Behavior Development Solutions

Ask Cipani Archives

2018 Archives

 
 
September
“Too Many Accidents!”
 

Case from S.D.                Ennio’s Response


Case from S.D.

I am involved with a very challenging student with severe intellectual disabilities, who likes to spend inordinate amounts of time in the bathroom. I used a simple procedure with behavioral momentum and a timer to reduce his time in the bathroom, and that seems to be working. However, he has many other self-stimulatory type behaviors, like picking skin, including his penis, spitting continually, etc. One problem that is particularly discerning lately is that he will pee in his pants, where he is. The data shows no pattern yet, at least to me, in regards to time of day, particular demands, and other antecedent conditions. He will change himself in a neutral manner, in terms of his mood. However, we cannot keep changing him 3-5 times a day. We recommended a full medical checkup, whereupon his urinary tract infection (UTI) examination came up fine. Any other ideas? A shower has been proposed as an aversive and natural consequence, but this will be too complicated at school. I am looking into edible rewards, as nothing else appears reinforcing.

S.D. BCBA


Ennio’s Response

Dear S.D.

Thank you S.D. for your submission. First, let me congratulate you on solving the bathroom duration problem using behavioral momentum. Dr.Phillip Belfiore (a very good friend of mine) was one of the original applied researchers on the classic study that uncovered this principle’s utility in clinical practice (Mace, Lalli, West, Belfiore, Pinter, & Brown, 1988). He would be happy to hear of your successful implementation of such. I would like to select the problem you delineate above as urinating in his pants for my analysis. Thank you for clarifying that a medical exam revealed no basis of this problem with a medical condition. You were very wise to have that checked out.

Here is the $64,000 question. “Why does he urinate in his pants?” From my early days as a clinician and behavioral consultant, I would be asked by other consultants and professionals how I approached the solving of problem behaviors in school and home settings. I conveyed to them the importance of viewing the problem as an operant behavior (unless the problem represents a respondent function). In doing so, I can assume that understanding the properties of operant behavior will lead me to a theoretical solution. Operant behaviors operate on the social and/or physical environment, thereby having functions under specific antecedent conditions. I believe a conceptual framework should be delineated prior to deploying any descriptive or experimental assessment method to verify function.

I have designed a uniform operant framework for behavioral functions (Cipani, 1990, 1994, 2017; Cipani & Schock, 2011) to help in the theoretical construction of the problem. I use my classification system as a model and framework for examining a variety of potential behavioral functions. The Cipani Behavioral Classification System (BCS) has 13 separate classification categories under the four major operant functions.1 Half of the four functions entail socially mediated functions. Let me examine if this behavior might be rendered functional via social mediation of the desired outcome.

Is it socially mediated?

Socially mediated functions involve the abolishing of a specific establishing operation (EO), by the behavior of the student affecting the behavior of an adult mediator. The adult mediator, who becomes discriminative for the specific type of relevant reinforcement, then provides the event (or removes an event from the student’s environment), that abolishes the EO for a certain length of time.

In order to proceed with this analysis, let me make some hypotheses. If urinating on oneself is maintained because it escapes an aversive instructional condition (EO), the following would be observed. An instructional condition is in effect, and such serves as an aversive EO to this student. Therefore, upon the student urinating in his pants, this instructional condition is temporarily terminated by the staff person (happens when the person changes the soiled clothing). To reiterate, the presentation of the instructional condition constitutes the operative aversive EO. With such an antecedent motivating condition, behaviors that have historically been effective in producing the desired outcome (removal of aversive EO) become very probable. If urinating on oneself is the most effective and efficient manner of having a classroom staff person remove him from the current instructional condition, a reliable function develops and strengthens. When the instructional condition becomes sufficiently aversive (the escalating progression of the aversive EO), urinating on himself occurs subsequently. The outcome of this event is that someone takes him away from the instructional condition (i.e., socially mediated escape or SME function). Further, other behaviors are less likely (or unlikely) to affect the social environment in such a way, i.e., they are ineffective in terminating the instructional task.

How would we move beyond conjecture to establish some supportive evidence? I would suggest using a scatter plot to collect data as a function of two distinct settings. The scatter plot should calculate the occurrence of this behavior according to whether such happened during one of two conditions: (a) instructional or (b) non-instructional times (e.g., recess, PE, lunch, transitions to activities, etc.) If the occurrence of the behavior is very probable during instructional times, and sporadic or non-existent during other times, you have some initial data to suggest that an SME function is operable with this behavior2. This response differentiation would be essential for considering this function, since several stimulus changes also occur with accidents (e.g., being naked for a while, getting a change of clothes to possibly something more preferable, etc.). Your case presentation seems to indicate that this is not the case, since you indicate that you have collected data that shows accidents by time of day to have no pattern.

While this hypothesis may have some appeal, I do not see this function (escape from an instructional condition) as a viable putative function for “toileting accidents” in this particular case. I rule out this possibility based on an analysis of behavior and its efficiency to produce the desired outcome. Behaviors that are historically the most effective and efficient (length of time to reinforcer) become functional. Behaviors that are either ineffective and/or inefficient (relative to other behaviors) undergo extinction. I would contend that there are usually more efficient behaviors to escape instruction. For example, running out of the classroom (what I term a Direct Escape function or DE) or hitting staff or self (SME Function) are often quite functional under this aversive EO. Urinating in one’s pants would require a reservoir of urine in the bladder to be available whenever the EO is presented (instructional task). In contrast, running out of the classroom involves a behavior that is always at the student’s disposal; hence, its occurrence can readily coincide with the advent of the aversive EO.

If an SME function with respect to instructional tasks is not viable, could it be functioning to access some desired event? This possibility would involve a socially mediated access (i.e., positive reinforcement) function or SMA. Obviously, peeing in one’s pants always results in change of clothing at your school (in addition to being naked for some length of time). Could such a reliable outcome be the function? If so, the motivating event would have to be one of two possible EO’s. Having non-preferred clothes on would be the antecedent condition for a behavior that would produce the following: removal of those clothes in exchange for clothes that are more (hopefully) preferred. This possibility seems remote, given that you report he urinates in his pants 3-5 times/day. It seems unlikely that staff would not have figured out that he prefers certain clothes and once they are placed on him, no more wetting himself occurs. A test for such a hypothesis would be to give him a non-preferred change of clothes when he soils himself. If the reinforcer is a preferred change of clothes, what should be the behavioral outcome of receiving another set of non-preferred items? Another incident!

A second related possibility is that he is used to changing clothes at home every hour or so. Going without changing clothes for several hours at school would then create a state of deprivation with respect to changing of clothes, which then makes a behavior that historically has produced the desired outcome very likely. A simple check with the parents with respect to their changing clothes routine might clear that up. However, this also too seems far-fetched.

Schedule trained vs independence

Here is the question at the core of this problem behavior. This query “hit me” when I read your sentence on how many accidents he has on a school day (i.e., 3-5/day). Is this student actually toilet trained to independence? In order to answer this question, the following data is needed. Record urine eliminations in the toilet as occurring under one of the following two conditions: (a) elimination occurred when placed on the toilet as per classroom toileting schedule and (b) elimination occurred spontaneously outside of any schedule toilet bathroom time, i.e., student initiated chain of behaviors ending in voiding in toilet. Based on some of the information you provided, I would like to make a forecast about the results of such data if/when obtained. Eliminations in the toilet when placed there occur, but infrequently and sporadically. Nevertheless, they do occasionally occur, when we get lucky. However, spontaneous eliminations (student walks over to the toilet without being prompted by staff, or requests to be taken) occurs rarely or not at all.

What I believe is the factor explaining his urinating in his pants is the result of a fixed time schedule for elimination. He is probably partially “schedule trained.” If he has to go, and he happens to be on the toilet because someone placed him there, great, he goes. He is willing to eliminate in the toilet if that is where he is when his bladder needs to be emptied. However, the three to five “accidents3” a day indicate to me that he usually has to eliminate at times when he is not by happenstance seated on the toilet. In summary, he is urinating on himself (instead of in the toilet) because he has not acquired the skill of independent toileting under the EO condition (somewhat full bladder or bowel). I would venture a prediction that he is not toilet trained to independence.

What needs to be done?

I assume that this child is in a special day class, and that there is a smaller student/adult ratio. My recommendation for intensive toilet training is usually for such a labor-intensive method to be conducted in the home setting. This would be particularly the case if the underpants have developed strong stimulus control over elimination, and the removal of such across the first few training days is needed. My column in the June newsletter was devoted to this issue (go to www.behaviordevelopmentsolutions.com and search for Ask Cipani). It delineates what needs to be done to transfer stimulus control from the underpants to the toilet seat with pants down.

Does this student require the intensive procedure with the special Taylor et al. (1994) adaptation? I do not believe he needs the adaptation. If this student does not inhibit elimination when on the toilet seat, as evidenced by some eliminations having occurred in the toilet in the past several weeks, then the being naked regimen would not need to be enforced. However, in this case, I do mandate that the intensive training method be deployed. This all-out effort requires that all other training would need to halt. School personnel would provide full and undivided attention to the Azrin-Foxx rapid method each day until acquisition of independent toileting occurs. In contrast, insisting on continuing the time –based toileting routine in hopes of eventual success will most likely lead to this student being incontinent for many years to come.

While I would not rule out conducting this intensive method at school, the need to focus all the staff person’s efforts on this training usually make such an imposition on the routine classroom regimen not viable. The teacher and aide who would conduct the training would need to forego such instructional activities as the “morning circle” with this student, seatwork and even extensive outside free time if they commit to this undertaking.

In addition, I want to inquire about another skill area which when developed, could facilitate accessing the toilet via requesting of such when needed. What is the extent of this student’s mand repertoire?4 Can this student, engage in a vocal or signed request for preferred items and activities (under relevant EO), or exhibit appropriate protests involving undesired activities (again under an aversive EO). I am going to guess that his ability to mand for desired items is minimal to non-existent. If it is non-existent, then the training that should commence immediately in the school setting is mand training in natural context, as well as running some discrete trials by setting up the EO repeatedly.

Once a number of mands have been acquired, in which the designated form of a request occurs in the absence of the item or activity, you could then re-visit the toileting problem. By having this student learn to ask for things when they are not in the immediate vicinity, requesting the toilet when the bladder or bowel needs to be relieved would be much easier to acquire. The extension to teaching the child to signal that he needs to go to the bathroom could be more viable.

Ennio Cipani, Ph.D.


1 The material defining the four major operant functions is contained in chapter 1 of my FBA text, which is available free online at publisher’s website or Amazon (but I would certainly encourage/insist that BCBA’s read all the first four chapters to gain a conceptually comprehensive view of my model). As a side note, the major functions are NOT attention, tangible, escape and sensory. These individual category functions are more appropriately classified under one of the four functions. In addition, “escape” as a function is ambiguous and vague; escape from what? If you read my text, you will gain an understanding of how functions are derived via a specification of their antecedent and consequent variables.

2 One would also want to experimentally manipulate the times of instructional or non-instructional conditions for a few days, so that one can rule out this factor, since it currently is confounded with the time of day being the same each day. The student may go every day around 9:30 AM because he has to urinate, it just so happens to always coincide with the same instructional activity being presented.

3 I would define urinating in one’s pants as an accident once the student has demonstrated that s/he is capable of independent toileting. The reliable occurrence of a direct chain of behaviors involving going to the toilet seat, pulling down one’s pants or dress, and voiding, or requesting the toilet when the bladder or bowel is full would constitute such criteria. If the toilet seat has not obtained some reasonable level of stimulus control over elimination, there exists a skill deficit.

I recommend Mary Barbera’s book, Verbal Behavior Approach, as well as Mark Sundberg’s VB-MAPP, both on Amazon. Additionally, an advertiser with this newsletter has a product that provides audio and video rich training on the VB-MAPP for those needing BACB CEU credits (www.vbmappapp.com).
References

Azrin, N.H. & Foxx, R. (1971). A rapid method of toilet training the institutionalized retarded. Journal of Applied Behavior Analysis, 4, 89-99.

Cipani, E. (1990). The communicative function hypothesis: An operant behavior perspective. Journal of Behavior Therapy and Experimental Psychiatry, 21, 239-247.

Cipani, E. (1994). Treating children’s severe behavior disorders: A behavioral diagnostic system. Journal of Behavior Therapy and Experimental Psychiatry, 25, 293-300.

Cipani, E. (2018). Functional behavioral assessment, diagnosis, and treatment: A complete system for education and mental health settings. (Third Edition) New York: Springer Publishing.

Cipani, E. & Schock, K. (2011). Functional behavioral assessment, diagnosis, and treatment: A complete system for education and mental health settings. (Second Edition) New York: Springer Publishing. (1st edition-2007)

Mace, F.C., M.L., Lalli, J.S.,, West, B.J., Belfiore, P., Pinter,E., & Brown, D.K.. (1988). Behavioral momentum in the treatment of non-compliance. Journal of Applied Behavior Analysis, 21,123-141. doi: 10.1901/jaba.1988.21-123

Taylor, S., Cipani, E., & Clardy, A. (1994). A stimulus control technique for improving the efficacy of an established toilet training program. Journal of Behavior Therapy and Experimental Psychiatry, 25, 155-160.

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April - June
Elopement in School Setting: Mom says, "Don’t Restrain!"

Part 1: Case From BACB K.K.                Part 2: Ennio’s Response           Part 3: Dr. Ennio Cipani’s Specific Recommendations


Part 1
CASE FROM BCBA K.K.

A behavior that I have struggled with lately is elopement. I work in a public-school district and several of our buildings are open-concept (meaning there are no doors and the rooms are divided with partitions only). One student in particular would run out of her classroom and run down the hallways. She ran into other classrooms and storage areas (none of these have doors). She would hide and if anyone chased her she would laugh and continue to run. If staff was within eye-sight but not chasing, she would up the ante to climbing walls and partitions to the ceiling or running out of the building into the parking lot. The building is two circles so it is nearly impossible to keep eyes on her unless she is being followed. The principal decided to sit in the doorway one day and she climbed out the window.

Child Eloping

There were several antecedents to the behavior including: being assigned work, being denied a preferred activity and conflicts with a peer. Consequences included being chased, being restrained, in-school suspension, out-of-school suspension, extended time in a 1:1 environment with a paraprofessional (excluded from classroom), and delaying/avoiding tasks.

The main struggle with this particular student is that she had a traumatic background and her mom insisted that her behavior is motivated by “fight or flight” and that any physical touch or seclusion could re-traumatize her. On the flip side the behavior was dangerous when the student is running unsupervised around the building. The mother threatened legal action if anyone was to put their hands on her child. We can restrain her if she is causing imminent danger to herself or others (going outside of the school-yard area would be imminent danger for a first grader). However, her mother is very against the restraining her and has made a police report against the school for restraining. Staff are very reluctant to restrain due to this. She was supposed to start attending an agency for her schooling where she would work 1:1 with a metal health specialist and eventually transition back to the school setting. The mental health worker quit after 2 days and the mental health clinic kicked her out after 6 days because she was too unsafe by eloping from their setting towards a very busy street.

The average rate of running is 1.35 times per day. However, the percentage on this one is not that beneficial because there are many days that she does not run at all. 13 of the last 20 days that she was in school she did not run. On the other 7 days she ran 4 or more times during that day. Usually if she is going to elope she does so before 10:30 and usually continues to do so several times throughout the day. If she is able to get into her routine successfully and does not elope before 10:30 she usually does not elope for the rest of the day.

She is a first-grade student. Her functioning level is a little difficult to quantify. For her initial eligibility report, the school testing found her below grade level in all areas. However, I have watched her with her mom and she is able to read above grade level and complete math very close to grade level. Her writing is definitely below grade level.

Any guidance on this would be appreciated! Please let me know if any additional information would be required for this scenario to be selected.

K.K. BCBA


Part 2
Ennio’s Initial Response

Dear K.K.

Thank you for submitting such an interesting case, which is fraught with problems from program design issues to logistical and legal issues. Elopement by children/students/clients poses a severe management problem, in both school and home settings. Before I address the possible function of this particular case of elopement, it is necessary to direct the dialogue to the risk management (legal) issue in this case. Due to the nature of the individual’s age, an act of elopement jeopardizes the individual’s welfare. In your case presentation, you have pointed out that the child’s parent has encumbered your attempts to restrict and restrain the child unless she walks out of the school area. As you have delineated, this limitation on the school’s staff impedes your ability to keep the child safe. It should be plainly obvious that containing her before she gets close to the street is more proactive and responsible. Hence, I believe that any court (fair hearing) would see such proactive measures as serving the best interests of the child (if it comes to that). In fact, the child’s prior placement in a mental health agency was terminated because of the dangerous nature of such acts.

I have been involved in similar types of circumstances where an action I deem necessary from a clinical and/or safety standpoint is rejected by some party (parent, school personnel, etc.). When I am impeded in my program design by unwarranted and ill-advised restrictions, I go “on the written record.” In some written client permanent records (behavioral assessment, IEP, etc.), I indicate what my program design/plan would have been and why it is necessary. I then write what I believe will be the threat to safety or client welfare if my plan is denied. For example, “if we are not allowed to physically intervene prior to the child’s reaching the street curb, we assert that such a limitation jeopardizes her welfare. We are being handicapped in keeping her safe by not being allowed to intervene way before she is in proximity to the street. It is against our strong objection that some members of the team reject our appeal, and we deem that they have placed the child’s welfare in jeopardy1.”

Let me now address the “elephant in the room.” The contention that she will be re-traumatized if anyone restrains her seems preposterous and mis-guided. Question: when you did physically restrain her on the several occasions you alluded to, did she suffer an emotional breakdown subsequently? If the answer is “Yes, she had to be hospitalized,” I withdraw my reservation. If not, such “real life” evidence that a traumatic event does not occur when she is held should be conveyed to everyone.

I realize that the mother is acting in her daughter’s best interests as she views it at this point. Unfortunately she is being mis-directed and mis-informed by someone that any physical contact with another person (male/female) will “bring up” traumatic emotions and thoughts2. Further, such a process (if it actually occurred), is dangerous and should be avoided at all costs. Such unproven contentions and deleterious myths are rampant in mental health. The evidence from clinical research demonstrates that one of the most effective therapies for PTSD3 is exposure and response prevention. This therapy approach provides repeated exposure to the “fear-provoking” stimulus.

Let me now address each of your proposed antecedents, and their potential for serving as establishing operations (EOs) for elopement.

Hypothesis #1: Is it escape from tasks? 

You mentioned that one antecedent is when she is assigned a task/work. I would presume that you are suggesting the possibility of an escape function for elopement, i.e., that the act of elopement functions as escape from an assigned task(s). An escape function exists when an aversive establishing operation (aversive EO) is presented, and a behavior produces the termination of that EO. Many escape functions involve problem behaviors that abolish the aversive EO through the actions of staff, teachers etc. These are termed socially mediated escape functions. Let us assume for the moment that presentation of tasks/instruction serves as an aversive EO for elopement. In this case, the behavior of leaving the area, upon the presentation of an aversive task, produces escape in a different fashion: it directly terminates the EO (without any social mediation needed). Hence, the act of elopement immediately and directly terminates the aversive EO. Therefore, if escape from tasks is a correct diagnosing of the function, the antecedent condition of the task creates an aversive EO. The elopement behavior is immediately effective in the termination of the task for the period of time the elopement occurs. Hence, one must conclude that assignments of some sort constitute aversive EOs.

Particularly when working with students who are not severely intellectually disabled, it is often necessary to determine why instruction is aversive to the particular student. When examining the reason why an instructional demand, assignment, or task(s) acquires aversive properties, one needs to determine which of two factors is at play. In the Cipani Behavioral Classification System (Cipani BCS), I have two classification categories that represent two different escape functions: Difficult tasks and/or lengthy tasks. Let us examine if either of these creates the aversive element for the instructional program.

I do not feel that task difficulty constitutes an aversive EO for this child. If this were the case, the evidence would be very clear that tasks not involving writing (e.g., math work, reading) would result in no elopement. In contrast, elopement would be far more common for tasks involving writing. I am not inclined to view this escape function as plausible in this case. It would seem that writing tasks would occur daily. Therefore, the behavior that terminates such would be more frequent. Your information on the rate of elopement is not congruent with this supposition.

The instructional stimulus condition can still be creating an EO for problem behavior, but not because of difficult material. The factor at play in the escape function is the length of the instructional period. This is often the case when a student’s performance does not differentially affect the termination of the task. Finishing one’s work before the end of the designated instructional period just results in getting more work. Do you see how such an outcome of completing (accurately) work will result in a punishment contingency (for completing one’s work)? It also creates an aversive EO for relatively lengthy tasks/assignments. I term this the “wacky contingency” (Cipani, 2017, pgs. 118-119), i.e., finish your work, you get more work!

However, I do not believe that instructional session length constitutes an EO for elopement with this student. Given that she goes many days without eloping, it does not appear that lengthy instruction creates an aversive EO (unless the length of the instruction varies across days).

Collecting evidence for task difficulty variable 

Difficult task. It seems that instructional difficulty is not the motivating variable. Nevertheless, for teaching purposes, let me delineate the following test that would reveal pertinent evidence for determining if difficulty of the task/assignment is operative. I term this functional analysis method the single EO hypothesis test (Cipani, 2017, pgs. 72-74). This test can be conducted in-vivo if the teacher is provided with the relevant instructional materials for the experimental condition. Given that there is an experimental manipulation, always obtain informed written consent before conducting this analysis. There are two conditions. The control condition consists of the current materials and tasks presented for a few designated sessions. The contrast condition, which tests whether difficulty is the variable, involves the presentation of tasks that are slightly below the student’s capability for an equal number of sessions. In academic school environments, selecting materials that are about one grade level below their norm-referenced tests should do the trick. The target problem behavior produces escape from the task in both conditions. These two conditions are alternated in a multi-element design. As you can imagine, the rates of the problem behavior would be significantly different if task difficulty creates an aversive EO.

Collecting evidence for task length variable 

Lengthy task. The same methodology described above can be used here as well. If the reason for the behavior is not difficulty, but it is the wacky contingency, then the control condition consists of the typical length of the instructional period. If the student finishes his/her work, they are given more to complete. The student must keep working until the instructional period ends. The contrast condition is a short session, possibly 50-80% of the usual duration. The student can be initially apprised of the short session (e.g., “When you finish this work sheet, you are done with this work”). Ditto on informed written consent here as well.

Hypothesis #2: Aversive EO is conflict with peers 

A second antecedent you mention is conflict with a peer. I will assume that you are suggesting that elopement functions to escape (terminate) such a circumstance. First, it would be necessary to state what the “conflict” consists of. For purposes of an example, let me arbitrarily designate the aversive EO as criticism from peers. If it is criticism, then there should be the following differential observed outcomes. When she interacts with persons who have historically criticized her (their presence can serve as an aversive EO), elopement is very probable (direct escape function). The behavior becomes particularly probable if the interaction eventually involves a direct criticism at some point in the interaction. When she interacts with peers or adults who do not criticize, the rate of such behavior is low or non-existent. That differential result would only hold up if the aversive component of social interaction were receiving criticism, or some other form of negative comments. If this were the case, then it would confirm this hypothesis.

This does not seem to be the case, given your information. If evading peer criticism were the function under an EO of receiving criticism, then she would simply leave that area (direct escape function). It would not be necessary to run out of the building, crawl over walls, etc. Further, after she is retrieved, if she contacts the same group again, elopement would occur immediately (as the aversive EO is present again). In time avoidance of that particular group would become prevalent, but not so with others who do not criticize her (i.e., aversive EO absent). Usually, for younger children, social situations that are aversive/unpleasant would also evoke crying at the point of the unpleasantry. Has she ever cried, engage in tantrums, shortly after contact with peers? Again, I would discount such a hypothesis as pertinent.

Hypothesis #3: Access to tangible items, activities? 

If elopement were maintained by access to tangible items, events, activities, one would see one of two reliable effects. In the first scenario, the elopement constitutes a socially maintained access function to tangible reinforcers (SMA 2.3 in my category system). An act of elopement would subsequently result in someone giving her something. In other words, the following would be in effect: “When I am told I cannot have something, I run away, they retrieve me, and then someone gives me “cake.” You mentioned that being told she cannot have something is an antecedent to elopement. Is it common that subsequent to elopement, she is given the item or activity she requested? If so, elopement would be functional under that particular EO.

How would you experimentally test for such a putative function? If the client elopes in order to get an item after being denied such, the test would involve a straightforward in-vivo manipulation. On select “test” days, instead of denying their request, give the item to her (i.e., honor the request). On other days, the current environmental arrangements would be in place. When requesting produces speedy and efficient access to the desired item, elopement should be minimal to non-existent. When requesting is highly ineffective, then elopement becomes the most efficient manner of obtaining the item. Ditto on informed written consent here as well.

For argument’s sake, let us say that no one gives her any item or activity subsequent to an act of elopement, e.g., “Okay, you can now play on the swings.” What is left? What does happen every act of elopement is the following. First, elopement immediately results in going outside the classroom and running around. Such a stimulus change in and of itself can be the maintaining reinforcer. In addition, elopement creates a threat to her safety, whereby staff will have to “chase” her. Consequently, such staff action possibly provides an activity that is of significant value at that particular point in time (e.g., Playing Catch me). While elopement may have inherent reinforcing properties in the act itself (getting to be outside), it is possible that staff chasing after her have added value to such an act.

How does one explain the rate of elopement to be multiple times in a given day and then zero occurrences on many other days? It may be that going for several days without access to such an activity is not sufficient to induce an EO4 . But once she has a “taste” of it, she wants more of it, on that same day. For example, you may not want to play video games for several days. However, once you start playing, you play for multiple hours in a day. This could then be followed by several days showing a lack of interest.

If it is socially mediated access (SMA 2.3) to the Catch me activity, what can be done? I will address my specific recommendations in the next newsletter! Stay tuned.

Ennio Cipani, Ph.D.


1 Given that you work for a school district, I would first consult with school legal counsel. However, if you feel strongly, no one can prevent you from stating your clinical opinion, but it might be wise to seek outside consultation also
2 based in psychodynamic theory
3 this is not my area of expertise, so I am only citing reports I have read of such studies
4 It is also unknown how often access to this type of activity, eloping, occurs in the home environment. Varying amount of access in the home certainly would affect the state of deprivation present at any given school day.

Part 3
Dr. Ennio Cipani’s Specific Recommendations

In part 2, a case involving elopement was analyzed in terms of the possible functions of such a problem behavior. Given the presenting information, two possible functions involving access to a desired activity could be feasible. If it is socially mediated access to the chase game1, or simply direct access to being outside the classroom, what can be done? Here is my analysis. This plan is based on the hypothesis that eloping from class is not the result of instructional conditions (e.g., difficult or lengthy instructional conditions). If such were the case, obviously this suggested plan would not be relevant. Rather, a plan that addresses either the task difficulty or the lengthy instructional session would be indicated.

A major obstacle when treating a problem behavior that involves a direct (automatic) reinforcement contingency is that the behavior immediately results in the desired outcome. Therefore, it is often necessary for an intervention to encumber such a direct and immediate contingency. For example, some clients engage in licking behavior for the sensation it produces2. If you are going to disable such a function, the early steps/ behaviors of the sequenced chain of behaviors (i.e., prior to the licking) have to be physically thwarted or blocked. Waiting to do something after the window has been licked is too late! The reinforcer has already been contacted, and possibly, at a level that achieves satiety at that point. Intervening as the client is going up to the window and sticking her tongue out needs to transpire.

Unfortunately, in this case, personnel restraining the student from eloping cannot be initiated until she is outside the schoolyard. By this time, the functional reinforcer (either getting outside and/or the chase game) has already been contacted. Further, the duration of being outside is entirely up to the student. I assume that she goes back into the class when she has satiated on such an activity. Therefore, it would be very difficult to design a plan that would use authorized access to outside, as part of a behavioral contingency (e.g., DRO3). If the student cannot be obstructed from going outside of her current classroom, then she still has ad lib access to the desired reinforcer. Hence, what is commonly referred to as function-based treatment would not be viable in this case. "If she does not earn the outside the class time or Chase game," she can simply leave of her own accord, and thus ensues the reinforcing activity.

When one reinforcer is not amenable to therapist manipulation (for whatever reason), it is necessary to entertain using some contrived contingency that has the following two factors: (a) such a reinforcer is under your control and (b) it is as powerful, or more so, than the unfeasible yet functionally derived, reinforcer. Here are the steps to program design for this particular case.

First, let us decide what type of behavioral contingency should be deployed, and then determine what constitutes the consequent condition. Given the rate is about seven occurrences per week, I would set up a DRL contingency for the week, maybe at four or less occurrences by Friday afternoon. I feel this is viable; the baseline report indicates there are many days where the elopement act does not occur. In addition, having the consequent event at the end of the week should not be so onerous for school personnel that its implementation is not feasible. While having a daily contingency might be also effective, it might produce days when the first act then "breaks the ice" and subsequent elopements occur that same day4. Realize that once the reinforcer is lost, due to an incident that may occur in the morning, the "incentive" to desist in such a behavior is lost. Hence, in clinical practice, we have seen that such a contingency often results in "really bad days" once the criterion has been exceeded. Setting a weekly contingency will (optimistically) not result in "bursts" of elopement.

Here are the program logistics. Each elopement incident will be handled in the same manner as currently exists, except that a prominent method of recording such an act occurs. Have a jar with four marbles in it, in an area where the student can see it. It is important to obtain consent of parent and IEP team for visual representation of number of incidents due to privacy issues. Each time an incident occurs, upon the student re-entering the class, one marble is taken out5. If any marble(s) remains on Friday afternoon, the student earns the contrived reinforcer. By taking marbles out of a jar, it is apparent to the student how far she is from losing the Friday activity at any point during the week.

The next program design requirement is to determine what should happen on Friday afternoon when the student stays under the criterion rate set by the DRL. One would want a unique (and previously unavailable and deprived at that time) powerful reinforcer(s). Such a contrived reinforcer needs to compete with the functional reinforcer of elopement. I have written about this phenomenon in my text (see chapter one; Contrived contingencies do produce a function).

There are many methods mentioned in basic behavioral texts on identifying potential powerful reinforcers. I would suggest a menu of activities and items to lessen the possibility of any one activity satiating in a given week. This student can select on Friday afternoon what she would like from the menu. In addition to these school-based contingencies, this program can involve a home-based reinforcement system. Earning the reinforcer at school can be supplemented by some special activity at home. However, one should not rely solely on a home-based contingency6.

Of course, the criterion for the designated low rate of elopement can be progressively altered with success over a period of consecutive weeks. Given that this program really stipulates no change in the manner in which elopements are currently handled, I would surmise that it should meet little objection from the student’s parent. However, the issues I raised in the prior column on this case are still valid. The management of elopements that do occur is of extreme concern to me, although this program can make elopements less frequent.

With the advent of summer, I thought that some material on toilet training might be apropos. Many of the children who need this skill will be out of school for the summer (at least some part of it). Since this might be the perfect time for in-home programs to target this skill, the following adaptation of a popular intensive toilet training method is delineated below.

Toilet Training the Naked Way!


I have heard the following discourse many times as a behavioral consultant to parents. "As soon as he comes off the toilet seat and the underpants/pampers are placed back, then he pees. I know he had to go when I placed him on the toilet, but he held it in until he had his underpants on! Is he doing this to spite me?" As you read this, many of you probably immediately recount a child (ren) where the same phenomena occurred during your training efforts. Many parents stipulate their child "knows" that eliminations belong in the toilet, because when asked where "pee" goes, they reply, "I pee in the potty." Yet, their child will have an "accident" 20 minutes later!

Why is teaching certain children how to eliminate in the toilet difficult? We do not have to develop the elimination response: that is already "built in." Rather, the elimination response simply needs to occur when the pants are off and the child is seated on the toilet. What inhibits the acquisition of such a seemingly simple behavior to us?

The following analysis of stimulus control will provide the "ah-ha" moment for you. Consider this: you are initiating toilet training for a hypothetical child at 3 years of age, which means that the elimination response has been present for that long. What would you guess are the more common stimulus conditions during most of this child’s eliminations: diapers on or diapers off? Can you see the conditioning history? Now for the technical explanation.

Because of this historical natural relationship between pants on and elimination, strong stimulus control over elimination occurs. Unfortunately, pants off (i.e., waist area is not in contact with any clothing) becomes the non- discriminative stimulus for elimination. Hence, when pants are off, elimination is inhibited. The discrimination that has developed over time is the following: Pants on- go ahead and eliminate when needed. Pants off- hold in urine until pants are back on.

You often hear that children who do not eliminate in the toilet may not be "ready." The same "experts" then stipulate that you should postpone toilet training until they are "ready." However, in actuality, postponing training is only making matters worse when training does commence. Postponing training translates to facilitating a lengthier successful history of elimination occurring with the pants or diaper being next to the body. If a child is only two years old, there is a shorter history of the pants being present during elimination than if the child is 5+ years old (and not toilet trained). Therefore, the longer the child goes without learning to eliminate in the potty, the more difficult it may become to transfer the elimination response from pants on to pants off (and seated on toilet). If the child has been taught to stay on the toilet seat for a sufficient duration7, postponing discrimination training seems only to potentially exacerbate problems in this area of self-care.

The "Rapid Method" (Azrin-Foxx)

Two behavioral psychologists, Drs. Nathan Azrin and Richard Foxx, developed an intensive toilet training program. The rapid toilet-training method is extremely successful (Azrin & Foxx, 1971). It has been used with both children with intellectual disabilities as well as non-handicapped individuals, with the latter group often achieving success in just one day8. However, there are cases, particularly when working with children with severe intellectual disabilities, where swift and large-scale results do not ensue. Here is the potential drawback of the rapid method.

Unfortunately, even with the rapid method, the presence of the current controlling discriminative stimulus or S-D (i.e., pants on), is still made available once the child is removed from the toilet. Hence, inhibition of elimination when on the toilet seat is observed. The child "holds it in." If elimination does not occur during the scheduled potty seat time, the bladder or bowels are still at levels that require elimination. Unfortunately, elimination occurs subsequently, when the child is taken off the toilet seat, and the underpants are placed back on him9.

Understanding this as a stimulus control problem allows for the deployment of a treatment strategy that is based on transferring stimulus control from the current S-D (pants on) to a new target S-D (pants off and sitting on toilet seat). Errorless learning approaches have been very successful with many academic and learning problems where the flaw is incorrect discriminated behavior. An adaptation to the rapid method was developed and tested with a child who had been extremely resistant to previous toileting efforts (Taylor, Cipani, & Clardy, 1994). This single case study demonstrated that the rapid method (Azrin & Foxx, 1971) resulted in continued accidents and infrequent success. In contrast, using the errorless transfer of stimulus control procedure produced significant changes in both accidents and appropriate eliminations in the desired directions. Further, follow up data collected four and ten-months after ending the specialized adaptation portrayed no accidents occurring and frequent eliminations in the toilet. Here is our primary adaptation to the rapid method (Taylor, et al., 1994).

Errorless learning- Stimulus manipulations

The same schedule is adhered to, as is the case in the rapid method. The major difference is the removal of the current controlling S-D (underpants), i.e., child is naked from waist down . This naked condition is then maintained over the course of the training day until elimination occurs in the toilet the first time. With the first success, the child is removed after completing the act and the underpants are placed on him/her for just a minute. The underpants are then taken off. The pants remain off until the next correct elimination. Subsequent to leaving the toilet upon the second elimination n the toilet, the time the underpants are placed on the child is extended by one minute, i.e., for two full minutes. Once two minutes elapses, the pants are taken off again until the next correct elimination. With each successful elimination, the length of time the pants were kept on was increased by one-minute from the prior value. In the study (Taylor et.al., 1994), the clothes remained on continuously after the 15th successful elimination . You can judge at what point elimination seems to be under control of the toilet seat and pants off, thereby negating the need to remove the underpants. You can teach self-dressing components of toileting (pulling pants up and pulling pants down) at that point.

The state of nakedness is not so much a concern for young children in their home, but can be a concern when the child is above the age of seven or eight years old. Obviously this method of training is not feasible to conduct in the school setting, so the child may have to miss several days of school (try to extend the training to include a weekend so as to minimize the number of days child will be absent from school). But if "scheduling toileting at three separate times in the school day has not worked after months (or years) of conducting such, the data is telling you, "try something else."

Practical Concerns

Implementing the Taylor et.al. (1994) adaptation to the rapid method needs to be considered in light of several practical matters. First, the training session is all day, from the moment the child gets up in the morning. Hence, the parent or therapist needs to be freed of other responsibilities. All other tasks and activities are shelved for the period that toilet training is pursued (for up to 3-4 days). For example, if the child lives in a house with a pool, s/he cannot go swimming on the training days (unless you are interested in changing the PH balance of your pool water). These restrictions should be in place until 15 successful eliminations have occurred and the pants being have been progressively increased. If appropriate toileting is not occurring sufficiently by the fourth day, the rapid intensive method might be temporarily disbanded, until the reason for lack of success can be determined.

The training should be done in close proximity to the toileting area . Although the absence of underpants will inhibit elimination for a period, the bladder will eventually be inflated to the point where the child will need to eliminate (i.e., cannot hold it in any longer). The adult must be vigilant for signs that the child needs to go (e.g., doing a dance, squatting close to the floor/carpet). These signs necessitate placing the child on the potty seat immediately. If a parent is conducting the training, make sure s/he understands the need for constant vigilance. If the supervision becomes lax, you may have the parent complain that their child peed on the floor a bunch of times as well as defecated. This is the result of not "watching" the child close enough." Any hint that the child is about to go should result in being put on the potty immediately and keeping them on for a sufficient length of time to obtain success.

Also, as time goes on and the child has yet to eliminate in the toilet, it may be necessary to increase the ratio of time spent on the toilet to 50-70%. You want to capitalize on the greater chance of being on the toilet when the child finally relents and eliminates (in the absence of underpants).

Have a great summer and see you in September! Ennio Cipani


1Safety protocol dictates that staff must follow the student upon leaving classroom area, and attempt to retrieve her. Whether such becomes a function of elopement is undetermined at this point. However, “ignoring” the act of elopement to remove this possible reinforcer is not permissible or ethical treatment.
2Although it is possible to have socially mediated functions for acts of licking objects.
3Absence of the elopement act for a designated period would result in its authorized access under tighter conditions involving designated space/area and ability to stop her from leaving a designated safe area.
4In particular, with this case, such a side effect of a daily DRO, or DRL would not be prudent with this case, since it exposes the student to additional safety hazards. This would be particularly troublesome in this case since the ability to stop the “onslaught” of elopements would again be hampered by the threat of a lawsuit.
5This method is more suited if the student is not capable of counting the marbles. If the student is capable of counting up to five (at least) than one could have the jar empty at the beginning and add marbles contingent upon an incident of elopement. Given the reported information about this girl’s functioning level, I believe such a procedure would invoke a conditioned punishing event for this child.
6You have no control over the implementation. Establishing the home-based contingency as the only programmed contingencies puts behavior change out of your hands.
7The intensive method requires the child to be capable of sitting for 5-10 minutes on toilet seat, hence if a child sits for 30 seconds and then wants to get up, training could be significantly impeded.
8
It is not the objective of this column to review the intensive procedures delineated in the initial research article. These researchers also wrote two books on the intensive method, Toilet training in a day, and Toilet training the mentally retarded.
9Whatever contingency is effected for accidents does not seem to be sufficient to "override" the strong control exerted by the pants on condition. The answer to this dilemma is not a change in current contingencies for accidents, and probably not an increase in the value of the consequence for correct elimination.
10Obviously, this training has to be done at home setting and also considering the age of the child.
11A data sheet that has eliminations from 1-15 typed in the first column, what type of elimination in the 2nd column, and the time of the elimination in the 3rd column should be sufficient.

References


Azrin, N.H. & Foxx, R. (1971). A rapid method of toilet training the institutionalized retarded. Journal of Applied Behavior Analysis, 4, 89-99.
Taylor, S., Cipani, E., & Clardy, A. (1994). A stimulus control technique for improving the efficacy of an established toilet training program. Journal of Behavior Therapy and Experimental Psychiatry, 25, 155-160.

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About: Ask Cipani! is a periodic column that addresses a submitted case presentation from a BCBA who wants some suggestions/advice on identifying the function of a particular challenging behavior(s). Dr. Ennio Cipani's response addresses the presenting case in terms of possible motivative conditions (EO) and subsequent environmental functions to consider, and possible tests/validation strategies to conduct to verify the putative function. The advice provided in the Ask Cipani! column is provided with the caveat that its use is considered carefully by a certified or licensed behavior analyst. Since Dr. Cipani is only aware of the information presented to him, each reader must make a determination of whether such advice fits any particular case. It also is incumbent on any reader to determine if additional consultation should be sought for either program design and/or logistical implementation.

Ennio Cipani, Ph.D., is the author of the popular text, Functional Behavioral Assessment, Diagnosis and Treatment (2018, 3rd edition), which features a unique function-based classification system, the Cipani Behavioral Classification System or Cipani BCS. He co-authored a diagnostic manual for school settings on the Cipani BCS with his daughter, Alessandra Cipani, titled, Behavioral Classification System for Problem Behaviors in Schools. He also authored an e-book called "A Clinical Treatment Guide to 10 Common Behavioral Pediatric Problems" which can be downloaded for free here. Dr. Cipani partnered with BDS to bring you a companion CE course for his free e-book called, "10 Common Pediatric Problems & Solutions," available here.

Please direct all comments, inquiries about the column, or correspondence for Ennio Cipani to joel@behaviordevelopmentsolutions.com 

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