzed and each nitty gritty point is explicitly taught to the student to mastery. Simply glossing over methods and assuming knowledge does not work. The student has to know what to do and the teacher has to be able to measure this ability.
    • You will often see it stated that students need to model both correct and incorrect procedures. I disagree with this because it facilitates the student being rewarded for inappropriate behavior. I believe the teacher models examples and non-examples and the student models only positive examples across various situations.
  • When teaching the student the replacement behavior or communication skill and afterward, a differential reinforcement strategy is employed in which the student is immediately rewarded for showing the replacement behavior at first and never rewarded for the problem behavior ever.
    • At the early stages, the teacher does need to drop everything and reinforce the communication skill as fast as humanly possible. The more immediate the reinforcement the faster the student will learn communication = reward.
    • So much as possible, the problem behavior is to be ignored, but it can be quickly and dispassionately consequenced if necessary (e.g., physical aggression targeting another student, sexual acting out, self-harm).
  • After the student is showing sufficient performance of the replacement behavior and the problem behavior appears to be approaching extinction, then the team devises a strategy to thin reinforcement. The strategies I recommend are best characterized by Greg Hanley (also see here for data on functional communication performance during reward thinning)
    • The teacher first increases the amount of time between the student using the replacement behavior and a reward. When at first reward was immediate, now the student has to learn to wait a reasonable amount of time (start with 10-15 seconds and increase from there as the student achieves success at any given delay).
    • Once this is tolerated, the teacher then may require an increasing number of replacement behaviors before receiving rewards. When at first the student was rewarded every single time they used communication, now they have to communicate more than once to contact reward (start with every other communication and increase from there as the student achieves success at any given interval).

Functional Communication Efficacy

Using these strategies, there appear to be both positive and negative effects of functional communication in schools. When functional communication training is carried out with high implementation fidelity, there is a net positive effect for both the student with B/ED being targeted for intervention as well as the class as a whole. Disruptions are reduced, and general behavior improves when classroom management includes a functional communication component (link, link, link). The other students learn these communication skills by observation. In the research reviewed, there appears a trend that the application of functional communication can be sufficient to prevent an at-risk student from requiring specialized services and removal from the general education setting (here).

Conversely, Hollo and Burt cite a wide range of studies that include elements of functional communication, but not a sufficient number of elements to consider the intervention valid. They describe situations wherein functional communication is used to design an intervention, but the verbal mands used by the students are ignored rather than rewarded. Teachers often feel they do not have the necessary time to dedicate to reinforcing communication. Hollo and Burt further identify a general difficulty within the literature to properly identify functional communication as different than more general differential reinforcement strategies, These discrepancies and lack of implementation fidelity need to be overcome to maximally prevent students with E/BD from being removed from the general education setting (for solutions see here, here, and here).

Conclusions / Path Ahead

Moving forward, it is essential that educators work to standardize methods for the intervention of problem behaviors. Within the research and education community studying students with autism, these definitions and methods have been relatively well established by the field of ABA.

Additionally, it is apparent that there is a need for more comprehensive evaluations including speech and language factors be carried out when a student is referred for special education services for B/ED. The lack of identification of SLI within the B/ED community poses a problem for special educators as the specialized programming required for these students may be misguided as they target behavior, rather than the potential communication disorders underlying the student’s difficulty.

Overall, functional communication is an effective strategy to reduce problem behavior in students with E/BD when implemented with fidelity. When there is a lack of fidelity or the plan does not focus explicitly on communication, this efficacy is eliminated. Further addressing the weakness of semantic and pragmatic components of language in students with E/BD provide an additional value for these students.


My specific proposal:

Some necessary background is that in the United States, based on IDEA (2004), students qualify for special education services under one of 13 categories. If a student has a documented SLI that results in a behavioral or emotional disorder, the primary educational disability is Speech and Language Impairment (SLI), not an emotional disturbance. More simply, if a student has challenging behaviors because they cannot communicate, any rational intervention must target building communication skills, and not target punishing or redirecting behaviors. Any special education for that student must be under an SLI label by law, as that is the disability that is impeding educational progress (OSEP Dear Colleague Letter here).

When a student is referred for interventions for challenging behaviors, the following steps should be carried out (in order as much as possible):

  1. The student will be screened for any potential speech and language impairments by trained staff or the speech and language pathologist assigned to the school
    • If a student has significant speech and language impairments, then a special education classification as SLI would be appropriate. The student also would qualify at that point for targeted speech therapy from a district speech-language pathologist.
    • If a student does not have significant speech and language impairments, it is still important l to improve student communication skills but they would not be given a special education classification as SLI.
  2. In parallel with step 1, a functional communication approach will be adopted as described above in collaboration with a speech and language pathologist.
    • The functional communication training will be implemented for 4 weeks. Data will be collected on problem behavior and communication.
    • This will fulfill the Tier 2 intervention requirements of the RtI/MTSS approach.
  3. If this approach is not sufficient, it will be continued with the addition of more targeted behavioral interventions
    • The functional communication training can be modified between the Tier 2 and Tier 3 steps to better target the behaviors, but it must be implemented with fidelity and data must be collected.
    • Additional interventions targeting the problem behavior and placing it on extinction will be combined with the functional communication training.
    • This will fulfill the Tier 3 requirements of the RtI/MTSS approach.
  4. A criterion for a classification of emotional disturbance will be evidence that functional communication training was insufficient to correct dangerous or challenging behaviors in the school setting.
    • This means the burden is on the district and school teams to demonstrate that SLI was specifically ruled out as a factor underlying any behavioral challenges.
    • This also supports the idea of the least dangerous assumption since teaching communication skills has no net deleterious effects on the student, whereas any gains in communication are beneficial regardless the effect on challenging behavior.

Finally, for anyone wanting to implement this approach, I have a series of data sheets available on Teachers Pay Teachers that may be helpful.


Please let me know your thoughts and experiences with this by commenting below!

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Moving Beyond ABA: How to do a Functional Analysis…

#Ooh Ooh Ooh! They Finally Did It!

“In all my years of doing Functional Analysis and treating problem behavior, I have never once, not once, been thanked by a parent for effecting a long-lasting, socially relevant change. None of them have been able to tell me I long-term changed their children’s lives for the better” – Greg Hanley, BCBA-D, Ph.D.

I recently went to a conference about critical issues impacting children and adolescents. I was hopefully optimistic that because the conference was in Utah there would not be too strong a focus on Applied Behavioral Analysis (ABA) as a primary treatment measure for autism.

Alas, I was slightly disappointed when I saw the presenter information and noticed Greg Hanley, Ph.D., BCBA-D was the keynote speaker and teaching all the sessions I was interested in. Anyone following this blog knows I do not put much stock in ABA as a science, which means I have a particular disdain for a rather large proportion of the methods used in ABA and have not shied away from being vocal about it. However, in speaking with my colleagues in the district office that are working toward their BCBA, I found out Dr. Hanley has a “unique and somewhat controversial approach” to functional analyses and the treatment of problematic and dangerous behaviors in autism, and that they were interested to see the “other side” of the debate among BCBA regarding treatment methods.

As a scientist and teacher, I do try to keep an open mind and I try very hard to give everyone the benefit of the doubt, so I took a deep breath, left my prejudice at the door (mostly), and focused on the science of what was being presented. All that being said, I am ecstatic I attended the conference as well as the fact I attended all of Dr. Hanley’s presentations. I enjoyed the presentations immensely and I left hopeful that the methods being used in ABA-based therapy are starting to evolve and treatments are becoming more humane – or at least some precedent is being laid down to justify such a movement.

I will refer the reader to the following links to get information about Dr. Hanley’s works I am speaking about. The first is his website outlining his methods. Under the presentations tab if you look at November 2-5, 2016 there are the powerpoints and handouts from the conference I attended. Relevant papers can be downloaded Here and Here (please contact me if you cannot get these or any articles I link to in this post, I have them and am very happy to share the science).


What is a “standard” Functional Analysis?

Before I dive further in, I do not mean to infer that all functional analyses are standardized tests. They aren’t. I use the term “standard” functional analysis in the same way Dr. Hanley does in his manuscripts. This means any functional analysis that isolates attention, escape, or tangibles as motivators will be referred as a “standard” functional analysis.

Rather than try to give an explanation of a functional analysis, I will give a pseudo-textbook definition and then explain quickly what it means. I leave deeper conversations regarding functional analyses, their validity, and methodology to others.

From Wikipedia:

A functional analysis is the most direct form of functional behavior assessment, in which specific antecedents and consequences are systematically manipulated to test their separate effects on the behavior of interest. Each manipulation of the antecedent and consequence in a particular situation is referred to a condition. In a functional analysis, conditions are typically alternated between quite rapidly independent of responding to test the different functions of behavior. When data paths are elevated above the control condition (described below) it can be said that there is a functional relation between that condition and the behavior of interest. Below, common examples of experimental conditions are described. A standard functional analysis normally has four conditions (three test conditions and one control):

Attention

In this condition, the experimenter gives the individual moderately preferred items and instructs them to go play. After that initial instruction, the experimenter pretends to act busy and ignores all bids for attention from the individual. If the individual engages in the behavior of interest, the experimenter provides the individual with attention (commonly in the form of a reprimand). Behaviors that occur more frequently in this condition can be said to be attention maintained.

Escape/Avoid

In this condition, the experimenter instructs the individual that it is time to work. After the initial instruction, the experimenter delivers a series of demands that the individual is typically required to complete (e.g. math problems, cleaning up, etc.). If the individual engages in the behavior of interest, the demand is removed and the child is allowed to take a break. Behaviors that occur more frequently in this condition can be said to be escape maintained.

Alone

Normally referred to as tangible condition. In this condition, the child is left alone with a variety of items to engage with. If the child engages in the behavior of interest, no programmed consequences are delivered. Behaviors that occur more frequently in this condition can be said to be automatically maintained.

Control (play)

In this condition, the child is allowed to engage with a variety of items during the session. No demands are placed on the child throughout the duration of the session. The experimenter provides attention to the individual throughout the session on any behavior that is not the target behavior. If the target behavior occurs, the experimenter removes attention until the behavior has subsided. This session is meant to act as a control condition, meaning that the environment is enriched for the purpose of the behavior not occurring. Said another way, by meeting environmental needs for all possible functions, the individual is not likely to engage in the behavior of interest. This condition is used as a comparison to the other conditions. Any condition that is elevated to a large degree form the control condition, shows a higher degree experimental control indicating the functional relationship between the specific environmental conditions and the behavior of interest.

In essence, a functional analysis is an experiment. The researcher, teacher, or behavioral analyst forms a hypothesis regarding the function of the behavior – or why the child engages in a certain behavior. They then place the child in a controlled environment and test their assumptions by repeatedly offering the child challenges by removing what they hypothesize the child wants and recording the responses. To preserve experimental replicability, the tangibles used in a standard analysis are held relatively constant across functional analyses, as are the escape and attention contingencies (where to escape and/or scripted attention).

The standard functional analysis can take hundreds of trials and takes a significant amount of time. If everything goes as predicted, the child will respond with a behavior when the experimenter removes the hypothesized contingency (attention, escape, or tangible), whereas removing the other contingencies will not result in similar flare-ups of behaviors. The standard functional analysis also interspersed free-play conditions they consider a control or no task condition. This differential effect is called “differentiation” and is the hallmark result of a behavioral analysis.

What is this new thing I am talking about (IISCA)?

What Dr. Hanley proposed in 2014 was a new way to perform a functional analysis. The quote I started this post with was what Dr. Hanley said as his motivation for changing how he does his functional analyses. He spent decades performing standard functional analyses and designing behavioral treatments based on the results of those analyses.

In his presentations, Dr. Hanley belabored a point I agree with entirely. He suggested it as a motivation for developing the IISCA and relying on open-ended rather than standardized interviews.

[F]rom a clinician perspective, it does not matter whether or not we can characterize the function of a behavior; just so long as we can identify the topography of the behavior and use our identified synthesized contingencies to turn the behavior on and off. If we can do that, then we can help the child or young adult. We get too bound up as BCBA and ABA therapists on characterizing the behavior that we forget that our goal is to help the child overcome problematic or dangerous behaviors. We get too bound up in positive and negative reinforcements and other definitions that we lose sight of our mission.

IISCA stands for Interview-Informed Synthesized Contingency Analysis. They chose to go with the clumsy acronym IISCA because it captures two procedural differences between this method and the traditional, “standard” functional analyses. The first is that the specific contingencies (and combinations thereof) assessed and materials used in the sessions are derived from the interviews, thus the analysis is interview informed rather than experimenter driven.

The first part of the IISCA is the open-ended interview (you can download the actual template here). This is important for two reasons: First, checklists like those commonly used by BCBA to interview parents tend to limit responses to multiple choices and thus can actually guide responses rather than allow parents or caretakers to report their experiences. And B, open-ended questionnaires take a lot less time to perform. Often, the checklist questionnaires take 60-90 minutes to perform, whereas the open-ended interviews take 30 minutes. Sometimes, parents even take the forms home, talk to their family, and return it at their leisure.

The second part that I will emphasize for the IISCA, and why I like it as a method, is that it accepts that reality is complicated. What I mean is that I have never met a child misbehaving for something as simple as “attention” or “escape”. I have never seen a student try to get out of doing work and being contented with fleeing from work to a corner of the room to do nothing. I also have never seen students seek any attention I am willing to give. They want a certain type of attention. Ditto for a tangible. Only rarely do children respond to any tangible-they prefer certain ones over others.

The IISCA method emphasizes the use of so-called “synthesized contingencies”. By “synthesized contingency”, Dr. Hanley (and I) is referring to the phenomenon that children tend to escape from tasks to play with toys while seeking attention from a preferred adult (i.e.,  escape to attention + tangible). Some children escape to predictability (i.e., they flee from unpredictability or transition to force the typical schedule). Others are rewarded by what is called “mand compliance”, or having adults comply with verbal demands. This is clearly a form of attention seeking, but it is qualitatively different enough that it needs its own category. Interestingly, in his presentations Dr. Hanlkey makes a point I agree with entirely:

The IISCA procedure also emphasizes using the specific reinforcers that the child responds maximally to. Oftentimes, they use whatever stimuli the parents bring with the child. The assumption is that there is a reason why the family brought those items: that reason is that those items sooth and calm the child.

Also, the IISCA emphasizes focusing on what are called precursor behaviors to the major problem behaviors. In other words, if a child always growls or yells prior to physically aggressing, then the experimenter or analysis terminates trials when the child growls or yells, rather than waiting until they engage in physical aggression.

Of interest is that the average IISCA takes approximately 30 minutes for the open-ended interview and then 30 minutes for the functional analysis. There are three 5-minute control sessions wherein the child is given access to reinforcers (even if that is adult attention, iPad, etc) regardless their behaviors. There are then three 5-minute sessions wherein the child is given demands and separated from the reinforcers. Once the child shows precursor behaviors the reinforcement is returned and the data are taken. Since the IISCA is only evaluating the synthesized contingency, there are only 2 conditions (control, experiment) and if there is differentiation, the IISCA is finished quickly (in one report Dr. Hanley suggests an IISCA can be performed in 5 minutes).

Another cool part with the IISCA, it has been shown to be easy enough a protocol that parents and teachers can replicate the findings of the experimenters, with only minimal training and assistance through Skype (manuscript here).

Is the IISCA really better?

Yes. Much better. In pretty much every way you can imagine.

I say this because the treatment informed by the IISCA is functional communication training (FCT). This means training the child to use communication to get reinforcement rather than using misbehavior to fulfill needs. Based on the literature, using the information obtained from the IISCA results in faster, more efficient, and longer lasting FCT than using information obtained through a standard functional analysis.  Below is a figure from a Master’s thesis showing that treatment based on standard functional assessments are much less reliable than those informed by an IISCA.

Basically, what this shows is that the kids are much more willing to use FCT to get their needs met if they are offered the entire reward (i.e., the synthesized contingency) rather than isolated attention, escape, or access to a tangible. They can even be taught to tolerate being told, “No” and tolerate rather long delays before receiving rewards because the reward is so salient when it is finally presented.

Conclusion

Overall, I am excited to see this new direction in the ABA community and I hope it will be implemented in the larger ABA community. For my part, I have already used the IISCA method twice this month and it works. It is basically the method I was using before to “figure out what is making this kid tick” as I put it, but it is nice to finally have a formalized method to follow so I do not have to keep justifying my methods that always appear at odds with what other people are doing. I can vouch for the rapidity of the method and the validity of the data. The kids also seem to have much more fun during this type of functional analysis compared to the standard functional analysis.

In my opinion, although Dr. Hanley’s ideas are new and novel, we can and should begin to use them in schools to help our kiddos overcome behavioral challenges to access their education. This will improve these students’ quality of life greatly, and in the end that is all we are after.