Increased Treatment Intensity Promotes Reduced Attrition in Parent Training Programs for Children With Challenging Behavior

Design

We conducted a retrospective, nonrandomized quasi-experimental study comparing participants who self-selected into one of three treatment arms: high intensity (consisting of daily, two-hour appointments across two consecutive weeks), moderate intensity (consisting of twice weekly, two-hour appointments across five consecutive weeks), and low intensity (consisting of once-weekly, one-hour appointments across 10 consecutive weeks). Regardless of the treatment arm, caregivers received the same information regarding treatment expectations, goal setting, and the requirement for home-based practice between appointments. Caregivers were provided information about the structure of all three treatment intensities (i.e., high, moderate, low) during the initial intake appointment. While no participants in the current study switched intensity level mid-treatment, they were invited to discuss issues with treatment acceptability with their clinician to navigate their concerns. All appointments were scheduled prior to the commencement of treatment based on caregiver preferences.

Functional Behavior Interview

Prior to the start of treatment, all participants and their caregivers participated in a semi-structured functional interview designed to inform subsequent functional assessment procedures. Specific components of the interview included: (1) identifying and defining target behavior, and (2) discussion of antecedent and consequent events that reliably precede and follow challenging behaviors. Specific questions were designed to both solicit relevant clinical information as well as to orient caregivers to the functional perspective of treatment (Edelstein et al., 2023).

Functional Behavior Assessment

Specific assessment procedures were individualized based on the dimensions of the challenging behavior being targeted for reduction and the clinical needs of the patient and families. These empirically supported functional assessment procedures were based on the functional analysis (Iwata et al., 1984/92), with modifications to increase ecological validity. The range of empirically-supported functional assessment procedures include measurement of the latency to the first target response (e.g., latency analysis; Thomason-Sassi et al., 2011), programming reinforcement for responses within a response class rather than high risk target behaviors (e.g., precursor analysis; Smith & Churchill, 2002), increasing ecological validity through synthesized contingencies (e.g., IISCA; Hanley et al., 2012), limiting the number and duration of sessions (e.g., brief functional analysis; Northup et al., 1991), and antecedent manipulation through structured descriptive assessment (Fisher et al., 1998). Test conditions involved experimentally testing variables in the child’s environment thought to evoke and maintain challenging behavior. All assessment procedures included a control condition involving an enriched environment that served as a comparison to test conditions. Specifically, enriched environments typically included the presence of preferred toys/activities identified by participants themselves (e.g., iPads, coloring, toys) as well as the absence of adult directives. Observance of problem behavior in test conditions and absent in relevant control conditions confirmed the functional hypotheses and aided in selection of relevant treatment components. The test conditions of each participant’s functional assessment served as the baseline for within-appointment data analysis.

Treatment Evaluation

Treatment for all participants included a habituation paradigm designed to increase tolerance to aversive contexts. Session content focused on improving adaptive skills across up to four phases, based on the behavioral analytic literature to promote tolerance for delays to reinforcement (e.g., Akers et al., 2019): (1) reinforcing an appropriate communication as a functional replacement for challenging behavior (i.e., functional communication training; FCT), (2) tolerating delays to access to preferred items/activities, (3) tolerating denied access to preferred items/activities, and (4) a cooperation procedure to increase compliance with task demands.

When training children to wait, caregivers used a digital or visual timer and stimuli (e.g. “clinic rules”) to help them communicate expectations for waiting with their children. Clinic rules were individualized based on the developmental level of the child but generally included appropriate behaviors that were incompatible with challenging behavior (e.g., safe body, calm voice). Practice trials began by clinicians coaching caregivers to programmatically restrict access to preferred items with which the child was engaged (e.g., “it’s my turn”). During wait intervals, the child was not required to engage in any specific behavior; that is, all behavior other than challenging behavior was reinforced at the end of the interval (i.e., differential reinforcement of other behavior; DRO). If the child engaged in challenging behavior at any point during skills practice, the timer was paused and caregivers were coached to remain quiet until the rules for appropriate waiting were followed. Wait times begin at 5 s for each participant and increased systematically as children and caregivers demonstrated mastery over the components of the procedure. Terminal wait criteria were determined in collaboration with caregivers and ranged from 2 to 5 min in length. Importantly, children were taught to engaged in appropriate waiting behavior without access to distractors to increase their tolerance for restricted access (i.e. habituation; Edelstein et al., 2022). Children were required to demonstrate appropriate waiting behavior in the absence of problem behavior for at least two consecutive trials prior to moving to the next phase of treatment.

After children demonstrated appropriate requesting and waiting behavior at the predetermined terminal wait criterion, clinicians taught caregivers to deny access to preferred items/activities. During denial training, participants were required to demonstrate appropriate behavior following an instance where a request is denied. Following the denial statement from their caregiver (i.e., “no, that’s not available”) participants were required to demonstrate appropriate behavior (i.e. clinic rules) to earn access to alternate, lesser preferred activities. Denial trials were unsignaled to participants to ensure that practice sessions had external validity and occurred on an unpredictable schedule (variable ratio three; VR3) intermixed with wait trials. Once an item or activity was denied, it remained in the treatment space but unavailable for the duration of the appointment.

Finally, for those children whose challenging behavior were identified as maintained by social negative reinforcement (i.e. escape, avoidance), the task extension procedure was used to build caregivers’ instructional control over their child’s task completion. Task demands (e.g., activities of daily living, homework completion) were inserted into the wait interval to provide caregivers with opportunities to practice key components of delivering effective instructions (i.e. providing clear instructions, setting contingencies, following through). Contingent on their child’s task avoidance or refusal, caregivers were taught to pause the timer to provide a functional consequence (i.e. escape extinction) for poor cooperation. Once the wait interval ends, the child was permitted to take a break from the demand and access their requested item for a pre-determined period. Practice trials were repeated in this way until the required task demand has been completed.

Concurrent with child-based skills training, caregivers were taught to implement treatment procedures related to differential reinforcement (i.e., reinforcing only adaptive behavior consistent with the identified function of their child’s challenging behavior), delivering effective instructions (i.e. clear concise language, minimal prompting, and consistent follow-through), and contingency management (i.e., limit-setting and follow-through). During periods where participants earned access to positive reinforcement, caregivers were encouraged to play and attend to their children using behavior specific praise. That is, caregivers were coached by clinicians simultaneously while their child was engaging in practice trials. This concurrent skills practice allowed caregivers to see the clinician interacting with their child using the procedure with high fidelity. All target skills were taught to caregivers via behavioral skills training (i.e., instruction, modeling, rehearsal, and feedback) at each phase of the intervention. The process of providing skills feedback also served as the vehicle for data collection on treatment procedural fidelity.