Severe Aggressive Behavior in an Advanced Learner Child: A Review

A quick reference to my title; I’ve never liked the designations of high and low functioning because they stereotype far more than describe. To that end, I typically use ‘early’ to ‘advanced learner’ instead.

While ‘low functioning’ can immediately lead to often mistaken perceptions of child capacity or competence, an ‘early learner’ designation may also be the result of ineffective instruction and unsuccessful environments rather than something within the child. So much of what we work with, from functional behavior to social deficits to communication to learning readiness to academic competence and adaptive skills, is much better configured as a learning and/or teaching concern; a potentially missed or misunderstood learning and/or teaching opportunity.

My writing and thoughts here were stimulated by a professional listserv in which I participate and an email asking for feedback with regards to persistent high intensity aggression in an advanced learner child. In that many of the key concerns identified are, in my experience, commonly held across the higher intensity behavioral spectrum, I saw this as a good scenario to present and discuss.

Pivotal concerns are as follows:

1. the ineffectiveness of planned ignoring or extinction procedures;

2. initial attempts to utilize escape extinction have been largely abandoned due to surges of behavior/child reactivity;

3. though acting out/aggression can get to a point where physical management and a brief need for restraint can become relevant due to safety issues, state and agency based guidelines seem to preclude restraint even for safety;

4. the child is very aware of and reactive to even small changes in the level of demands placed;

5. token economies are ineffective;

6. stronger reinforcing tangibles seem to wear off quickly since the child is typically able to access strong or stronger preferences later…or, in effect, self-reinforce/has strong control over own ‘reinforcement schedule’ by simply waiting out lower preference instructional sessions.

How many of these circumstances look familiar!

The first place to go is a brief discussion with regards to the use/applicability of restraint.

To begin with, physical restraint of any sort should absolutely and always be the last intervention used in any intervention hierarchy. At the same time, if there is an immediate risk to the safety, health and welfare of the child or primary others based on the intensity and/or duration of a given behavioral event, the use of safe, acceptable and trained restraint employed to the minimum degree necessary to be effective remains relevant.

Another point is that ‘restraint’ comes in many different forms and procedures and full body restraint is only very rarely necessary once specific training for and experience with higher intensity behavioral need populations is adequately in place. As I will also discuss more below, alternatives to full restraint include use of guided compliance, partial participation, blocking out with positive redirection and more prescriptively designed escape extinction procedures.

Should restraint procedures become necessary to ensure fundamental safety, documentation is immediately necessary towards the primary goal of how to greatly decrease the probability of these severe episodes in the first place. The first step in this process, of course, is the prioritized administration of a functional behavioral assessment (I have my own copy written system towards this end).

When the function is primarily escape/avoidance, use of escape extinction can very productive even though, as another writer on that listserve pointed out, effective use of escape extinction ‘isn’t always pretty.’

Most important in the use of any extinction procedure is the simultaneous and front loaded high intensity application of proactive instruction towards specific skills, appropriate alternative and competing behaviors that will reduce the child’s need to engage in act out and aggressive behaviors while making the interfering behaviors increasingly ineffective and inefficient.

A problem with extinction/escape extinction is that it can, indeed, sometimes strongly surge an already hyper escalated child to include as part of the predictable extinction burst.

Another risk under these circumstances are potential Response Class Effects; that is, when yet to be identified members of the Response Class in which the specifically targeted interfering behavior resides increase due to over attention to that one particular Response Class member. Intensive instruction on appropriate alternative behaviors and other related skill deficits can help to greatly mute Response Class Effects.

When such a behavioral surge - extinction burst - occurs, whether it can be reasonably managed still dictates whether some form of escape extinction should be utilized. There are also different models for escape extinction to include guided compliance, partial participation and blocking out with active positive redirection rather than full hands on.

One example of a minimal hands-on escape extinction strategy I use for higher intensity behavioral episodes is to keep the child in the general area in which the activity/task is expected while blocking attempts to get away and or engage in property damage, backing off and engaging again but only to the degree needed....backing off and repeat until responsiveness returns. This is simultaneously paired with intermittent positive redirects back to the activity while not directly verbally engaging the escalation. Though not a specific recommendation, of course, I offer this up as an example! I also will often utilize a Limited Hold Contingency reinforcement schedule (see below) as part of such behavioral/instructional planning.

Above all, it is of paramount importance to use information from the FBA in order to better respond to the problem/interfering behavioral event(s) before they even occur based on several things to especially include antecedent conditions and the presence of selective MOs. Since instructional control is very often a pivotal and very primary issue, this is where I often start.

I use a Preference and Activity Assessment self-report/interview (part of my original FBA packet) to identify communication competencies along with a range of preferences starting from those lower to neutral to higher preference. I also look to identify Maintenance Activities; or those skills well within the child’s repertoire with which he or she generally is more responsive to and willing to interactively engage. By setting some of these up and directly participating, it is also frequently very possible to start inserting slightly lower preference requests within an ongoing activity which the child already doesn’t mind doing. This also becomes an application of a prompted behavioral momentum routine (another of my own original protocols).

As part of my FBA interview, I also try to collect as many possibly successful scenarios and circumstances as can be identified. In other words, I ask about environmental conditions, interactive circumstances, strategies and the like which have helped before - where the probability of behavioral escalation is also the lowest - to include other definable operants under which the child had more success.

We don’t often use Success as a behavioral or instructional strategy nearly often enough!

As a for instance…we might know that the child does well during school recess or when at the park. Though we can’t schedule recess in a classroom or the family’s home, what we can do is better identify transferable conditional operants and free operants that are more likely to occur during recess towards some level of replication across other higher behavioral probability/lower preference conditions.

Recess, then, might include having more choice opportunities, active interaction with selected peers/peer groups, more physical movement and lots of hands-on opportunities. While we can’t schedule recess all day, we can insert and use these types of strategies more directly in our instructional sessions and/or home activities.

The use of more effective and individualized reinforcement schedules also becomes of paramount importance. Here, a thorough understanding of the Matching Law becomes very helpful in behavioral intervention and instructional planning.

In the context of children who routinely engage in more substantial and severe behaviors, the FBA must also actively consider the potential reinforcers/motivators that child has regular access to across his or her day. In some cases, even established reinforcers will often not hold their strength under instructional conditions. Too often, this is because the child knows he or she can simply wait out the instructor and have access to those items/activities in their own way later on. More idiosyncratic reinforcers must also be clearly identified as part of the ongoing FBA.

When reinforcer control and effectiveness becomes difficult for these reasons, I’ve typically done a couple of things.

One is to set up what I call ‘Motivating Activities' (I have my own protocols for this model). Fundamentally, these are mildly higher than neutral preference activities a child likes that I will then always have going, and rotating, in the background as something we can both engage together and come back to following other activities…or attempted activities, for that matter.

For instance, let’s say the child likes but doesn’t love puzzles. I might have a couple puzzles out and available to be used together…and always interactively! That helps gain instructional control as I’ve written about above, can help better shape the adult as a reinforcing agent and provides an always available activity to redirect back to since it’s much easier to manage more intense escalation when you have an alternative to do or redirect to which is positive rather than using strings of verbal reprimands/corrections or trying to 'bull' through the primary task. Just use the intervention and, when appropriate, return to the primary activity.

By using my Motivating Activity model, it then becomes possible to drop in very brief (to start) lower preference requests which I've previously categorized from very low to not as lower preference. Once the child is having success within the Motivating Activities, I’ll then start moving the child to longer instructional activities and back to the Motivating Activity until fading out the Motivating Activity entirely.

Towards more traditional reinforcer access; rather than earning or losing, what I tend to do is to set things up where the child either has access or access is delayed but not, most often, lost - taken away - based on obvious child initiated behavioral interruptions (which can then be so identified to the child in much more matter of fact manner). This includes an application of a Limited Hold

Contingency, or restricting the time a reinforcer is available and/or the magnitude of that reinforcer following a given interval.

Towards reinforcer magnitude (and access); if a task block has been timed for 30 minutes with the established knowledge that the given activity should only take the child about 10 or 15 minutes and he or she successfully completes it in 15, the child then has full access to something he/she likely has chosen and/or we’ve identified through the Preference Assessment. At the same time, if it takes 25 minutes because of interfering behaviors, he/she doesn’t lose out but winds up with less time for the preferred activity. And if he/she carries on the WHOLE 30 minutes, the activity can just become available on the next cycle (rather than just taken away/lost).

I think it also very important to point out that reinforcement does not, and should not always be, simply a 1:1 exchange. And this is especially true for children who are more reactive to transitions since work time, break time, reinforcement time, work time, etc. can inadvertently embed so many more high probability transitions than a particular child might be able to tolerate at the time. In essence, we wind up creating far more triggers to behavioral escalation than intended.

Instead, reinforcing/motivating activities can be built into the routine, rather than 'creating' an interruption, to include active adult involvement/participation.

Finally, I often actively discourage adults from ‘talking about’ previous behavioral events with kids and definitely so earlier on in the treatment/instructional process since those same behaviors can quickly become a great way for the child to, in effect, 'start a conversation.' Such follow-up discussions about interfering behavioral events more often very strongly reinforces, rather than reduces, their occurrence.

If the child like to talk; to socially engage...that's great. The strategy can then focus on increasing positive conversation/engagement when he or she is responsive/more successful and minimizing it when he or she is engaging in behavioral escalation/is less successful.

For the record, extinction doesn't at all mean NO interaction or full ignoring (since ignoring often isn't exactly even possible!) but an obvious change in the nature and quality of contingently available social interaction to make it more, or less, reinforcing and relevant to the child contingent to specific criteria that identifies success or the lack thereof.

And, last but very certainly not least, when a behavioral event is over…It's Over!.

Delayed aversive consequences to include, for instance, loss of preferred activities later and/or later follow-up ‘discussions’ about the behavior more often wind up extending it out for ALL concerned rather than allowing us to move the child forward from that point. The child often winds up with the belief that he/she is in trouble all of the time; a perception which may be shared by primary adults. And extending negative behavioral consequences/contingencies to the next day is, almost always, also not at all a good idea!

Something else I very actively advise against is to use food as an aversive/punitive strategy to include taking away scheduled snacks or to reduce naturally occurring choice at lunch time. The most often best strategy is to move forward to something productive, positive and instructionally valuable rather than linger on that which has already occurred.

I provide Telebehavior clinical services and BCBA supervision through my website…www.bridgingbehavior.com