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Research in Developmental Disabilities 30 (2009) 409–425

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Research in Developmental Disabilities

Review

A review of empirical support for differential reinforcement of alternative behavior

Erin S. Petscher a,*, Catalina Rey b, Jon S. Bailey b

a University of Florida, United States b Florida State University, United States

A R T I C L E I N F O A B S T R A C T

Article history: Received 16 July 2008 Received in revised form 12 August 2008 Accepted 30 August 2008

Keywords: Differential reinforcement of alternative behavior Functional communication training Empirically supported treatments Destructive behavior Problem behavior Aberrant behavior Behavior analysis

Differential reinforcement of alternative behavior (DRA) is one of the most common behavior analytic interventions used to decrease unwanted behavior. We reviewed the DRA literature from the past 30 years to identify the aspects that are thoroughly researched and those that would benefit from further emphasis. We found and coded 116 empirical studies that used DRA, later grouping them into categories that met APA Division 12 Task Force criteria. We found that DRA has been successful at reducing behaviors on a continuum from relatively minor problems like prelinguistic communication to life-threatening failure to thrive. DRA with and without extinction is well established for treating destructive behavior of those with developmental disabilities, and to combat food refusal.

Contents

1. Methods . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411 1.1. Inclusion and exclusion criteria. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411 1.2. Experimental design. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411 1.3. Participant and setting characteristics . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411 1.4. Behavior topography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 411 1.5. Assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 412 1.6. Procedural manipulations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 412 1.7. Generalization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 412

* Corresponding author. Tel.: +1 850 322 1797. E-mail address: [email protected] (E.S. Petscher).

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http://www.sciencedirect.com/science/journal/08914222

http://dx.doi.org/10.1016/j.ridd.2008.08.008

410 E.S. Petscher et al. / Research in Developmental Disabilities 30 (2009) 409–425

1.8. Task Force criteria . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 412 1.9. Inter-rater reliability . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 412

2. Results and discussion. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 412 2.1. Experimental design. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 413 2.2. Participants and settings . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 414 2.3. Behavior topography . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 416 2.4. Assessments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417 2.5. Procedural variations . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417

2.5.1. Schedule thinning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 417 2.6. Generalization . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 418 2.7. Empirically supported treatments . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 418

2.7.1. DRA with extinction is a well-established treatment for destructive behavior . . . 419 2.7.2. DRA without extinction is a well-established treatment for destructive behavior . . . 419 2.7.3. DRA with extinction is well established for the treatment of food refusal. . . . . . . 419 2.7.4. DRA plus NCR is an experimental treatment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 419

3. Conclusion . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 420 Acknowledgements. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 420 References . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 420

Differential reinforcement is the withholding of reinforcers for one behavior and delivering them for another. Through the years many specific variations of differential reinforcement have emerged to demonstrate impressive behavior reductions with difficult clients (see Vollmer & Iwata, 1992). In fact, Lennox, Miltenberger, Spengler, and Efanian (1988) found that differential reinforcement (DR) procedures are among the most frequently used to suppress unwanted behaviors.

In recent years the field of behavior analysis has moved toward the use of function-based treatments to reduce unwanted behaviors. Function-based treatments are considered to be among the most efficient and effective behavioral interventions (Beare, Severtson, & Brandt, 2004; Iwata, Dorsey, Slifer, Bauman, & Richman, 1982/1994). Differential reinforcement is particularly appropriate today as the extinction component requires the assessment of maintaining variables, helping it meet the definition a function-based treatment.

Extinction alone may produce more unwanted side effects than when it is combined with another intervention (Lerman, Iwata, & Wallace, 1999; Petscher & Bailey, 2008). Differential reinforcement of alternative behavior (DRA) withholds the reinforcer for unwanted behavior while simultaneously reinforcing a specific, alternative response (Cooper, Heron, & Heward, 2007; Vollmer, Roane, Ringdahl, & Marcus, 1999). DRA may be the ideal intervention in many cases because it reduces behavior without the concern of extinction-induced side effects and provides an appropriate option for the clients to earn valuable reinforcers once they are no longer provided for unwanted behaviors (Rolider & Van Houten, 1990).

Some DRA literature has been reviewed for specific client types. For example, Mirenda reviewed the use of functional communication training through augmentative alternative communication devices (1997). Matson, Dixon and Matson (2005) reviewed treatment of aggressive behaviors among those with developmental disabilities, finding that a variation of DRA, functional communication training (FCT), is one of the most common interventions. However, a comprehensive review of DRA has not yet been performed. The authors of the current study feel that demonstrating the empirical support of DRA to those outside of applied behavior analysis is important for the dissemination of the field. Therefore, in addition to summarizing the status of DRA literature, the current study also utilizes the model offered by Severtson, Carr, and Lepper (2008) by coding articles according to the Task Force criteria.

Since 1995, The Division 12 Task Force on the Promotion and Dissemination of Psychological Procedures (Task Force) has been identifying treatments that meet the criteria they set to demonstrate empirical validation. Members of the Task Force publish lists of interventions found to meet their standards as well established, probably efficacious, or experimental (Chambless et al., 1996; Task Force, 1995). Unfortunately, while many behavioral interventions may be effective and efficacious, few have been included in the Task Force lists (see Chambless & Hollon, 1998).

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The purposes of the current study are to review the published studies on DRA in the past 30 years, report the characteristics that meet criteria for being well established or probably efficacious, and to identify the variants that need further research.

1. Methods

The articles selected were each evaluated by the first or second author, and some were also reviewed by a second, independent observer who was trained to search for the relevant elements. Observers coded information about the participants, variables, interventions, results and follow-up.

1.1. Inclusion and exclusion criteria

Peer-reviewed journal articles that reported data on an intervention with DRA since 1977 were reviewed for this paper. The search terms, ‘‘differential reinforcement of alternative behavior’’, and ‘‘functional communication training’’, ‘‘DRA’’, and ‘‘FCT’’, were used within the search engines PsychInfo and Educational Resources Information Center (ERIC), Journal of Applied Behavior Analysis abstracts and Journal of the Experimental Analysis of Behavior abstracts. Reference lists of the articles obtained were also scanned for interventions that matched the definition but did not actually report it as DRA or FCT (e.g., Coe et al., 1997; Riordan, Iwata, Finney, Wohl, & Stanley, 1984). Search criteria permitted all dates through the end of 2007 and only the English language. Eliminations were made for those who either did not present data or used non-human subjects. Review articles and group designs that did not present individual participants’ data were excluded.

1.2. Experimental design

Experimental design was tracked by participants rather than studies. The designs were matched by definitions given by Bailey and Burch (2002). AB designs were listed if intervention just followed baseline. A multielement design involved the rapid alternation between at least two conditions. A reversal design required that at least two conditions were introduced twice. Variations of reversal designs, such as an ABCBA, where additional conditions were added to the design, were included. A multiple baseline was marked if two or more baselines of different durations were followed by the intervention. Those that added other conditions without replication, such as an ABCDE were categorized as additive designs. Changing criterion designs involved the stepwise progression of behavior requirements. Finally, if the participants were introduced to designs with multiple characteristics, this was tracked as a combination.

The experimenter who implemented the intervention was recorded as staff, parents or family members, teachers, therapist, or a behavior analyst. When not specified or the data collectors were trained observers or interns, these were considered behavior analysts.

1.3. Participant and setting characteristics

The number and age of participants was recorded, along with the first two diagnoses reported for each. Participants were grouped as children (up to 18 years old), or adults (19 and over). If a participant was diagnosed with an intellectual or physical disability that could be considered a developmental disability other than autism this was also recorded. Autism was tracked separately to show any distinction, although it was combined with developmental disabilities when studies were evaluated for Task Force criteria. The settings were inpatient facilities, clinics, schools, home, and vocational programs.

1.4. Behavior topography

The topographies of alternative behavior and problem behaviors were reported. Aggression, self- injurious behavior, property destruction, and disruptions were later grouped to encompass destructive behavior (Fisher, Thompson, Hagopian, Bowman, & Krug, 2000). The article reviewers

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also tracked whether the individual data were presented for problem behavior, replacement behavior or both.

1.5. Assessments

Articles were scanned for reports and results of preference, reinforcer, and functional assessments. Functional assessments were tracked as descriptive, indirect, antecedent-behavior-consequence, motivation assessment scale (Durand, 1990), functional analysis or as a modified experimental analysis.

1.6. Procedural manipulations

While all studies included in this paper involved the use of DRA, some could be further distinguished as differential negative reinforcement of alternative behavior (DNRA) and FCT. DNRA specifies that the alternative behavior is negatively reinforced by the removal of an aversive stimulus. FCT requires that the presumed function of the unwanted behavior is made contingent upon the alternative response, rather than utilizing any or several arbitrary reinforcers. The specific style of DRA used was coded by reviewers.

Many studies manipulated antecedents and consequences in addition to the DRA intervention. Some were combined with DRA and these modifications were tracked as function-based or arbitrary. In addition, recorders reported the schedule thinning techniques that were utilized.

1.7. Generalization

When experimenters reported a generalization or follow-up condition these and the data trend were monitored. In addition, if side effects were reported, the perceived value of them was tracked as desired or undesired.

1.8. Task Force criteria

The criteria set by the Task Force for single subject designs require that the intervention is compared to a control or other acceptable treatment, has a treatment manual or other specific instructions, appropriate design and practically significant results, participants with details reported and similar characteristics, and at least two different investigators performed the studies (Chambless et al., 1996; Task Force, 1995). It is well established if at least 10 single subject cases meet criteria.

The Task Force criteria were used to group studies along identical interventions and similar participant characteristics and target behaviors. Reversal, multielement, some combinations and concurrent multiple baselines were all considered appropriate experimental designs if the first author found visually significant differences in trend, level, and variability (Bailey & Burch, 2002). However, a multiple baseline differed from the previous definition as a minimum of three panels were required to have the possibility of demonstrating control (Chambless & Hollon, 1998).

1.9. Inter-rater reliability

A trained, second reader independently analyzed 35% of the articles to determine inter-rater agreement on the evaluation of the studies. Agreement was calculated by an item-by-item comparison of data sheets. The number of item agreements was divided by the total number of agreements plus disagreements and multipled by 100 (Hanley, Iwata, & McCord, 2003). Average inter- rater agreement was 93% (range 82–100%).

2. Results and discussion

The initial search identified 538 articles and 116 remained after the exclusionary criteria were applied. These articles were each reviewed multiple times, and are all denoted in the reference list.

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Table 1 Experimental design and experimenter type for all reviewed studies

Number Percent

Design AB 5 4.3 Additive 8 6.9 Combination 32 27.6 Multielement 7 6.0 Multiple baseline 29 25.0 Other 10 8.7 Reversal 25 21.6

Experimenter Behavior analyst 70 60.3 Combination 3 2.6 Parent/family 11 9.5 Staff 13 11.2 Teacher 8 6.9 Therapist 11 9.5

Although the findings and designs of all 116 did not meet Task Force criteria, many still offered substantial contributions to the DRA body of literature, so were included in the sample of articles used for Tables 1–4.

2.1. Experimental design

Table 1 displays the experimental design and experimenter type for 116 articles that utilized DRA. Many research designs replicated variables in order to properly demonstrate experimental control (Ringdahl et al., 2002; Roberts, Mace, & Daggett, 1995; Vollmer, Iwata, Smith, & Rodgers, 1992). Some authors selected experimental designs that involved no or limited opportunity to demonstrate experimental control (Beare et al., 2004; Dura, 1991; Earles & Myles, 1994; Walsh, 1991). As the control is demonstrated by the replication of the findings in single subject designs, such findings

Table 2 Age of participants, different settings, and first two diagnoses for participants

Characteristic Number Percent

Age category Child 277 82.4 Adult 59 17.6

Total participants 336 100

Diagnosis Autism 116 27.4 Developmental disability 271 64.1 Gastroesophageal reflux 6 1.4 None 3 0.7 Other 27 6.4

Total diagnoses 423 100

Setting Clinic 17 14.7 Home 21 18.1 Hospital 36 31.0 Multiple 4 3.4 Other 3 2.6 School 32 27.6 Vocational 3 2.6

Total studies 116 100

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Table 3 Topography of alternative and unwanted behaviors

Number Percent

Problem behavior Aggression 31 9.2 Destruction/combination 160 47.6 Disruption 9 2.7 Food rejection/packing 15 4.5 Not specified/unclear 11 3.3 Other 26 7.7 Self-Injury 74 22.0 Vocalizations 10 3.0

Alternative behavior Communication 287 85.4 Compliance 8 2.4 Exchange cigarette 4 1.1 Food acceptance 18 5.4 Play/social 4 1.1 Task engagement 13 3.9 Transitions 2 0.6

should be replicated either across participants, settings, behaviors, or intervention phases. The AB and most additive designs alone, therefore, added little to indicate that the interventions were responsible for any behavior changes.

Most studies used a combination of at least two designs, which often were needed to evaluate multiple components of interventions. For example, in one study a reversal design was used first with full implementation of DRA compared to baseline. Next, modified versions of DRA were alternated to demonstrate the effects of partial DRA implementation on problem and alternative behavior (Vollmer et al., 1999). Other combination designs did not provide the opportunity to display experimental control, but still suggested interventions for further inquiry. For example, Fisher et al. (2005) combined a reversal and multielement design for Kim. However, the baseline conditions were too short to indicate a trend. These data suggested a positive response to the intervention and indicated that further study could be beneficial.

Behavior analysts typically performed the interventions. Such studies are likely to produce consistent results and treatment fidelity (Vollmer et al., 1999). However, those studies in which parents or staff implemented the intervention were programmed for generalization from the beginning. For example, Bird, Dores, Moniz, and Robinson (1989) performed their study in a classroom and the teacher enforced the intervention. This should increase consumer’s confidence that the intervention would continue successfully after the study ended. Unfortunately, it can be especially difficult to train teachers or parents to perform interventions while they are also held responsible for their typical duties. It can also confound the intervention and cause confusion if it does not sufficiently produce behavior change. Therefore, an approach commonly employed is to implement the intervention first with a trained experimenter, then transfer the training to someone who naturally interacts with the participant in the absence of a study. For example, after Goh, Iwata, and Kahng (1999) successfully reduced cigarette pica, they reportedly transferred the intervention to multiple settings and therapists.

2.2. Participants and settings

The number, first two diagnoses and age of participants are reported in Table 2. Over 80% of the participants were children, which corresponded with a similarly high percent of studies located in schools. Wright-Gallo et al. (2006) performed one such study, in which they achieved their goal of performing classroom-based functional analyses and DRA treatments for students diagnosed with emotional/behavioral disorders. Furthermore, their findings support the use of function-based interventions in the actual classroom, rather than an empty treatment room at a school or other location.

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Table 4 Studies that demonstrated DRA with extinction as a well-established treatment of destructive behavior for children and adults with developmental disabilities

Study Participant Problem behaviora Alternative behaviorb Function

Children Bowman et al. (1997) Ben PD, SIB, AGG COM Compliance from

others Carr and Durand (1985) Jim AGG, TAN, OP Academic tasks Attention Carr and Durand (1985) Eve AGG, SIB, OP Academic tasks Attention Carr and Durand (1985) Tom AGG, TAN, OS Academic tasks Attention Carr and Durand (1985) Sue AGG, TAN, SIB Academic tasks Attention DeLeon et al. (2000) Jake AGG COM Tangible Derby et al. (1998) Lana SIB COM Attention Durand (1999) Allison Crying, screaming COM Tangible Durand (1999) Mike SIB, PD COM Tangible Durand (1999) Ron AGG COM Attention Durand (1999) David SIB COM Escape Durand (1999) Matt SIB, screaming COM Escape Durand and Carr (1991) Hal SIB Correct responses Escape Durand and Carr (1991) Ben AGG Correct responses Attention, escape Durand and Carr (1991) Tim SIB, AGG Correct responses Escape Durand and Carr (1992) Sam TAN, PD Correct responses Attention Durand and Carr (1992) Ted TAN, PD, OP Correct responses Attention Durand and Carr (1992) Ian TAN, PD, OP Correct responses Attention Durand and Carr (1992) Ray AGG, TAN, PD Correct responses Attention Durand and Carr (1992) Mike TAN Correct responses Attention Durand and Carr (1992) Jaynie OP, TAN Correct responses Attention Fisher, Adelinis, Thompson, Tina AGG COM Escape

Worsdell, and Zarcone (1998) Fisher, Adelinis, et al. (1998) Ike AGG COM Escape Fisher, Kuhn, et al. (1998) Ned AGG, PD COM Attention Fisher, Kuhn, et al. (1998) Amy SIB, AGG, PD COM Tangible, attention Fisher et al. (2000) Ken AGG, SIB, PD COM Attention Fyffe, Kahng, Fittro, and Russell Matt ISB COM Attention

(2004) Hagopian et al. (1998) Case 17 SIB, AGG, DIS COM Tangible Hagopian et al. (1998) Case 19 SIB, AGG, DIS COM Attention, escape Hagopian, Kuhn, Long, and Rush Stephen SIB, AGG, DIS COM Attention

(2005) Hagopian et al. (2005) James SIB, AGG, DIS COM Attention Hagopian et al. (2005) Matt AGG COM Tangible Hanley et al. (1997) Tony AGG, DIS COM Attention Hanley et al. (1997) Carla DIS, AGG COM Attention Kahng, Hendrickson, and Vu (2000) Ashby SIB, AGG, DIS COM Tangible Kelley, Lerman, and Van Camp Gary AGG COM Escape

(2002) Lalli et al. (1995) Joe SIB COM Escape Lalli et al. (1995) Jen SIB COM Escape Lalli et al. (1995) Kim AGG COM Escape Mancil et al. (2006) Scott TAN COM Tangible Marcus and Vollmer (1996) CJ SIB, AGG, DIS COM Tangible Piazza et al. (1999) Ike TAN COM Attention Roane et al. (2004) Carl AGG COM Tangible Roberts et al. (1995) Mary SIB Tasks Escape Sigafoos and Meikle (1996) Pete AGG, SIB, DIS COM Attention, tangible Sigafoos and Meikle (1996) Dale AGG, SIB, DIS COM Attention, tangible Thompson, Fisher, Piazza, Ernie AGG COM Attention

and Kuhn (1998) Vollmer et al. (1999) Rachel SIB, AGG Compliance, COM Escape Vollmer et al. (1999) Todd SIB Compliance, COM Tangible Vollmer et al. (1999) Kyle AGG Compliance, COM Escape

Adults Bird et al. (1989) Jim AGG, SIB COM Multiple Fisher et al. (2000) Glen SIB, AGG, PD COM Tangible

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Table 4 (Continued )

Study Participant Problem behaviora Alternative behaviorb Function

Hanley, Iwata, and Thompson Karen SIB COM Attention (2001)

Hanley et al. (2001) Jake SIB COM Tangible Hanley et al. (2001) Julie SIB, AGG COM Attention Kahng, Iwata, DeLeon, and Todd SIB COM Escape

Worsdell (1997) Kahng et al. (1997) Lynn SIB COM Attention Kahng et al. (1997) Bob SIB COM Escape Lindauer et al. (2002) Sam SIB COM Attention Vollmer et al. (1992) Bob SIB Compliance Escape, attention

a AGG = aggression; SIB = self-injurious behavior; DIS = disruption; ISB = inappropriate sexual behavior; TAN = tantrum; PD = property destruction; OP = oppositional behavior; OS = out of seat. b COM = communication.

Adults exhibiting behavior problems may pose additional challenges as their longer learning histories and physical size is difficult when aggression or escape-maintained behaviors are present. In one study, a 24-year old with a developmental disability was treated in a multielement design comparing baseline and two forms of FCT. Although one form of FCT improved communication, both still resulted in variable rates of aggression (Bailey, McComas, Benavides, & Lovascz, 2002).

Most studies were performed in inpatient hospitals, where clients typically have severe and urgent needs for interventions that work quickly. The choice to utilize DRA in these cases indicates that experimenters are confident of its efficacy. Schools housed many studies as well, supporting the use of FCT as an instructional technique necessary for successful school behavior.

The vast majority of participants in DRA studies were diagnosed with autism or another developmental disability. Considering the impressive overall findings of this literature, the preference for clients with developmental disabilities over other diagnoses may suggest that they are the best fit for DRA interventions. However, some authors also utilized DRA to improve problem behavior of those with other diagnoses. Wilder and colleagues used DRA to decrease bizarre vocalizations for a 43-year old diagnosed with Schizophrenia (2001). The impressive behavior reduction indicated that DRA may be effective with similar clients and aberrant behavior in the future.

2.3. Behavior topography

Table 3 lists the unwanted and alternative behavior topographies that were targeted during DRA studies. Destruction included a combination of aggressive and disruptive behaviors, and was the most common presenting problem. Many authors published data on several of their clients’ destructive behaviors (e.g., LeBlanc, Hagopian, Marhefka, & Wilke, 2001; Piazza et al., 1999), while others opted to demonstrate how DRA improved specific topographies (e.g., McCord, Thomson, & Iwata, 2001). In one study, authors tracked changes in aggression and self-injury separately, demonstrating that the behavior frequencies varied based on the corresponding reinforcer schedule (Lindauer, Zarcone, Richman, & Schroeder, 2002).

In addition to reducing destructive behaviors, DRA has been effective in treating severe behaviors for children diagnosed with a failure to thrive (Kahng, Tarbox, & Wilke, 2001; Peck, Wacker, Berg, & Cooper, 1996). In these cases it may be vital for effective interventions to be provided immediately, and the data show that DRA satisfies the requirements.

Some behaviors targeted by authors are less severe but can lead to more restrictive placements if left untreated. For example, inappropriate vocalizations are often targeted in schools and many produce positive results (e.g., Dixon et al., 2004; Keen, Sigafoos, & Woodyatt, 2001; Lee, McComas, & Jawor, 2002). Alternative behaviors ranged from task completion to cigarette exchanges, with appropriate communication being the most frequent. It is an obvious target with DRA because conceptually the need is to improve client’s repertoires by adding appropriate ways for them to obtain reinforcers. When these reinforcers become available for other behaviors, those that require the least response effort will be utilized. In a fascinating display, the DRA intervention was provided as baseline

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in which responses already in the participant’s repertoire were reinforced. During a Lag 1 DRA phase, only appropriate novel responses were reinforced. When reinforcers were provided for appropriate responses, novel (i.e., more difficult) behaviors rarely occurred. However, when the reinforcers were contingent upon appropriate and novel responses, participants exhibited many more of these (Lee et al., 2002).

2.4. Assessments

It may be important to perform functional analyses even if the function of behavior appears clear, as an incorrect hypothesis could waste time and other resources (Vollmer et al., 1992). The studies reviewed in this article provide further support for the use of functional analysis in developing high- quality treatments. Seventy-nine of the studies reported the use of an experimental analysis of maintaining variables prior to the intervention. Out of the 27 studies with at least one data set meeting Task Force criteria for reducing destructive behavior of children, 85% performed some type of functional analysis, and only one study did not specify methods to identify the function. This indicates that the articles that used functional analyses were more likely to produce good data and designs. However, it is also possible that those researchers who designed studies with the good validity and reliability needed to produce good results were those that included a functional analysis prior to training.

Since 1982, Iwata and colleagues have suggested that function-based treatments may be more beneficial than those based on arbitrary reinforcers (Iwata et al., 1982/1994). Apparently the authors of DRA studies agreed as 84% of the articles utilized the hypothesized maintaining variable during DRA. However, some of the studies that employed functional analyses did not use the maintaining reinforcer for the intervention. Two studies used a functional analysis and concluded that multiple reinforcers maintained the behavior. Thus, they provided a preferred item for appropriate behavior but the interventions did not yield adequate results until response cost was added for problem behavior (Bowman, Fisher, Thompson, & Piazza, 1997; Ross, 2002).

2.5. Procedural variations

The DRA intervention in over 70% of the studies would be considered FCT. The emphasis on many of these designs is on the increase of appropriate communication rather than the reduction of unwanted behavior. As such, several experimenters used FCT without extinction to increase appropriate communication (Fisher, Kuhn, & Thompson, 1998; Johnson, McComas, Thompson, & Symons, 2004; Koegel, Stiebel, & Koegel, 1998; Schindler & Horner, 2005).

Many studies used a DNRA intervention successfully, supporting the use of DRA among various functions of problem behavior. For example, Fisher and colleagues demonstrated nice results of a DNRA intervention in which the alternate behavior resulted in the termination of prompts that interfered with their preferred activities.

Most studies used extinction to reduce target behaviors, but other techniques were also examined. In some cases DRA was paired with another intervention such as demand fading (Piazza, Moes, & Fisher, 1996), punishment (Fisher et al., 2000), or time out (Derby et al., 1997). In other situations, the experimenters compared DRA to approaches other than no-treatment baseline like noncontingent reinforcement (Goh et al., 1999), differential reinforcement of other behavior (Wacker, Steege, Northup, & Sasso, 1990), and escape-extinction (McConnachie & Carr, 1997). Many variables were combined with or compared to DRA.

2.5.1. Schedule thinning Some authors altered the schedules of reinforcement for unwanted or alternative behaviors. In a

few studies, reinforcer delivery was incrementally delayed for the alternative behavior (Fisher et al., 2000; Hagopian, Fisher, Sullivan, Acquisto, & LeBlanc, 1998). Others increased the fixed ratio of delivery from continuous to more reasonable frequencies (Lalli, Casey, & Kates, 1995). Finally, Roane et al. (2004) restricted access to the operandum needed for the participant to perform the response. Such schedule thinning techniques have resulted in appropriate levels of replacement behaviors without the high cost of excessive reinforcer delivery.

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In some cases, the reinforcer rate for problem behavior was manipulated until an appropriate level of both targeted behaviors occurred (Deleon, Fisher, Herman, & Crosland, 2000; Vollmer et al., 1999). Another approach to this was the addition of noncontingent reinforcement, which was faded over time (Goh, Iwata, & Deleon, 2000; Marcus & Vollmer, 1996).

Reinforcer magnitude was also studied for the alternative behavior in a DRA intervention. The experimenters monitored post-reinforcement pauses and response frequency to discover that the duration of access to reinforcers did not affect overall response rates (Lerman, Kelley, Vorndran, Kuhn, & LaRue, 2002).

2.6. Generalization

Almost 20% of the studies included a generalization phase after the conclusion of the primary intervention. For example, Jensen, McConnachie, and Pierson (2001) demonstrated that the intervention generalized across locations. Similarly, Mancil, Conroy, Nakao, and Alter (2006) discovered that the treatment successfully generalized from the experimenter to the participant’s mother.

Twenty-eight studies reported results of follow-up data collection. Koegel et al. (1998) collected encouraging evidence that the intervention maintained as much as 1 year after the intervention had ended. Even when demonstrated by a few probe data points, the application of this technique adds considerably to the quality of such studies. The follow-up data collected by many authors provide evidence that the results of DRA are longstanding rather than being produced by either reactivity or novelty effects.

Seventeen of the studies reported some type of side or collateral effects, and eight of these used data to illustrate the phenomena. The desirable collateral effects varied from necessary weight gain (Kahng et al., 2001), to less teacher stress (McConnachie & Carr, 1997), and attention to tasks (Sisson, Hersen, & Van Hasselt, 1993). Only two of the studies mentioned the presence of unwanted side effects. Roane et al. (2004) reported that the participant tried harder to obtain the reinforcer when it was unavailable, while Carr and Carlson (1993) found that participants performed the alternative response too frequently.

2.7. Empirically supported treatments

The 116 articles using DRA were grouped by participant diagnosis and problem behavior to identify those that had sufficient empirical support according to Task Force criteria. As most participants were diagnosed with a developmental disability, most of the findings involved this type of client. Task Force criteria require that participant characteristics such as age and gender are described in the studies but do not specify that the treatments are only applied by these

Table 5 Studies that demonstrate FCT without extinction is a well-established intervention for persons with developmental disabilities

Study Participant Problem behaviora Alternative behavior Function

Fisher, Kuhn, et al. (1998) Amy SIB, PD, aggression Communication Tangible Johnson et al. (2004) Abe Aggression Communication Escape Koegel et al. (1998) Child 1 Aggression Communication Multiple Koegel et al. (1998) Child 2 Aggression Communication Multiple Koegel et al. (1998) Child 3 Aggression Communication Multiple Roane et al. (2004) Juan Aggression Communication Attention Schindler and Horner (2005) Neal Pinch, whine Communication Activity Schindler and Horner (2005) Ellie Scream Communication Escape Schindler and Horner (2005) Kit Scream, whine, Communication Avoid transition

noncompliance Worsdell, Iwata, Hanley, Thompson, Jedb SIB Communication Tangible

and Kahng (2000) a SIB = self-injurious behavior; PD = property destruction. b Adult participant.

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Table 6 Students that demonstrate DRA is a well-established treatment for food refusal

Study Participant Diagnosisa

Kahng, Boscoe, and Byrne (2003) Clara Speech delay, possible PDD Najdowski, Wallace, Doney, and Ghezzi (2003) Jack Autism Patel et al. (2002) Alex Congenital heart disease, GER Patel et al. (2002) Sunshine GER, DD Patel et al. (2002) Jarred GER, DD Piazza et al. (2003) Chris Feeding disorder, FTT Piazza et al. Cameron Feeding disorder, FTT Piazza et al. Zane Feeding disorder, FTT Piazza et al. Zack Feeding disorder, FTT Riordan et al. (1984) Joan Cerebral palsy Riordan et al. (1984) Nancy Chromosomal aberration Riordan et al. (1984) Jerry Seizures, left hemiplegia Riordan et al. (1984) Holly FTT, hydrocephalus

a PDD = pervasive developmental disorder; GER = gastroesophageal reflux; DD = developmental disabilities; FTT = failure to thrive.

characteristics. Therefore, since so many studies demonstrated visually significant results, in Table 4 the studies are grouped into child and adult participants. In Tables 5 and 6 the participants are all children except when noted.

Tables 4–6 display the lists of studies that met Task Force criteria to determine that DRA with and without extinction is well established for treating destructive behaviors of children and adults with developmental disabilities. It is also well established for the treatment of food refusal. DRA with noncontingent reinforcement meets criteria of an experimental approach.

2.7.1. DRA with extinction is a well-established treatment for destructive behavior Table 4 shows the studies that contributed to our finding that DRA with extinction is a well-

established treatment for destructive behavior of both adults and children with developmental disabilities. The participants in the list all showed marked behavior improvements when DRA with extinction was compared to either a baseline or other treatment. In all these cases, graphs displayed problem behavior but it was not required that they reported data for the alternative. In a specific case, Roberts et al. (1995) reported positive results on the presence of self-injury, but compliance data were not included in the report.

2.7.2. DRA without extinction is a well-established treatment for destructive behavior DRA without extinction is a well-established treatment for destructive behavior of persons with

developmental disabilities. These studies are listed in Table 5. It is important to note that, while the Task Force criteria were met for this intervention, several other participants were exposed to it in a similar way and it failed to produce sufficient behavior change. For example, Fisher et al. (2000) introduced Ken to FCT without extinction but his destruction remained with high variability until extinction was added to the intervention. Therefore, when extinction can be performed in conjunction with DRA, it will likely produce more rapid and complete behavior changes.

2.7.3. DRA with extinction is well established for the treatment of food refusal Table 6 lists the participants who refused food prior to treatment and accepted more as a result of

the DRA intervention. In 1984, Riordan and colleagues ignored food expulsion and received praise for bites accepted. The intervention improved food accepted in four severe cases.

2.7.4. DRA plus NCR is an experimental treatment The studies that used DRA with NCR to treat destructive behavior for persons with developmental

disabilities showed promise. Some authors were concerned about the presence of side effects that could have resulted from DRA, so added NCR to their intervention. Two participants were found who had visually significant results from this intervention (Hagopian, Wilson, & Wilder, 2001; Marcus & Vollmer, 1996). In another study, two adult participants with self-injurious behavior improved with

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DRA plus NCR (Goh et al., 2000). However, the multiple baseline design did not meet Task Force criteria as a third participant would have been required.

3. Conclusion

DRA has been successful at reducing severe behaviors for many participants, while replacing the unwanted response with appropriate behaviors that can enhance participants’ quality of life. It rarely produced unwanted side effects but instead commonly resulted in positive collateral changes. However, in those cases where the alternative behavior rate would be difficult to maintain, schedule thinning has been shown to successfully reduce the rate to acceptable levels.

DRA has been performed in many studies and is a well-established treatment for food refusal and participants with developmental disabilities exhibiting destructive behavior. The published studies with participants otherwise diagnosed, such as Schizophrenia (Wilder, Masuda, O’Connor, & Baham, 2001) were generally positive and warrant further study.

Many studies were identified whose data were promising but the designs did not meet Task Force criteria. Most often the design did not replicate findings appropriately, such as the ABCD design in Derby et al. (1997), and multiple baselines whose lengths were not varied enough in Durand (1993). While they were commonly successful at answering their research questions, the data could not be used for the current review. Over time this can cause problems because the interventions cannot demonstrate empirical validity accepted by mainstream psychology. If behavior analysts desire to increase such awareness, we suggest that designs are tweaked when possible to meet the Task Force criteria.

Future research should focus on DRA with NCR for the treatment of destructive behavior of persons with developmental disabilities in order for it to be considered a well-established treatment. Additional directions of interest would include participants without diagnoses or with those other than developmental disabilities, and with behaviors other than destruction and food refusal. Other promising areas include the studies manipulating response effort and reinforcer magnitude.

Acknowledgements

This paper includes some information submitted as a qualifying examination by the first author in partial fulfillment of the PhD degree at the Florida State University. We thank committee members Barbara and Mark Licht, Bruce Thyer, and Tom Welsh for their input and review of the original manuscript. Our gratitude extends to David Lee and Kellyn Johnson for their collection of inter-rater reliability data, and to Gregory Hanley and his anonymous reviewers for their comments on an earlier version of this manuscript.

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