Published for the British Institute of Learning Disabilities

Journal of Applied Research in Intellectual Disabilities 2014, 27, 187–199

REVIEW

Assessment and Treatment of Challenging Behaviour for Individuals with Intellectual Disability: A Research Review Blair P. Lloyd* and Craig H. Kennedy*,† *Department of Special Education, Vanderbilt University, Nashville, TN, USA Present address: †Department of Communication Sciences and Special Education, University of Georgia, Athens, GA, USA

Accepted for publication 6 January 2014

Background Challenging behaviour is frequently associated with the presence of intellectual disability. If not effectively treated, chronic challenging behaviour can negatively impact a variety of quality of life outcomes for individuals with intellectual disability. Methods and Results We review the current status of research relating to the assessment and treatment of challenging behaviour for people with intellectual disability. We briefly review the history of interventions for challenging behaviour that led to the development of function-based approaches widely in use today. We

then discuss the various operant functions of challenging behaviour, functional behaviour assessment technologies and reinforcement-based interventions. Conclusions We conclude with a discussion of future directions that include models of prevention, ecological validity of assessment procedures and the widespread use of comprehensive behavioural support programmes.

Challenging behaviour takes many forms, including aggression, property destruction, self-injury and stereotypy (Luiselli 2012). Although the forms that challenging behaviour can take are varied, one consistent effect these behaviours have is to negatively impact the individual’s quality of life. Challenging behaviours have been documented to increase social isolation, use of physical and pharmaceutical restraints, institutionalization and service costs (Robertson et al. 2004). The net result could be characterized as some of the most concerning quality of life outcomes for individuals with intellectual disability. It has often been noted that challenging behaviours are frequently associated with the presence of intellectual disability. Even the earliest descriptions of intellectual disability mention challenging behaviour as a characteristic (Berkson 2004, 2006). For example, in his original description of Victor, ‘the wild boy of Aveyron’, Jean-Marc-Gaspard Itard noted the presence of challenging behaviour as one of the most pressing of

intervention concerns (Lane 1976). Ever since the publication of this initial description of educating a child with developmental delays, the presence of challenging behaviour has been identified as a characteristic of intellectual disability as well as a moderator of outcomes. Recent prevalence estimates suggest approximately 10– 15% of people with intellectual disability present with challenging behaviours (Emerson et al. 2001a; Lowe et al. 2007), with similar estimates for high-risk behaviours including self-injury (15%; Kahng et al. 2002) and physical aggression in adults with intellectual disability (10–24%; Cooper et al. 2009; Crocker et al. 2006). For people with profound and multiple disabilities, the prevalence of challenging behaviour may be much higher (Poppes et al. 2010). These behaviours appear to increase in prevalence from childhood through adolescence where they remain relatively consistent, at least from an epidemiological perspective, throughout adulthood (Davies & Oliver 2013). Unfortunately, once challenging

© 2014 John Wiley & Sons Ltd

Keywords: challenging behaviour, functional assessment, intellectual disability

10.1111/jar.12089

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behaviours become well established in a person’s repertoire, the behaviours typically require treatment as a chronic condition that, if not effectively managed, tends to relapse into increased levels of problematic behaviour (Emerson et al. 2001b). All of these observations argue strongly for the importance of interventions to reduce the development and maintenance of challenging behaviours. In the early 1960s, behavioural approaches for treating challenging behaviour emerged. Some of the earliest research focused on using electrical shock, or other forms of positive punishment, to reduce challenging behaviours (Simmons & Lovaas 1969). Other approaches during this same period focused on the use of contrived positive reinforcers to shape alternative and more adaptive behaviours (Wolf et al. 1967). These early approaches, which were the first effective psychological interventions for challenging behaviours, offered an alternative to pharmacological treatments (e.g. antipsychotic mediations such as haloperidol). However, as researchers continued to develop and test new interventions, a pattern of differential effectiveness emerged. Even within individual studies, treatments would be effective for some participants, but not for others, without any clear indication of why. In addition, recommendations for which intervention to use in a particular case were derived primarily from clinician intuition. The summative effect was intermittent and unpredictable treatment success (Repp et al. 1988). Interestingly, a common element in the approaches being developed at this time was the use of arbitrary or contrived stimuli within a variety of reinforcement and punishment contingencies (e.g. candy being delivered or withdrawn contingent upon a behaviour). In effect, interventions were driven by clinical experience rather than assessment results. Researchers began to consider other approaches following the publication of a theoretical paper suggesting challenging behaviour could serve operant functions and that these behaviours were shaped and maintained by specific positive and/or negative reinforcement contingencies (Carr 1977). Carr’s conceptualization reframed the understanding of challenging behaviour from a focus on behaviour topographies to the operant function the behaviours served. This perspective was rapidly tested in research studies showing precise reinforcement contingencies could be identified for challenging behaviour (Carr et al. 1980; Iwata et al. 1982/ 1994a). The observation that many challenging behaviours were maintained by reinforcement contingencies that could be readily identified was a significant breakthrough

in the challenging behaviour literature. This general approach to identifying variables maintaining challenging behaviour has come to be referred to as functional behaviour assessment. The assessment of reinforcement contingencies also led to the development of function-based interventions for challenging behaviour. Rather than using arbitrary reinforcers to change behaviours, researchers began matching the stimulus function(s) maintaining challenging behaviour with the reinforcers used for interventions. For example, if a child self-injured for adult attention, adult attention could be used as a potent positive reinforcer for more appropriate behaviours and withheld for self-injury. This led to the development of functional communication training (Carr & Durand 1985) and differential reinforcement procedures based on functional assessment outcomes (Lerman & Iwata 1996). The research literature that has emerged during the following 30 years suggests much broader effectiveness than earlier approaches as well as a direct link between the accuracy of functional behaviour assessment outcomes and the effectiveness of function-based interventions (Hanley et al. 2003). In the remainder of this paper, we review behaviour functions, their assessment and corresponding interventions, and future directions for the study of challenging behaviour. Our goal is to provide the reader with a contemporary update on the status of assessing and treating challenging behaviour for people with intellectual disability (although the methods of assessment and treatment discussed in this review have been applied beyond this population). We begin the literature review with a discussion of the reinforcer functions that shape and maintain challenging behaviour.

Behaviour Functions Functions of challenging behaviour have been categorized in terms of social positive reinforcement, social negative reinforcement and sensory (i.e. automatic) reinforcement (Carr 1977). The social positive reinforcement hypothesis states challenging behaviour is maintained by the contingent delivery of a socially mediated stimulus. Examples of social positive reinforcers include various forms of adult attention [e.g. verbal reprimands (Iwata et al. 1982/1994a); physical attention (Richman & Hagopian 1999)], peer attention (e.g. Northup et al. 1995), tangible items [e.g. toys (Lalli et al. 1997)] or preferred activities [e.g. access to walks (Ringdahl et al. 2009)]. The social negative reinforcement hypothesis states that challenging behaviour is © 2014 John Wiley & Sons Ltd, 27, 187–199

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maintained by the contingent removal of a socially mediated stimulus. Examples of social negative reinforcers include removal of task demands (e.g. Carr et al. 1976, 1980; Carr & Durand 1985), escape from aversive contextual stimuli [e.g. noise (McCord et al. 2001)] or social avoidance (e.g. Taylor & Carr 1992). The treatment implication for behaviours sensitive to socially mediated consequences is that these behaviours may be altered by adjusting environmental contingencies (Carr 1977). For example, an intervention component for aggressive behaviour maintained by access to preferred activities might include withholding preferred activities following aggression. The automatic reinforcement hypothesis states that reinforcement is contacted through the act of engaging in the behaviour itself and is thus independent of the social environment (Vaughan & Michael 1982). That is, although positive and negative reinforcers are still involved, they are not mediated by the behaviour of other people. Because the relevant antecedents and consequences are internal to the individual engaging in the behaviour, the precise mechanisms by which these behaviours are evoked and maintained are difficult to assess (Kennedy 1994; Vollmer 1994; Piazza et al. 2000). As mechanisms of reinforcement may not be identified from the environment, researchers have begun to explore other classes of variables, including biological factors. Models of automatically reinforced self-injury, for example, have been expanded to incorporate autonomic nervous system regulation, altered sensory processes (e.g. thresholds to painful stimuli) and health conditions (e.g. dysmenorrhoea or otitis media; Symons & Kennedy 2012). The treatment implication for behaviours sensitive to non-social reinforcement is that such behaviours may be reduced by decreasing the value of the reinforcing consequences themselves (Carr 1977). For example, if self-injury occurred in the presence of pain caused by a headache, medication to treat the headache pain would alter the value of sensory stimulation (or escape from pain) as a reinforcer. The categories of behaviour function described above are by no means mutually exclusive. That is, challenging behaviour may be maintained by a combination of social positive, social negative and automatic reinforcement. In some cases, the function of challenging behaviour has been found to vary by topography. For example, Derby et al. (1994) identified stereotypy to be maintained by automatic reinforcement and self-injury to be maintained by social positive or social negative reinforcement for two individuals with intellectual disability. In other cases, the functions of © 2014 John Wiley & Sons Ltd, 27, 187–199

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challenging behaviour may vary by setting or context. Lang et al. (2009) identified screaming and aggression to be maintained by adult attention in a playground setting yet maintained by access to tangible items in a classroom setting for a young boy with autism. Functions of challenging behaviour also have been shown to change over time. For three of four adults with profound intellectual disability, Lerman et al. (1994) found treatment relapses to be the result of new or additional functions emerging between 2 months and 2 years following initially successful interventions for self-injury. Additional evidence suggests self-injury initially maintained by automatic reinforcement may become sensitive to socially mediated stimuli over time (Hall et al. 2001; Richman & Lindauer 2005). These studies, among many others, demonstrate the complexity of behaviour–environment relations. Specifically, challenging behaviour may serve multiple functions, each of which may vary by topography, context or time. As to the prevalence of behaviour functions for people with intellectual disability, recent evidence has highlighted the identification of multiple (versus single) functions for individuals with varying levels of intellectual disability (e.g. Matson & Boisjoli 2007; Hagopian et al. 2013). However, more research has focused on potential relations between behaviour topography and function. For example, several researchers have identified self-injury and stereotypy as more likely maintained by non-social (automatic) reinforcement, and aggressive/destructive behaviours as more likely maintained by social positive or negative reinforcement (e.g. Emerson & Bromley 1995; Matson et al. 1999; Rojahn et al. 2012; Querim et al. 2013). Data from other studies, however, have revealed higher proportions of cases of self-injury maintained by social positive and/or negative reinforcement (e.g. Iwata et al. 1994b; Hanley et al. 2003; Hagopian et al. 2013). It is possible, however, that the method used to assess behaviour function (indirect rating scales versus direct experimental analyses) may account for variation in outcomes.

Assessment Techniques What we know about the complexity of behaviour function has been revealed through refinements in functional assessment techniques. Many of the complex behaviour–environment relations have been identified through functional analysis methodology (Carr & Durand 1985; Iwata et al. 1982/1994a), which involves systematic manipulations of environmental stimuli to

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determine antecedent conditions that evoke and/or occasion challenging behaviour and consequences that maintain challenging behaviour. Whereas the term functional analysis specifically refers to such experimental contingency manipulations, functional behaviour assessment encompasses a broad range of assessment approaches, including indirect, descriptive and experimental assessments (Horner 1994).

Indirect assessments Indirect assessment approaches include interviews, questionnaires and rating scales that are typically completed by those in close contact with the individual whose behaviour is being assessed (e.g. teachers, family members, direct service providers), and in some cases, the individual herself. Examples of indirect measures include the Functional Analysis Interview (FAI; O’Neill et al. 1997), the Motivation Assessment Scale (MAS; Durand & Crimmins 1992), the Questions About Behavioural Functioning Scale (QABF; Vollmer & Matson 1999), the Problem Behaviour Questionnaire (PBQ; Lewis et al. 1994), the Student-Assisted Functional Assessment Interview (Kern et al. 1994), and the Functional Analysis Screening Tool (FAST; Iwata et al. 2013). These indirect measures provide informant accounts of challenging behaviours targeted for assessment (e.g. physical descriptions, frequencies, levels of severity), events that typically precede and/or follow challenging behaviours, and in some cases, ratings of hypothesized motivations. Indirect measures may be a helpful starting point to functional assessment, and for cases in which challenging behaviour occurs at very low frequencies and with high intensity, may be the only feasible method of assessment (O’Neill et al. 1997). Indirect assessments are time- and cost-efficient, minimally intrusive and require less training and expertise than descriptive and experimental methods. The information provided by third parties, however, is ultimately subjective and may reflect biased accounts of behaviour patterns. In addition, the status of research on measurement properties of these assessments has been described as inadequate and inconsistent with the assumptions on which functional assessment is based (Floyd et al. 2005; Kelley et al. 2011).

Descriptive assessments Unlike indirect assessments, descriptive assessments involve direct measurements of challenging behaviour

as it occurs in natural settings. Types of descriptive data range from hand-written anecdotal notes on behaviour– environment sequences to computer-generated timed event data capturing multiple dimensions of behaviour and environmental stimuli. Approaches commonly used by practitioners include antecedent–behaviour– consequence (ABC) narrative recordings (Bijou et al. 1968) or checklists (O’Neill et al. 1997) and scatter plots (Touchette et al. 1985). ABC data collection involves the documentation of antecedent events, instances of challenging behaviour and consequent events as they occur across time. Scatter plot graphs are completed by marking intervals of time during which challenging behaviour occurs on a graph displaying time intervals on the y-axis and consecutive days on the x-axis. Scatterplots provide a visual representation of the occurrence of challenging behaviour across intervals of time that correspond to various contexts and activities throughout the day. Both of these measurement strategies may be used to hypothesize environmental conditions that contribute to the occurrence of challenging behaviour. Other approaches to descriptive assessment involve the use of sequential analysis methods to quantify and describe temporal associations between antecedent stimuli and challenging behaviour or between challenging behaviour and consequent stimuli. Within the descriptive assessment literature on challenging behaviour, common methods of quantifying sequential or contingent relations include the calculation and comparison of transitional probabilities and (to a lesser extent) the calculation of statistics of sequential association. Transitional probabilities are proportions of one event followed by another event in sequence (Yoder & Symons 2010) and have been used to describe behaviour–environment contingencies in natural settings (e.g. Watson 1997; Vollmer et al. 2001; Anderson & Long 2002; Martens et al. 2008). Statistics reflecting the degree of sequential association between two events (e.g. Yule’s Q; Yule & Kendall 1957) also have been used to describe naturally occurring behaviour–environment contingencies (e.g. McComas et al. 2009; Symons et al. 2003; see Lloyd et al. 2013 for a detailed account and comparison of transitional probabilities versus statistics of sequential association to measure contingencies). Data collected from descriptive assessments may be used to (i) estimate baseline rates of challenging behaviour, (ii) assess correspondence with information collected via indirect assessments and (iii) formulate hypotheses regarding the conditions under which challenging behaviour occurs and/or the function © 2014 John Wiley & Sons Ltd, 27, 187–199

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challenging behaviour serves in a given context (Horner & Carr 1997). Quantitative descriptions of naturally occurring behaviour patterns also may guide subsequent experimental analyses. Approximate contingencies identified via descriptive assessments, for example, may be programmed into experimental test conditions to better represent naturally occurring schedules (Vollmer et al. 2001). Alternatively, following the experimental verification of behaviour function, contingencies identified via previous descriptive assessments may indicate approximate schedules of reinforcement typical of natural settings (Borrero & Vollmer 2002). If experimental analyses are not feasible, hypotheses developed from descriptive data also may be evaluated based on the effectiveness of interventions matched to each hypothesis (e.g. Karsh et al. 1995). Descriptive assessments are less likely to evoke challenging behaviour than experimental assessments, but may require extensive time and resources to complete, depending on the frequency with which targeted behaviours occur and the complexity of procedures used to collect and analyse data. In addition, no clear guidelines have been accepted concerning how much observation is sufficient to provide reliable descriptions of behaviour patterns. Finally, and most importantly, none of the descriptive approaches to functional assessment allow for the verification of functional relations between challenging behaviour and environmental stimuli. That is, descriptive data only may be used to describe, and not explain, behaviour– environment patterns.

Experimental analyses Experimental functional analyses alone allow the empirical verification of behaviour–environment relations and thus remain the gold standard of functional assessment. Functional analyses involve the systematic manipulation of antecedent stimuli, consequent stimuli or some combination thereof (Horner & Carr 1997; e.g. Carr & Durand 1985; Iwata et al. 1982/1994a). These systematic manipulations are designed such that multiple hypotheses of behaviour function may be tested. For example, a condition testing the social positive reinforcement hypothesis may consist of restricted attention as an antecedent and the contingent delivery of attention following challenging behaviour. A condition testing the social negative reinforcement hypothesis may consist of demand delivery as an antecedent and the contingent removal of demands following challenging behaviour. A condition testing the automatic © 2014 John Wiley & Sons Ltd, 27, 187–199

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reinforcement hypothesis may consist of the individual being alone to determine whether challenging behaviour continues in the absence of socially mediated stimuli. Levels of challenging behaviour during each test condition may be compared to levels of challenging behaviour during a control condition, during which the individual may have unlimited access to attention and preferred items or activities without prompts to complete any task demands. Higher levels of challenging behaviour in one or more test conditions relative to a control condition confirm corresponding hypotheses. Although the majority of published functional analyses have been shown to produce clear outcomes (Iwata et al. 1994b; Hanley et al. 2003; Mueller et al. 2011), a number of procedural modifications to the traditional functional analysis have been shown to clarify outcomes that are initially ambiguous (i.e. undifferentiated levels of challenging behaviour across conditions; see Hagopian et al. 2013 for review). In addition, models of multiphase experimental assessments have been proposed, such that each subsequent phase may be used to clarify inconclusive outcomes from the previous phase (e.g. Vollmer et al. 1995b). Within-session analyses also have been used to identify differential moment-by-moment patterns of challenging behaviour when overall rates are similar across test conditions (Roane et al. 1999). Other suggested strategies for clarifying ambiguous functional analysis outcomes include linking descriptive and experimental approaches such that variables idiosyncratic to the individual’s environment may be incorporated into the experimental analysis (e.g. Carr 1994; Kennedy 2000). This approach is based on previous research indicating differential functional analysis outcomes depending on the specific stimuli used in analogue test conditions (e.g. Carr et al. 1997; see Schlichenmeyer et al. 2013 for review). Although a clear advantage of functional analyses over indirect and descriptive assessments is the ability to test hypotheses and confirm the function(s) of challenging behaviour, this methodology does present various resource-related challenges and, in some cases, ethical concerns. Functional analyses, by definition, involve creating conditions intended to temporarily evoke and/or reinforce challenging behaviour. In cases of potentially dangerous behaviour (e.g. high-risk physical aggression or self-injury causing tissue damage), it is important to consider the potential risks of conducting the functional analysis when determining the most appropriate assessment technique. In response to such concerns, several adapted versions of traditional functional analysis methods have been proposed with

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the goal of minimizing risk to those involved. Some examples include the brief functional analysis (Northup et al. 1991), an abbreviated version conducted within a single clinic visit, and the trial-based functional analysis (Sigafoos & Saggers 1995; LaRue et al. 2010; Bloom et al. 2011), in which brief trials are distributed within naturally occurring routines. Other examples include using the latency to challenging behaviour as the dependent measure such that each session ends following the first instance of challenging behaviour (Thomason-Sassi et al. 2011) or targeting precursor behaviours (i.e. behaviours shown to reliably precede severe challenging behaviour; e.g. Borrero & Borrero 2008; Smith & Churchill 2002) rather than severe challenging behaviour as the dependent variable. In summary, functional assessment methods represent a powerful set of technologies to investigate behaviour– environment relations. Continued extensions and refinements of these techniques may allow for wider applications of functional assessment procedures within the context of challenging behaviour.

Intervention Approaches The rationale for the many variations and extensions of functional assessment techniques is a better understanding of behaviour–environment relations that may lead to more effective interventions. Evidence from the literature on high-risk challenging behaviours among individuals with intellectual disability suggests interventions based on functional assessment outcomes are more effective than those that are not function-based (Carr et al. 1999a; Didden et al. 1997; Didden et al. 2006). Some researchers have questioned, however, the extent to which this relation holds for individuals with higher incidence disabilities and less severe topographies of challenging behaviour (Sasso et al. 2001; Gresham 2003). A primary advantage of function-based interventions is an increased likelihood of implementing reinforcementbased procedures over punishment-based procedures to treat severe topographies of challenging behaviour (Pelios et al. 1999). Despite previous treatment research demonstrating the effectiveness of punishment (see Matson & DiLorenzo 1984; for review), current legal mandates and ethical guidelines reflect a shift away from punishment procedures towards reinforcementbased interventions (IDEA 1997, 2004; Behavior Analyst Certification Board 2010). The following reinforcementbased strategies represent a subset of interventions shown to effectively reduce challenging behaviours for individuals with intellectual disability.

Differential reinforcement and extinction Extinction is a procedure in which a previously reinforced response is no longer reinforced (Catania 2013). For example, if screaming is positively reinforced by the delivery of preferred items, extinction would consist of no longer providing these preferred items following instances of screaming. (This example may be contrasted with a negative punishment procedure, in which the preferred item would be taken away contingent on screaming.) Although extinction alone has been shown to effectively reduce challenging behaviour (e.g. Repp et al. 1988), extinction is typically used in conjunction with a differential reinforcement procedure. Differential reinforcement consists of providing reinforcement contingent on an alternative response [i.e. differential reinforcement of alternative behaviour (DRA)] or contingent on intervals of time without the occurrence of a targeted behaviour [i.e. differential reinforcement of other behaviour (DRO); Catania 2013]. For example, in addition to withholding preferred items following instances of screaming, the preferred items may also be delivered contingent on an appropriate request [e.g. ‘Toys please’ (DRA)] or 5-min intervals without any instances of screaming (DRO). Differential reinforcement procedures (alone or as part of an intervention package) have been shown to effectively reduce challenging behaviour in both adults with intellectual disability (Chowdury & Benson 2011) and children with intellectual and/or developmental disabilities (Petscher et al. 2009). Based on the premise that challenging behaviour itself is a form of communication (especially for individuals with significant developmental delays and minimal functional language), functional communication training (FCT) incorporates differential reinforcement and extinction to replace challenging behaviours with appropriate forms of communication (Carr & Durand 1985; Durand 1990; Durand & Carr 1991). Thus, a primary advantage of FCT interventions is the promotion of pro-social behaviours in addition to the reduction of challenging behaviours. FCT has been established as an evidence-based intervention for treating challenging behaviour in children and adolescents with intellectual disability (and is ‘probably efficacious’ for adults with intellectual disability, as fewer studies have included older participants; Kurtz et al. 2011).

Noncontingent reinforcement Noncontingent reinforcement (NCR) is another reinforcement-based procedure that has been shown to © 2014 John Wiley & Sons Ltd, 27, 187–199

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reduce challenging behaviours for individuals with intellectual disability. NCR consists of delivering reinforcers on a fixed or variable time schedule such that reinforcement is provided independent of responding. NCR has been shown to effectively decrease challenging behaviours maintained by socially mediated consequences (e.g. Mace & Lalli 1991; Vollmer et al. 1995a) as well as challenging behaviours maintained by non-social reinforcement (e.g. Lindberg et al. 2003). For social reinforcers, NCR typically includes an extinction component – although reinforcement is delivered on a time-based schedule, it is withheld immediately following instances of challenging behaviour (Lindberg et al. 2003). For nonsocial reinforcers, however, the source of reinforcement is often unknown or may not be provided or withdrawn by another person (see Rincover & Devany 1982 for the exception of sensory extinction). In these cases, access to items providing stimulation expected to compete with the automatically reinforced behaviour is delivered noncontingently. The mechanism by which NCR alters challenging behaviour has been described in terms of deprivation and satiation states. By providing reinforcement either continuously or on a dense schedule independent of responding, the value of that reinforcer may be decreased, as will the likelihood of behaviours that previously produced the reinforcer (i.e. abolishing operation; Laraway et al. 2003). Potential limitations of NCR as an intervention for challenging behaviour, however, include (a) the impracticality of maintaining dense or continuous schedules of reinforcement in natural settings, and (b) the lack of a component involving teaching and reinforcing appropriate, prosocial behaviours (e.g. Goh et al. 2000).

Antecedent interventions Although NCR may be considered an antecedent-based intervention, other antecedent interventions have been shown to effectively prevent challenging behaviours, especially within the context of natural settings (e.g. educational, vocational). Two common antecedent interventions include curricular revisions and choicemaking interventions. Examples of curricular revisions include adjustment of task types (e.g. fine versus gross motor, drill versus problem-solving), task duration and task difficulty (Dunlap et al. 1991). Curricular revisions are designed to decrease the aversiveness of task demands and therefore may be effective treatments for challenging behaviour maintained by escape from task demands (i.e. negative reinforcement). Incorporating © 2014 John Wiley & Sons Ltd, 27, 187–199

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opportunities for choice-making also has been shown to effectively reduce challenging behaviour for children and adults with intellectual disability across a variety of activities and contexts (Kern et al. 1998; see Dyer et al. 1990 and Vaughn & Horner 1997 for examples). The mechanism by which choice-making interventions decrease challenge behaviour has been discussed in terms of both negative and positive reinforcement hypotheses. For example, offering students a choice among tasks may result in the decreased aversiveness of completing the chosen task and could thus be conceptualized in terms of negative reinforcement. Making choices, however, also has been described as exercising control over one’s environment, which may be a reinforcing consequence in and of itself (Vaughn & Horner 1997; Romaniuk & Miltenberger 2001). Regardless of the precise mechanism by which choicemaking interventions are effective, advantages include its simplicity and consistency with current value-based recommendations to promote independence and develop self-determination skills for individuals with intellectual disability (Shogren et al. 2004). Similar to the functional classifications of challenging behaviour, interventions designed to reduce challenging behaviour should not be considered mutually exclusive and should address all behaviour–environment relations identified via functional assessment. An intervention designed for aggression maintained by both attention and escape from difficult demands, for example, might include a FCT component to address the attention function and curricular revision to address the escape function. Evidence suggests multicomponent interventions are more effective than single component intervention strategies in the treatment of challenging behaviour maintained by multiple sources of reinforcement (e.g. Day et al. 1994).

Current Challenges and Future Directions Despite the quantity of research on challenging behaviour among individuals with intellectual disability, challenges remain with respect to models of prevention, assessment, intervention and widespread application. With respect to models of prevention, for example, there is the challenge of early identification of young children at risk for developing chronic self-injury. Evidence from recent longitudinal studies measuring motor stereotypies in young children with developmental disabilities suggest these behaviours may precede the onset of selfinjury (Berkson et al. 2001; Berkson 2002; Richman & Lindauer 2005). The ability to identify children at risk

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for developing severe and chronic challenging behaviour is a necessary step for evaluating methods of prevention. Potential prevention strategies may include early communication training for socially maintained repetitive behaviours and enriched environments or competing stimuli for non-socially maintained repetitive behaviours (Richman & Lindauer 2005). Although a great deal of research has been conducted on interventions designed to alter established patterns of challenging behaviour, future research is needed to identify methods of preventing challenging behaviour from becoming established in an individual’s repertoire. With respect to functional analysis methodology, one critical challenge includes preserving the ecological validity (i.e. the extent to which behaviour–environment relations tested in the analysis represent those in the natural environment; Hanley et al. 2003) of assessment results without sacrificing experimental control. The recent increase in applications of functional behaviour assessment within school settings as a result of changing legislation (IDEA 1997, 2004) is one area of research in which this tension is evident. Empirical evidence demonstrating the effects of contextual and idiosyncratic variables on functional analysis outcomes (e.g. Carr et al. 1997; Ringdahl & Sellers 2000; Schlichenmeyer et al. 2013) highlights the importance of matching the context of assessment to the context in which behaviour support is needed. Despite inherent challenges of conducting experimental analyses in complex, natural settings (i.e. controlling extraneous variables, maintaining procedural fidelity), doing so allows for the inclusion of relevant contextual stimuli across test conditions and thus increases the likelihood of ecologically valid results. The further development and refinement of practical hypothesis testing techniques within natural settings remains an important area for future research. Despite the variety of intervention approaches that have been demonstrated to effectively reduce challenging behaviour for individuals with intellectual disability, further research is needed on comprehensive interventions that produce generalized and maintained behaviour change in natural settings. Horner & Carr (1997) described interventions as comprehensive when they (i) address all challenging behaviours, (ii) are based on functional assessment outcomes, (iii) are applied across contexts, (iv) incorporate multiple intervention types and (v) are comprised of procedures consistent with the values, skills and resources of the implementers. Although some research has been conducted on interventions meeting these requirements (e.g. Carr et al. 1999b), the majority of intervention studies have

evaluated the effects of few treatment components within highly controlled environments. In addition to research on comprehensive interventions across natural environments, continued research is needed to identify variables that facilitate or inhibit the maintenance and generalization of treatment effects. These investigations may be conducted by analysing generalized treatment effects across stimuli (e.g. Berg et al. 2007) or by evaluating the persistence of treatment effects given various challenges to implementation (Wacker et al. 2011). Understanding the conditions under which intervention effects are likely to maintain and generalize in natural settings is critical to the success of comprehensive interventions for individuals with intellectual disability and challenging behaviour. Finally, despite substantial empirical evidence supporting the effectiveness of behavioural interventions for individuals with intellectual disability and challenging behaviour (Didden et al. 1997, 2006), evidence is lacking on the extent to which these assessment and treatment methods are being implemented on a wide-scale basis. Within the public education system, for example, Weber et al. (2005) found that a majority of the 50 states have established resources for completing IDEA-mandated functional behaviour assessment, but with substantial variation among state education agencies in terms of which assessment components are included. In fact, the fewest number of agencies were shown to provide any resources on reinforcer identification procedures (seven states) and experimental analyses (11 states). This descriptive study suggests two of the most critical components of functional assessment are not being implemented consistently in public education settings for students with disabilities. Within community and institutional settings, Feldman et al. (2004) found that less than half of over 2000 interventions for people with intellectual disability and challenging behaviour were ‘formal’ (i.e. included documented input from a professional, written intervention plans and systematic evaluation). These studies, among others, highlight an unfortunate gap between services shown to be effective for individuals with intellectual disability and challenging behaviour and those most commonly provided. The related question of how functional assessment and intervention methods may be incorporated into existing service delivery models is also relevant to the issue of widespread implementation. Matson & Minshawi (2007) commented on a likely distinction between two types of service delivery systems—namely, that experimental assessment approaches (functional analyses and evaluations of function-based © 2014 John Wiley & Sons Ltd, 27, 187–199

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interventions) are more likely to be used regularly within smaller applied settings with greater resources (e.g. university-based clinics, private schools for children with developmental disabilities), whereas rating scales and checklists are more likely to be used in larger developmental centres or group homes with fewer resources. Although the costs of providing highquality and comprehensive behavioural support services are not minor, they must be considered in terms of the potential savings of preventing more restrictive and expensive placements (Coland & Weisler 1995; Sturmey 2006). Additional empirical work estimating cost–benefit parameters of functional assessment and intervention for individuals with intellectual disability and challenging behaviour will be imperative, especially in light of recent predictions that cost–benefit rationales will be prioritized in the decision to offer residential or other services (Wolfensberger 2011).

Conclusion In the current review, we presented the status of research on challenging behaviour in individuals with intellectual disability from a functional assessment perspective. Although methods of assessing and treating challenging behaviour for individuals with intellectual disability have been informed by decades of empirical research, our review highlights several areas worthy of further investigation. These areas include (i) continued adaptation and refinement of functional assessment techniques, (ii) the development and evaluation of both models of prevention and comprehensive interventions and (iii) improvements in the quality of services available to the broader population.

Correspondence Any correspondence should be directed to Blair Lloyd, Department of Special Education, Box 228 Peabody College, Vanderbilt University, Nashville, Tennessee 37203, USA (e-mail: [email protected]).

References Anderson C. M. & Long E. S. (2002) Use of a structured descriptive assessment methodology to identify variables affecting problem behavior. Journal of Applied Behavior Analysis 35, 137–154. Behavior Analyst Certification Board (2010) Guidelines for Responsible Conduct for Behavior Analysts. Available at: http://

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