Behavioral treatment of sleep dysfunction in patients with the Rett syndrome.

Aberrant sleep patterns are commonly experienced by girls with the Rett syndrome. In this investigation, the problematic sleep of three girls with the Rett syndrome was regulated using a bedtime fading procedure with response cost. The treatment involved systematically delaying the bedtime and utilized a response cost component, removing the child from bed for one hour, when the child did not experience short latency to sleep onset. Daytime sleep was interrupted, except during regularly scheduled naps. A fading procedure was then successfully utilized to advance the bedtimes. This treatment resulted in more regular sleep patterns for the girls by increasing appropriate nighttime sleep, reducing inappropriate daytime sleep and reducing problematic nighttime behaviors (e.g., night wakings). These preliminary findings are important because they suggest that the dysfunctional sleep patterns of girls with the Rett syndrome may be amenable to behavioral treatments.

Aberrant sleep patterns in children with the Rett syndrome.

Previous studies on the characteristics of disturbed sleep/wake patterns in children with the Rett syndrome have yielded inconsistent findings. In the current study, momentary time sampling procedures were used to measure the sleep/wake patterns of 20 girls with classical Rett syndrome. These patients had significantly more total sleep than age peers (M = 110.1; Zm = 2.58; p = .01), significantly less nighttime sleep (M = 80.8; Zm = -7.53; p less than .0001), and significantly more daytime sleep (M = 24.5; Zm = 8.71; p less than .0001). Night sleep was negatively correlated with age (r = -.59; p less than .01); day sleep was positively correlated with age (r = .54; p = .01). These girls also displayed night wakings on 20.9% of nights, delayed sleep onset on 67.8% of nights and early wakings on 24.5% of nights. These data clearly demonstrate that children with the Rett syndrome have markedly impaired sleep/wake patterns and suggests that the sleep dysfunction may worsen over time.

Integrating caregiver report with systematic choice assessment to enhance reinforcer identification.

To determine client preferences, we asked caregivers to rank-order, according to predicted client preference, a standard list of items and a list generated using a structured interview for caregivers, the Reinforcer Assessment for Individuals with Severe Disabilities. Systematic choice assessments were then conducted with both sets of stimuli. A concurrent operants paradigm was used to compare the reinforcing effects of the highest preference stimulus identified from each list. Results indicated that caregiver predictions of client preferences were slightly better for the set of stimuli they generated than for the standard set, and the choice assessment identified more potent reinforcers from the set of stimuli generated by the caregivers than from the standard set.

Using chronotherapy to treat severe sleep problems: a case study.

Chronotherapy was used to treat severe sleep problems (irregular sleep onset times, frequent night and early wakings, and short total sleep times) in a girl with mental retardation. Chronotherapy involved systematically delaying the child's bedtime each night while maintaining a regular schedule during waking hours until an age-appropriate bedtime was achieved. Immediate improvements in the child's sleep pattern were observed with the introduction of treatment, and an age-appropriate bedtime was achieved in 11 days. Four months of follow-up data indicated that improvements maintained in the home. Although chronotherapy was developed specifically for adults with delayed sleep phase insomnia, the current results suggest that the treatment may be useful for other populations and problems.

Bedtime fading in the treatment of pediatric insomnia.

In this paper, the sleep-wake cycles of two children with severe sleep problems were regulated by delaying bedtimes, thus increasing the probability of short latency to sleep onset. A fading procedure was then utilized to advance the bedtimes and gradually increase duration of sleep. Several treatments had previously been attempted with both of these patients without success. The advantages of this treatment over other interventions for pediatric sleep disorders are discussed.

Assessing independent and interactive effects of behavioral and pharmacologic interventions for a client with dual diagnoses.

Behavior analytic methods were applied to the assessment and treatment of the problem behaviors of an 8-year-old male classified as having moderate mental retardation and atypical psychosis. Functional assessment procedures demonstrated that verbal behaviors diagnosed as hallucinatory were affected by environmental contingencies. Next, a multi-element/multiple baseline design was used to evaluate the independent and interactive effects of contingency management and pharmacologic interventions on three dependent variables: (1) psychotic speech; (2) aggressive-disruptive behavior; and (3) appropriate speech. Results indicated that contingency management without haloperidol was the most effective treatment for all inappropriate and appropriate behaviors. These results are important in that behavior analytic methods were shown to have utility for: (1) assessing the functional relationship between environmental contingencies and behaviors related to differential diagnosis; and (2) evaluating the independent and interactive effects of behavioral and pharmacologic treatments.

Analysis of aberrant behaviour associated with Rett syndrome.

PURPOSE: The purpose of this study was to identify the variables involved in the maintenance of aberrant behaviours associated with Rett syndrome. The occurrence of aberrant behaviours associated with Rett syndrome is typically attributed to biological variables associated with the disorder. In some cases. however, these behaviours have been shown to be sensitive to manipulations of environmental variables (i.e. operant contingencies). However, little research exists regarding the variables involved in the maintenance of these behaviours and the manner in which these variables can be manipulated to effectively reduce the occurrence of these behaviours. METHOD: We conducted functional analyses of the aberrant behaviours exhibited by two females diagnosed with Rett syndrome. Following the functional analyses, treatments were developed to disrupt the relationship between the aberrant response and the reinforcer maintaining it. RESULTS: Results from the functional analysis suggested that in both cases the aberrant behaviours (i.e. hand wringing and hand mouthing) were maintained by automatic reinforcement. Treatment, which included interrupting hand wringing for one individual and preventing hand mouthing for the other participant, resulted in dramatic changes in the levels of aberrant behaviour for both participants. These changes suggested that preventing reinforcement delivery reduced the motivation to engage in aberrant behaviour. CONCLUSIONS: These results suggest that operant variables can be manipulated to influence the occurrence of aberrant behaviour associated with Rett syndrome.

Reinforcement of incontinent stools in the treatment of encopresis.

In this paper, fecal incontinence and constipation were treated in two mentally retarded individuals using a novel intervention wherein incontinent stools were first rewarded in order to increase the frequency of bowel movements. This intervention was implemented only after more traditional pediatric and behavioral treatments were unsuccessful. The reinforcement of incontinent stools procedure resulted in an increase in both the frequency and the number of continent stools for both individuals. Hypotheses regarding the failure of previous treatments and the success of the current treatment are discussed as well as directions for future research.

Enhancing child compliance with nebulized respiratory treatment. A case study.

A 2.7-year-old developmentally delayed boy diagnosed as having chronic lung disease, severe hyaline membrane disease, and persistent pulmonary hypertension with interstitial emphysema was referred in hopes of modifying his refusal to wear a mask during nebulized administrations of Chromolyn. The child was prescribed four 20-minute nebulized treatments daily but resisted treatment and removed the mask by turning his head and pushing the mask away with his hands. A procedure was implemented to gradually teach the child that turning his head and pushing the mask would not result in mask removal, and that by wearing the mask he would receive positive attention. By the end of treatment, the child was consistently wearing his mask for the required 20-minute intervals. Follow-up at 3 months confirmed maintenance of treatment effects.

The effects of noncontingent and contingent attention for self-injury, manding, and collateral responses.

To date, most functional analysis studies have focused on the effects of treatment contingencies on specific targeted aberrant and alternative responses. In the current investigation, the main and collateral effects of the assessment and treatment of attention-maintained self-injury were assessed. Specifically, we evaluated the effects of noncontingent and contingent social attention on four categories of behavior: self-injury, a novel mand, preexisting prosocial responses (e.g., babbling and reaching out), and other aberrant responses (i.e., aggression and destruction). Results suggested that self-injury, prosocial responses, and other aberrant behaviors were within the same functional response class. Possible impact of these results when selecting mands for functional communication training is discussed.

Comparing methods for maintaining the safety of a child with pica.

Pica, a potentially life-threatening behavior problem exhibited among persons with mental retardation is sometimes addressed by methods such as application of restraints to reduce or eliminate associated risks (Rojahn, Schroeder, & Mulick, 1980). However, restraints may be associated with decreases in social interaction and negative impact on quality of life. We evaluated two methods (restraint vs. no restraint) for maintaining the safety of a client with pica on three dimensions: (a) level of pica, (b) therapist effort, and (c) impact on quality of life. Both methods prevented pica, however, the no restraint condition required less therapist effort and had less negative impact on quality of life. All three dimensions were included in a clinical decision-making model to determine the least restrictive, safe level of restraint for a 4-year-old girl while assessment and treatment procedures were conducted. The clinical utility of this multifactor decision-making model is discussed.

Empirically derived consequences: a data-based method for prescribing treatments for destructive behavior.

Behavioral treatments are often prescribed on the basis of a functional assessment. However, in a significant number of cases, functional assessment results are equivocal or suggest that internal stimuli are maintaining the behavior. In this investigation, we evaluated an alternative data-based assessment that may be useful in such cases. This assessment was used to identify reinforcers and punishers based on the reinforcement assessment procedure described by Pace, Ivancic, Edwards, Iwata, and Page (1985). We then assessed whether empirically derived reinforcers and punishers could be combined to treat the destructive behaviors of two clients. For both clients, the rates of destructive behavior decreased markedly. The results suggest that empirically derived consequences may be useful in decreasing destructive behavior when a functional assessment is inconclusive or is consistent with the hypothesis that the behavior is stereo-typic and maintained by internal stimuli.

Stimulus control and resistance to extinction in attention-maintained SIB.

A functional analysis of the self-injurious behavior (SIB) of a young man diagnosed with severe mental retardation demonstrated that SIB was sensitive to social attention as reinforcement. In addition, lower but consistent rates of SIB occurred in sessions where a person was present (Demand and Toy Play), and a gradual decrease in SIB was observed across sessions where a person was not present (Alone). Evaluation of the within-session trends of SIB during the functional analysis demonstrated that SIB maintained throughout each Social Attention session and declined within and across Alone sessions. This pattern of responding suggested that the presence of a person may have differentially affected rates of SIB independent of the programmed consequences for SIB. In a subsequent analysis, SIB was reduced to near-zero levels in the absence of a person, but maintained in the presence of a person even when attention was withheld, suggesting that the response was highly resistant to extinction. The results of these assessments then were used to develop a treatment to reduce the client's SIB. During treatment, a person was present and delivered attention only when the client appropriately communicated. SIB resulted in the removal of the antecedent stimulus that exerted control over the response (i.e., the person left the room). The findings of this investigation are discussed in terms of the differential effects of stimuli on interpretation of functional analysis results and the subsequent development of treatment.

The establishing effects of client location on self-injurious behavior.

Three functional assessments were conducted with a client with self-injurious behavior (SIB), which indicated that SIB appeared to be sensitive to attention as reinforcement. In addition, levels of SIB were much higher when the client was seated in his wheelchair. An additional analysis was conducted in which client location (in and out of wheelchair) was altered while reinforcement contingencies (attention) for SIB were held constant. Levels of SIB again were higher when the client was positioned in his wheelchair, even though the consequences for SIB were identical. The results of this final analysis suggested that the wheelchair functioned as an establishing stimulus altering the efficacy of social positive reinforcement.

On the establishing and reinforcing effects of termination of demands for destructive behavior maintained by positive and negative reinforcement.

The results of functional analyses suggested that the destructive behavior of two individuals was sensitive to escape and attention as reinforcement. In an instructional context, we evaluated the effects of reinforcing compliance with functional reinforcers when destructive behavior produced a break. For one participant we also evaluated the effects of reinforcing compliance with functional reinforcers when destructive behavior produced no differential consequence (escape extinction). We hypothesized that destructive behavior failed to decrease in an instructional context when compliance resulted in a break because presentation of a break evoked attention-maintained destructive behavior. The results of a reinforcer assessment supported this hypothesis by demonstrating that demands functioned as positive reinforcement when no alternative activities were available. These results are discussed in terms of the importance of establishing operations in determining the appetitive or aversive properties of stimuli when destructive behavior is multiply controlled.

Noncontingent reinforcement: effects of satiation versus choice responding.

Recent research findings suggest that the initial reductive effects of noncontingent reinforcement (NCR) schedules on destructive behavior result from the establishing effects of an antecedent stimulus (i.e., the availability of "free" reinforcement) rather than extinction. A number of authors have suggested that these antecedent effects result primarily from reinforcer satiation, but an alternative hypothesis is that the individual attempts to access contingent reinforcement primarily when noncontingent reinforcement is unavailable, but chooses not to access contingent reinforcement when noncontingent reinforcement is available. If the satiation hypothesis is more accurate, then the reductive effects of NCR should increase over the course of a session, especially for denser schedules of NCR, and should occur during both NCR delivery and the NCR inter-reinforcement interval (NCR IRI). If the choice hypothesis is more accurate, then the reductive effects of NCR should be relatively constant over the course of a session for both denser and leaner schedules of NCR and should occur almost exclusively during the NCR interval (rather than the NCR IRI). To evaluate these hypotheses, we examined within-session trends of destructive behavior with denser and leaner schedules of NCR (without extinction), and also measured responding in the NCR interval separate from responding in the NCR IRI. Reductions in destructive behavior were mostly due to the participants choosing not to access contingent reinforcement when NCR was being delivered and only minimally due to reinforcer satiation.

A faded bedtime with response cost protocol for treatment of multiple sleep problems in children.

The sleep-wake cycles of 4 developmentally delayed individuals with longstanding severe sleep disturbances were regulated using a faded bedtime procedure with response cost. Bedtimes were systematically delayed for each individual, thus increasing the probability of short latency to sleep onset. The response cost component, consisting of removing the individual from bed for 1 hour, was implemented when an individual did not experience short latency to sleep onset. A fading procedure was then applied successfully to advance the bedtimes and to gradually increase durations of sleep. Specifically, all 4 individuals had decreased amounts of nighttime sleep that increased following treatment. Two of the 4 individuals showed excessive daytime sleep that decreased following treatment. Three of the 4 individuals experienced decreases in night wakings following treatment. Both environmental and biological manipulations of the sleep-wake cycle are hypothesized as mechanisms of treatment. The relative advantages of this procedure over other procedures for the treatment of pediatric sleep disorders are discussed, as are directions for future research.

Combining stimulus fading, reinforcement, and extinction to treat food refusal.

The food refusal of a 6-year-old girl with destructive behavior was treated using stimulus fading, reinforcement, and escape extinction. Intake increased and compliance with prompting procedures remained relatively stable despite the increased consumption requirement.

Analysis of free-time contingencies as positive versus negative reinforcement.

Providing a short break contingent on completed work may increase responding through positive reinforcement (e.g., access to preferred activities) or negative reinforcement (e.g., escape form work). In this investigation, three analyses conducted with a boy with profound mental retardation showed that (a) a 20-s break increased responding more than a positive reinforcer (cola) did, and (b) the reinforcing effect of a 20-s break were affected by the availability of positive reinforcers during the break were affected by the availability of positive reinforcers during the break.

Functional assessment and treatment of life-threatening drug ingestion in a dually diagnosed youth.

Few data exist on operant mechanisms associated with drug overdose. In this investigation, a functional analysis indicated that life-threatening drug ingestion exhibited by a dually diagnosed youth was maintained by negative reinforcement. An operant intervention, derived from behavioral assessment data, reduced drug ingestion to near-zero levels.