Types of treatment

Types of treatment

Since every behavior is different and should be analyzed for its intricacies, there is no universal treatment for every setting and/or individual.  As important as it is to generate individualized plans, it is also important to note that the most successful plans are often a combination of strategies from two or more of these approaches.  Such multi-component interventions have often been found to be more successful than counterpart programs focusing on only one technique, especially when dealing with multifunctional behaviors.  While the number of existing intervention strategies is very high, the approaches we will focus on can be grouped in four overarching categories.

Alternate Teaching
Alternate teaching is a proactive strategy through which individuals are taught and reinforced for engaging in appropriate alternative behaviors that satisfy the same function as target maladaptive behaviors. Communication skills are at the center of this approach and access to communication is key as it allows not only comprehension of instructions but also helps individuals communicate preferences, needs, and choices.   In addition to communicative goals, alternate teaching often focuses on training in social skills, assertiveness, problem-solving, self-control, compliance and patience as well as modeling, self-reinforcement and choice making opportunities.  New and emerging techniques that fall under the umbrella of alternate teaching focus on relaxation training, covert imagery and progressive muscle relaxation.   Sensory approaches also fall into this category in that reinforcing sensory characteristics of are identified and replaced with appropriate items that have similar characteristics.

The Environmental/Ecological Preventative Strategy

The Environmental/Ecological preventative approach revolves around the identification and modification of environmental antecedent factors and events, as identified through functional analysis, that cause and/or maintain targeted maladaptive behaviors.   Having an understanding of antecedents can help a care giver intervene earlier and preempt the inappropriate learned response.  Examples of such antecedent factors include task ease or difficulty, boredom and fatigue, fast/slow pacing of instruction, novelty of  material, excessive auditory (vs visual) processing, heat, light, sensory acuity, and poorly matched curriculum.  This antecedent-based strategy is particularly effective in the classroom setting as it directly combats the escape function of behavior.  The application of ecological strategies in the classroom might include student choice of activity and reinforcer, rearranging schedule, variation in lesson instruction/task difficulty, mixing of mastered and novel tasks, and errorless learning.  Accordingly, by reducing boredom and frustration the need for task escape/avoidance is also reduced.  Incidental teaching, or the use of “teachable moments” and Pivotal Response Training (PRT), or environment based trials that utilize natural consequences, are central to this approach.

Reinforcement-based Strategy

Reinforcement-based Interventions systematically reinforce desirable behaviors and reduce or eliminate reinforcers associated with undesirable behaviors.  A reinforcer can be defined as a stimulus (situation or event) that occurs in response to a behavior that increases or maintains the future likelihood of that behavior recurring.  Reinforcers are only effective if they are powerful enough to motivate behavior.  This strategy focuses not only on the systematic reinforcement of desirable behaviors, but on the elimination of stimuli that reinforce maladaptive behaviors.

In token programs, tokens are earned in response to appropriate and/or on-task behaviors and can be traded for desired activities, items, events, etc. based on a menu of predetermined reinforcers.

Nonexclusionary timeouts are those involving removal from reinforcing environment/situations in response to maladaptive behaviors.  Release from timeout paired with the opportunity to participate in reinforcing events is intended to motivate appropriate behavior and discourage maladaptive behaviors.

Differential reinforcement (DR) systems all focus on delivering reinforcement based on a set of predetermined and routine factors.

Punishment-based Strategy

Disciplinary based strategies utilize socially valid consequent stimuli, environmental or organismic,  that are reactive, and occur in response to a targeted behavior.  While positive and proactive strategies are preferable, according to ethical and moral considerations, there are situations where punishment strategies are rationalized and utilized.  Punishment strategies can vary in intrusiveness, and consistent reports across the literature explain that the least invasive procedure should always be used first.

Loss of earned reinforcers is an example of a minimally intrusive punishment.

Response blocking is a minimally intrusive punishment technique through which the therapist responds to the initiation of a target behavior by giving a verbal command to stop and/or a physical cue/block (hand prompt, touch chin, etc.) of the targeted behavior.

Another research based punishment technique is restitution, or the requirement of the individual to restore the environment to the status in which it was found before the behavior occurred.

The most intrusive, and, in turn, most controversial punishment methods include aversive stimuli and restraint.  These programs use aversive stimuli that decrease the probability that a behavior will reoccur in the future.  Aversive stimuli and/or restraint are almost always used in combination with other techniques and strategies.  Literature suggests that when such techniques are employed, like in the case described above, the goal should be to discontinue the use of aversive stimuli over time.