Tech behavioral Modification homework

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JOURNAL OF APPLIED BEHAVIOR ANALYSIS 1999, 32, 1–8 NUMBER 1 (SPRING 1999)

SIDE EFFECTS OF EXTINCTION: PREVALENCE OF BURSTING AND

AGGRESSION DURING THE TREATMENT OF SELF-INJURIOUS BEHAVIOR

DOROTHEA C. LERMAN LOUISIANA STATE UNIVERSITY

AND

BRIAN A. IWATA AND MICHELE D. WALLACE THE UNIVERSITY OF FLORIDA

Findings from basic and applied research suggest that treatment with operant extinction may produce adverse side effects; two of these commonly noted are an increase in the frequency of the target response (extinction burst) and an increase in aggression (extinc- tion-induced aggression). Although extinction is often used to treat problem behavior in clinical settings, few applied studies have examined the prevalence of these side effects or their possible attenuation with other operant procedures. An analysis of 41 data sets for individuals who received treatment for self-injurious behavior indicated that extinction bursts or increases in aggression occurred in nearly one half of the cases. The prevalence of bursting and aggression was substantially lower when extinction was implemented as part of a treatment package rather than as the sole intervention.

DESCRIPTORS: extinction, extinction burst, extinction-induced aggression, side ef- fects, behavior disorders, self-injurious behavior

Numerous research findings have shown that operant extinction (i.e., terminating the reinforcement contingency that maintains a response) can produce rapid reductions in problem behavior (e.g., Forehand, 1973; Repp, Felce, & Barton, 1988). The devel- opment of methodologies for identifying the maintaining consequences of problem be- havior has facilitated the use of extinction as treatment for severe behavior disorders. Moreover, results of studies have demon- strated that extinction can be critical to the success of other treatments, such as differ- ential reinforcement (e.g., Mazaleski, Iwata, Vollmer, Zarcone, & Smith, 1993; Wacker et al., 1990; Zarcone, Iwata, Smith, Maza- leski, & Lerman, 1994). As a result, an in- creasing amount of research has focused on

Reprints may be obtained from Dorothea C. Ler- man, 236 Audubon Hall, Louisiana State University, Baton Rouge, Louisiana 70803. (E-mail: dlerman@ unix.1.sncc.lsu.edu).

developing and refining treatments based on extinction (e.g., Iwata, Pace, Cowdery, & Miltenberger, 1994; Iwata, Pace, Kalsher, Cowdery, & Cataldo, 1990; Rincover & De- vany, 1982), and such procedures are now commonly used to treat behavior disorders in clinical settings.

Nevertheless, results of basic and applied studies suggest that extinction may be asso- ciated with a number of undesirable effects. The two most common side effects de- scribed in applied texts and literature reviews are the extinction burst, which is a tempo- rary increase in the frequency, duration, or magnitude of the target response, and ex- tinction-induced aggression, which is an in- crease in aggression. Although few studies have systematically examined either phe- nomenon, both side effects have been re- ported in applied research findings (e.g., France & Hudson, 1990; Goh & Iwata, 1994; Herbert, Pinkston, Cordua, & Jack-

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son, 1973). For this reason, a number of au- thors have cautioned against using extinction in clinical settings (e.g., LaVigna & Don- nellan, 1986).

Treatment with extinction may indeed be contraindicated for use outside laboratory settings if response bursts and extinction-in- duced aggression occur frequently and in- crease the risk of physical harm to the in- dividual or to caregivers (e.g., when treating self-injury of large adults). On the other hand, extinction typically is combined with reinforcement or other procedures in applied studies, and several authors have suggested that these alternative procedures (e.g., dif- ferential reinforcement of alternative behav- ior [DRA], antecedent manipulations) may mitigate the undesirable effects of extinction (Kazdin, 1994). However, the extent to which these factors might influence the like- lihood of extinction bursts or extinction-in- duced aggression is unclear because, with one exception (Lerman & Iwata, 1995), the prevalence of these side effects has not been investigated.

Lerman and Iwata (1995) examined 113 published and unpublished treatment cases to determine the prevalence of the extinction burst. Results indicated that extinction bursts occurred less often than previously as- sumed (they were observed in 24% of the cases), particularly when extinction was combined with other treatment procedures. Only 12% of cases were characterized by bursting when extinction was implemented in conjunction with reinforcement or other procedures, whereas 36% of cases showed evidence of bursting when extinction was implemented alone. However, the generality of these results was somewhat limited be- cause of various methodological differences among the cases. For example, factors that could alter the likelihood of detecting an ex- tinction burst, such as session length and data calculation or presentation methods, varied widely among the cases. Moreover,

the prevalence of other side effects, such as increases in aggression, could not be deter- mined because aggression was often the tar- get of treatment, and data on other nontar- geted responses were rarely presented.

Further research on the prevalence and characteristics of extinction bursts and ex- tinction-induced aggression is needed to de- termine whether greater emphasis should be placed on alternatives to extinction in both laboratory and clinical settings. If research findings suggest that these side effects are prevalent when extinction is included in treatment, caregivers probably should con- tinue to reinforce problem behavior while implementing procedures that can be effec- tive in the absence of extinction, such as noncontingent reinforcement (NCR; Fi- scher, Iwata, & Mazaleski, 1997) and ante- cedent manipulations (Pace, Ivancic, & Jef- ferson, 1994; Smith, Iwata, Goh, & Shore, 1995). On the other hand, alternatives to extinction may be unnecessary if these side effects rarely occur or if common treatment components, such as differential reinforce- ment, attenuate response bursting and ex- tinction-induced aggression. In this study, an analysis similar to that conducted by Lerman and Iwata (1995) was used to determine the prevalence of both extinction bursts and in- creases in aggression with individuals who had received treatment for self-injurious be- havior (SIB).

METHOD

Participants and Setting Data records for individuals who had re-

ceived treatment for SIB in our day program between 1989 and 1997 were examined for potential inclusion in the study. Cases were included if they met the following criteria: (a) Aggression was not targeted for treat- ment; (b) data on aggression and SIB were collected across all baseline and treatment sessions; (c) treatment was preceded by a

3SIDE EFFECTS OF EXTINCTION

baseline condition in which reinforcement was delivered for SIB, but no programmed consequences were provided for aggression; (d) the transition from baseline to treatment involved extinction (withholding the iden- tified reinforcers that maintained SIB); and (e) procedures implemented in conjunction with extinction included differential rein- forcement, NCR, or antecedent manipula- tions (e.g., stimulus fading). Some partici- pants were exposed to two or more treat- ments prior to their discharge, in which case the first treatment meeting the above criteria was included in the analysis. If a participant was exposed to treatment with both extinc- tion alone and extinction combined with an- other procedure, both data sets were includ- ed in the analysis if they satisfied the criteria. Forty-one data sets from 30 participants met the criteria for inclusion. Nine of the 41 data sets had been included in the previous anal- ysis (Lerman & Iwata, 1995). Ten partici- pants were exposed to extinction alone, 9 participants were exposed to extinction in conjunction with alternative procedures, and the remaining 11 participants were exposed to both extinction alone and extinction com- bined with other procedures.

Participants had been diagnosed with moderate to profound mental retardation, and their ages ranged from 5 to 54; however, all but 1 participant was above age 18. Prior to treatment, the maintaining consequences of SIB were identified via functional analyses for all participants (Iwata, Pace, Dorsey, et al., 1994). Results indicated that SIB was maintained by escape from demands (21 cas- es), access to attention (13 cases), access to materials (four cases), and automatic rein- forcement (three cases). Specific treatments were determined by the individual’s partici- pation in other ongoing research projects. Sessions for all but 1 participant were con- ducted in therapy rooms at the day program, which was located on the grounds of a res- idential facility for individuals with devel-

opmental disabilities. For 1 participant, ses- sions were conducted in an empty classroom at a noncategorical preschool. The therapy rooms contained tables, chairs, and other materials relevant to the individualized treat- ments.

Response Measurement and Reliability

Topographies of SIB included head and body hitting, eye poking, hand biting, hand mouthing, and body scratching. Topogra- phies of aggression included hitting, pinch- ing, scratching, biting, and kicking others. Observers were undergraduate and graduate students who had prior experience in using the data collection system. Data on SIB were collected using frequency or partial-interval recording, and the data were expressed as re- sponses per minute or percentage of 10-s in- tervals scored. Data on aggression were col- lected using frequency recording and were expressed as number of responses per min- ute.

An extinction burst was defined as an in- crease in responding during any of the first three treatment sessions above that observed during all of the last five baseline sessions or all of baseline if it was briefer than five ses- sions (Lerman & Iwata, 1995). The occur- rence or nonoccurrence of extinction bursts was determined by visually inspecting graphs displaying session-by-session data on SIB. Extinction-induced aggression was defined as an increase in aggression during any of the first three treatment sessions above that ob- served during all of the last five baseline ses- sions or all of baseline if it was briefer than five sessions. The occurrence or nonoccur- rence of extinction-induced aggression was determined by visually inspecting graphs dis- playing session-by-session data on aggres- sion.

A second observer independently collect- ed data on SIB and aggression during at least 25% of sessions for all participants. Agree- ment percentages were calculated on an in-

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Figure 1. Number of cases showing the occurrence and nonoccurrence of extinction bursts (top panel) or increases in aggression (bottom panel) during treatment overall and with extinction alone versus extinction (EXT) combined with alternative procedures.

terval-by-interval basis. For frequency re- cording, the smaller number of responses in each 10-s interval was divided by the larger number of responses. These fractions were then summed, divided by the total number of intervals in the session, and multiplied by 100%. For partial-interval recording, per- centage of agreement was calculated by di- viding the number of agreements by the number of agreements plus disagreements and multiplying by 100%. Mean interob- server agreement across participants was 95% (range, 81% to 100%) for SIB and 99% (range, 94% to 100%) for aggression. A second observer also examined all of the data sets to make independent determina- tions about the occurrence and nonoccur- rence of the extinction burst and extinction-

induced aggression. Percentage agreement was 100% for all of these determinations.

RESULTS

As displayed in Figure 1, overall results for the 41 cases indicated that 16 cases, or 39%, showed response bursting, and nine cases, or 22%, showed increases in aggression (see far left bars of upper and lower panels). Eight cases (19%) were associated with both side effects, eight cases (19%) were associated with the extinction burst only, one case (2%) was associated with increases in aggression only, and 24 cases (58%) showed neither side effect during treatment. Fifteen of the 30 participants, or 50%, showed at least one of the two side effects.

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Extinction was combined with differential reinforcement, noncontingent reinforce- ment, or antecedent manipulations in 20 (49%) of the cases. Results displayed in the top panel of Figure 1 show that a larger number of cases were associated with a burst when extinction was implemented as a single intervention (13 of 21, or 62%) than when it was combined with other treatment com- ponents (3 of 20, or 15%). As shown in the bottom panel, extinction-induced aggression also was more likely to occur when extinc- tion was implemented alone (6 of 21 cases, or 29%) than when it was combined with alternative procedures (3 of 20 cases, or 15%).

Overall, the prevalence of the extinction burst was higher for cases in which SIB was maintained by social negative reinforcement (12 of 21 cases, or 57%) than for cases in which SIB was maintained by social positive reinforcement (4 of 17, or 23%).1 Extinc- tion-induced aggression was equally likely to occur, regardless of whether SIB was main- tained by social negative reinforcement or social positive reinforcement (it was ob- served in approximately 23% of the cases for each). The three cases in which SIB was maintained by automatic reinforcement were not associated with either side effect.

DISCUSSION

An analysis of 41 data sets in which SIB was treated with extinction revealed that about 40% of cases showed at least one of two side effects (i.e., response bursts or in- creases in aggression) and that almost 20% of the cases showed both phenomena. The overall prevalence of bursting was somewhat higher than that of extinction-induced ag-

1 Prevalence data for cases in which SIB was main- tained by access to attention were combined with those for cases in which SIB was maintained by access to materials because of the small proportion of cases having either function.

gression. Nevertheless, both side effects were less likely when extinction was combined with alternative procedures.

Results showed that only a small propor- tion of cases were characterized by response bursts or increases in aggression when ex- tinction was implemented as a component of a treatment package rather than as the sole intervention (at least one side effect oc- curred in 20% of the former cases and 62% of the latter). This finding suggests that the occurrence of these side effects may be min- imized in clinical settings when extinction is combined with differential reinforcement, NCR, or antecedent manipulations. Al- though this outcome replicated that ob- tained by Lerman and Iwata (1995), the overall prevalence of the burst in the current study was somewhat higher than that re- ported previously (i.e., 39% vs. 24%). One possible reason for this difference was that data on SIB in the current study were col- lected during relatively brief (10- to 15-min) sessions. Conversely, much of the published data analyzed in the earlier study were col- lected and summarized across lengthier ob- servation periods (e.g., several hours), which might obscure short-lived extinction bursts. This finding suggests that even fleeting re- sponse bursts can be reduced by combining extinction with alternative procedures.

Nevertheless, additional research is need- ed to identify strategies that might reduce the likelihood of these side effects, which could be problematic in applied settings. Ex- tinction bursts and extinction-induced ag- gression could be mitigated even further by using certain reinforcement parameters (e.g., rich schedules of reinforcement during dif- ferential reinforcement) or specific proce- dures (e.g., DRA rather than antecedent ma- nipulations), or by combining extinction with more than one alternative procedure (e.g., differential reinforcement plus demand fading). Such factors could not be identified in the current analysis because specific treat-

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ment components varied widely among the cases. Although results suggested that burst- ing was most likely to occur for cases main- tained by social negative reinforcement (i.e., escape from demands), the relationship be- tween behavioral function and the preva- lence of extinction-related side effects also warrants further investigation. A thorough analysis of this relationship was not possible because some maintaining consequences (e.g., access to materials, automatic rein- forcement) were represented by a small number of cases.

Other conclusions presented here must re- main tentative for several reasons. First, the effects of alternative procedures on the oc- currence and severity of extinction bursts and extinction-induced aggression were not examined on a within-subject basis. For ex- ample, it is not possible to determine wheth- er participants who did not show an increase in aggression when extinction was imple- mented as part of a treatment package would have done so if extinction had been imple- mented alone. Second, 10 of the 11 partic- ipants who received two treatments (extinc- tion alone and extinction combined with al- ternative procedures) were exposed to the treatment package prior to extinction alone. As such, the prevalence of side effects during extinction alone may have been underesti- mated because of the participants’ prior ex- perience with extinction. Further analysis of the data, however, showed that the preva- lence of bursting and aggression for these in- dividuals was similar to that for individuals who received extinction alone as their initial treatment. Third, the generality of these findings may be limited to individuals who receive treatment for SIB rather than for other behavior disorders (e.g., disruption). Fourth, results may not be applicable to oth- er dimensions of extinction bursts that have been reported in the literature, such as in- creases in the intensity or variability of be- havior.

Finally, it is not clear why extinction was associated with increases in aggression. It has been suggested that the withdrawal of rein- forcement for responding can be an aversive event, eliciting attack responses similar to those observed when laboratory subjects are exposed to shock, intense heat, or physical blows noncontingent on behavior (Azrin, Hutchinson, & Hake, 1966). Termination of the response–reinforcer relationship while treating SIB might have elicited attack re- sponses similar to those observed in basic studies on extinction-induced aggression. Al- ternatively, if aggression was a member of the same response class as SIB, extinction might have occasioned aggression by induc- ing response variability (Goh & Iwata, 1994). Further research on the characteris- tics and etiology of extinction-induced ag- gression is needed to better identify strate- gies that would minimize the occurrence of this side effect in clinical settings, where ex- tinction is a common component of treat- ments for problem behavior.

REFERENCES

Azrin, N. H., Hutchinson, R. R., & Hake, D. F. (1966). Extinction-induced aggression. Journal of the Experimental Analysis of Behavior, 9, 191–204.

Fischer, S. M., Iwata, B. A., & Mazaleski, J. L. (1997). Noncontingent delivery of arbitrary re- inforcers as treatment for self-injurious behavior. Journal of Applied Behavior Analysis, 30, 239–249.

Forehand, R. (1973). Teacher recording of deviant behavior: A stimulus for behavior change. Journal of Behavior Therapy and Experimental Psychiatry, 4, 39–40.

France, K. G., & Hudson, S. M. (1990). Behavior management of infant sleep disturbance. Journal of Applied Behavior Analysis, 23, 91–98.

Goh, H., & Iwata, B. A. (1994). Behavioral persis- tence and variability during extinction of SIB maintained by escape. Journal of Applied Behavior Analysis, 27, 173–174.

Herbert, E. W., Pinkston, E. M., Cordua, G., & Jack- son, C. (1973). Adverse side effects of differential parent attention. Journal of Applied Behavior Anal- ysis, 6, 15–30.

Iwata, B. A., Pace, G. M., Cowdery, G. E., & Mil- tenberger, R. G. (1994). What makes extinction

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work: An analysis of procedural form and func- tion. Journal of Applied Behavior Analysis, 27, 131–144.

Iwata, B. A., Pace, G. M., Dorsey, M. F., Zarcone, J. R., Vollmer, T. R., Smith, R. G., Rodgers, T. A., Lerman, D. C., Shore, B. A., Mazaleski, J. L., Goh, H. L., Cowdery, G. E., Kalsher, M. J., McCosh, K. C., & Willis, K. D. (1994). The functions of self-injurious behavior: An experi- mental-epidemiological analysis. Journal of Applied Behavior Analysis, 27, 215–240.

Iwata, B. A., Pace, G. M., Kalsher, M. J., Cowdery, G. E., & Cataldo, M. F. (1990). Experimental analysis and extinction of self-injurious escape be- havior. Journal of Applied Behavior Analysis, 23, 11–27.

Kazdin, A. E. (1994). Behavior modification in applied settings (5th ed.). Pacific Grove, CA: Brooks/Cole.

LaVigna, G. W., & Donnellan, A. M. (1986). Alter- natives to punishment: Solving behavior problems with non-aversive strategies. New York: Irvington.

Lerman, D. C., & Iwata, B. A. (1995). Prevalence of the extinction burst and its attenuation during treatment. Journal of Applied Behavior Analysis, 28, 93–94.

Mazaleski, J. L., Iwata, B. A., Vollmer, T. R., Zarcone, J. R., & Smith, R. G. (1993). Analysis of the reinforcement and extinction components in DRO contingencies with self-injury. Journal of Ap- plied Behavior Analysis, 26, 143–156.

Pace, G. M., Ivancic, M. T., & Jefferson, G. (1994).

Stimulus fading as treatment for obscenity in a brain-injured adult. Journal of Applied Behavior Analysis, 27, 301–305.

Repp, A. C., Felce, D., & Barton, L. E. (1988). Bas- ing the treatment of stereotypic and self-injurious behaviors on hypotheses of their causes. Journal of Applied Behavior Analysis, 21, 281–289.

Rincover, A., & Devany, J. (1982). The application of sensory extinction procedures to self-injury. Analysis and Intervention in Developmental Dis- abilities, 2, 67–81.

Smith, R. G., Iwata, B. A., Goh, H., & Shore, B. A. (1995). Analysis of establishing operations for self-injury maintained by escape. Journal of Ap- plied Behavior Analysis, 28, 515–535.

Wacker, D. P., Steege, M. W., Northup, J., Sasso, G., Berg, W., Reimers, T., Cooper, L., Cigrand, K., & Donn, L. (1990). A component analysis of functional communication training across three topographies of severe behavior problems. Journal of Applied Behavior Analysis, 23, 417–429.

Zarcone, J. R., Iwata, B. A., Smith, R. G., Mazaleski, J. L., & Lerman, D. C. (1994). Reemergence and extinction of self-injurious escape behavior during stimulus (instructional) fading. Journal of Applied Behavior Analysis, 27, 307–316.

Received April 6, 1998 Initial editorial decision June 2, 1998 Final acceptance August 24, 1998 Action Editor, Cathleen C. Piazza

STUDY QUESTIONS

1. What side effects of extinction have been reported, and why is it important to establish the prevalence of these effects?

2. The results of functional analyses for participants in this study indicated that their SIB was maintained by escape from demands, access to attention, access to materials, or automatic reinforcement. Briefly describe how extinction might be implemented for each of these functions.

3. What were the authors’ criteria for the occurrence of side effects during extinction? Describe an alternative method for identifying these side effects.

4. What two methods were used for calculating reliability? Why wasn’t an interval measure used for all of the data?

5. What was the prevalence of side effects in this study? How did the presence of additional treatment com- ponents influence the occurrence of side effects?

8 DOROTHEA C. LERMAN et al.

6. Side effects appeared to be most common when extinction was applied to behavior maintained by negative reinforcement. What features of the demand context (or of extinction used in such a context) might account for this finding?

7. What behavioral mechanism is most likely responsible for the reduction of extinction-induced responding when differential reinforcement is combined with extinction?

8. The authors suggested that observed increases in aggression may have been either ‘‘elicited’’ or merely were occurrences of behavior that shared functional characteristics with SIB. How might one identify the function of extinction-induced aggression?

Questions prepared by Eileen M. Roscoe and Rachel H. Thompson, The University of Florida