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Journal of Autism and Developmental Disorders (2022) 52:3586–3597 https://doi.org/10.1007/s10803-021-05246-8

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ORIGINAL PAPER

Using Functional Communication Training to Reduce Self‑Injurious Behavior for Individuals with Autism Spectrum Disorder

Maryam Alakhzami1  · Morgan Chitiyo2,3

Accepted: 15 August 2021 / Published online: 20 August 2021 © The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature 2021

Abstract Children with autism spectrum disorders (ASD) have a high risk of developing self-injurious behavior (SIB), which is often a result of deficits in communication skills. The use of functional communication training (FCT) to address SIB maintained by negative reinforcement among children with ASD is supported by an emerging trend of behavioral research. The purpose of this study was to examine the effects of FCT on the SIB of children with ASD and to find out if the results would be maintained during periods of nonreinforcement. The results indicated significant reduction in SIB for all three participants and maintained for over two weeks following the withdrawal of the intervention. However, resurgence of SIB occurred when extinction was implemented for all participants.

Keywords Autism · Functional communication training · Demand fading · Self-injurious behavior · Resurgence

Introduction

Autism spectrum disorder (ASD) has been identified as a risk marker of self-injurious behavior (SIB), which is linked to both persistence and severity of ASD (Cohen et al., 2010; Richards et al., 2012). The occurrence of SIB in this popula- tion has also been attributed to many factors, including the level of cognitive functioning (e.g., the degree of intellectual disability is associated the prevalence of SIB; Hagopian & Leoni, 2017), difficulties in acquiring conventional language (Chezan et al., 2017), and deficits in executive function (Richards et al., 2012). SIB may hinder the individual’s inte- gration in their natural environment (Kahng et al., 2002) and result in excessive use of medication in an attempt to con- trol the behavior (Hagopian & Leoni, 2017). SIB also puts individuals at higher risk for abuse, neglect, and deprivation

(Emerson, 1990). In order to develop SIB interventions for individuals with ASD it is important to understand the fac- tors maintaining such behavior (Hagopian & Leoni, 2017).

Sigafoos and Meikle (1996) suggested that SIB can be conditioned as a verbal operant when others deliver reinforc- ing consequences (e.g., attention, escape demands, access to preferred items) contingent on such behaviors. That is, SIB is acquired and maintained via different types of operant conditioning that could be positive, negative, or automatic reinforcement (Iwata, et al., 1994). As such, it is important to develop function-based interventions by using operant conditioning procedures, which help to establish alternative appropriate behaviors and decrease SIB (Carr & Durand, 1985). Since ASD is characterized by deficits in language and communication skills, researchers (e.g., Carr & Kemp, 1989; Hagopian & Frank-Crawford, 2018) have explored the relationship between communication deficits and SIB and found that providing communication-based supports for stu- dents exhibiting SIB is imperative because communication skills can give students a socially valid approach that meets their needs (Walker et al., 2018).

Functional communication training (FCT) is a well- established function-based intervention for problem behav- iors (Tiger et al., 2008). It is a differential reinforcement strategy (Tiger et al., 2008) that has emerged as an evidence- based practice (EBP) for individuals with ASD (Kurtz et al., 2011). It is a communication strategy that decreases different

* Maryam Alakhzami [email protected]

Morgan Chitiyo [email protected]

1 Special Education-Autism Spectrum Disorder At Duquesne University, Pittsburgh, PA, USA

2 School of Education, Duquesne University, Pittsburgh, PA, USA

3 School of Education, University of North Carolina, Greensboro, NC, USA

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types of problem behaviors, including SIB (Carr & Durand, 1985) and is based on the theory that problem behavior may be a representation of a person’s inability to communicate needs and wants in more socially acceptable ways (Kurtz et al., 2011). Thus, teaching such individuals to request the reinforcer using an appropriate communication response and withholding the reinforcement for problem behavior (i.e., extinction) may decrease such problem behavior (Reichle & Wacker, 2017; Tiger et al., 2008).

Although extinction is a necessary and important compo- nent of FCT, it is not always possible to implement it (Ath- ens & Vollmer, 2010). A growing body of research points out that extinction bursts typically occur during FCT with extinction (Davis et al., 2012; Saini et al., 2016). Extinc- tion burst refers to an increase in problem behavior’s fre- quency, rate, magnitude, or variability when reinforcement is removed (Braithwaite & Richdale, 2000) and is reported to be a serious problem when it is used for individuals who display SIB (Davis et al., 2012). Therefore, this study aimed to address such problems produced by pairing FCT with extinction. By applying FCT without extinction to prevent worsening of the problem behavior (e.g., greater intensity, additional topographies) and to reduce the possibility of intervention resistance (Clay et al., 2017).

The current study was also designed to address concerns related to the implementation of FCT, such as reducing the resurgence of SIB. Previous research (e.g., Derby et al., 1997; Erturk et al., 2017; Lattal & St. Peter Pipkin, 2009; Mace et al., 2010) indicated that FCT procedures could inad- vertently strengthen problem behavior, leading to its resur- gence. One of the reasons why FCT leads to reemergence of SIB, according to extant literature, is that frequent rein- forcement is not practical in natural environments (Hago- pian et al., 2011). For instance, a child may request breaks frequently, and as a result, the engagement in any academic task will be shallow (Peck Peterson et al., 2005). There- fore, resurgence could occur because one or more of the child's communication attempts (e.g., break request) is not reinforced, leading to deprivation—a condition in which the reinforcer is not delivered (Fisher et al., 1998; Fisher et al., 2000). Delivering the requested reinforcers every time the child asks for it may not be feasible in the long run for ser- vice providers or caregivers; consequently, the acceptability of FCT as an intervention might be tampered (Peck Peter- son et al., 2005). Thus, the current study was also designed to address this concern by using FCT with demand fading procedures to reduce break requests and allow the interven- tion to be executed seamlessly in the natural environment (Rooker et al., 2013).

Furthermore, there is currently a lack of evidence on how to sustain treatment gains (i.e., FCT) obtained after treat- ment is discontinued (Mace & Nevin, 2017). Therefore, these researchers wanted to address this gap while adding

to previous research on the effectiveness of FCT for chil- dren with ASD. Specifically, this current study was designed to examine the effects of FCT and demand fading proce- dures using concurrent schedules of reinforcement, instead of extinction, and most-to-least prompting procedures to replace SIB among students with ASD. The study was guided by the following questions: 1) To what extent do FCT and most-to-least prompting reduce self-injurious behavior of children with ASD? 2) To what extent do children with ASD maintain their use of socially appropriate requests to communicate needs/request desired items over time after the intervention is ceased? 3) To what extent is resurgence of self-injurious behavior observed during maintenance?

Method

Participants and Setting

Participants

Three children were included in the current study based on the following criteria: they had to (1) have a diagnosis of ASD based on the Childhood Autism Rating Scale (Chle- bowski et al., 2010) or other equivalent tests (e.g., Gilliam Autism Rating Scale-Second Edition [Gilliam, 2005]), (2) exhibit limited functional communication skills, (3) be between the ages of four and 14 years, (4) display SIB that is maintained by escape from demands as determined by functional behavior assessment and functional analysis.

Recruitment of Participants

Once the primary investigator obtained Institutional Review Board’s approval for the study, approval was sought from public schools in the state of Pennsylvania. The primary researcher then sought permission from the teachers and consent from the children’s parents.

Student participants. Three participants, Sean, Mary, and Ben (pseudonyms), participated in this study.

Sean. Sean was four years and six months old at the beginning of this study and was diagnosed with autism at the age of three. He was in a Pre-K program in a public elemen- tary school. He also receives early intervention services and supports in his school, which included speech therapy, occu- pational therapy, physical therapy, and special education services. His classroom consisted of one teacher and one paraprofessional. At the time of conducting this research, Sean did not take any medication except for a multivitamin. Sean displayed mild delays in his receptive language and notable delays in his expressive language. Sean had limited speech; he had a limited vocal repertoire that comprised of a few words plus echolalia. Sean’s teacher reported that he

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engaged in SIB in the classroom or other school settings, at home, and community settings daily. The SIB was reported to include hitting himself with an open or closed hand (fist) and also banging his head on a wall or table. This behavior was reported to be moderate to severe in nature. Results from the Functional Analysis Screening Tool (FAST) showed that Sean's behavior was maintained by escape from non-preferred demands and to gain preferred items. Specifi- cally, the functional analysis conditions showed that Sean engaged in SIB to escape non-preferred demands during all academic activities.

Mary. Mary was fourteen years old at the beginning of this study with a diagnosis of autism. She was in seventh grade receiving all special education services (e.g., academic and social skill instructions) in a self-contained classroom (i.e., autistic support classroom) in a public high school. The classroom consisted of one teacher and six paraprofession- als. Mary also received speech therapy services. According to teacher interviews, she experienced developmental delays in academic performance, socialization, and motor skills. Mary's language skills comprised of only a few vocaliza- tions and her communication consisted of two to five-word utterances. She had challenges in verbally communicating her wants/needs and needed verbal and visual prompts to communicate. At the time of conducting this research, Mary did not take any medications. Before implementation of this study, Mary's SIB was reported by teachers to be moderate to severe in nature, in the form of head-banging and head- hitting. Previously, interventions had been implemented to increase pairing with adults and remove any demands/tasks. This did not decrease the level of SIB. Results from the FAST showed that Mary's behavior was maintained by either escape from non-preferred demands or teacher's attention (see Table 1), which was confirmed via the functional analy- sis conditions. Specifically, the functional analysis showed that Mary engaged in SIB to escape non-preferred academic demands including math, writing, and reading.

Ben. Ben was thirteen years and six months of age at the beginning of this study with a diagnosis of autism (see Table 1). He was in seventh grade receiving special educa- tion services (e.g., academic and social skill instructions) in a self-contained classroom (i.e., autistic support classroom) within a public middle school. His class consisted of seven students and two teachers (i.e., special education teacher and

teacher’s aide). Ben received speech therapy to address the lack of communication and occupational therapy to improve his fine motor skills. The school staff reported that Ben had a history of SIB in the form of self-hits to his head.

In terms of language, Ben could communicate in full sentences that others could understand and displayed some intraverbal behavior (e.g., he could understand questions and answer them accordingly). However, sometimes he did not respond to the service providers' commands and did not respond to his name. At the time of conducting this research, Ben did not take any medications, and he did not display any issues related to hearing or vision. Before implementa- tion of this study, Ben's SIB in the classroom was addressed by reducing or removing demands, which had not reduced his level of self-injury as he continued to exhibit SIB daily. Results from the FAST, and confirmed by a functional analy- sis, showed that Ben’s behavior was maintained by escape from non-preferred demands (see Table 1).

Settings

The participants were recruited from public K-12 school dis- tricts. All schools were located in a large metropolitan city in the northeastern United States. All the study procedures (i.e., functional behavior assessments, functional analysis, and intervention sessions) were conducted in an academic setting (self-contained classrooms) in which the target SIB occurred most frequently as well as in the participants’ homes. All FCT and prompting sessions were taught in a one-on-one format within the participant’s current class- room/home environment.

Response Measurement and Reliability

Dependent Variables

Self‑Injurious Behavior

The topographies of SIB examined in this study included head-banging and head-hitting. For Ben, SIB was recorded when he engaged in self-injury in the form of hitting his head or face with his hand. For Mary, SIB was recorded when she engaged in self-injury in the form of head-banging

Table 1 Characteristics of the Participants

Note. Age: Y = years, M = months

Participant Age Gender Diagnosis Topography of SIB FAST Results FA Results

Sean 4Y, 6 M Male Autism head-banging & head-hitting Escape & Tangible Escape Mary 14Y Female Autism head-banging & head-hitting Escape & Attention Escape Ben 13Y, 6 M Male Autism head-hitting Escape & Attention Escape

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and head-hitting. Head banging for Mary was defined as forceful contact between the head and hard surfaces (e.g., head butting walls, table) as well as head-hitting, which was defined as hitting her head or face with her hand. For Sean, SIB was recorded when he engaged in self-injury in the form of head-banging and head-hitting. Head banging (Sean) was defined as forceful contact between the head and hard sur- faces (e.g., table) as well as head-hitting, which was defined as hitting his head or face with his hand.

Interobserver agreement

The mean count-per-interval interobserver agreement (IOA) (Cooper et al., 2007) was used in this study. The observation period was divided into a series of smaller counting times of 1 to 2 min. The mean count-per-interval IOA was calculated by dividing the number of intervals with agreements by the total number of intervals in a session and converting the quotient to a percentage.

Procedure

Phase 1: Functional Behavior Assessments (FBA)

The study procedures commenced with a FBA of SIB for each participant to collect information about whether or not the participant's SIB was maintained by escape from task demands, and whether or not communication skills could become a robust replacement of SIB. FBA methods in this study included: indirect functional behavior assessment, descriptive functional behavior assessment, functional anal- ysis screening tool, and functional (experimental) analysis (Cooper et al., 2007).

Indirect Functional Behavior Assessment (FAI)

Interviews were conducted with teachers using functional assessment interviews (O’Neill et al., 2015). Each interview lasted approximately 20–30 min.

Descriptive Functional Behavior Assessment

Direct observations were conducted using the ABC method for continuous recording (Cooper et al., 2007), in which A refers to the antecedent, B refers to observed behavior, and C refers to the consequences (Delgado et al., 2017). In ABC continuous recording, the occurrence of SIB was manually recorded on the datasheet using a partial interval recording system (Cooper et al., 2007). The observations took place during structured one-to-one activities. Each participant was observed during six sessions that were conducted across three days. Each observation lasted from 60 to 90 min.

Functional Analysis Screening Tool (FAST)

Teachers of the participating students were asked to com- plete the FAST (Iwata et al., 2013) in order to collect infor- mation about the participants and the function of their SIB. Results of the FAST were used to verify the top two suspected behavioral functions (e.g., attention and escape conditions), which guided direct observation in many dif- ferent situations for these top two conditions. Therefore, the primary investigator only administered FA for the top two conditions that were identified as possible behavioral func- tions by the participants' teachers.

Phase 2: Functional Analysis

Functional analysis encompassed four conditions—contin- gent attention, contingent escape, tangible, and control— with each condition being presented systematically one at a time (Cooper et al., 2007; Iwata, Dorsey, et al., 1994). Each session lasted for 10 min, with a brief break (2 min) between each session. For each participant, nine 10-min sessions were administered over three days. Partial interval recording procedures were used to record the target SIB.

Escape

During escape conditions, an instruction to complete a task was presented to the participant. If the participant did not respond after 5 s, the demand was repeated. If the participant completed the task, prompted or unprompted, the investiga- tor provided praise (e.g., saying "Good job"). Contingent upon SIB, the task was removed, and the investigator turned away for 10 s (the investigator stated: “You don’t have to.”).

Tangible

During tangible conditions, the participant was granted access to a highly preferred item such as an iPad for one minute. The investigator restricted access to the item after a set interval of 45 s and stated, "My turn with the iPad." Con- tingent upon SIB, the investigator provided the participant access to the preferred item. No other demands were placed on the participant.

Attention

During attention conditions, the investigator provided roughly one minute of access to attention, and then turned away her attention towards activities such as filling paper- work. Contingent on SIB, the investigator provided access to attention in the form of verbal reprimands (e.g., "hitting yourself isn't nice") for 20 s. When no SIB occurred, the investigator did not give the participant any social attention.

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Control

During control conditions (free play), the participant was allowed access to preferred tangible items and neutrally- stimulating materials/activities or a non-academic task (e.g., coloring pages). The investigator provided attention approximately every 20 s to the participant. No instruc- tional demands were placed on the participant.

Phase 3: Treatment

The current study used a multiple probe across participants design (Gast, Lloyd, & Ledford, 2018) in six phases: (1) Baseline, (2) FCT pretraining, (3) FCT plus demand fad- ing, (4) generalization, (5) maintenance probes, and (6) resurgence condition.

Baseline

Baseline sessions were three to five minutes in duration (five minutes for Mary and Ben, and three minutes for Sean). The investigator held three baseline sessions a day until the data were visually stable. During these base- line sessions, the participants were asked to engage in activities/tasks such as solving math problems or writing assignments chosen by the participants’ teachers. Upon the occurrence of SIB, the task was removed for about one minute, and praise was delivered contingent upon com- pletion of the task. The primary investigator continued to repeat the instructions until the task was completed or three/five minutes had elapsed.

FCT Pretraining

During the FCT pretraining, the participants were taught to request a break to receive breaks from task demands. Just like with baseline sessions, the FCT was conducted in sessions that lasted for five minutes (three sessions a day) for Mary and Ben, and three minutes (three sessions a day) for Sean. If a participant was verbal (e.g., Ben and Mary), and was exhibiting SIB to escape task demands, the investigators taught him/her to request a break by saying "break" as a replacement behavior for SIB. If a participant was exhibiting very limited verbal skills (e.g., Sean), and was exhibiting SIB to escape task demands, the investi- gators taught him/her to request a break by touching the communication card or the communication device for the break or help as a replacement behavior for SIB. Most-to- least prompting procedures were used simultaneously for the participants to practice touching the card before they got a break (e.g., removing work materials and turning

away from the participant for 30 s). Prompting was given based on the frequency of the participants’ independent responses.

FCT and Demand Fading

During demand fading, the investigators systematically increased the number of demands/tasks the participant was required to complete before presenting the discriminative stimulus for the high-quality break. The word work, for example, was printed on a red card for the work communica- tion card and the word break was printed on a green card for the break communication card. The green card served as a discriminative stimulus for the availability of a high-quality break (e.g., removing work materials and turning away from the participant for 1 min plus access to preferred activities/ items), which was always available during FCT. The par- ticipant was provided with a 1-min task break with access to preferred activities (high-quality break) upon completing the task and emitting functional communication responses (FCRs). Any break requests before completing the tasks/ demands resulted in a low-quality break. If the participant displayed SIB at any time, task materials were removed for 10 s, but no activities were provided during the task break (low-quality break). At the end of each break, a new trial was initiated, and the above sequence was reintroduced. At first, the participants were required to complete one step. This requirement then increased by one step if the participant completed the work while SIB occurred at low levels for three consecutive sessions. Contingent upon three consecu- tive sessions of a low level of SIB, the number of demands required for the presentation of the green card were doubled.

Generalization

The fourth phase consisted of generalization probes, which were conducted in each participant’s home. Generalization probes were similar to those in the intervention conditions and comprised of academic demands/activities identified via FA and FBA to increase the occurrences of SIB, but in home settings instead of school or classroom settings.

FCT maintenance

The fifth phase consisted of maintenance probes. Mainte- nance probes occurred 7, 10, and 14 days for all the stu- dents after the intervention concluded to examine if the com- munication responses were maintained. The investigators observed the participants during regular schoolwork activi- ties that were conducted in home settings. Continuous direct observational data were collected using similar procedures as described in the baseline and intervention conditions. The procedures were similar to those in the intervention

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conditions, but no prompts were given for the communica- tion responses.

Resurgence Condition

Resurgence followed the maintenance condition as described by Volkert et al. (2009). Resurgence condition occurred one week after the maintenance condition. Following stability of low levels of SIB for all the participants, the SIB was placed on extinction in the resurgence phase. During the resurgence condition, all intervention procedures were withdrawn, and direct observations was conducted. The investigator admin- istered only six sessions across three days for all the partici- pants. Two 3-5-minute sessions were conducted over three days. The procedures were similar to those in the FCT main- tenance condition except that the functional reinforcer was no longer provided for either SIB or the alternative commu- nicative response (Volkert et al., 2009). The purpose of this condition was to observe any resurgence. Resurgence was defined as the occurrence of SIB at a rate exceeding levels observed during the FCT maintenance condition in at least one of the six sessions (Volkert et al., 2009).

Results

The data from each stage of the study were visually ana- lyzed for each participant and presented in line graph format within and between conditions and phases.

Question 1: To What Extent Do Functional Communication Training And Most‑To‑Least Prompting Reduce SIB for Children with ASD?

To answer this question, the results of the baseline, FCT, generalization, maintenance, and resurgence phases were analyzed.

Baseline

Data showed relatively high levels of SIB during baseline conditions for the three participants, with a range varying from 30 to 100%.

Sean. Sean's percentage of intervals of SIB averaged 92.8% of 10-s intervals throughout five 3-min sessions during baseline with a range of 88%–100% (see Fig. 1). The data remained stable (except for the last session) from 88%–94%, and no data point in the baseline varied more than 50% from the mean of the baseline.

Mary. Mary's percentage of intervals of SIB averaged 66% of 10-s intervals throughout nine 5-min sessions during baseline with a range of 50%–100% (see Fig. 1). The data

remained at a moderate and stable level with low variability (except in session six, where SIB reached 100%).

Ben. SIB occurred at the highest-level during baseline with a mean of 37% of 10-s intervals throughout twelve 5-min sessions. The range of SIB in baseline was 30%–40% of intervals (see Fig. 1). The data were stable at a low-to- moderate level (no data point of the baseline varied more than 50% from the mean of the baseline) with low variability and a slight increasing trend.

Intervention

A minimum number of data points illustrating the level, trend, and variability of the data was determined to be five data points (5 sessions) at a stable level (for the participant assigned to the first tier, Sean). Simultaneously, the baseline data for the other two participants (Mary and Ben) remained relatively stable.

Sean. Figure 1 showed SIB exhibited by Sean during each session in the intervention phase over the course of 25 3-min sessions. Functional communication training pro- duced a decreasing trend in SIB and had a mean of 19% of intervals and a range of 0%–65% of intervals. The SIB initially occurred at high levels across the FA and baseline conditions; however, the SIBs decreased dramatically after the first intervention sessions. There was a gradual decreas- ing trend in the percentage of SIB from the first intervention session (65%) to the last intervention session (0%); this pat- tern in the data indicated a decelerating trend in a therapeu- tic direction.

Mary. Mary stayed in the baseline phase until an average of 53% reduction of SIB was observed in Sean’s intervention sessions relative to baseline sessions. Figure 1 shows SIB exhibited by Mary during each session in the intervention phase over the course of 21 5-min sessions. Functional com- munication training produced a decreasing trend in SIB and with a mean of 18% of intervals and a range of 37%–10% of intervals. SIB initially occurred at high levels across the FA and baseline conditions. After the first intervention ses- sions, however, SIB decreased to low levels, but SIB did not drop to zero. There was also a gradual decreasing trend in the percentage of SIB from the first intervention session (37%) to the last intervention session (10%) for Mary; this pattern in the data showed a decelerating trend in a thera- peutic direction.

Ben. Once a functional relation was established for Mary, the intervention for Ben was started. Specifically, the intervention was introduced for Ben after a mean of 30% reduction of SIB was observed in Mary’s data relative to the baseline data. Figure 1 shows SIB exhibited by Ben during each session in the intervention phase over the course of 18 5-min sessions. FCT produced a decreasing trend in SIB with a mean of 7% of intervals and a range of 20% to 0% of

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Fig. 1 Percentage of intervals of self-injurious behavior during the baseline, intervention, generalization, maintenance, and resurgence for Sean, Mary, and Ben. FCT = functional communication training

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intervals. A slight variability in the data was also observed during the intervention. Furthermore, there was a gradual decreasing trend in the percentage of SIB from the first inter- vention session (20%) to the last intervention session (0%) for Ben; this data pattern indicated a decelerating trend in a therapeutic direction.

Generalization

Generalization sessions were conducted in each participant’s home. The generalization sessions started in sessions 26 for Sean, 22 for Mary, and 19 for Ben.

Sean. Figure 1 shows SIB exhibited by Sean during each session in the generalization phase over the course of 8 3-min sessions. Sean's SIB remained at low and stable levels throughout this phase (M = 2%; range from 6 to 0%), indicating that the results generalized to the home setting.

Mary. Figure 1 displays SIB exhibited by Mary during each session in the generalization phase over the course of 11 5-min sessions. Even though Mary engaged in SIB at higher levels than Ben and Sean, Mary's SIB remained at low and stable levels compared to the baseline levels throughout this phase (M = 7%; range from 13 to 0%), dem- onstrating the intervention’s effect in reducing SIB general- ized to the home setting.

Ben. Figure 1 displays SIB exhibited by Ben during each session in the generalization phase over the course of 15 5-min sessions. Ben's SIB remained at low and stable levels throughout this phase (M = 1%; range 0% to 6%), demon- strating the intervention impact in reducing SIB generalized to the home setting.

Question 2: To what Extent do Children with ASD Maintain their use of Socially Appropriate Requests to Communicate Needs/Request Desired Items Over Time After the Intervention is Ceased?

Maintenance began 7, 10, and 14 days for all the students after the intervention concluded at which point the demand requirement remained the same for all the participants in this phase (e.g., for Ben, four tasks were required to be com- pleted before the reinforcer became available; for

Sean, three tasks were required; for Mary, two tasks were required).

Sean. Figure 1 displays SIB exhibited by Sean during each session in the maintenance phase over the course of nine 3-min sessions. The level and trend of SIB maintained near-zero levels throughout the maintenance condition (M = 0.6%; range from 6 to 0%) indicating the intervention impact in reducing SIB maintained over time.

Mary. Figure 1 displays SIB, exhibited by Mary during each session in the maintenance phase over the course of nine 5-min sessions. Mary had a small increase in the level

and trend of SIB in the maintenance condition (M = 9.6%; range from 13 to 7%), relative to the generalization phase (M = 7%). However, Mary’s SIB remained at low and sta- ble levels compared to the baseline levels throughout this phase, indicating the intervention impact in reducing SIB maintained over time.

Ben. Figure 1 displays SIB exhibited by Ben during each session in the maintenance phase over the course of nine 5-min sessions. Ben did not engage in any SIB during the maintenance phase. The level and trend of SIB maintained at zero levels throughout the maintenance condition (M = 0%).

Question 3: To What Extent is Resurgence of Self‑Injurious Behavior Observed During Maintenance?

Resurgence phase began one week after the maintenance phase ended, and all the intervention procedures ceased so as to examine whether the effectiveness of FCT procedures in reducing SIB were maintained.

Sean. Figure 1 displays SIB exhibited by Sean during each session in the resurgence phase over the course of six 3-min sessions. The data revealed that the overall trend of SIB increased and had a mean of 18% of intervals and a range of 12% to 35% of intervals relative to the maintenance condition (0.6%).

Mary. The SIB exhibited by Mary during each session in the resurgence phase over the course of six 5-min ses- sions is displayed in Fig. 1. The data were variable, and the overall trend of SIB was increasing and had a mean of 23% of intervals and a range of 20% to 27% of intervals relative to the maintenance condition (9.6%).

Ben. The SIB exhibited by Ben during each session in the resurgence phase over the course of six 5-min sessions is displayed in Fig. 1. The data revealed that the overall trend of SIB increased with a mean of 6% of intervals and a range of 3% to 10% of intervals relative to the maintenance condi- tion (0%).

Interobserver Agreement Results

Functional Analysis

Interobserver agreement (IOA) was calculated for 33% of the functional analysis sessions for each participant. IOA on the number of SIB for each of the participants was 100% (M = 100%).

Baseline

IOA was calculated on 40% of baseline sessions for Sean and 33% of baseline sessions for both Mary and Ben. Agreement

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on SIB ranged from 94% to 100% (M = 97%) for Sean, 100% (M = 100%) for Mary, and 89% to 100% (M = 97%) for Ben.

Intervention IOA was calculated for SIB on 32% of the intervention sessions for Sean and 33% of the interven- tion sessions for Mary and Ben. Agreement on SIB for Sean ranged from 88 to 100% (M = 97.4%), 90% to 100% (M = 95%) for Mary, and 85% to 100% (M = 97.5%) for Ben. Reliability on SIB was also calculated on 38% of the inter- vention sessions (generalization) for Sean, 36% for Mary, and 33% for Ben. Agreement on SIB for Sean and Mary was 100% (M = 100%) and 50% to 100% (M = 90%) for Ben.

Maintenance Reliability was calculated on 33% of the maintenance sessions across all the participants. Agreement on SIB for both Sean and Ben on maintenance was 100% (M = 100%), and 86% to 100% (M = 95%) for Mary. Agree- ment on maintenance for Sean ranged from 89 to 100% (M = 97%). There were no IOA sessions conducted in the resurgence phase.

Procedural Integrity Checklist for FCT

Treatment integrity data were collected on 33% of the intervention sessions for all the participants. The behavior specialists and/or the classroom teacher monitored directly for treatment integrity on 33% of sessions. Checklists of the intervention components were created to measure the accuracy of treatment implementation (e.g., the readiness of the materials, the presentation of the stimulus, the rein- forcement, and the level of prompt). Using a checklist of the intervention components, the teacher and/or the behavior specialists marked whether each intervention component was demonstrated by the primary investigator. Treatment integrity was calculated by dividing the number of times the intervention was implemented correctly by the number of sessions of implementation and then multiplied by 100. The average score of 100% accuracy was recorded across all the participants.

Discussion

Results of the study indicated that FCT coupled with most- to-least prompting procedures effectively decreased SIB for all the participants and FCRs efficiently replaced SIB in the participants’ repertoires. Findings of this study replicate and extend the previous literature in three aspects: (1) the effectiveness of FCT without extinction, (2) the treatment of negatively reinforced problem behaviors (i.e., SIB), and (3) the relationship between FCT and concurrent schedules of reinforcement and resurgence of SIB. First, the results of this study showed that using FCT without extinction was

effective in reducing SIB and increasing the use of the alter- native response in lieu of the inappropriate behavior for all the participants. These findings are consistent with previous studies (e.g., Casey & Merical, 2006; Davis et al., 2018; Fisher et al., 2018; Peterson et al., 2017) that demonstrated that utilizing FCT without extinction decreased problem behaviors. The aforementioned studies proposed two pos- sible reasons for these outcomes. One possibility was that FCT without extinction was effective as long as the problem behavior became less frequently reinforced than the alterna- tive responses (Peterson et al., 2017). This current study, for example, provided a shorter break time for SIB (10 s), while the alternative response (i.e., functional reinforcer) received a longer break time (30 s to 1 min). A second possibility was that using FCT without extinction is an option if the problem behavior is known to be maintained by escape from demand (Casey & Merical, 2006; Davis et al., 2018; Fisher et al., 2018; Peterson et al., 2017). In this current study, partici- pants’ SIB was initially assessed through functional analysis in order to identify participants who exhibited SIB that was maintained by escape from task demands. The results of functional analysis indicated that all participants’ SIB was maintained by escaping from demands. Other studies (e.g., Carr & Durand, 1985; Volkert et al., 2009), however, found that using FCT with extinction reduced the level of SIB as well as established an alternative communicative response (as replacement of escape).

Second, regarding the treatment of negatively reinforced SIB, Lalli et al. (1999) used concurrent schedules of rein- forcement to decrease SIB maintained by escape from tasks of five participants with developmental disabilities (includ- ing ASD). The findings of this current study revealed that using alternative reinforcement (e.g., preferred items, praise) increased compliance and decreased negatively reinforced problem behavior without the use of extinction although problem behavior resulted in a 30-s break from the task. Lalli and colleagues (1999) indicated that these results were due to the alternative reinforcement served as an abolishing operation, which in turn decreased the par- ticipants’ desire to escape from task demands by exhibiting problem behaviors. Similarly, Lomas et al. (2010) replicated the Lalli et al.’s (1999) study in which they recruited three participants with ASD who exhibited problem behaviors, including SIB, maintained by escape from demands that was executed without escape extinction using schedule-thinning procedures. This current study found similar results to Lalli et al.’s (1999) in which the problem behaviors maintained by escape from demands reduced to near-zero. Furthermore, Zangrillo and colleagues (2016) found that combining FCT with the thinning schedule of reinforcement decreased problem behaviors reinforced by escape from nonpreferred tasks. The current study also used high preference items or alternative reinforcement to aid in increasing the alternative

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responses and decreasing negatively reinforced SIB without the use of extinction, which led to near-zero levels of SIB for two participants (Sean and Ben).

Third, regarding the relationship between FCT and con- current schedules of reinforcement and resurgence of SIB, results from this current study extend the findings of Volkert and colleagues (2009), which showed that the FCT inter- vention could have some limitations when confronted with delays in previously reinforced communicative response. The thinning of the reinforcement schedule for the alterna- tive response produced a resurgence of problem behavior. Our results extend these findings by revealing that resur- gence of SIB occurred when a thinning schedule of rein- forcement was implemented for all participants.

The study's findings have implications for practice regard- ing the effectiveness of FCT treatment to replace SIB in school and home settings. While many studies have docu- mented the effectiveness of FCT in clinical settings (e.g., Davis et al., 2018; Fisher et al., 2014; Fuhrman et al., 2018) very few studies have been done in applied settings (Casey & Merical, 2006). Since this study was conducted in the participants’ natural environments—school and home—it adds to this scarce literature and serves as a good resource for classroom teachers.

Research Limitations

The results and implications of the current findings must be explained relative to several limitations. First, the multiple baseline design required collecting the data over extended periods of time during the baseline. For example, Mary (the second participant) received the first intervention session after nine data points and Ben (the third participant) received the intervention after 12 data points. In fact, this problem, to some extent, was addressed by collecting the data inter- mittently via using multiple probe design, which according to Cooper et al. (2007) reduces the length of baseline to increase time for intervention, unlike continuous measure- ments that require collecting the data continuously, which consumes time that could be used for treatment.

A second limitation was that this study used the standard FA method (Iwata, Dorsey, et al., 1994) to guide the primary investigator toward producing the function-based interven- tion (i.e., FCT) to treat SIB efficiently. However, given the seriousness of SIB, using a more practical and effective method such as an Interview-Informed, Synthesized Con- tingency Analysis (IISCA; Hanley et al., 2014), could be a better replacement of the standard FA method, because it requires fewer resources, is safer, and more timely (Coffey et al., 2020). A last limitation of the current study is that par- ticipants of this study had different levels of communication abilities (e.g., using a communication device for Sean and

verbally asking for a break for both Ben and Mary); thus, generalization of the results of this study could be limited.

Recommendations for Future Research

The findings of this research have implications for further research. First, future research could assess the practical aspect of this study to which paraprofessional and/or special education teachers can execute the intervention procedures described in this research in order to identify its use by other educators. Furthermore, future research could consider com- paring older participants (e.g., teenagers and adolescents) versus younger participants (the range of the ages, four to six years old) to evaluate the differential impacts of FCT procedures on both groups (older vs. younger participants). Future researchers may also wish to use the IISCA instead of the standard FA method to identify the function of the problem behavior because it is easier and more practical than FA. Finally, research has shown that FCT suppresses problem behavior under particular conditions, but when a component of the FCT is eliminated (e.g., FCR placed on extinction), problem behavior reoccurs (Derby et al., 1997). Therefore, during resurgence condition, future studies may wish to provide intermittent reinforcement for FCRs instead of extinction, to enhance the persistence of FCRs.

Conclusion

For many children with ASD, communication deficits are associated with the occurrence of SIB. Such deficits can affect children's ability to interact effectively and negatively influence other areas of development. The current study spe- cifically targeted children who exhibited SIB as a result of having difficulties with communication skills. The current study contributes to our understanding of the use of FCT without extinction; FCT produced significant reductions in SIB and increased rates of appropriate communicative behavior for all three participants in school settings. In addi- tion, such outcomes generalized across a new setting (i.e., home) and maintained for over two weeks after intervention had been withdrawn. However, resurgence of SIB occurred when an extinction or a thin schedule of reinforcement was implemented for all participants.

Author contributions The first author, MA, wrote the manuscript, provided data for Table 1 and Fig 1, and conducted all experimentala- nalyses. The second author, MC, reviewed and revised the manuscript.

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Declarations

Conflict of interest The authors declare that they have no conflict of interest.

Research Involving Human Participants and/or Animals Approval was obtained from the ethics committee of Duquesne University. The pro- cedures used in this study adhere to the tenets of the Declaration of Helsinki.

Informed Consent Informed consent was obtained from all individual participants included in the study.

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