Resurgence as Choice: Basic and Clinical Studies
Condition: Increasing Functional Communicative Behavior; Decreasing Destructive Behavior; Analysis of Treatment Dosage; Empirically Determined Reinforcement Schedule Thinning
Study type: Interventional

Summary: 
      Background: Functional communication training (FCT) is a commonly used intervention for
      teaching appropriate communication skills to children with intellectual disabilities who
      exhibit severe destructive behavior. Resurgence as Choice (RaC) Theory, a quantitative model
      of behavior, may help to explain why treatment relapse often occurs after FCT. This project
      will use the predictions of RaC to improve FCT treatments.

      Objective: To test the predictions made by RaC with human subjects who exhibit severe
      destructive behavior.

      Eligibility: Children between the ages of 3 and 18 who display destructive behavior that is
      maintained by social consequences, who have IQ and adaptive behavior scores between 35 and
      70, who are on a stable psychoactive drug regimen (or drug free) for at least 10 half-lives
      of each medication with no anticipated changes, and who have a stable educational plan and
      placement will be be eligible to enroll.
    

Detailed description: 
      Children with intellectual disabilities often display severe destructive behaviors that pose
      significant risk to self or others and represent barriers to community integration. These
      destructive behaviors are often treated with behavioral interventions derived from a
      functional analysis (FA), which is used to identify the environmental antecedents and
      consequences that occasion and reinforce (i.e., reward) the target response. One such
      treatment is called differential reinforcement of alternative behavior (DRA), which involves
      extinction (i.e., removal of rewards) of destructive behavior and reinforcement of an
      alternative communication response with the consequence that previously reinforced
      destructive behavior. Results from review studies indicate that interventions based on an FA,
      like DRA, typically reduce problem behavior by 90% or more.

      One commonly used DRA intervention is functional communication training (FCT). During FCT,
      clinicians withhold reinforcement for destructive behavior and teach the individual a
      functional communication response to access reinforcement. For instance, a clinician may
      teach the child to exchange communication cards to express their wants and needs. However,
      DRA interventions reported in the literature have typically been evaluated by experts in
      controlled research settings, and treatment relapse often occurs in the natural environment
      when a caregiver is unable reinforce the DRA response every time that the response occurs due
      to competing responsibilities. Accordingly, a recent investigation of 25 applications of DRA
      found that relapse of problem behavior occurred in 76% of cases.

      Resurgence as Choice Theory helps to explain why treatment relapse occurs under these
      circumstances and also provides mathematical equations that can be used to predict the
      variables that increase and decrease the likelihood that treatment relapse will occur. In
      this project, the investigators have used these equations to identify refinements to DRA that
      are likely to decrease the probability that treatment relapse will occur when the DRA
      response is not reinforced. In some cases, these refinements are at odds with what is
      recommended in the clinical literature on DRA. Therefore, it is important to compare these
      refinements that are derived from Resurgence as Choice Theory with current clinical practice
      in order to determine the best way to implement DRA, so that treatment remains effective when
      it is implemented with less than perfect precision by caregivers in the natural environment.

      The two predictions that are most relevant to our project are (a) resurgence of destructive
      behavior will decrease with increased DRA treatment duration, and (b) reinforcement schedule
      thinning show included slow, small decreases in reward deliveries (smaller than those
      previously reported in the literature). Accordingly, our project will examine the effects of
      different durations of DRA on resurgence and the effects of adjusting the schedule of
      reinforcement for each session to include slow and small decreases to avoid resurgence.
      Findings from this project could have vast clinical implications in that the investigators
      will demonstrate that time in treatment affects relapse and that schedule thinning can be
      accomplished without recurrence of destructive behavior. The investigators will compare
      short, moderate, and extended durations of treatment with DRA to identify the optimal
      duration of treatment to reduce the extent of relapse of destructive behavior. The
      investigators will demonstrate that the degree of relapse may depend on the length of
      treatment with DRA.

      The investigators will use measurements of destructive behavior, appropriate behavior, and
      reinforcer deliveries during each treatment session to inform the number of reinforcers that
      will be available during upcoming treatment sessions, informed by both the Resurgence as
      Choice (RaC) Theory and on the results of a coordinated study with nonhuman animals. The
      investigators will demonstrate that this schedule thinning progression is efficacious at
      maintaining an 85% reduction in problem behavior (i.e., relative to baseline) during each
      treatment session.
    

Intervention name(s): Functional communication training; RaC-enhanced functional communication training
Intervention type(s): Behavioral; Behavioral
Intervention description(s): During functional communication training (FCT), the social consequence (e.g., attention, toys, breaks from instructions) that heretofore reinforced destructive behavior (i.e., as determined through a functional analysis) is delivered contingent on an appropriate communication response, while destructive behavior is on extinction (i.e., reinforcers are no longer provided). For example, if a functional analysis shows that aggression is reinforced by escape from demands, FCT would typically involve (a) teaching the child to access breaks from demands via a functional communication response (FCR; e.g., saying, "Break, please") and (b) placing destructive behavior on extinction (i.e., continuing with scheduled demands independent of destructive behavior).; We will use the quantitative predictions of Resurgence as Choice (RaC) Theory to tailor a set of reinforcement-schedule thinning steps for each subject. This quantitative prediction will allow for dynamic decisions regarding how to conduct upcoming treatment sessions, as based on both the subject's recent response to treatment and the RaC equation.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Treatment
Keywords: Functional communication training; Reinforcement Schedule Thinning; Resurgence; Treatment Dosage; Treatment Relapse