Behavioral interventions can be grouped as either antecedent-based interventions (ABI) or consequence-based interventions (CBI). CBI is a group of practices in which the problem behaviors are addressed by manipulating the reinforcement or punishment stimuli following an observed behavior, whereas ABI refers to a group of behavioral interventions that are concerned with the modification of environmental factors that are believed to precede problem behaviors (Tullis, Cannella-Malone, & Payne, 2015). Therefore, ABI strategies are implemented before the problem behavior occurs, so their unique quality is the possibility of problem behavior prevention, which makes the behavioral change easier to maintain compared to results achieved with CBI strategies (Radley & Dart, 2016).
Although antecedent strategies can be used to modify behavior in various settings and apply to different populations, they are usually used for the reduction of non-compliant behaviors in children and adolescents (Radley & Dart, 2016). Some examples of non-compliant behaviors targeted by ABI strategies include academic engagement levels and transition behavior. Transition behavior is defined as “a teacher or other environmental prompt to cease an ongoing activity or task and begin to engage in another task” (Tullis et al., 2015, p. 91). Children with developmental disorders, such as autism spectrum disorders or Down syndrome, have transition-related disorders and low compliance rates in general, so ABI strategies are often used to address transitional task-related problem behaviors. ABI also proved to be successful for increasing compliance and addressing problem behavior among children without a psychological diagnosis (Wilder, Allison, Nicholson, Abellon, & Saulnier, 2010).
Established Intervention Methods
Changing problem behaviors with antecedent strategies is common for all ABI methods, so regardless of the intervention method used, planning an intervention depends on the assessment of problem behaviors. In order to determine the purpose or function of the problem behavior, various researchers and practitioners advocate the implementation of a functional behavior assessment (FBA) because it is considered to be the best practice for developing behavior intervention plans (Scott et al., 2005). However, Scott et al. (2005) found that an FBA alone cannot be used as a valid link between a function and intervention. Tullis et al. (2015) reported that most behavioral intervention studies do not use FBAs or functional assessments, and even though an assessment is useful for developing an intervention plan, they did not find an association between functional assessments and successful interventions. Therefore, most researchers agree that identifying the desired replacement behavior and choosing an appropriate intervention protocol are more important determinants of successful interventions compared to FBA (Scott et al., 2005; Tullis et al., 2015). The three ABI methods established in the literature include high-probability request sequencing (HPRS), noncontingent reinforcement (NCR), and functional communication training (FCT).
High-probability Request Sequence
The HPRS intervention is based on the theory of behavioral momentum, which was developed during the 1980s. Nevin, Mandell, and Atak (1983) found that a higher rate of reinforcement was associated with higher resistance to behavioral change, so they defined behavioral momentum as a dependent variable that can be used to measure the effects of learning conditions on behavioral response rates, as well as the persistence of response rates in modified conditions. The first application of the behavioral momentum theory in clinical practice was reported by Mace et al. (1988, as cited in Chavez, 2013), and it was found that “behaviors that have high rates of reinforcement helped maintain compliance to behaviors that have a low rate of reinforcement” (p. 14).
In order to implement the HPRS protocol, it is important to identify the requests with a low probability of compliance (i.e., low-p requests) and requests with a high probability of compliance (Radley & Dart, 2016). The interventionist then makes between three and five high-p requests before delivering the low-p request because conforming to a low-p request is more likely after the treatment subject conforms to several high-p requests (Chavez, 2013). The HPRS protocol proved to be useful for increasing compliance among both children and adults when it comes to transition-related tasks, food intake, social interaction, and academic engagement, but the protocol is less effective for adults than it is for children and adolescents between 3 and 18 years of age (Chavez, 2013).
HPRS intervention results are usually easy to maintain and persist even after the high-p requests fade or are completely removed, but it is important to note that long-term success in some cases can depend on the application of consequent strategies during the fading condition (Radley & Dart, 2016). Using programmed reinforcement and five-second inter-instruction intervals proved to be the most effective form of HPRS for increasing compliance among children with autism spectrum disorders (Pitts & Dymond, 2012). Zuluaga and Norman (2008) also found that compliance with low-p instructions is not always associated with increased compliance with high-p instructions, but providing some form of reinforcement following a low-p request compliance improves the chances of HPRS success.
An example of a HPRS intervention protocol is provided in Table 1. The case used to illustrate the application of HPRS is based on the study by Zuluaga and Norman (2008), in which the researches included a 4-year-old boy with developmental delay and non-compliance issues. The transitional behavior problems occurred when the boy was instructed to put on his shoes or to put away the toys. To improve compliance with the requests, the interventionists identified three high-p requests to use during the intervention and improve compliance with transition-related tasks.
High-probability request sequence example protocol
Source: Zuluaga and Norman (2008)
Ethical issues. Potential ethical issues associated with HPRS interventions include conflict of interest and the possibility of practicing psychology without informed consent. If the intervention is implemented by parents or teachers to increase the compliance of children, they will violate the American Psychological Association (APA, 2010) Standard 3.06, which states that taking on a professional role is not acceptable when personal interests can interfere with objectivity or competence. If parents or teachers attempt to teach children new behaviors, they could choose low-p requests that are in their best interests rather than those that are in the child’s best interests. Implementing HPRS without informed consent could be an issue if teachers implement the intervention without the parents’ consent because it would violate APA (2010) Standard 3.10, which states that informed consent is required to conduct assessments or interventions. Children are not legally able to provide informed consent, so their parents need to do it to prevent any ethical issues associated with informed consent.
Legal issues. If the intervention takes place in a school setting, it is important to consider that the Individuals with Disabilities Education Act of 1990 requires schools to support a least restrictive environment. That means children with disabilities should be educated with non-disabled children if the nature and severity of their disorders permits it. The implementation of the HPRS method should not lead to the segregation of children with disabilities because of the way teachers make requests during the intervention.
Socio-cultural issues. Increasing compliance by manipulating the sequence of requirements may go against the norms or customs of certain social groups. For example, fathers in Latino families expect a high degree of compliance from their children, and similar values may also be observed in non-Hispanic White families (Roosa, Morgan-Lopez, Cree, & Specter, 2002). Therefore, parents from families that have a firm hierarchical structure may be against implementing the HPRS method in cases when a child has no diagnoses that would warrant manipulating request sequences to achieve the desired response behavior to a prompt.
Non-contingent Reinforcement
NCR is an intervention method that consists of “the delivery of reinforcers according to some response-independent schedule” (Virues‐Ortega, Iwata, Fahmie, & Harper, 2013, p. 603). Therefore, even though NCR is based on Skinner’s theory of operant conditioning and implements positive or negative reinforcement to address problem behaviors, the stimuli delivery occurs independent of the person’s behavior (Panahon & Martens, 2013). For example, the interventionist can choose to deliver a stimuli every 30 seconds, even in situations when the person does not display problem behavior or replacement behavior. NCR proved to be effective for treating a variety of problem behaviors, including disruptive behavior, self-injury, and non-compliance (Dupuis, Lerman, Tsami, & Shireman, 2015).
The positive effects of NCR on problem behaviors is usually attributed to either satiation or extinction, and there is evidence that supports both explanations (Virues‐Ortega et al., 2013). Satiation refers to the frequent exposure to reinforcers, which is associated with the attenuation of problem behaviors. Extinction refers to the decrease of problem behavior once the response-reinforcer contingency is removed. Although interventionists can use various types of reinforcement procedures, some types of reinforcers proved to be more effective than others. Rispoli, Ganz, Neely, and Goodwyn (2013) found that non-contingent tangible reinforcement proved to be more effective in reducing problem behaviors in children with autism compared to non-contingent escape. Although escape extinction can be used effectively in many cases, it is best used in less severe cases because the problem behavior tends to worsen before extinction in those interventions (Dupuis et al., 2015). NCR can also be combined with contingent reinforcement, which is implemented upon the successful TK (Panahon & Martens, 2013)
An example of a HPRS intervention protocol is provided in Table 2. The example case is based on the case study conducted by Moore, Robinson, Coleman, Cihak, and Park (2016). The boy refused to engage in activities during class and disrupted other students, so non-contingent escape from learning activities was provided for the student. The researchers reported a reduction of disruptive classroom behavior and increased task engagement as a result of the intervention.
Non-contingent reinforcement example protocol
Source: Dupuis et al. (2013)
Ethical issues. According to Geiger, Carr, and LeBlanc (2010) the interventionist has an ethical obligation to improve the learning environment for children with disabilities rather than to teach them to tolerate ineffective environments. However, using NCR opens the possibility of teaching children to escape learning situations rather than address other factors that could contribute to their problem behaviors. For most children with disabilities, problem behaviors in educational settings are often associated with the need to escape from a situation or avoid it, and some factors that contribute to those behaviors are task difficulties, teaching pace, or teachers’ prompting strategies (Geiger et al., 2010). Therefore, for long-term success, interventionists need to ensure that their plans consider the improvement of the learning environment rather than focusing on escaping ineffective environments.
Legal issues. Interventionists can conduct NCR with positive or negative reinforcement, but the severity of the problem behavior needs to be considered because behaviors can sometimes escalate at the beginning of the intervention implementation (Dupuis et al., 2013). For example, an individual with aggressive behavior will more likely increase aggressive behavior in order to achieve a desired outcome, and the exacerbation of aggressive behavior may compromise the safety of others or increase the probability of self-injury. Therefore, the interventionist is legally liable for any damage resulting from an intervention that has a negative effect on the safety of the intervention subject or others.
Socio-cultural issues. The key socio-cultural issue that must be considered before the implementation of NCR is the relevance of the intervention to the needs of the individual’s cultural or subcultural group. The motivation to reduce problem behavior increases only when the content of the intervention is relevant to the norms, values, and developmental needs of groups (Castro, Barrera Jr, & Steiker, 2010). Therefore, interventionists working with children with disabilities need to take those factors in account when designing a behavior intervention.
Functional Communication Training
The FCT intervention is based on a differential reinforcement procedure, which is characterized by the following: (a) the reinforcer used is the same type as the reinforcement responsible for maintaining the problem behavior, and (b) the replacement behavior is a socially acceptable form of communication (Rooker, Jessel, Kurtz, & Hagopian, 2013). The implementation of FCT starts with two considerations: (a) the communicative response reinforcer and (b) the communicative response topography (Tiger, Hanley, & Bruzek, 2008). Identifying the reinforcer is the first step in which the interventionists observe environmental events to identify those factors that reinforce problem behavior. The interventionist can choose among several topographies (e.g., verbal, sign language, gestures, visual exchanges, or output devices) to encourage the desired response, but the selected response should require minimal effort and be socially recognizable.
FCT proved to be a useful intervention for several problem behaviors, including disruptive behaviors, self-injury, and aggression (Bonas, 2012). The application of FCT has been empirically supported for individuals with developmental disability, mental deficits, traumatic brain injuries, autism, attention-deficit hyperactivity disorder, and speech or language delays, but there is limited empirical support of FCT when it comes to addressing problem behaviors in children with no diagnoses (Tiger et al., 2008). Although FCT can be effective for resolving problem behaviors in adults, it is more effective for children and adolescents (Heath, Ganz, Parker, Burke, & Ninci, 2015).
An example of an FCT protocol is shown in Table 3. The example is based on the study by Wacker et al. (2013), in which the intervention was designed to teach children with mild disabilities to communicate their desire to change activities. However, the children were allowed to play with preferred toys only after complying with the parents’ requests. The number of tasks completed successfully before taking a break increased from two at the beginning of the intervention to eight at the end of the intervention. Extinction of the stimulus resulted in a slight resurgence of destructive behavior and reduction in successful communication, but improvements compared to baseline were observed.
Functional communication training example protocol
Source: Wacker et al. (2013)
Ethical issues. Few ethical issues have been associated with FCT in the literature, but it is important to note that some studies found that combining reinforcement with punishment in FCT (Tiger et al., 2008). However, the application of punishment for treating problem behavior raises various ethical issues, including possible child abuse, infliction of harm, harassment, and other issues. Punishment contingency as a form of therapy may be warranted and acceptable in cases of sever problem behaviors. For example, Hagopian et al. (1998, as cited in Tiger et al., 2008) found that adding a punishment contingency reduces problem behaviors in 90% cases that show no response to FCT with reinforcement alone.
Legal issues. In addition to ethical issues, the use of punishment in FCT interventions can raise various legal issues associated with abuse if inappropriate punishment methods are used. To avoid legal liability, some examples of acceptable punishment contingencies include room timeout and brief manual restraint (Tiger et al., 2008). If punishments are too severe for the behavior, they will not reduce problem behaviors and can be considered a form of physical or psychological abuse (O'Donohue, Fisher, & Hayes, 2004). Depending on local or federal laws, teachers may be obligated to include parents in their children’s education, so parents need to be involved in the planning and conducting an intervention that involves reinforcement or punishment of their children to avoid legal issues (O'Donohue et al., 2004).
Socio-cultural issues. FCT uses the reinforcer responsible for problem behavior to motivate socially-acceptable communicative responses, so it is important to consider how culture defines acceptable communicative responses (Castro et al., 2010). For example, collectivist cultures tend to have firm hierarchical relationships within social groups, so patients may not communicate in the same manner with their interventionist as they communicate with their peers.
Advantages and Disadvantages of Antecedent Interventions
The first advantage of ABI methods is the ability to implement the intervention in various settings, and they can also be used to address issues in different environments. Whereas some interventions are confined to clinical settings, ABI methods can be implemented in real world settings at home or in school. The second advantage of ABI methods is the temporal relation of the intervention to the problem behavior. ABI methods are implemented before a problem behavior occurs, so the interventions are able to prevent behaviors rather than allow then to occur before implementing consequence-based strategies. The third advantage of ABI methods is the applicability of interventions to address non-compliance regardless of the underlying diagnoses. Although the utility of FCT was not confirmed in children without a diagnosis, HPRS and NCR can improve compliance to requests even among children without a psychological impairment.
A significant limitation of the ABI methods is the possibility of implementing punishment to modify behaviors. HPRS and NCR methods benefit from adding behavior-contingent rewards to the interventions, but for FCT interventions, punishment proved to be an effective complementary strategy. If the interventionist chooses to use punishment in the intervention, it will be justified only in cases of severe problem behaviors that put the subject and others at significant risk. Another limitation is the possibility of planning interventions to increase compliance for requests that are convenient for teachers rather than those that are relevant to the development and future social integration of the child. That limitation is addressed with legal regulations that require teachers to involve parents in decisions concerning their children’s education.
Conclusion
HPRS, NCR, and FCT are antecedent intervention methods that have been extensively validated in the empirical literature, and those methods proved to be effective for treating problem behaviors in children with development disorders, autism spectrum disorder, speech or language delays, and various other psychological disorders. HPRS and NCR are also validated methods for increasing compliance in children with no diagnosis, but FCT did not prove to be effective in those cases. Although adults may also respond to antecedent interventions, those interventions are more effective for children and are usually implemented in clinical and non-clinical settings for increasing compliance with requests and preventing destructive or self-destructive behaviors.
The main advantage of antecedent interventions over consequence-based interventions is the temporal relation of the intervention to the problem behavior. The implementation of an antecedent intervention takes place before a problem behavior occurs, so the interventions focus on proactive prevention rather than reacting to problem behaviors. However, it is important to note that a combination of antecedent- and consequence-based interventions proved to be more effective than either of the two approaches. The implementation of contingent rewards can increase the effectiveness of HPRS and NCR, whereas punishment proved to enhance the success of FCT, but punishment is recommended only in the most severe and non-responsive cases to avoid potential ethical and legal issues.
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