Tourette Syndrome Plus - Behavior - Is Behavior Modification Even Appropriate?

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Information Section: Behavior
Article: Is Behavior Modification Even Appropriate? (Commentary)
Source: Leslie E. Packer, PhD, 2004

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LIMITS OF BEHAVIOR MODIFICATION

One of the things I learned in my training as a behavioral psychologist is to know the limits of your technology, and to see if there is any basis for applying behavioral technology to a particular behavior. When it comes to children's behavior, however, a lot of people claim to know what to do, but have never actually validated their claims through careful research. Others may give advice based on their personal or individual professional experiences.

So here we are, considering behavioral features or behaviors in children who have been diagnosed as having some "neurological" or "neurobehavioral" or "neuropsychiatric" condition. We have children and adolescents engaging in "inappropriate" behaviors or symptoms at home, in school, and in the community, and we want to know what to do. Many parents are uncomfortable with the idea of behavior modification because they have been told that the problems are "neurological," not "behavioral," or because they've already tried some behavioral interventions with no or little success. Teachers, in contrast, do tend to think in terms of behavior modification, but have generally not been given the rigorous behavioral training they'd need to apply it effectively. In an Internet survey I conducted a few years, parents of children with TS+ reported on the school's attempts to use behavior modification. The majority of the outcomes in the small sample were reportedly neutral or negative, reinforcing the idea that teachers need more professional guidance and support if they intend to try to alter what are often behavioral features or symptoms of these conditions (Packer, 2002, in press).

Of course, before we even think about how to apply behavioral technology, we need to determine if it's even appropriate.

When parents and teachers disagree about whether to try a behavior intervention, the disagreement can become heated for a variety of reasons. Perhaps the correct answer for a particular child would become clearer if we were to reformulate the question this way with a particular child and a particular behavior or symptom in mind:

What does available research show about the effectiveness of behavior modification in altering this type of behavior (or this class of behaviors)?
What individual factors affect the usefulness of behavior modfication for this behavior or class of behaviors?
What is this child's history with the proposed or similar approaches in the past?
What does the Functional Behavioral Assessment suggest about the function(s) of the behavior?
Do the parents (and/or school team) have the necessary skills to design, implement, and evaluate a behavior modification plan, and if not, do they have the professional supports they'd need to do a good job?

In another article on this site, I deal with the value of a Functional Behavioral Assessment and how it can lead us towards certain types of interventions -- including behavior modification. But the answers to the other questions above are also important if the team is considering behavior modification. Indeed, if a teacher recommends using behavior modification, an informed parent should ask, "I'll be happy to consider it, but before I can agree to this, I'd like to see a Functional Behavioral Assessment, and I'd want to know if there's actually research that shows that this works as a school-based intervention for this type of problem."

OK, SO WHAT DOES THE RESEARCH SHOW?

There has been a tremendous amount of research on behavior modification over the past 5+ decades. Its effectiveness has varied with the specific type of behavior or class of behaviors and the specific type of behavioral intervention.

As but one example, a review of behavior modification reports and studies addressing control of tics indicates that one technique, massed practice, had very mixed results -- often having no beneficial effect, occasionally having a positive effect, and sometimes having a negative effect. Another behavioral technique for dealing with tics -- Habit Reversal, -- has had fairly consistent positive results, but may not be suitable for all children or adolescents with tics. Thus, one cannot say "Behavior modification works for tics" (or "doesn't work for tics") because there are different outcomes for different types of behavior modification techniques.

Cognitive-Behavior Therapy (in which behavioral interventions are part of the package) have been shown to be effective both for depression and Obsessive-Compulsive Disorder. With respect to depression, using cognitive group interventions in school to modify depressive thinking styles and to teach problem solving has been associated with decreased risk of developing full depression. Note that such interventions are not strict "behavior modfication programs" or programs that only apply consequences to the child's behavior. Programs that attempt to teach the students skills and that also incorporate the parents and home tend to be more effective, and some of the parent training programs for parents of children with ADHD have been empirically validated.

Empirically supported interventions that are effective in school settings also include targeted classroom-based contingency management for children with a diagnosis of ADHD. Contingency management appears to reduce aggressive behaviors when the contingencies are implemented classroom-wide (as opposed to being applied just to one student in the classroom). Such approaches are more consistent with traditional "behavior modification" plans, but applied to the entire class and not just the individual. As another example, the "good-behavior game" for first-graders has been demonstrated to have long-term benefits in reducing disruptive behaviors in middle school. For students with chronically disruptive behaviors, behavior modification techniques such as point or token systems, time-out, contingent reinforcement, and response cost may be effective for individual students.

In another article on this site, "Reflections of a Former Rat-Runner," I describe a bit of my professional and personal history using behavior modification and explain that I do not think it appropriate or effective for some of the most problematic behaviors we see in children because the problems are often indicative of widespread dysregulation and changing one little behavior doesn't really change the bigger picture. In that article, I outline a different way of approaching problematic behaviors. For now, it is important to note that any behavior intervention oriented towards changing behavior towards peers or others -- whether at home or school -- should be both socially valid and ecologically valid. By socially valid, I mean that the goal of any proposed intervention should have social significance for the child that the proposed intervention uses socially acceptable means to achieve the goal.

From an ecological perspective, a child's school-related problems arise from a combination of factors:

child characteristics
home environment
teacher characteristics
classroom environment
peer characteristics
curricular demands
other factors

Attempts to simply "target" a behavior without consideration of whether other factors need to be addressed leaves us in a position of simply trying to change the child's behavior without considering what function the behavior serves for the child and whether we need to change or modify the other factors that may be contributing to the behavior. School-based Functional Behavioral Assessments, if done properly, help reduce the tendency to start applying consequences to the child's behavior without trying to modify antecedent conditions, address any skill deficits, etc.

OK, let's assume that a functional behavioral assessment has been conducted, other factors will be addressed, and the team is recommending a behavior modification approach to the behavior. What then? Now is the time to consider other important questions, such as whether there's any research to show that behavior modficiation might work. If there is no research to guide you and if parents and teachers feel that a behavioral intervention might be appropriate for a particular child and a particular behavior, parents and teachers should sit down together and see if the behavior can pass "The Acid Test." Go through the questions one by one, as the answers may help you determine whether the proposed behavior modification approach is appropriate. Some of the questions should have been answered by the Functional Behavioral Assessment, but if they haven't been, now's the time to consider them.

If the behavior passes the "acid test," then the question becomes, "How do we design and implement an effective intervention?" Even when a functional behavioral assessment is conducted properly, how do we select what type of positive behavioral intervention to use for a particular child and a particular behavior? Do we use a token economy system or direct immediate reinforcement, or do we consider a response-cost system? How often should reinforcers be administered and will the school personnel really be able to implement the proposed plan consistently?

These are not easy questions to answers. The article, "Pitfalls in Behavior Modification" will give you some possible problems that may sabotage the effectiveness of any proposed plan. Again, some of the flaws would probably be avoided if the school team has conducted a good functional behavioral assessment, but even a well-done FBA does not necessarily lead to a good behavior intervention plan in terms of the behavioral technology.

SUMMARY

Behavior modification may be highly effective with some children or teens for some behaviors -- if used appropriately. The problems I've seen come from inappropriate application, poor assessment, and/or poor designs and implementation. If a child or adolescent's behavior is causing problems for them, then it needs to be addressed. In contrast to those who throw up the "But it's a symptom" barrier or explanation, I'm suggesting that we all take a somewhat more temperate and what I think is a more realistic approach: that we recognize that even if something is a symptom, if it's problematic for the child or adolescent, then it's problematic and it needs to be addressed. But we usually need to change the environment as well as -- or before -- trying direct consequences for the behavior, and we may need to provide skills training, peer education, and make curricular modifications. Yes, we try to change the child's behavior -- but not necessarily by applying consequences to the behavior as our sole or first strategy.

Parents also need to keep in mind that even if behavior modification could be of benefit for a particular behavior, we need to remain aware of the 'bigger picture' if the child is dysregulated, and that we incorporate training in self-management. Learning not to call out without raising your hand in science class is nice, but if it doesn't generalize to other classes, and if learning not to interrupt or call out doesn't generalize to social situations, it's of limited value.

Information Section: Behavior
Article: Is Behavior Modification Even Appropriate? (Commentary)
Source: Leslie E. Packer, PhD, 2004

Page 1 of 1

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