Effects of Reinforcement without Extinction on

JOURNAL OF APPLIED BEHAVIOR ANALYSIS

2018, 9999, 1–7

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9999 ()

EFFECTS OF REINFORCEMENT WITHOUT EXTINCTION ON INCREASING COMPLIANCE WITH NAIL CUTTING: A SYSTEMATIC REPLICATION ART DOWDY MELMARK PENNSYLVANIA

MATT TINCANI TEMPLE UNIVERSITY

TIMOTHY NIPE MELMARK PENNSYLVANIA

MARY JANE WEISS MELMARK PENNSYLVANIA

Personal hygiene routines, such as nail cutting, are essential for maintaining good health. However, individuals with autism spectrum disorder (ASD) and other developmental disabilities often struggle to comply with essential, personal hygiene routines. We conducted a systematic replication of Schumacher and Rapp (2011), Shabani and Fisher (2006), and Bishop et al. (2013) to evaluate an intervention that did not require escape extinction for increasing compliance with nail cutting. With two adolescents diagnosed with ASD who resisted nail cutting, we evaluated the effects of delivering a preferred edible item contingent on compliance with nail cutting. Results indicated that the treatment reduced participants’ escape responses and increased their compliance with nail cutting. Key words: autism, compliance, hygiene, nail cutting, reinforcement, self-care

with personal hygiene tasks, including dental flossing (Dahlquist & Gil, 1986), haircuts (Schumacher & Rapp, 2011), toothbrushing (Bishop et al., 2013), as well as toileting, bathing, and dressing (Piazza, Contrucci, Hanley, & Fisher, 1997). Individuals with ASD and other developmental disabilities often engage in extreme forms of responding (e.g., screaming, tantrums, repetitive behavior, and other forms of problem behavior) when presented with tactile stimulation (Baranek, Foster, & Berkson, 1997), which can be problematic during personal hygiene routines (e.g., Ellis, Ala’i-Rosales, Glenn, Rosales-Ruis, & Greenspoon, 2006). Although previous studies on increasing compliance with personal hygiene routines typically have not employed functional analyses to determine the behavioral function of such problematic responding (e.g., Bishop et al., 2013;

Individuals with autism spectrum disorder (ASD) and other developmental disabilities often resist participating in personal hygiene routines with caregivers, including fingernail cutting and toenail cutting (Collado, Faulks, & Hennequin, 2008). Poor personal hygiene among persons with disabilities can lead to social stigma and may compromise personal health. For example, ungroomed fingernails increase the likelihood of infection (Centers for Disease Control and Prevention, 2009), and poorly maintained toenails can produce pain and immobility (Malkin & Berridge, 2009). Researchers have used behavioral interventions to increase individuals’ compliance Correspondence concerning this article should be addressed to Art Dowdy, Melmark Pennsylvania, 2600 Wayland Rd, Berwyn, PA 19312. Contact: arthur. [email protected] doi: 10.1002/jaba.484

© 2018 Society for the Experimental Analysis of Behavior

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Schumacher & Rapp, 2011), resistance to personal hygiene routines is likely to be reinforced by escape from aversive tactile stimulation, at least in part. Topographically, escape responses may consist of blocking or pulling away from the tactile stimulus, or otherwise leaving the area (Schumacher & Rapp, 2011). Consequently, behavior analysts may consider implementing escape extinction, a common treatment for escape-maintained problem behavior (e.g., Piazza, Patel, Gulotta, Sevin, & Layer, 2003). However, escape extinction may not be a viable option to gain compliance with personal hygiene routines due to the heightened risk of participant injury during extinction bursts (see Lerman & Iwata, 1995). The risk of injury during escape extinction may be heightened during personal hygiene routines that involve sharp instruments (Shabani & Fisher, 2006). Delivery of positive reinforcement for compliant behavior may be a viable alternative to escape extinction when treating escape-maintained problem behavior. Slocum and Vollmer (2015) compared the delivery of nonfunctional edible items to the delivery of escape in reducing escape-maintained problem behavior and increasing compliance of five children with developmental disabilities. Delivery of edible items was effective in both reducing problem behavior and increasing compliance for all five participants, whereas delivery of escape was effective in reducing problem behavior and increasing compliance for only two of the five participants. Shabani and Fisher (2006) developed a treatment using stimulus fading and positive reinforcement without escape extinction to increase compliance with blood-glucose monitoring for a diabetic adolescent diagnosed with ASD. The participant had a needle phobia and resisted blood draws, that prevented caregivers from monitoring his blood-glucose levels for over 2 years. Shabani and Fisher used stimulus fading by progressively reducing the distance between the lancet and the participant’s index

finger, combined with differential reinforcement of other behavior using edibles. The intervention resulted in the participant tolerating blood draws for up to 2 months. Similarly, Schumacher and Rapp (2011) increased haircut compliance of a boy with ASD by delivering an edible item contingent on compliance with sitting during haircuts for progressively increasing durations of time. Shumacher and Rapp programmed a concurrent schedule of reinforcement in which compliance produced edibles and escape responses produced breaks. The intervention immediately reduced the boy’s escape responses to zero levels (i.e., the boy never contacted the break contingency), and the boy sat for 160 s for haircuts by the end of the study. Finally, Bishop et al. (2013) evaluated the effects of stimulus fading without the use of escape extinction to increase toothbrushing compliance of three children with ASD. Bishop et al. used a 30-step stimulus-fading procedure to first gradually decrease the distance between the participants and the toothbrush and then to gradually increase the duration that participants tolerated toothbrushing. These experimenters differentially reinforced compliance with the current step of the stimulus-fading procedure using edibles. The intervention increased each participant’s tolerance of toothbrushing for up to 60 s, and these results generalized to caregivers. The present study was a systematic replication of Shabani and Fisher (2006), Schumacher and Rapp (2011), and Bishop et al. (2013) in which we evaluated the use of differential reinforcement without escape extinction on escape responding and compliance with nail cutting of two adolescents with ASD who resisted nail cutting. METHOD Participants, Setting, and Materials Two male adolescents living in a residential treatment facility participated. Jackson was a 16-year-old male diagnosed with ASD, attention

INCREASING COMPLIANCE WITH NAIL CUTTING deficit hyperactivity disorder (ADHD), Marfan’s syndrome, DiGeorge syndrome, and a profound intellectual disability. Jackson was nonvocal and communicated via the speech-generating device, Proloquo2Go™ installed on his iPad®. Jackson complied with most instructions that involved listener responding during daily routines. However, Jackson’s teacher and residential director reported that attempts to cut his toenails were unsuccessful because he frequently engaged in escape behavior during the routine. Steven was a 12-year-old male diagnosed with ASD, epilepsy, ADHD, diabetes insipidus, hypopituitarism, sleep apnea, and a severe intellectual disability. Steven also was nonvocal and communicated via Proloquo2Go™ on his iPad®. Steven could follow one-step directions, such as “sit down.” However, Steven’s teacher and residential director reported that attempts to cut his fingernails were unsuccessful because he frequently engaged in escape behavior during the routine. All sessions occurred at the residential treatment facility in which both participants lived. Sessions occurred in either a classroom (43% of sessions for Jackson, 59% for Steven) or in a general residential setting (57% of sessions for Jackson, 41% for Steven). In both settings, daily schedules consisted of 30-min blocks, that included but were not limited to, math, reading, and job sampling in the classroom setting and homework, chores, and job sampling in the residential setting. Personal hygiene (e.g., nail cutting, toothbrushing, hand washing, face washing) was included in both participants’ schedules in the classroom and in the residential setting. Materials for all sessions consisted of nail clippers, sanitizing wipes for the nail clippers, and preferred edible items for each participant. Response Measurement and Interobserver Agreement We collected frequency data on problem behavior (i.e., escape responses) and on nails cut. Escape response consisted of any instance or

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attempt by the participant to pull his hand or foot away from the therapist or any attempt to block the cutting of the target nail using any other body part. Nail cut was scored if the participant allowed the therapist to cut all of the free margin of the target nail. In some cases, this required multiple cuts to the target nail. We targeted toenail cutting with Jackson and fingernail cutting with Steven. We converted the frequency of escape responses to responses per minute by dividing the number of escape responses per session by the session duration (s) and then multiplying by 60 s. We converted nails cut to a percentage by dividing the number nails cut per session by 10 (total number of toenails or fingernails) and then multiplying by 100. Observers collected data on laptop computers using BDataPro™ (Bullock, Fisher, & Hagopian, 2017). An independent second observer assessed interobserver agreement (IOA) on 41% of Jackson’s sessions and on 38% of Steven’s sessions, each distributed equally across baseline and treatment conditions. We calculated IOA according to the procedures described by Mudford, Taylor, and Martin (2009) by dividing sessions into 10-s intervals and scoring an agreement when both observers recorded the same (exact) number of nails cut per interval. We then divided the number of agreement intervals by the total number of intervals and multiplied by 100. We used the same IOA calculation for escape responses. For Jackson, IOA averaged 97% for nails cut (range, 96% to 100%) and 98% for escape responses (range, 96% to 100%). For Steven, IOA averaged 98% for nails cut (range, 95% to 100%) and 96% for escape responses (range, 94% to 100%). Procedural Fidelity Trained observers collected procedural fidelity data using “yes/no” checklists on 64% of Jackson’s baseline and treatment sessions and

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on 68% of Steven’s baseline and treatment sessions. The steps on the procedural fidelity checklist included (a) having materials ready and present, (b) ensuring that the participant was seated, (c) holding nail clippers in hand and in the participant’s line of sight, (c) bringing nail clippers to the nails, (d) delivering an edible contingent on a complete nail cut, (e) allowing 5 s of escape contingent on an escape response, (f) not cutting the next nail until the entire free margin of the target nail was cut, and (g) ending the session after 5 min or after all nails were cut, whichever came first. We calculated procedural fidelity by dividing “yes” responses by the sum of

“yes” and “no” responses and then multiplying by 100. Procedural fidelity averaged 98% (range, 92% to 100%) for Jackson and 96% (range, 89% to 100%) for Steven.

Design and Procedures We used a reversal design to determine the effects of reinforcement without extinction on compliance with nail cutting and escape responses. Each baseline and treatment session ended after 5 min or after all the participant’s nails were cut, whichever came first. Consecutive sessions were separated by an average of 2 weeks to ensure sufficient nail growth.

Figure 1. Toenail cutting data for Jackson and fingernail cutting data for Steven.

INCREASING COMPLIANCE WITH NAIL CUTTING Pre-experimental assessment. We conducted a multiple-stimulus-without-replacement preference assessment (DeLeon & Iwata, 1996) at the beginning of the study with each participant to identify preferred edible items to be used during treatment. The most-preferred edible items identified for Jackson and Steven were Reese’s Peanut Butter Cups and Whoppers, respectively. Baseline. At the start of each baseline session, the therapist escorted the participant to a chair to sit down. The therapist said to the participant, “I am going to cut your nails,” and the therapist then held, raised, and moved the clippers toward the participant’s first target nail. The therapist provided 5 s of escape following each escape response, after which time, the therapist again re-presented the nail clippers directed toward the target nail. Neither participant attempted to leave the chair during baseline or treatment. Treatment. The treatment condition was identical to baseline, except the therapist informed the participant, “For each nail I cut, you will earn a snack.” Preferred edible items remained visible throughout session, and the therapist provided immediate access to one piece of the preferred edible item following each successful nail cut. Participants could consume the edible item at any point during or following the session. Escape responses continued to produce a 5-s break from nail cutting. RESULTS AND DISCUSSION Figure 1 shows the percentage of toenails and fingernails cut per session across baseline and treatment conditions for Jackson (top panel) and Steven (bottom panel), respectively. We cut 0% of Jackson’s toenails across baseline phases, and Jackson engaged in a mean of 5.4 escape responses per minute (range, 2.2-8.2). Across treatment phases, Jackson’s mean percentage of toenails cut was 91% (range, 50%100%). During each of the last three

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sessions of the treatment phases, the therapist was able to cut all of Jackson’s toenails. During combined treatment phases, Jackson engaged in 1.7 mean escape responses per minute (range, 0-4.6). Maintenance of these gains was evaluated at 1- and 2-month intervals. All of Jackson’s toenails were cut during each maintenance probe. For Steven, across baseline phases, we cut a mean of 31% (range, 10%-50%) of Steven’s fingernails, and Steven engaged in a mean of 4.5 escape responses per minute (range, 2.0-6.1). Across treatment phases, Steven’s mean percentage of fingernails cut increased to 92% (range, 70%-100%), whereas his combined mean escape responses per minute reduced to 1.1 (range, 0.6-2.8). Thus, Steven’s results closely replicated those of Jackson’s results. The use of extinction in treatment often can be accompanied by undesirable side effects, such as initial increases in problem behavior (i.e., an extinction burst; Lerman & Iwata, 1995). Similar to Shabani and Fisher (2006), who also examined the use of positive reinforcement without extinction to increase compliance with blood draws, escape extinction was contraindicated in the present study due the presence of a sharp instrument (i.e., nail clippers) and the increased potential for injury to the participant and caregiver. Delivering preferred edible items following compliance with nail cutting led to decreased rates of escape responses and increased levels of compliance with two participants diagnosed with ASD in the present study even though escape responses continued to produce escape from nail cutting in treatment. These findings replicate those published by Schumacher and Rapp (2011), Shabani and Fisher (2006), and Bishop et al. (2013) and extend the literature on treating escape-maintained problem behavior without the use of escape extinction by targeting a novel, yet important personal hygiene routine, nail cutting.

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Both participants emitted lower rates of escape responses during treatment, and it is possible that the delivery of preferred edible items for compliance with nail cutting served as an abolishing operation for escape behavior. That is, delivering preferred edible items may have diminished the value of escape from nail cutting as a reinforcer and simultaneously decreased the likelihood of responses that have historically resulted in escape from nail cutting. Schumacher and Rapp (2011) observed similarly immediate reductions in escape responding when they arranged edible items for compliance with hair cutting even though escape remained available for escape responses. Our study provides further evidence supporting the use of positive reinforcement for compliance when escape extinction is impractical. There are three contributions of the present study. First, we increased each participant’s compliance with nail cutting and decreased escape responses using a concurrent schedule of reinforcement that arranged positive reinforcement for compliance and negative reinforcement for escape responses. Therefore, this study adds to the literature on compliance training without escape extinction using concurrent schedules of reinforcement (e.g., Athens & Vollmer, 2010; Carter, 2010; Hoch, McComas, Thompson, & Paone, 2002; Lalli et al., 1999). Given the difficulties of implementing escape extinction, such procedures have special utility and relevance as they provide a simple yet effective alternative to escape extinction. Second, we evaluated treatment across educational and residential settings, suggesting that treatment effects extended across the two settings. Third, treatment effects maintained with Jackson at the 1- and 2-month follow ups, suggesting that treatment effects may persist over an extended period of time. There are at least four potential limitations to the present study. First, although treatment was implemented with high fidelity, trained

therapists implemented all treatment sessions. Future researchers should attempt to replicate these procedures with primary caretakers. Second, although maintenance data showed persistence of treatment effects for Jackson, the durability of Steven’s treatment gains is unknown due to his discharge from the residential treatment facility. Third, we did not evaluate whether the contingency-specifying statement, “For each nail I cut, you will earn a snack,” was necessary in facilitating the treatment effects. Finally, problem behavior was characterized as “escape responding” throughout the present study; however, we did not conduct a functional analysis of these responses, and thus, are unable to confirm that these responses were indeed reinforced by escape from nail cutting. Additional research is needed to further refine, generalize, and extend the application of these and similar procedures to more individuals and to other health and personal hygiene routines. An alternative approach to the procedures in this study would be to evaluate the effects of noncontingent escape during nail cutting (cf. Allen & Wallace, 2013). Regardless of the specific procedures implemented, when compared to escape-extinction procedures, which may initially increase problem behavior and create potentially unsafe situations, treatments that do not require escape extinction are more practical for caregivers to implement and are likely to be less prone to producing untoward side effects. REFERENCES Allen, K. D., & Wallace, D. P. (2013). Effectiveness of using noncontingent escape for general behavior management in a pediatric dental clinic. Journal of Applied Behavior Analysis, 46, 723–737. https://doi. org/10.1002/jaba.82 Athens, E. S., & Vollmer, T. R. (2010). An investigation of differential reinforcement of alternative behavior without extinction. Journal of Applied Behavior Analysis, 43, 569–589. https://doi.org/10.1901/jaba. 2010.43-569

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