James K. Luiselli (Ed.), Antecedent Assessment and Intervention: Supporting Children and Adults with Developmental Disabilities in Community Settings.

James K. Luiselli (Ed.), Antecedent Assessment and Intervention: Supporting Children and Adults with Developmental Disabilities in Community Settings. James K. Luiselli (Ed.), Antecedent Assessment and Intervention:Supporting Children and Adults with Developmental Disabilities inCommunity Settings. Baltimore: Paul H. Brookes Publishing Co. 2006. 334pgs., Softbound. $39.95 Reviewed by Helen Bittman Sysko, Western Psychiatric Institute andClinic, Pittsburgh, PA. As a clinical psychologist, certified health care provider,diplomate in behavioral psychology and Board Certified Behavior Analyst,James K. Luiselli's career includes active roles in clinicaltreatment, consultation, research and training. His experience inaddressing challenging behaviors presented by children and adults withdevelopmental disabilities, such as self-injury and feeding problems,has led to over 240 publications, including several books. In 1998, Dr.Luiselli and Michael J. Cameron co-edited the book, Antecedent Control:Innovative Approaches to Behavior Support to illuminate the benefits ofantecedent-based intervention. Dr. Luiselli edited this second book,Antecedent Assessment and Intervention: Supporting Children and Adultswith Developmental Disabilities in Community Settings in response toincreased interest in this area, as noted by the special sectionpublished in the Journal of Applied Behavior Analysis, 2000 (33),regarding establishing operations and motivation. His goals for thisbook were threefold. First, the book was to offer a compendium of recentresearch and intervention with chapters written by authorswell-recognized in their specialized field of developmentaldisabilities. Second, the contributors were to focus on how antecedentassessments and interventions are implemented in natural settings, andfinally, he urged his authors to integrate theory, evidenced-basedtreatment recommendations and to include their views on futureimplications. The book is logically organized with an initial presentation oftheoretical concepts, followed by chapters on the assessment, design,and implementation of antecedent interventions, and areas for futureconsideration. A major strength of the book is its incorporation of caseexamples and visual data displays which illustrate the functionalbehavior analysis-to-intervention process. Readers new to the fieldmight begin with the Dr. Luiselli's final chapter, "Summaryand Future Decisions." Here, the premise of using antecedentinterventions to address challenging behaviors, as preferable tonegative consequence-based (punishment) strategies, is clearly explainedwith specific references to the book's previous chapters. Theissues surrounding effective intervention implementation are presentedin a context of conceptual and practical considerations regardingtreatment of persons diagnosed with developmental disabilities. Returning to the Introduction section in Chapter 1 entitled,"The Evolution of Antecedent-Based Interventions" by David P.Wacker, Wendy K. Berg and Jay W. Harding, the reader receives a historyof the roles of establishing operations (EOs) and discriminative stimuli([S.sup.D]) in designing applied behavioral interventions. At the end ofthis chapter, there is an interesting case example combining analyses ofantecedent-response and response- consequence interventions for a4-year-old child with autism to decrease aggression and noncompliance.Using functional behavior analysis (FBA), it was determined that bothpositive (tangible) and negative (escape) reinforcement maintainedproblem behavior. Further analyses using a choice assessment (comparingcombinations of alone/attention and highly preferred/less preferredconditions) showed that the child's behavior was primarilycontrolled by access to highly preferred toys. Functional communicationtraining (FCT) was used to teach the child to touch a card for workbreaks. Results of time allocation during observation indicated that thechild almost always chose to work to obtain his preferred toys andproblem behaviors decreased to zero levels, thus highlighting theimportance of understanding the contribution of establishing operations(EOs) and [S.sup.D] (discriminating stimuli or triggers) to problembehavior. In Chapter 2, "Contribution of Establishing Operation toAntecedent Intervention," by Patrick C. Friman and Renee O.Hawkins, the concept of EOs is discussed in further depth and describedas a relative newcomer (in the last 25 years) to the field of appliedbehavior psychology. The paradigm for early operant conditioning focusedon three elements: discriminative stimuli ([S.sup.D]), responses andcontingent consequences. However, changing states outside the three termreinforcement contingency often change the reinforcing value of the sameconsequence (i.e., access to food and water). The authors explain,"Motivational events are what make people want what they want"(p. 32) and may explain what variables mediate the value of consequencesfor certain behaviors at a given time. It is posited that identifyingkey aspects of a person's life outside of the three-term model iscrucial in planning interventions for changing behavior with people withdevelopmental disabilities. Clinical examples of several states such assleep deprivation and pain illustrate this concept. Interestingly, theauthors maintain that a person with sleep deprivation can displayimpulsivity and symptoms similar to someone diagnosed with ADHD; lack ofsleep can function as an EO to strengthen the reinforcers of short-term,rewarding consequences and escape from demands. Chapter 3, "Assessment of Antecedent Influences on ChallengingBehavior" by Lee Kern, Natalie G. Sokol and Glen Dunlap describesthe benefits of antecedent intervention as a preventive strategy for anindividual and others who may be negatively affected by theindividual's challenging behavior. Antecedent assessment isintended to supplement a complete functional assessment so thateffective techniques are identified to eliminate or significantlydecrease targeted behaviors. The goal is to "identify specificstimuli that lead to or are associated with challenging behaviors, aswell as those stimuli that reduce responses that are incompatible withchallenging behavior or that are associated with an absence ofchallenging behavior" (p. 67). Examples of several tools forantecedent assessment, such as descriptive assessments (e.g., ABCnarrative), behavior checklists, and scatterplots, that result inhypothesis statements are presented with the caveat that to beeffective, interventions must fit with the individual's dailyroutine, preferences, goals, setting and treatment team approach. How to address challenging behavior of persons with developmentaldisabilities who also have health problems (i.e., gastrointestinaldisorders, constipation, allergies, premenstrual symptoms, otitismedia), is the topic in Chapter 4, " Health conditions inAntecedent Assessment" by Craig H. Kennedy and Angela Becker. Here,the authors advocate that health assessments by medical professionalsshould supplement the FBA so that their possible influence onmaintaining problem behavior is considered when designing theintervention. The following seven chapters in the next section, InterventionFormulation and Implementation: Methods, Challenging Behaviors, andPopulation, offer a diverse array of treatment topics and settings.Several chapters are worth highlighting. Chapter 5, "AntecedentInterventions for Challenging Behaviors Maintained by Escape fromInstructional Activities" by Raymond C. Miltenberger, discusses theimportance of EOs at work during classroom tasks. Identification offactors such as "proximal (i.e., frequency of demand, level ofdifficulty, task length, student's mood, amount of teacherattention, predictability of the schedule and level of student'schoice or control over school work.) and distal (i.e., setting eventsthat take place some time before the class such as sleep deprivation)antecedents " (p.102-103) provide avenues for intervention thatwill likely decrease the student's motivation to escape andincrease on-task behavior. An in-depth comparison of consequence-based and antecedent-basedinterventions for feeding disorders is presented in Chapter 8,"Pediatric Feeding Disorders" written by the book'seditor, James Luiselli. Food selectivity and food refusal in childrenwith developmental disabilities are common but concerning problems.Although pediatric feeding disorders may be assessed as being maintainedby positive (attention) and negative (removal of food) socialreinforcement, the author purports that the efficacy ofconsequence-based feeding interventions (the most prevalent types) hashad mixed results and some limitations. Positive reinforcementinterventions using preferred foods and sensory stimuli (e.g., music)can be effective with food selectivity, but not necessarily with foodrefusal. Negative reinforcement interventions such as preventing escapeuntil food has been consumed or physical guidance used by the caregiverto open the child's mouth are considered to be potentiallystressful, physically injurious and may spur an increase in new problembehaviors. Alternatively, approaches that include antecedent-basedintervention (i.e., food blending, simultaneous food presentation,stimuli fading and shaping) are preferable to consequence-basedintervention because their approach is non-aversive and preventive. Chapter 9, "Communication and Social Skill Intervention"by Mark F O'Reilly, Helen I. Cannella, Jeff Sigafoos and GiulioLancioni, features antecedent intervention strategies implemented whenchallenging behaviors occur due to deficits in communication and/orsocial skills, which are symptoms typically associated with AutismSpectrum Disorders. For individuals with limited means to communicate,treatment is typically a two-pronged educational approach; first toassess the function of the behavior as a means of communication (e.g.,wanting a break), and then to replace the maladaptive behavior with anappropriate form of communication. Some individuals with some expressivelanguage (e.g., Aspergers Disorder, Down Syndrome) may have difficultycommunicating because they can not discriminate social cues or thenuances of pragmatic language that rely heavily on social context.Although challenging behaviors in these circumstances may be less severe(e.g., refusing to talk to an unfamiliar person, using scripting orrepetitive language), the person may be stigmatized or socially excludedas a result. Current treatment options for building communication skillsinclude: choice making, augmentative and alternative communication (ACC)strategies such as the Picture Exchange Communication System (PECS) andvoice output communication aids (VOCAs). Social problem-solving orsocial skills training methods include verbal instruction, modeling androle-play to teach social skills. Since 2000, the use of social storieshas been implemented to help individuals identify requisites of aspecific social context (e.g., birthday party) and teach an appropriateset of behaviors and conversation for that event. The authors maintainthat, "An educational environment that focuses actively onenhancing communication, choice and social skills may be one of the mostpowerful antecedent interventions for challenging behavior" (p.202). Short-term memory loss, perceptual difficulties, behavioraloutbursts, attention deficits, impulsivity and reduced physical strengthare some of the symptoms associated with brain injury. Each year, thereis an estimated 1.5 million American adults and children who experiencea traumatic, acquired brain injury (ABI) caused by an external force(i.e., fall, physical assault, sports or vehicular accident). In Chapter10, "Antecedent Intervention in Brain Injury Rehabilitation,"authors Gary M. Pace, Robin S. Codding and Jeffrey Skowron present caseexamples of how interventions for persons with ABI reduce disruptivebehavior, improve academic assessment and instruction, and generalizeskills. They state, "If our assessment reveals that an event isaversive because it reduces an individual's control of theirenvironment, we may consider antecedent intervention that provideschoice of items or tasks within a class" (p. 209). For a10-year-old boy with tantrums, property destruction, physical aggressionand self-injurious behavior, (SIB) a functional assessment indicatedthat aggression and SIB were maintained by negative reinforcement,especially during times of transitions, changes in routine, demands withno choice and use of specific language (e.g., "no") whendemands were given with no choice. An effective antecedent interventionincluded transition warnings, a visual schedule, choices embedded inorder of demands, and language changes when demands were given. In theclassroom, differential responding by students with ABI to previouslymastered tasks was shown to be due not to the difficulty of the task butto the presentation sequence, properties of the stimulus materials(e.g., single-digit numbers vs. double digit numbers or adding numbersfrom highest to lowest or vice versa) or academic splinter skills (e.g.,reading a whole sentence but not able to distinguish individual lettersof the alphabet). Students with ABI have idiosyncratic learning needs,but in general, by providing additional time to allow opportunities forpractice and giving increased reinforcement for high performance,fluency and mastery is improved for these students. Recommendations forincreasing generalization of skills include training all staff to usethe same prompting social cues and taking photographs of actual itemsthat are being taught (rather than downloaded images or replicas). Chapter 11, "Combining Antecedent & Consequence Proceduresin Multicomponent Behavior Support Plans: A Guide to Writing Plans withFunctional Efficacy" by Joseph N. Ricciardi presents usefulguidelines to prepare practitioners to write coherent plans that includemultiple antecedent and consequence interventions. In this pursuit,clearly defined procedures with operational, observable terms, writtento reflect the individualized needs of the client, are essential inexplaining a treatment procedure that must be consistently implementedin different settings with several staff. A change of venue is offered in the next two chapters of thesection entitled Lifestyle and Systems Application. In Chapter 12,"Life Enjoyment, Happiness, and Antecedent Support" theauthors, Dennis H. Reid and Carolyn W. Green maintain that increasingone's sense of enjoyment will decrease the likelihood of problembehaviors, especially with those with developmental disabilities.However, defining "happiness" and assessing the level of anindividual's sense of enjoyment is difficult with persons withcognitive and or communication skill delays and thus, remains a frontierfor study. The use of mindfulness skills for staff and clients withdevelopmental disabilities, a skill set made known by Marsha Linehan inthe 1980s in treatment of persons diagnosed with borderline personalitydisorders, is presented as a promising approach in Chapter 13, "Mindfulness Based Caregiving and Support" by Nirbhay N. Singh, AlanS.W. Wintorn, Judy Singh, Kristen McAleavey Robert G. Wahler andMohamend Sabaawi. Mindfulness is defined as "the awareness andnonjudgmental acceptance by a clear, calm mind of one'smoment-to-moment experience without either pursuing the experience orpushing it away" (p.270). Built on the theory that teachingmindfulness skills should increase the probability of positiveinteractions between staff and clients, staff members are trainedself-calming strategies first, followed by the staff teachingmindfulness-based supports to their clients. Preliminary researchfindings show promising decreases in aggression, noncompliance andself-injury in children and increased satisfaction in caretaking skillsand in child-caretaker interactions. Although many authors offer their experiences in this edited book;there is unity in the message regarding the advantages of usingantecedent variables to change targeted behavior with people diagnosedwith developmental disabilities. Further research on antecedentintervention implemented in natural settings is advocated, well-meritedand will likely yield more evidence-based strategies. In turn, effectivetreatment of behavior problems will enhance the quality of life forclients, their caregivers, teachers and treatment providers. There is aheavily cited, evidence-based tone to this book, and it is a worthwhileread which offers a thorough tour of the history, clinicalimplementation and research issues surrounding antecedent assessment andintervention.