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Behavioral Approaches to the Treatment of Autism and Severe Behavior Disorders

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Title: Behavioral Approaches to the Treatment of Autism and Severe Behavior Disorders


1
Behavioral Approaches to the Treatment of Autism
and Severe Behavior Disorders
  • Wayne W. Fisher
  • University of Nebraska Medical Centers
  • Munroe-Meyer Institute

2
Autism and Childhood Schizophrenia
  • Once thought to be a form of schizophrenia
  • Differs from schizophrenia in terms of symptoms,
    age of onset, family history, etiology, and
    response to treatment

3
Definition of Autism
  • markedly abnormal or impaired development in
  • social interaction
  • Communication
  • and markedly restricted repertoire of activities
    and interests.

4
Definition of Autism
  • Definitions are cheap, but explanations are dear,
    and we must be careful not to confuse them.
  • David Palmer, 2004

5
Prevalence of Autism
  • Typically diagnosed within first three years
  • Recent estimate indicate that the prevalence of
    ASD is between 1 in 38 and
  • 1 in 88
  • Four times more prevalent in boys than girls

6
Recurrence Risk for Siblings
  • If an older sibling has and autism spectrum
    disorder, the risk for a
  • Younger brother is 1 in 4
  • Younger sister is 1 in 11

7
NIH Research Dollars Devoted to Autism
  • When Compared with Other Serious Childhood
    Conditions, Autism is Much More Common, but Fewer
    Dollars Per Case are Spent on Autism.

8

Prevalence of Autism and Other Conditions (Number
of Cases per 10,000 Children)
70
60
50
40
30
20
10
0
Autism
Juvenile Diabetes
Muscular Dystrophy
Leukemia
Cystic Fibrosis
9

NIH Research Dollars for Autism and Other
Conditions (Number of Dollars per Case)
140,000
120,000
100,000
80,000
60,000
40,000
20,000
-
Autism
Juvenile Diabetes
Muscular Dystrophy
Leukemia
Cystic Fibrosis
10
Unfortunately, you have what we call no
insurance.
11
Demographics of Autism
  • Affects all racial, ethnic, and national groups
  • Family income, lifestyle, and educational levels
    do not affect the chance of autism's occurrence
  • Diagnosis of autism is growing at a rate of 10-17
    percent per year (U.S. Department of Education,
    2002)

12
Assessment and Diagnosis of Autism
  • No medical tests for diagnosing autism
  • Accurate diagnosis is based on observation of the
    individual's communication, behavior, and
    developmental levels.
  • Autism Diagnostic Interview-R (ADI-R)
  • Autism Diagnostic Observation Schedule (ADOS)
  • Home and/or school observation
  • Video analysis of behavioral observation

13
Social Behavior Generally Requires Little or No
Explicit Training
14
Assessment and Acquired Autism
  • Autism is most often diagnosed between 2 and 5
    years of age.
  • Thus, it is natural for parents to look for
    environmental events occurring shortly before
    this time that may have caused the autism, such
    as childhood vaccines.

15
MMR Vaccines and Autism
  • 10 of the original 13 authors of the
    investigation that started the controversy have
    retracted the studys interpretation, as has the
    journal, The Lancet
  • Prevalence rates of autism are equivalent in
    children who have and have not been vaccinated.
  • Increases in the prevalence of autism did not
    abate when thimerosal was removed from vaccines.
  • Regression in autism is no more likely in the
    months after the MMR vaccine than in the months
    before the vaccine.

16
Identifying the Genetic Bases of Autism Spectrum
Disorders
  • Etiologic Workups Identify Specific Genetic
    Causes for Autism in About 20 of Cases.
  • At the Munroe Meyer Institute, Shaefer and
    Colleagues (2006) have developed a 3-Tiered
    Approach that Identifies Genetic Causes in 40 of
    Cases.

17
Associated Disorders
Autism ASD
  • Mental Retardation 50
    15
  • Seizure Disorder
    35 10
  • Self-Injury, Aggression 50
  • Tourette Disorder
  • Bipolar Disorder

18
Associated Etiologic Diagnoses
  • Fragile-X syndrome
  • Tuberous Sclerosis
  • Williams syndrome
  • Landau-Kleffner syndrome
  • Congenital Rubella
  • Smith-Magenis syndrome
  • Neurofibromatosis

19
Genetics and Twin Studies
  • Autism runs in families
  • Heritability for autism is about 90
  • Monozygotic twin concordance, 60-100
  • Dizygotic twin concordance, 10
  • Associated with abnormalities on chromosomes 7q,
    2q, and 15q

20
Applied Behavior Analysis (ABA)
  • What is ABA?
  • How is it different from other approaches?
  • How is it Done?

21
How Effective is ABA for Autism?
  • About 50 of Children with Autism and no More
    than Mild Mental Retardation who Receive Early
    Intervention with ABA Attain Normal IQs and are
    Educated in Regular Classrooms with Minimal
    Assistance.

22
Outcomes of ABA for Autism
35
30
25
20
Increases in IQ Scores
r .79
15
p lt .02
10
5
0
0
5
10
15
20
25
30
35
40
45
Hours per Week of Treatment
23
Cost-Benefit Analysis of Early, Intensive ABA
for Autism
  • Average Lifetime Cost for a Person with Autism is
    over 4 million
  • Average cost of Early, Intensive ABA is 150,000
    over about 3 years
  • Average Lifetime Savings from ABA Treatment is
    Between 1.6 and 2.7 million

24
Cost-Benefit Analysis of ABA treatment for
Severe Behavior Disorders
  • Children with Autism and Severe Destructive
    Behavior Cost 8 million over a lifetime.
  • Keeping just one child out of chronic care pays
    for treatment of hundreds more.
  • Our treatment approach has over an 80 success
    rate.

25
Case Example (Costs since 1986)
4,050,000
4000
3500
3000
2500
2000
Dollars in Thousands
1500
1000
500
85,924
0
Inpatient and Outpatient Costs
Residential Costs Over 25 Years
26
Autism and Problem Behavior
  • 98 of children with autism have one or more of
    the following problems
  • Feeding problems
  • Sleeping problems
  • Tantrums
  • Self-injurious behavior
  • Aggression
  • Dominick et al. (2007)

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Variables Related to Problem Behavior in Autism
  • Lower IQ scores were associated more problem
    behaviors
  • Lower expressive language scores were associated
    with more problem behaviors
  • Increased social deficits were associated with
    more problem behaviors
  • Dominick et al. (2007)

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35
  • Functional Analysis and Treatment of Aberrant
    Behavior

36
Structural vs. Functional Diagnosis
  • Structural Approach
  • How often a particular set of symptoms or
    responses cluster or covary.
  • Functional Approach
  • Whether and which environmental variables
    influence the response.

37
Functional Analysis
  • Identifies the environmental contexts in which
    aberrant behavior is likely and unlikely.
  • Identifies the consequences that reinforce and
    maintain the behavior.
  • Used to prescribe effective treatments.

38
Common Functions of SIB
  • Social Positive Reinforcement (Attention,
    Tangible items)
  • Social Negative Reinforcement (Escape)
  • Automatic Reinforcement (e.g., Sensory
    Stimulation)

39
Essential Features of Functional Analysis
Conditions
  • Unique discriminative stimuli that signal the
    available of a specific reinforcer
  • Establishing operation (EO) that increases
    motivation for the specific reinforcer
  • An EO is an environmental condition that
    momentarily increases the effectiveness of a
    reinforcer and that evokes responses that have
    produced that reinforcer in the past.
  • Contingency between the target behavior and the
    specific reinforcer

40
Identifying the Essential Features of Functional
Analysis Conditions
  • See if you can identify the discriminative
    stimulus, the establishing operation, and the
    reinforcement contingency in each of the
    following functional analysis conditions.

41
Attention Condition
  • Adult is busy reading. Child is expected to play
    quietly with toys.
  • Adult attention shifts to child following SIB
    (e.g., Please dont hit yourself).
  • Determines whether adult attention functions as
    reinforcement for SIB.

42
Essential Features of the Attention Condition
  • Discriminative Stimulus Adult is seated in a
    chair reading a book.
  • EO Attention is unavailable.
  • Contingency SIB produces attention.

43
Tangible Condition
  • Adult takes preferred toys or leisure materials
    from the child and returns them following SIB.
  • Determines whether access to preferred items
    functions as reinforcement for SIB.

44
Essential Features of the Tangible Condition
  • Discriminative Stimulus Adult takes and holds
    the preferred tangible item at the start of the
    session.
  • EO Tangible item is unavailable in the absence
    of SIB.
  • Contingency SIB produces the tangible item.

45
Demand Condition
  • Child is prompted to complete non-preferred tasks
    by an adult.
  • The task is removed and the child is given a
    short break following SIB.
  • Determines whether termination of non-preferred
    activities functions as reinforcement for SIB.

46
Essential Features of the Demand Condition
  • Discriminative Stimulus Instructional materials
    and demands are presented.
  • EO Nonpreferred demands are presented.
  • Contingency SIB results in temporary removal of
    the demands.

47
Alone Condition
  • Child is placed in a room alone without toys or
    materials.
  • Indirectly assesses whether SIB may be maintained
    by automatic reinforcement (e.g., sensory
    stimulation).

48
Essential Features of the Alone Condition
  • Discriminative Stimulus Absence of another
    individual or materials.
  • EO Alternative sources of stimulation are
    unavailable.
  • Contingency SIB produces self-stimulation.

49
Toy Play Condition
  • Child and adult play together with preferred toys
    or leisure items.
  • Adult delivers praise about once every 30 seconds
    for the absence of SIB.
  • Designed to be an analogue of an enriched
    environment, which serves as a control condition.

50
Essential Features of the Toy Play Condition
  • Discriminative Stimulus Adult and toys are near
    the individual.
  • EO (or AO) Attention and tangible items (toys)
    are freely available and no demands are
    presented.
  • Contingency SIB produces no consequence.

51
3
Attention
2
Per Minute
Aggressive Responses
Ignore
1
Demand
Tangible
Play
0
1
3
5
7
9
11
13
15
17
19
21
23
25
27
29
31
33
35
37
39
Sessions
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Functional Analysis of Covert Drug Ingestion
  • Three Operant Hypotheses Generated After
    Caregiver Interview and Chart Review
  • Attention/Excitement From Medical Procedures
  • Attention From Mother
  • Escape From Work Activities

54
Functional Analysis of Covert Drug Ingestion
(cont.)
  • Sessions Conducted in a Classroom and an
    Adjoining Medication Room Baited With Placebos in
    a Pillbox.
  • Patient was Left Unsupervised in the Classroom
    With a Schoolwork Assignment.

55
Functional Analysis of Covert Drug Ingestion
(cont.)
  • In the Pillbox Were Four Pill Bottles Containing
    Placebos.
  • Each Pill Bottle had a Uniquely Colored Label.
  • Consuming Pills From Each Pill Bottle Produced a
    Specific Consequence.

56
Functional Analysis of Covert Drug Ingestion
(cont.)
  • Red Medical Attention
  • Orange Attention From Mother
  • Blue Rest Period (Escape)
  • Yellow Control (Ignore)

57
20
Escape From Work
15
Parent Attention
PILLS INGESTED PER MINUTE
10
Control
5
Medical Attention
LYLE
0
1
5
10
15
SESSIONS
FUNCTIONAL ANALYSIS
58
Treatment of Escape-Maintained Drug Ingestion
  • Lyle Earned Preferred, Nonwork Activities for
    Completing Scheduled Activities and Turning in
    Pills.
  • He was Required to Complete His Least Preferred
    Work Activity (Shoe Polishing) if He Ingested
    Pills.

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Treatment Extension of Escape-Maintained Drug
Ingestion
  • Lyle was Gradually Exposed to Different Settings
    where He was Observed and Supervised Less.
  • Detection Methods Were Faded From Direct
    Observation to Pill Bottles With Residue and Then
    to Weekly Tox Screens.

61
Functional Communication Training (FCT)
  • Functional communication training (FCT) is a
    treatment commonly prescribed when a functional
    analysis has shown that an individuals problem
    behavior is maintained by social consequences
    (e.g., Carr Durand, 1985 Fisher et al., 1993
    Horner, Day, Sprague, OBrien, Heathfield,
    1991 Lalli, Casey, Kates, 1995 Wacker et al.,
    1990).

62
Functional Communication Training (FCT)
  • With FCT, the individual is taught a
    communicative response that produces access to
    the reinforcer responsible for maintenance of the
    problem.
  • For example, an individual whose problem behavior
    is maintained by escape from tasks might be
    taught to request a break by signing finished
    (e.g., Hagopian, Fisher, Sullivan, Acquisto,
    LeBlanc, 1998).

63
Unique Features of FCT
  • FCT is a DRA procedure that
  • specifies its reinforcer (i.e., a mand
    specifying the reinforcer that previously
    maintained problem behavior),
  • requires minimal response effort,
  • is initially reinforced on a dense schedule
    (e.g., FR 1),
  • can recruit reinforcement across environmental
    contexts.

64
Unique Features of FCT
  • Because of the ease and consistency with which
    reinforcement can be obtained during FCT, some
    authors have suggested that the client
    controls the delivery of reinforcement (e.g.,
    Carr Durand, 1985).
  • In addition, Carr and Durand suggested that
    control over reinforcement, contributed to the
    effectiveness of FCT.

65
Unique Features of FCT
  • Two investigations found that noncontingent
    reinforcement (NCR), which does not allow the
    client to control the schedule of reinforcement,
    and FCT, which does, produced equivalent
    reductions in problem behavior (Hanley, Piazza,
    Fisher, Contrucci, Maglieri, 1997 Kahng et
    al., 1997).
  • Nevertheless, we found that participants
    preferred FCT over NCR when given a choice
    (Hanley et al., 1997).

66
Unique Features of FCT
  • FCT may promote generalization and maintenance
    because the communication response may prompt
    both trained and untrained caregivers to deliver
    differential reinforcement appropriately (e.g.,
    Durand Carr, 1991).

67
Limitations of FCT
  • Teaching the FCT response may evoke problem
    behavior (particularly if it is maintained by
    escape).
  • Individuals may display the FCT response at
    exceedingly high rates (e.g., requesting a break
    from every school task).
  • Individuals may request reinforcement at times
    when it is impossible or inconvenient to deliver
    (e.g., caregiver tending to an infant sibling).

68
Selecting the Functional Communication Response
(FCR)
  • The FCR should be simple.
  • The FCR should produce the reinforcer identified
    during the functional analysis.
  • The FCR should quickly remove the establishing
    operation for problem behavior.

69
Training the Communication Response
  • The communication response matches the function
    of the childs problem behavior.
  • Demand -gt Break please.
  • Attention -gt Play with me, please.
  • Tangible -gt Toy please.

70
Training the Communication Response
  • Children who do not speak are often taught to use
    a picture-exchange communication response.
  • Attention -gt Child hands over a picture of the
    adult and child playing together.
  • Demand -gt Child hands over a picture of the child
    leaving a work table.

71
Function-Based Extinction
  • EXT (Att) Attention no longer follows the target
    behavior
  • EXT (Tang) Tangible item is longer presented
    following the target behavior
  • EXT (Esc) Demands continue following the target
    behavior
  • EXT (Auto) The sensory consequences of the
    target response are eliminated or the response is
    prevented.

72
Stimulus Control Refinements of FCT
  • Controlling the establishing operation for
    problem behavior is particularly important during
    the early stages of treatment.
  • Bringing the functional communication response
    under tight discriminative control is
    particularly important for increasing the
    practicality and generality of FCT.

73
Study 1 Does strict control of exposure to the
establishing operation (EO) for problem behavior
facilitate the effectiveness of FCT?
  • We compared FCT using a picture exchange (or card
    touch) as the FCR with a vocal FCR.
  • The picture exchange version of FCT (FCT-card)
    allows strict control of the EO, because the
    therapist can immediately guide the FCR and
    deliver the reinforcer, which removes the EO.
  • The vocal version of FCT (FCT-vocal) does not
    allow strict control of the EO, because one
    cannot guide a vocal response.

74
Study 1 Procedures
  • Following baseline, the two FCT treatments
    (FCT-card and FCT-vocal) were both introduced
    using a progressive time-delay procedure to teach
    each FCR.
  • The two treatments were compared using a
    multielement phase.
  • Following a return to baseline, the more
    effective treatment was re-introduced in the
    final phase.

75
t 3.0 p .01
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Study 1 Conclusions
  • The FCT-card card condition allowed better
    control of the EO for problem behavior.
  • The FCT-card condition produced more rapid
    reductions in problem behavior.
  • The FCT-vocal condition was associated with an
    extinction burst for one participant, which was
    not observed in the FCT-card condition.

78
Controlling the EO While Training the
Communication Response
  • When FCT is initiated, the communication response
    should always produce the reinforcer.
  • If the child cannot do the response
    independently, we help them and then immediately
    deliver the reinforcer.

79
Stimulus Control Refinements of FCT
  • Controlling the establishing operation for
    problem behavior is particularly important during
    the early stages of treatment.
  • Bringing the functional communication response
    under tight discriminative control is
    particularly important for increasing the
    practicality and generality of FCT.

80
Schedule Thinning During Functional Communication
Training
  • Signaled and unsignaled delayed reinforcement
    (Vollmer et al., 1999)
  • Activities or alternative reinforcers during the
    reinforcement delays (Fisher et al., 1998 2000)
  • Multiple schedules with reinforcement and
    extinction components (Betz et al., 2913 Fisher
    et al., 1998 Hanley et al., 2001)

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Typical Multiple-Schedule Training During FCT
  • Quasi-random alternation between and FR-1
    schedule and EXT for communication
  • Each component correlated with a specific signal
  • Initially, the duration of the reinforcement
    component is 3 to 4 times longer than the EXT
    component
  • Gradually, the EXT component is lengthened
    relative to the SR component

83
FR1
Extinction
Decreases reinforcer deliveries by about 75
FADING STEPS
84
Purpose
  • To identify the necessary and sufficient
    components for the reinforcement schedule
    thinning
  • Study 2 Evaluated the effects of
    contingency-correlated stimuli during FCT
  • Study 3 Evaluated the necessity of systematic
    and gradual fading steps during schedule thinning
    under multiple schedule components
  • Study 4 Evaluated the extent to which
    contingency-correlated stimuli facilitated
    generalization across therapists and environments

85
Functional Analysis and FCT Treatment Evaluations
  • Prior to Studies 2, 3, and 4, we conducted
    functional analyses to show that problem behavior
    was reinforced by social positive reinforcement
    for all participants.
  • We also conducted treatment evaluations using an
    ABAB design to show that FCT was an effective
    treatment.

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Study 2 Are contingency-correlated stimuli
necessary?
  • Compared rates of FCR and problem behavior under
    equivalent mixed and multiple schedules using an
    ABAB design
  • Mixed FR-160 s / EXT60 s
  • Multiple FR-160 s / EXT60 s
  • Data on problem behavior is not shown because it
    remained at near-zero levels throughout this
    study.

90
Mixed vs. Multiple Assessment
  • General Procedures
  • Sessions 10 min
  • Contingency specifying stimuli in both conditions
  • FR1 60 s
  • Extinction 60 s
  • All sessions started with reinforcement interval
  • All problem behavior was on extinction

91
CASEY
FR1 60 s
EXT 60 s
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Study 3 Is schedule fading necessary?
  • Compared rates of alternative and problem
    behavior when schedules were switched from rich
    to lean without schedule fading in a multiple
    baseline design
  • Mult FR-160 s / EXT60 s to Mult FR-160 s /
    EXT240 s
  • Mixed FR-160 s / EXT60 s to Mult FR-160 s /
    EXT240 s
  • Data on problem behavior is not shown because it
    remained at near-zero levels throughout this
    study.

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96
Study 4 Do contingency-correlated stimuli
facilitate generalization across therapists and
settings?
  • Compared rates of alternative and problem
    behavior when a multiple schedule was introduce
    across therapists or settings in a multiple
    baseline design
  • Mixed FR-160 s / EXT60 s to Mult FR-160 s /
    EXT60 s
  • Mult FR-160 s / EXT60 s to Mult FR-160 s /
    EXT300 s
  • Data on problem behavior is not shown because it
    remained at near-zero levels throughout this
    study.

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Conclusions
  • Study 2 showed that inclusion of contingency-
    correlated stimuli was a necessary component of
    FCT schedule thinning.
  • Study 3 showed that inclusion of contingency-
    correlated stimuli was sufficient to maintain
    appropriate responding without gradually fading
    the schedule density during FCT schedule
    thinning.
  • Study 4 showed that contingency-correlated
    stimuli also facilitated generalization of FCT
    effects across therapists and settings.

101
Study 5 How effective is Mult-FCT across a large
cohort of patients with problem behavior?
  • Hagopian et al. (1998) found that FCT with EXT
    (FCTE) failed in 14 of 25 cases during schedule
    thinning.
  • They also found that FCT with punishment (FCTP)
    reduced destructive behavior by 90 or more in
    all cases, even following reinforcer-schedule
    thinning.
  • In the current study, we summarized the results
    of 14 applications of Mult-FCT implemented with
    12 cases and compared the results with those of
    Hagopian et al.

212
102
Amount of Reinforcer-Schedule Thinning
  • The reinforcement schedule was thinned to the
    values listed below by rapidly lengthening the
    duration of the EXT component once the
    participant showed discriminated responding in
    Mult-FCT.
  • 60/240 Seven applications (80 reduction in Sr)
  • 60/540 Six applications (90 reduction in Sr)
  • FR1/400 One application (gt 90 reduction in Sr)

103
Calculating Percentage Reduction in Problem
Behavior
  • Percentage reductions in problem behavior were
    calculated using the following formula (same as
    in Hagopian et al. 1998)
  • Mean rate during last 5 sessions
  • 1
  • Mean rate during baseline

104
Fading
105
Future Grants and Research onConsequence
Control Refinements of FCT
  • Using behavioral momentum theory (BMT) and
    accompanying equations to prevent relapse and
    resurgence of problem behavior.
  • BMT makes predictions that are at odds with
    current clinical best practices.

106
Limitations of FCT (cont.)
  • When a parent is busy and fails to deliver
    reinforcement for the childs FCT response, the
    child is likely to revert to problem behavior, a
    phenomena called resurgence.
  • Recent research has shown that resurgence of
    problem behavior is quite common, and problem
    behavior often occurs at pre-treatment levels
    when the FCT response goes unreinforced (Mace et
    al., 2010 Volkert et al., 2009).

107
Mace et al., (2010)
108
Volkert et al., (2009)
109
Behavioral Momentum Theory
  • Behavioral momentum theory is a quantitative
    theory of behavior that employs a comparative
    metaphor based on the classical mechanics of the
    momentum of physical objects.
  • Behavioral momentum theory is relevant to FCT
    because it provides quantitative models and
    predictions about the persistence and resurgence
    of problem behavior when the FCT produces
    reinforcement and when it does not.

110
The Momentum Metaphor
  • In classical mechanics, the momentum of an object
    is a joint function of its mass and velocity.
  • Momentum of a moving object
  • mass x velocity
  • Momentum of a response
  • rate of reinforcement x response rate

111
Equation 7 Predicts the Effects of Adding and
Removing Reinforcement for the FCT Response
112
Common Practice Guidelines for FCT
  • Decreases may occur more rapidly during
    treatment if problem behavior is reinforced on a
    CRF schedule during baseline (Fisher Bouxsein,
    2011).
  • we strongly recommend that the communicative
    response be reinforced on a CRF schedule
    initially (Tiger, Hanley, Bruzek, 2008).
  • Clinical guidelines on dosage levels of FCT are
    not available (i.e., How many sessions of FCT are
    needed before parent training and discharge?).

113
Specific Recommendations of BMT
  • The magnitude of resurgence predicted by Equation
    7 is minimized by
  • maximizing the value of t conducting many FCT
    sessions before exposure to an EXT challenge
  • maximizing the value of d by correlating periods
    of reinforcement and EXT of the FCR with
    discriminative stimuli

114
Specific Recommendations of BMT
  • The magnitude of resurgence predicted by Equation
    7 is minimized by
  • minimizing the value of r by delivering the
    lowest possible rate of reinforcement for
    destructive behavior during baseline and
  • minimizing the value of Ra by delivering the
    lowest possible rate of reinforcement of the FCR
    during FCT.

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119
Concluding Comments
  • Mathematical models like behavioral momentum
    theory provide a method for developing new and
    interesting clinical research questions that have
    the potential to greatly improve treatments like
    FCT.

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