Motivational Refinements for Decreasing Destructive Behavior

Recruiting at 1 trial location

Overseen By Daniel R Mitteer, Ph.D.

Age: < 18

Sex: Any

Trial Phase: Academic

Sponsor: Rutgers, The State University of New Jersey

Must be taking: Psychoactive drugs

Disqualifiers: Rett syndrome, Degenerative conditions, others

No Placebo Group All trial participants will receive the active study treatment (no placebo)

Compensation: Varies

Number of Visits: Unknown

Duration: 4 weeks

30 Participants Needed

Trial Summary

What is the purpose of this trial?

Destructive behavior represents a comorbid condition of developmental disability for which risk increases with intellectual disability severity, communication deficits, and co-occurring autism spectrum disorder. Destructive behavior, such as self-injurious behavior and aggression, causes harm to the child and others and increases the risk for institutionalization, social isolation, physical restraint, medication overuse, and abuse. Clinicians have used functional analyses to identify the variables that reinforce destructive behavior and to develop effective, function-based treatments. Functional communication training (FCT) is an empirically supported, function-based treatment that decreases destructive behavior. Using FCT, the clinician teaches the child to use a functional communication response (FCR) to request the reinforcer maintaining destructive behavior, while placing destructive behavior on extinction. For example, if functional analysis results showed that attention reinforced destructive behavior, the clinician would provide attention when the child used the FCR ("Play with me, please") and would not provide attention for destructive behavior. Two limitations of FCT are that (a) schedules of reinforcement maintaining the FCR must often be thinned gradually to levels that are practical for caregivers to implement consistently in the home and in the community, and (b) this necessary process of reinforcement schedule thinning regularly causes destructive behavior to increase following initially effective treatment, a form of treatment relapse called resurgence. The current project aims to improve these limitations of FCT by (a) hastening the process of reinforcement schedule thinning by removing unnecessary schedule-thinning steps using the results of a progressive interval assessment and (b) mitigating the resurgence of destructive behavior by providing stimuli that highly compete with the reinforcer maintaining destructive behavior. The investigators will conduct a randomized clinical trial to evaluate the extent to which these two promising refinements to FCT improve the process of reinforcement schedule thinning, and an exploratory experiment will examine the interactive effects of these two approaches. This novel project has the potential to substantially improve standards of care guiding the treatment of severe destructive behavior and to improve the long-term outcomes for children and families afflicted by these debilitating behavior disorders.

Will I have to stop taking my current medications?

The trial requires that participants be on a stable psychoactive drug regimen for at least 10 half-lives per drug or be drug-free. This means you may need to maintain your current medications without changes during the trial.

What data supports the effectiveness of the treatment PIA-Informed Schedule Thinning for decreasing destructive behavior?

Research shows that schedule thinning, a method used to gradually reduce the frequency of rewards, can effectively maintain positive behavior changes and reduce problem behaviors. Studies indicate that using signals to indicate when rewards are available helps make the treatment more practical and effective, supporting the use of schedule thinning in managing destructive behavior. ^{1 2 3 4 5}

Is schedule thinning generally safe for humans?

Research on schedule thinning, often used in behavior therapy, suggests it can be safely implemented with proper guidance, as it helps reduce problem behaviors without needing additional punishment. ^{1 3 4 5 6}

How is the treatment PIA-Informed Schedule Thinning different from other treatments for decreasing destructive behavior?

PIA-Informed Schedule Thinning is unique because it uses a method called schedule thinning, which gradually reduces the frequency of rewards given for good behavior, making it more practical for real-life settings. This approach is informed by the individual's behavior patterns and can include competing stimuli to help maintain low levels of problem behavior, unlike traditional methods that may not adapt to individual needs. ^{1 2 3 7 8}

Research Team

Brian D Greer, Ph.D.

Principal Investigator

Rutgers, The State University of New Jersey

Eligibility Criteria

This trial is for boys and girls aged 3-17 with developmental disabilities who exhibit destructive behaviors reinforced by social consequences, occurring at least 10 times a day. They must be on a stable drug regimen or drug-free, with no changes in educational placement expected during the study.

Inclusion Criteria

Stable educational plan and placement with no anticipated changes during the child's treatment

I've been on the same mental health medication for a while or not taking any.

I am between 3 and 17 years old.

Exclusion Criteria

A comorbid health condition or major mental disorder that would interfere with study participation

My protective supports and medication for self-injury are stable.

Occurrence of self-injury during study assessments that presents a risk of serious or permanent harm (e.g., detached retinas) based on routine clinical-risk assessment

Timeline

Screening

Participants are screened for eligibility to participate in the trial

2-4 weeks

Treatment

Participants undergo reinforcement schedule thinning using functional communication training (FCT) with progressive interval assessment (PIA) and competing stimuli

4 weeks

Multiple sessions per week

Follow-up

Participants are monitored for safety and effectiveness after treatment

4 weeks

Treatment Details

Interventions

• PIA-Informed Schedule Thinning
• PIA-Informed Schedule Thinning with Competing Stimuli
• Traditional Schedule Thinning

Trial Overview The trial tests two enhancements to Functional Communication Training (FCT) aimed at reducing destructive behavior: one speeds up reinforcement schedule thinning using progressive interval assessment; another adds competing stimuli to prevent relapse.

Participant Groups

Group I: Evaluation of PIA-Informed Schedule Thinning Experimental Treatment 2 Interventions

The goal of Arm 1 will be to will extend pilot work on the utility of individualizing the starting point for reinforcement schedule thinning based on the results of a progressive-interval assessement (PIA). The investigators will do so by conducting reinforcement schedule thinning using a multielement design in two separate contexts, one informed by the results of a PIA and another not so informed. The criteria for schedule thinning will be identical across both conditions but will be applied to each condition independently. Investigators will determine the efficiency of schedule thinning, reductions of destructive behavior, and durability of functional communication responses across the two conditions.

Group II: Evaluation of Competing Items Experimental Treatment 2 Interventions

The goal of Arm 2 will be to evaluate the utility of competing items (e.g., alternative reinforcement or activities) during schedule thinning. Both conditions will be informed by the PIA, similar to the experimental condition in Arm 1. PIA-informed schedule thinning with competing stimuli will be identical to that of PIA-informed schedule thinning, except (a) the therapist will provide continuous access to the highly competing stimulus identified by that participant's competing stimulus assessment (e.g., providing attention while an iPad is unavailable, playing music while working), and (b) it will occur in the other context (e.g., the yellow context). Investigators will determine the efficiency of schedule thinning, reductions of destructive behavior, the durability of functional communication responses across the two conditions, and resurgence of destructive behavior during prolonged periods of extinction.

Group III: Effects of Competing Items on PIA Outcomes Experimental Treatment 1 Intervention

The goal of Arm 3 will be to examine potential interaction effects between the above two experimental arms by conducting PIAs with no, low, moderate, and high competing stimuli to determine the schedule duration at which schedule thinning should commence with each competing stimulus. All participants will complete this arm prior to enrollment in Arms 1 or 2. The investigators will randomize the sequence of each of the four PIAs (PIA with no competing stimuli, PIA with low competing stimuli, PIA with moderately competing stimuli, PIA with highly competing stimuli) across participants.

Who Is Running the Clinical Trial?

Rutgers, The State University of New Jersey

Lead Sponsor

Trials

471

Recruited

81,700+

Findings from Research

The study evaluated a noncontingent reinforcement treatment that effectively established stimulus control, which helped in gradually reducing the reinforcement schedule, making it easier to implement in clinical settings.

The findings support previous research indicating that using stimulus control across different treatment components can enhance the effectiveness of behavioral interventions.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Multiple Schedules Facilitate Rapid Noncontingent Reinforcement Schedule Thinning. Kelley, ME., Clark, RJ., McGarry, KM., et al.[2023]

The paper reviews the importance of thinning reinforcement schedules after functional communication training (FCT) to manage excessive communication responses, which can make consistent reinforcement impractical in real-life situations.

It discusses various schedule arrangements and methods for effectively reducing reinforcement while maintaining low levels of problem behavior, highlighting the need for further research on managing the reemergence of such behaviors during this process.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Reinforcement schedule thinning following functional communication training: review and recommendations. Hagopian, LP., Boelter, EW., Jarmolowicz, DP.[2021]

In a study involving college students, both methods of thinning reinforcement—differential reinforcement of alternative behavior and differential reinforcement of other behavior—showed tolerance to problem behavior, indicating that both methods can be effective in reducing undesired actions.

However, the differential reinforcement of alternative behavior led to higher rates of contextually appropriate behavior, suggesting it may be a more effective strategy for promoting positive behaviors when reinforcement is delayed.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

A translational comparison of contingency-based progressive delay procedures and their effects on contextually appropriate behavior. Iannaccone, JA., Jessel, J.[2021]

Functional communication training (FCT) effectively reduces destructive behaviors while promoting acceptable communication responses, as demonstrated in 25 applications across 20 cases.

Using discriminative stimuli to thin reinforcement schedules for the communication responses helps maintain the effectiveness of FCT, reducing the reliance on punishment or additional interventions.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Functional communication training during reinforcement schedule thinning: An analysis of 25 applications. Greer, BD., Fisher, WW., Saini, V., et al.[2019]

The study evaluated methods to improve communication responses in individuals by using multiple reinforcement schedules, leading to quick reductions in destructive behavior in all 4 participants.

By assessing the initial duration of extinction and using competing stimuli, the researchers were able to effectively thin reinforcement schedules, achieving therapeutic goals more rapidly than traditional methods.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Procedures for determining and then modifying the extinction component of multiple schedules for destructive behavior. Miller, SA., Fisher, WW., Greer, BD., et al.[2022]

In experiments with rats, thinning alternative reinforcement using a progressive-interval schedule led to a significant resurgence of previously suppressed target behaviors, indicating that the method of reinforcement affects behavior recovery.

The study found that the timing of reinforcement and the overall rate of alternative reinforcement play crucial roles in the resurgence of behaviors, suggesting that understanding these mechanisms could help in behavior modification strategies.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

Resurgence and repeated within-session progressive-interval thinning of alternative reinforcement. Nist, AN., Shahan, TA.[2021]

Both fixed increment and adjusting interresponse time (IRT) schedules of noncontingent reinforcement (NCR) were effective in reducing self-injurious behavior (SIB) in three individuals diagnosed with mental retardation.

The study demonstrated that both methods maintained their effectiveness in suppressing SIB even as the reinforcement schedules were thinned, indicating their potential utility in behavioral interventions.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

A comparison of procedures for programming noncontingent reinforcement schedules. Kahng, SW., Iwata, BA., DeLeon, IG., et al.[2018]

In a study involving 3 clients with severe problem behavior, using fixed lean (FL) reinforcement schedules from the start led to quicker achievement of treatment goals for 2 out of the 3 participants compared to starting with dense-to-lean (DTL) schedules.

The findings suggest that beginning treatment with lean reinforcement schedules may be more effective and practical in reducing problem behaviors, potentially improving the overall efficiency of behavior-reduction interventions.

NCBI (Pubmed)

pubmed.ncbi.nlm.nih.gov

A comparison of dense-to-lean and fixed lean schedules of alternative reinforcement and extinction. Hagopian, LP., Toole, LM., Long, ES., et al.[2019]

References

1. Switzerland pubmed.ncbi.nlm.nih.gov

Multiple Schedules Facilitate Rapid Noncontingent Reinforcement Schedule Thinning. [2023]

2. Switzerland pubmed.ncbi.nlm.nih.gov

Reinforcement schedule thinning following functional communication training: review and recommendations. [2021]

3. United States pubmed.ncbi.nlm.nih.gov

A translational comparison of contingency-based progressive delay procedures and their effects on contextually appropriate behavior. [2021]

4. United States pubmed.ncbi.nlm.nih.gov

Functional communication training during reinforcement schedule thinning: An analysis of 25 applications. [2019]

5. United States pubmed.ncbi.nlm.nih.gov

Procedures for determining and then modifying the extinction component of multiple schedules for destructive behavior. [2022]

6. United States pubmed.ncbi.nlm.nih.gov

Resurgence and repeated within-session progressive-interval thinning of alternative reinforcement. [2021]

7. United States pubmed.ncbi.nlm.nih.gov

A comparison of procedures for programming noncontingent reinforcement schedules. [2018]

8. United States pubmed.ncbi.nlm.nih.gov

A comparison of dense-to-lean and fixed lean schedules of alternative reinforcement and extinction. [2019]