Effects of functional versus non-functional

03 mccausland (ds) 23/11/04 1:11 pm Page 351

a rt i c l e

Effects of functional versus non-functional explanations for challenging behaviours on treatment acceptability DA R R AG H M C C AU S L A N D IAN M. GREY

Trinity College, Dublin, Ireland

Stewarts Hospital Services and Trinity College, Dublin,

Ireland

G RY W E S T E R

Journal of Learning Disabilities © 2004 sage publications London,Thousand Oaks and New Delhi vol 8(4) 351‒369 issn 1469-0047(200412)8:4 doi: 10.1177⁄1469004704047505

Trinity College, Dublin, Ireland

BRIAN MCCLEAN

Brothers of Charity, Roscommon, Ireland

The study evaluated the effects of type of information naive participants received about challenging behaviour on ratings of acceptability of two multi-element treatment plans. Three groups of 20 undergraduate students with no experience of intellectual disability watched an identical 5 minute acted video of an individual with an intellectual disability engage in aggressive behaviour. Voiceover on the video differed: one group was exposed to information derived from a functional assessment, one to causal information that reflected personality and emotional factors, and the third to no causal information. Participants then rated two multielement treatment plans: one based upon functional assessment, and the other upon general non-aversive interventions. Results indicate that all groups were more accepting of the functional plan. However, individuals exposed to information derived from functional assessment were less accepting of non-functional treatment plans. Results have implications for staff cultures and the explanations for challenging behaviours that these cultures endorse.

Abstract

Keywords challenging behaviour; function based interventions; staff culture; treatment acceptability

Introduction Developing and implementing functionally based and successful behavioural interventions is a key concern for those who work with populations with intellectual disabilities and challenging behaviour. It has been widely 351

Downloaded from jid.sagepub.com at Leabharlann TCD / Trinity College Dublin Library on March 13, 2016


JOURNAL OF LEARNING DISABILITIES

8(4)

documented that functionally based interventions are one of the most effective ways of treating challenging behaviour (Ager and O’May, 2001; Carr et al., 1999; Emerson, 2001; Koegel et al., 1996). However, research indicates that interventions deemed ‘best practice’ are often at odds with the type of interventions that front-line care staff actually implement (Grey et al., 2002; Hastings, 1995; 1997; Oliver et al., 1996). Typical staff responses to challenging behaviour can sometimes reinforce rather than improve the presenting behaviour (Hastings and Remington, 1994; Oliver et al., 1996), which raises the question of why staff might implement such interventions. One factor identified as influencing the type of interventions carried out by care staff is treatment acceptability (Kazdin, 1977; 1980; Wolf, 1978), which is defined by Kazdin as ‘judgements by laypersons, clients and others of whether treatment procedures are appropriate, fair and reasonable for the problem or client’ (1981, p. 493). Research has identified that those charged with the implementation of behaviourally based interventions might be less willing and therefore less likely to do so successfully if they find an intervention unacceptable (Elliott, 1988; Miltenberger, 1990; Reimers et al., 1987). Of the various factors found to influence treatment acceptability, the severity of the challenging behaviour has been most documented in the literature and the function of the behaviour perhaps least documented (Foxx et al., 1996a; Hastings et al., 2004; Miltenberger and Lumley, 1997). Behaviours exhibited by care staff in response to challenging behaviours often indicate a lack of understanding in respect of the function of that behaviour (Hastings and Remington, 1994; Oliver et al., 1996). In response, some researchers have raised the concern that knowledge of behavioural function might not be passed on to newly employed care staff (Hastings et al., 2004); or if knowledge of function of challenging behaviour is learned by staff in formal training schemes, it may be quickly suppressed by informal staff culture (Kemp et al., 1996). It therefore stands to reason that first-time staff might be more accepting of treatment plans not derived from functional assessment if their knowledge of behavioural function is limited. So far, few studies have examined the link between treatment acceptability and behavioural function, and the findings have been somewhat varied. Miltenberger and Lumley (1997) investigated whether knowledge of function would affect treatment acceptability by manipulating vignettes describing a challenging behaviour maintained by either attention or escape, and subsequently instructed care staff to rate two functionally based treatments for the behaviour, time out and guided compliance. Time out was found more acceptable regardless of the function of the behaviour, which reflects the robust finding that less intrusive interventions tend to be rated more acceptable than intrusive interventions (Kemp et al., 1996; 352



M C C AU S L A N D E T A L . : T R E AT M E N T AC C E P TA B I L I T Y

Miltenberger, 1990). Weigle and Scotti (2000) examined whether providing teachers with functional information had an effect on how they subsequently rated functional and non-functional behavioural interventions. Those who were provided with contextual functional information about the presenting behaviour found an intervention based on a simple interruption less acceptable. However, participants failed to discriminate between the functions that were maintaining the behaviour and to pick appropriate interventions based upon that discrimination. The interruption intervention was found to be more acceptable regardless of whether the behaviour was maintained by attention or escape/avoidance (Weigle and Scotti, 2000). Jones and Lungaro (2000) studied treatment acceptability among primary school teachers by asking them to rate treatment plans for challenging behaviours described in vignettes. The treatment plans were either linked or not linked to functional assessment information. The teachers judged described treatments more acceptable if they were based on the functional assessment provided. Finally, Hastings et al. (2004) compared the effects of behavioural function on experienced versus inexperienced staff’s perceived acceptability of a range of treatments. Participants watched one of two videos demonstrating self-injurious behaviour maintained by either attention or escape/avoidance. They then rated a number of singleelement interventions, both relevant and irrelevant to the behaviour’s function. Although staff showed some sensitivity to functional information in a social disapproval condition, few strong effects of behavioural function were found. The above studies do not present any clear overall picture regarding possible effects of information about the function of challenging behaviour on treatment acceptability. Indeed, if anything, they might beg the question as to whether information based upon a functional assessment has an effect on treatment acceptability at all. Nevertheless, research in the field is still at an early stage and there are quite a few outstanding methodological issues that may have confounded findings thus far. Miltenberger and Lumley (1997), Jones and Lungaro (2000) and Weigle and Scotti (2000) all used written vignettes to describe the challenging behaviour, therefore raising concerns about the ecological validity of their findings. The amount of contextual information that can be presented in a vignette is very limited. Moreover, respondents may not be able to relate the information to actual clinical practice and they might not be sensitive to functional information presented in written form (Grey et al., 2002; Hastings and Jones, 2003; Mossman et al., 2002). Another methodological concern is the nature of the treatment plans described (Hastings et al., 2004; Jones and Lungaro, 2000; Miltenberger 353




8(4)

and Lumley, 1997; Weigle and Scotti, 2000). Without exception, the studies have had a narrow focus and have offered separate single-component interventions for challenging behaviour. While such designs may lead in theory to clearer results, they overlook the multi-component interventions that are being used with increasing frequency of success in the field of positive behaviour support (Carr et al., 1999; Koegel et al., 1996; La Vigna and Willis, 1995). Furthermore, the primary emphasis in research has been on experienced care staff (Miltenberger and Lumley, 1997; Weigle and Scotti, 2000) or on teachers (Jones and Lungaro, 2000) rather than on naive or potential staff. There is an argument to be made for looking at how participants initially exposed to aspects of a staff culture might rate behavioural treatment plans. First, one can determine whether inexperienced individuals show an initial sensitivity to information about the function of a challenging behaviour (e.g. whether a staff culture that reflects the importance of information regarding the function of challenging behaviour promotes greater acceptance of functionally based treatment plans in new staff members). Second, there are concerns that knowledgeable and experienced staff might rate treatment plans in accordance with what they think their employers want to hear even though this might be at odds with what they practise in staff culture (Kemp et al., 1996). By using inexperienced individuals this concern is avoided. The present study explored the effect of information regarding behavioural function, presented in a voiceover fashion, on treatment acceptability and addressed some of the methodological concerns identified in previous research. The focus was on the extent of treatment acceptability among potential staff members entering a new ‘staff culture’ where existing staff emphasize either functional or non-functional causes of the challenging behaviour in an intellectually disabled individual. A number of aspects of the present study aimed to increase ecological validity. The video clip was shot in a day service setting to appear as naturalistic as possible and the scene is based on an actual incident, with the actor closely portraying an actual intellectually disabled individual. Moreover, both the function of the client’s behaviour and the treatment plan used are drawn from the actual client’s functional assessment. Moving forward from research examining single-element interventions, the treatments used in the study were both multi-element and the functional treatment plan was in keeping with positive behaviour support strategies (Carr et al., 1999; La Vigna and Willis, 1995). It was hypothesized that those who viewed the video with a voiceover describing information derived from a functional assessment would be significantly less accepting of the general non-aversive treatment plan and more accepting of the functional treatment plan. Conversely, those who heard the voiceover describing non-functional causes were predicted 354




to be significantly more accepting of the non-functional treatment plan and less accepting of the functional treatment plan.

Method Participants Sixty participants took part in the study: 11 first-year psychology students took part and were rewarded with research credits for doing so, and the remaining 49 participants were students of other disciplines. As such the sample is one of convenience. Excluding two mature students aged 38 and 57, the mean age of the participants was 21.1 with a range of 17 to 25. Before taking part in the study, participants answered questions on whether they had any previous experience of working with intellectual disabilities or had attended courses on intellectual disabilities. Those who had previous experience of or had attended courses on intellectual disability were excluded from the study. Research design The study used an independent groups design. The participants were split into three groups of 20 and randomly assigned to one of three experimental conditions. The conditions varied on one factor: the type of information in the voiceover that accompanied the 5 minute video. All participants watched a video clip where an actor played an intellectually disabled client (Pat1) in a day service setting engaging in aggressive behaviour toward a staff member. Those in the first condition (functional) heard a voiceover reflecting information derived from the results of a functional assessment that had been conducted for the actual client played by the actor (described subsequently). In this condition a staff member described Pat’s aggressive behaviour in a way that included relevant functional information about the hypothesized cause of the behaviour. In the second condition (non-functional) the staff member described Pat’s behaviour in a way that included little information about the actual function of the behaviour, and instead focused on aspects of Pat’s personality and on the negative and frustrating consequences of the behaviour for staff members and other intellectually disabled clients. The third and final condition (control) contained only a brief description of Pat (e.g. his age and level of intellectual disability). After viewing the clip, participants were asked to use Tarnowski and Simonian’s (1992) Abbreviated Acceptability Rating Profile (AARP) to rate the acceptability of two multi-element behavioural treatment plans for the client: one was derived from a previously conducted functional assessment, and the other was a non-aversive treatment reflecting general interventions 355




8(4)

that had previously been suggested for implementation with Pat. One of the treatment plans contained functionally relevant treatments in line with positive behaviour support (Carr et al., 1999; La Vigna and Willis, 1995); the other was non-aversive and non-functional, containing environmental strategies not directly relevant to the function of Pat’s aggression, the use of medication and the reactive strategy of placing Pat in a safe place. The AARP ratings given to the treatment plans were the dependent measures.

Materials Video content A video was carefully created to depict Pat engaging in aggressive behaviour toward a member of care staff in a day service setting. A care staff member familiar with Pat played the part of Pat. With the exception of the voiceover segment at the beginning, the video was the same for all three conditions. Pat sat on a chair in the foreground while in the background a staff member filled out forms at a desk. Over the course of the scene, Pat attempts to engage the staff member in conversation about what he did during the day and when he would be able to take part in new chores or activities. The staff member, although friendly toward Pat, is involved in the activity, rarely looks up from the task at hand as he addresses Pat, and makes vague promises about doing something later. On two separate occasions Pat gets up from his chair and asks to do a chore. Both times the staff member tells him to sit down and relax. On the third occasion, Pat screams loudly and runs aggressively toward the staff member. He is restrained and held against the floor until he calms down. As a measure of ecological validity, a staff member who had previously worked with Pat saw the acted scene and considered it to be a realistic enactment of a typical incident. Treatment plans Two five-element treatment plans were drawn up, a functional treatment plan and a non-functional treatment plan. The plans were labelled A and B. In order to control for priming effects the label on each treatment plan was switched for half the participants in each experimental group, e.g. for 10 participants the functional plan was plan A and for the remaining 10 participants the functional plan was plan B. Functional plan The functional treatment plan was a multi-element positive behavioural support intervention, which contained five strategies. These addressed the function of Pat’s behaviour as identified in his functional assessment. A comprehensive behavioural assessment and intervention plan was completed 356




which met the standards established in the Behaviour Assessment Report and Intervention Plan Evaluation Instrument (La Vigna and Willis, 1995). Assessment was multimodal, and included (1) informant assessment, consisting of cognitive, communicational, ecological, medical and psychiatric assessments, and including review of files and interviews with the individual and key informants such as staff; (2) descriptive assessment, including behavioural observation, historical analysis, antecedent analysis and consequence analysis; and (3) hypothesis development and systematic observation to test hypotheses. The hypotheses of function were used as a basis for designing the multi-element behaviour support plan, based on the model developed by La Vigna and Willis (1995). The strategies addressed deficient environmental conditions and Pat’s deficient behaviour repertoires (see Carr et al., 1999). For example, an environmental deficiency is the failure of the environment to provide Pat with a sense of status and importance within his peer group and to staff. This deficiency is addressed in the treatment plan element: ‘Provide Pat with a sense of importance by giving him small simple paid jobs that he can do outside the treatment unit. Provide him with a uniform to increase status.’ A functional reinforcementbased intervention for Pat’s behaviour is also suggested, where, for every hour without aggression, Pat receives cards with information about significant others to be used during a ‘talk time’ (see Table 1). Non-functional plan The non-functional treatment plan contains a number of non-aversive but non-functional interventions for Pat’s behaviour, and includes the reactive strategies of placing Pat in a safe setting and increasing medication. Such strategies, although commonly employed by care staff, are described by Carr et al. as being unhelpful and ‘conform best to a crisis management paradigm’ (1999, p. 5), whereas positive behaviour support strategies can be seen as a prevention paradigm (see Table 1). The strategies listed in the plan were non-functional in two respects. First, they had either been suggested or implemented prior to functional assessment and found to be unsuccessful. Second, they do not readily match the identified function of Pat’s behaviour. Staff voiceovers In each experimental condition the participants heard a short voiceover before the video started. In order to avoid distraction, the voiceover accompanied a still close-up shot of Pat’s face. Once the voiceover was finished, the video then ran as normal. There were three separate voiceovers: functional, non-functional and control. A female postgraduate psychology student read out the three voiceovers in a manner that 357




Table 1

8(4)

Functional and non-functional treatment plans

Non-functional treatment plan

Functional treatment plan

1 Increase Pat’s level of happiness by increasing the number of pleasurable activities available such as the number of bus rides throughout the day and week. 2 Teach new skills that would be fulfilling and of use in the world such as requesting a bus ride from staff.

1 Provide Pat with a sense of importance by giving him small simple paid jobs that he can do outside the treatment unit. Provide him with a uniform to increase status.

2 Increase status within the home and positive regard by others by having Pat do particular tasks within the bungalow such as baking. 3 When Pat becomes aggressive, place 3 Introduce a daily picture schedule to Pat. him in a secure and quiet place where This has daily photos of activities of Pat he can have some time on his own to doing jobs and the jobs he has to do today relax. are the only ones shown. 4 Introduce a simple reward system to 4 Introduce scheduled ‘talk times’ with Pat increase Pat’s motivation to remain with only one member of staff at a time. behaved throughout the day. Pat gets Conversation style is to slow down, and the a can of cola or his favourite food/drink staff member will repeat what is said to if he has behaved himself during the day. increase Pat’s understanding. 5 Alongside the other treatments, increase 5 Introduce a reward system. For each hour medication to try help Pat calm himself without aggression Pat is provided with a down. card with a piece of information about significant others on it. These cards can be used during ‘talk times’.

sounded conversational and naturalistic. The voiceovers were designed to sound as if a staff member who worked with Pat was describing him and his behaviour (see Appendix 1). The first voiceover was functional and provided detailed information that addressed the function of Pat’s behaviour (drawn from Pat’s functional assessment). Its focus was on deficient environmental conditions such as Pat’s unstructured days and that, although Pat likes nothing more than talking to staff as an equal, staff tend to talk among themselves. The second condition was non-functional: the voiceover provided a non-functional explanation of Pat’s behaviour derived from comments made by actual care staff and in keeping with Hastings’s (1997) findings. The reasons given for his aggression attribute it to him rather than environmental deficiencies, for example that he is unruly and acts aggressively to wind the others up or get his own way. The functional and non-functional voiceovers were controlled for word length. Finally, those in the control group heard only a short description of Pat, that he lives in a special treatment unit, has an intellectual disability and can be aggressive. 358




Abbreviated Acceptability Rating Profile Participants rated the two treatment plans on the Abbreviated Acceptability Rating Profile (AARP) (Tarnowski and Simonian, 1992). The AARP is a modified version of the Intervention Rating Profile (Witt and Elliott, 1985). Tarnowski and Simonian (1992) removed seven of the 15 items and reworded the items to improve readability. It was found that all items in the AARP loaded onto a single factor, treatment acceptability (Tarnowski and Simonian, 1992). For the purpose of the current study, the AARP has been reworded slightly to include Pat’s name and changed from a sixpoint to a five-point Likert scale in order to provide for a neutral middle ground. To encode the Likert values for statistical analysis, each item was given an integer score between –2 for strongly disagree and +2 for strongly agree. The overall AARP rating for each plan therefore had a potential range of +16 (strongly acceptable) to –16 (strongly unacceptable) (see Appendix 2).

Procedure All 60 participants took the test in a room in a psychology department. Participants were tested individually or in groups no bigger than four. Across all conditions participants viewed a 5 minute clip of Pat’s behaviour. The video was presented in full screen mode on a 15 inch laptop monitor, with the room lights turned off to avoid distraction. Before watching the video, participants signed and filled out a consent form, which included age, gender and whether they had previous experience with intellectually disabled clients. After watching the video, the participants in all conditions filled out a sister study on attributions. They then carefully read the two treatment plans before rating them on the AARP scale. Afterwards, they were debriefed about the study in simple terms and told that Pat was an actor.

Results The mean overall scores for each treatment plan are shown as a function of the experimental conditions in Figure 1. The main analysis investigated whether the type of information presented in the video voiceover had any impact on respondents’ acceptability ratings of the two treatment plans. The scores on the AARP for both treatment plans were compared across the three conditions. Across all three conditions there was no significant difference in how people rated the functional treatment plan, with all groups finding it similarly acceptable and rating it 7.6 (control), 8.0 (functional) and 8.25 (nonfunctional). 359




8(4)

Mean score on AARP

10 8 6 Functional treatment plan Non-functional treatment plan

4 2 0 –2 –4 Functional Non-functional

Control

Type of staff explanation Figure 1 The mean AARP scores of both treatment plans across the experimental conditions

However, differences in ratings for the non-functional plan were evident across the three conditions: 0.1 (control), –3.0 (functional) and 3.3 (non-functional). A significant main effect in how the non-functional treatment plan was rated was observed across the three groups (2(2) = 7.22, p < 0.05). A series of separate Mann–Whitney U-tests was run to identify specific significant differences between the three groups when rating the non-functional plan. No significant difference was found between the functional group and the control group (U = –1.750, p > 0.05) or between the non-functional information and no-information control group (U = –1.493, p > 0.05). However, participants in the functional condition were significantly less accepting of the non-functional plan than those in the non-functional condition (U = –2.388, p < 0.05). Potential differences within the independent groups were explored by running a series of Wilcoxon signed ranks tests. In all three groups, the functional plan was preferred. The most pronounced difference in how the plans were rated was in the functional condition, with a difference in scores of 11.3 (8.0 for the functional plan and –3.3 for the non-functional plan) (Z = –3.529, p < 0.05). A smaller significant difference was found in the control condition, 7.6 versus 0.1 (Z = –3.213, p < 0.05), and in the nonfunctional condition the difference was least pronounced but still significant (Z = –2.784, p = 0.05) (see Figure 1). The AARP has not been widely used in the literature, and because it was slightly modified for the purpose of this study a reliability analysis of the instrument was conducted for both treatment plans. The alpha 360




coefficients were 0.89 for the functional treatment plan and slightly higher at 0.91 for the non-functional treatment plan.

Discussion The main finding of the current study is that the type of information presented in a staff voiceover had a strong effect on how participants rated a non-aversive but non-functional treatment plan. Specifically, those who heard a non-functional explanation for challenging behaviour were significantly more accepting of a non-functional treatment plan than those who heard a functional explanation for observed challenging behaviour. This finding goes some way toward validating the hypothesis, though there was no significant difference in how participants rated the functional treatment plan across conditions. Although this result does not comfortably fit the original hypothesis, it is not unusual in light of much treatment acceptability research. It has been consistently found that regardless of the severity of the presenting problem, of the person rating the plan, or of the actual effectiveness of the intervention, positive and non-intrusive interventions are rated as more acceptable than reactive or intrusive interventions (Foxx et al., 1996a; Miltenberger, 1990; Reimers et al., 1992). Returning to the main findings regarding acceptability of the nonfunctional plan, the results are encouraging. It appears that individuals working with people with intellectual disability are indeed sensitive to relevant functional information about a client with challenging behaviour. Moreover, they can use this information to be more critical and less accepting of the type of reactive, non-functional interventions that experienced staff are consistently found to implement (Grey et al., 2002; Hastings, 1995; 1997; Oliver et al., 1996). The implication for service providers is that the type of staff culture naive care workers are exposed to can have an impact on their subsequent understanding, acceptance and implementation of treatment procedures (Miltenberger, 1990; Reimers et al., 1987). Therefore it follows that service providers should endeavour to have a staff culture which espouses the importance of behavioural function. To do so would mean breaking the existing circle where the quick results of reactive strategies such as seclusion and medication may have reinforced staff behaviour (Hastings and Remington, 1994). There are a number of reasons as to why behavioural function effects appear stronger in the current study than those reported in previous studies (e.g. Hastings et al., 2004; Jones and Lungaro, 2000; Weigle and Scotti, 2000). It appears that functional information might have a stronger impact on perceived treatment acceptability when combined with informal staff cultural values. In other words, presenting the functional or non-functional 361




8(4)

information as a conversational voiceover from a staff member, with all the cultural factors that entails (see Grey et al., 2002; Hastings and Remington, 1994), has a stronger effect than merely presenting the information on a page as previous research has done (e.g. Jones and Lungaro, 2000; Miltenberger and Lumley, 1997; Weigle and Scotti, 2000). Second, the study used a multi-element treatment plan that is in line with current advances in the practice of positive behaviour support (Carr et al., 1999; Koegel et al., 1996). The aim was to illustrate a complete treatment intervention and overcome the narrow, artificial nature of previous studies focused on single-element treatments (e.g. Hastings et al., 2004; Weigle and Scotti, 2000). An advantage to this approach was that it showed that participants are able to apply functional knowledge to their acceptability of treatment procedures when considering the broad multi-element plans that are being used increasingly by service providers (Carr et al., 1999; Kincaid et al., 2002). The above propositions rest upon the argument that knowledge of behavioural function mediated the differences observed. It may also be argued that the functional treatment plan resonated with participants’ own moral views on treatment or intervention. On initial inspection this argument would appear to be hard to support, as all interventions were essentially non-aversive and all have the potential to be functional interventions depending upon the results of functional assessment. However, the results from the control group do suggest that not all interventions are considered equally acceptable. In the absence of any information, participants in the control group significantly rated the functional treatment plan as more acceptable than the non-functional treatment plan. At this point it remains unknown what elements or combination of elements produced this result. A direction for additional research could be for participants to rank order interventions in the absence of information and consequently design a study controlling for intervention preference across information conditions. The current study was carried out among a population of undergraduate college students, and not actual naive care workers. This raises concerns about validity, e.g. whether it is possible to apply the findings to clinical practice. Although external validity may in fact be reduced, in Elliott’s (1988) review of treatment acceptability it was found that no significant differences were found between treatment acceptability studies using college students and those using care staff. In addition, Foxx (1996a; 1996b) carried out two separate treatment acceptability studies, one among students and the other among care staff, and found no significant differences between the groups. Furthermore, the clinical field is moving toward more complete social integration for intellectually disabled clients (Carr et 362




al., 1999). Therefore, members of the public may be increasingly expected to rate acceptability of community-based treatment practices (Foxx et al., 1996a). However, this should not be taken to mean that a student population and a care staff population are equivalent or that the results are representative of a care staff population. Undoubtedly, a sample sharing greater similarity with a care staff population would be more representative and should be a target for future research. The results obtained here suggest that such research may be worthwhile. The findings in the current study are strong but it would be unwise to draw immediate conclusions. A number of methodological concerns were identified, and these should be considered in further research. One of the advantages of the current study also serves as a drawback, namely its use of multi-element treatment plans. Because all the elements were considered in a complete behaviour support package, no discriminations can be made regarding the relative effects each type of element had on treatment acceptability. Furthermore, only one type of behaviour was presented and its function was the same across all three groups. In addition, participants were provided with the functional assessment information rather than deducing it for themselves, meaning that no conclusions can be drawn as to the effects of different types of behavioural function on treatment acceptability. In Hastings et al. (2004), the researcher manipulates a video in order to make it look like the function of the behaviour is one of two different functions (escape/avoidance versus attention). An interesting but complex future direction for research might be to use two video clips but to use multi-element functional plans rather than the single-element plans. Because the use of video technology as an alternative to written vignettes is still relatively in its infancy, there is plenty of scope for future research on treatment acceptability and challenging behaviour. Previous experiments relying on vignettes (Jones and Lungaro, 2000; Miltenberger and Lumley, 1997; Weigle and Scotti, 2000) might be replicated using video technology in order to determine whether participants are more sensitive to the functional information when it is presented in the rich context of a video clip. Further research might also want to look more closely at the effect of having a staff member reading out the video voiceover. For example, would participants find a treatment more acceptable if a qualified clinical psychologist rather than a member of care staff read out the accompanying voiceover? There is some mention of this type of effect in treatment acceptability reviews, and Reimers et al. (1987) call it treatment integrity. However, little follow-up research has been carried out to explore its effects. As it stands, the study of treatment acceptability has been somewhat neglected in intellectual disability research, which is surprising considering the emphasis placed on social validity across the literature 363




8(4)

(Carr et al., 1999; Emerson, 2001). The scope for future research is broad and full of possibility. In conclusion, Hastings et al. (2004) express concern that information regarding the function of challenging behaviour has weak effects on treatment acceptability of behavioural interventions and finds this discouraging because of the empirical support for such interventions in clinical practice. The present study’s findings, while not detailed enough to show whether staff can discriminate between different behavioural functions when rating an intervention, should still encourage and lead to future exploration. By nurturing a staff culture that places importance on functional interventions, it appears that, at the very least, naive care workers will be less accepting of non-functional interventions.

Appendix 1: staff voiceovers Functional This is Pat. Pat is 36 years of age. He has an intellectual disability. He lives in a special treatment unit for people with severe behavioural problems, and four other men live there as well. He has punched, kicked and scratched the other residents he lives with. This has been going on for 7 months and I’d say on average five times a week. He’s in the unit now nearly all of the time, except when the staff bring him out for a walk or for a bus drive. When he goes on the bus rides and walks alone with the staff, he is very rarely aggressive. For the rest of the time, he sits or lies on a sofa. He has no hobbies really, and he doesn’t watch TV either. There’s no structure to the day really, and he has no job or activity that makes him feel good about himself or important. He feels important alright when he is doing things with staff. He also likes talking to the staff but he doesn’t understand much of what they’re saying really, and he’ll get lost quickly in the conversation. Being able to tell the staff pieces of information about other staff and to have fun with them, that makes him feel important about himself alright. However, most of the staff tend to talk amongst themselves really. And the staff as well talk to him less now because of his behaviour and what’s going on. Non-functional This is Pat. Pat is 36 years of age. He has an intellectual disability. He lives in a special treatment unit for people with severe behavioural problems, and four other men live there as well. His problem is really that he hits the other lads who live there and staff as well, and it looks really like there’s no reason. Like, you could be out on a walk with him and all of a sudden 364




he can turn around and he’d scratch you in the face. Every day he does something like this really, and it’s been going on for months. He used to have a day placement where he went out during the day, but because of this kind of thing he’s just here all the time now. He just sits on his own inside or in the garden. He’s just bold, acting up, and he just wants to attack the others and the staff. There’s one in particular that he likes winding up. Sometimes he goes out on a bus drive. We never really have any problems with him on the bus. I think he needs a lot more medication than what he is on at the moment. He’s just out of control really, to be honest, and I think something’s got to be done about it. The staff are worn out and no one really seems to care at all.

Control This is Pat. Pat is 36 years of age. He has an intellectual disability. He lives in a special treatment unit for people with severe behavioural problems, and four other men live there as well. He has punched, kicked and scratched the other residents he lives with.

Appendix 2: Abbreviated Acceptability Rating Profile (AARP) You are after viewing a short video of someone with an intellectual disability (Pat) engaging in aggressive behaviour. In front of you are two treatment plans designed specifically to treat the behaviour, treatment plan A and treatment plan B. Carefully read both treatment plans and then use the following scale to rate how effective you think each plan might be for Pat. The scale contains eight statements about the effectiveness of each treatment plan. Please read each statement very carefully and rate it by ticking the most suitable box on the corresponding scale of 1 to 5. You will have to do this twice for each statement, once for plan A and once for plan B. 1 This is an acceptable treatment plan for Pat’s behaviour. Plan A: Not at all acceptable Very acceptable 1 2 3 4 5 ( ) ( ) ( ) ( ) ( ) Plan B: Not at all acceptable Very acceptable 1 2 3 4 5 ( ) ( ) ( ) ( ) ( )

365




8(4)

2 This treatment should be effective in changing Pat’s behaviour. Plan A: Not at all acceptable Very acceptable 1 2 3 4 5 ( ) ( ) ( ) ( ) ( ) Plan B: Not at all acceptable Very acceptable 1 2 3 4 5 ( ) ( ) ( ) ( ) ( ) 3 Pat’s behaviour is severe enough to justify the use of this treatment plan. Plan A: Not at all severe enough Severe enough 1 2 3 4 5 ( ) ( ) ( ) ( ) ( ) Plan B: Not at all severe enough Severe enough 1 2 3 4 5 ( ) ( ) ( ) ( ) ( ) 4 I would be willing to use this treatment if Pat were a member of my family. Plan A: Not at all willing Very willing 1 2 3 4 5 ( ) ( ) ( ) ( ) ( ) Plan B: Not at all willing Very willing 1 2 3 4 5 ( ) ( ) ( ) ( ) ( ) 5 This treatment would not have bad side effects for Pat Plan A: Not at all have Would have 1 2 3 4 5 ( ) ( ) ( ) ( ) ( ) Plan B: Not at all have Would have 1 2 3 4 5 ( ) ( ) ( ) ( ) ( ) 366




6 I liked this treatment plan. Plan A: Not at all 1 ( ) Not at all 1 ( )

2 (

3 )

( ) Plan B:

2 (

(

3 )

(

)

Very much so 5 ( )

)

Very much so 5 ( )

4

4 )

(

7 The treatment plan was a good way to handle Pat’s behaviour. Plan A: Not at all good way Very good way 1 2 3 4 5 ( ) ( ) ( ) ( ) ( ) Plan B: Not at all good way Very good way 1 2 3 4 5 ( ) ( ) ( ) ( ) ( ) 8 Overall the treatment would help Pat. Plan A: Not at all help him 1 2 3 ( ) ( ) ( ) Plan B: Not at all help him 1 2 3 ( ) ( ) ( )

Help him very much 4 5 ( ) ( ) Help him very much 4 5 ( ) ( )

Acknowledgements The authors would like to thank Philip Malone and John Browne, founding members of the Stewarts Hospital Services Acting and Ballet Company, for their participation in the video. Thanks also to Mr Eddie Dennihan, Director of Day Services, for providing the location and Ellen Murphy for doing the voice-overs for the video. Notes

1

The client’s real name was changed to ensure complete anonymity.

367




8(4)

References AG E R , A .

& O ’ M AY, F. (2001) ‘Issues in the Definition and Implementation of “Best Practice” for Staff Delivery of Interventions for Challenging Behaviour’, Journal of Intellectual and Developmental Disability 26: 243–56. C A R R , E . G . , H O R N E R , R . H . , T U R N B U L L , A . , M A R Q U I S , J . G . , M AG I T O , E . , M C L AU G H L I N , D . , M C AT E E , M . L . , S M I T H , C . E . , A N D E R S O N RYA N , K . , RU E F , M . B . & D O O L A B H , A . (1999) Positive Behaviour Support for People with Developmental Disabilities: A Research Synthesis. Washington, DC: American Association on Mental Retardation. E L L I O T T, S . N . (1988) ‘Acceptability of Behavioural Treatments: Review of Variables that Influence Treatment Selection Contents’, Professional Psychology: Research and Practice 19: 68–80. E M E R S O N , E . (2001) Challenging Behaviour: Analysis and Intervention in People with Intellectual Disabilities. New York: Cambridge University Press. F OX X , R . M . , B R E M E R , B . A . , S C H U LT Z , C . , VA L D E Z , J . & J O H N D ROW. C . (1996a) ‘Increasing Treatment Acceptability through Video’, Behavioural Interventions 11: 171–80. F OX X , R . M . , M C H E N RY, W. C . & B R E M E R , B . A . (1996b) ‘The Effects of a Video Vignette on Increasing Treatment Acceptability’, Behavioural Interventions 11: 131–40. G R E Y, I . M . , M C C L E A N , B . & B A R N E S - H O L M E S , D . (2002) ‘Staff Attributions about the Causes of Challenging Behaviours: Effects of Longitudinal Training in Multi-Element Behaviour Support’, Journal of Learning Disabilities 6: 297–312. H A S T I N G S , R . P. (1995) ‘Understanding Factors that Influence Staff Responses to Challenging Behaviours: An Exploratory Interview Study’, Mental Handicap Research 8: 296–320. H A S T I N G S , R . P. (1997) ‘Staff Beliefs about the Challenging Behaviours of Children and Adults with Mental Retardation’, Clinical Psychology Review 17: 775–90. H A S T I N G S , R . P. & J O N E S , C . (2003) ‘Staff Reactions to Self-Injurious Behaviours in Learning Disability Services: Attributions, Emotional Responses and Helping’, British Journal of Clinical Psychology 42: 189–204. H A S T I N G S , R . P. & R E M I N G T O N , B . (1994) ‘Rules of Engagement: Toward an Analysis of Challenging Behaviour’, Research in Developmental Disabilities 15: 279–98. H A S T I N G S , R . P. , B O U LT O N , H . V. N . , M O N Z A N I , L . C . & T O M B S , A . K . H . (2004) ‘Behavioral Function Effects on Intervention Acceptability and Effectiveness for Self-Injurious Behavior’, Research in Developmental Disabilities 25: 139–54. J O N E S , K . M . & L U N G A RO , C . J . (2000) ‘Teacher Acceptability of Functional Assessment Derived Treatments’, Journal of Educational and Psychological Consultation 11: 323–32. K A Z D I N , A . E . (1977) ‘Assessing the Clinical or Applied Importance of Behaviour Change through Social Validation’, Behaviour Modification 1: 427–51. K A Z D I N , A . E . (1980) ‘Acceptability of Alternative Treatments for Deviant Child Behaviour’, Journal of Applied Behaviour Analysis 13: 259–73. K A Z D I N , A . E . (1981) ‘Acceptability of Child Treatment Techniques: The Influence of Treatment Efficacy and Adverse Side Effects’, Behaviour Therapy 12: 493–506. K E M P, F . D . , M I LT E N B E R G E R , R . G . & L U M L E Y, V. A . (1996) ‘Treatment Acceptability and “Faking Good”: Are Staff Telling Us What They Think We Want To Hear?’, Behavioural Interventions 11: 181–91. K I N C A I D , D . , K N O S T E R , T. & H A R ROW E R , J . K . (2002) ‘Measuring the Impact of Positive Behaviour Support’, Journal of Positive Behaviour Interventions 4: 109–17.

368



M C C AU S L A N D E T A L . : T R E AT M E N T AC C E P TA B I L I T Y KO E G E L , L . K . , KO E G E L , R . L .

& D U N L A P, G . (1996) Positive Behaviour Support: Including People with Difficult Behaviour in the Community. Baltimore, MD: Brookes. L A V I G N A , G . & W I L L I S , T. (1995) ‘Challenging Behaviour: A Model for Breaking the Barriers to Social and Community Integration’, Positive Practices 1: 8–15. M I LT E N B E R G E R , R . G . (1990) ‘Assessment of Treatment Acceptability: A Review of the Literature’, Topics in Early Childhood Special Education 10: 24–38. M I LT E N B E R G E R , R . G . & L U M L E Y, V. A . (1997) ‘Evaluating the Influence of Problem Function on Treatment Acceptability’, Behavioural Interventions 12: 105–11. M O S S M A N , D . A . , H A S T I N G S , R . P. & B ROW N , T. (2002) ‘Mediators’ Emotional Responses to Self-Injurious Behaviour: An Experimental Study’, American Journal on Mental Retardation 107: 252–60. O L I V E R , C . , H A L L , S . , H A L E S , J . & H E A D , D . (1996) ‘Self-Injurious Behaviour and People with Intellectual Disabilities: Assessing the Behavioural Knowledge and Causal Explanations of Care Staff’, Journal of Applied Research in Intellectual Disabilities 9: 229–39. R E I M E R S , T. M . , WAC K E R , D . P. & C O O P E R , G . (1987) ‘Acceptability of Behavioural Interventions: A Review of the Literature’, School Psychology Review 16: 216–27. R E I M E R S , T. M . , WAC K E R , D . P. , C O O P E R , G . & D E R A A D , A . O . (1992) ‘Clinical Evaluation of the Variables Associated with Treatment Acceptability and their Relation to Compliance’, Behavioural Disorders 18: 67–76. TA R N OW S K I , K . J . & S I M O N I A N , S . J . (1992) ‘Assessing Treatment Acceptance: The Abbreviated Acceptability Rating Profile’, Journal of Behavioural Theory and Experimental Psychiatry 23: 101–6. W E I G L E , K . L . & S C O T T I , J . R . (2000) ‘Effects of Functional Analysis Information on Ratings of Intervention Effectiveness and Acceptability’, Journal of the Association for Persons with Severe Handicaps 25: 201–11. WO L F , M . M . (1978) ‘Social Validity: The Case for Subjective Measurement, or How Applied Behaviour Analysis Is Finding its Heart’, Journal of Applied Behaviour Analysis 11: 203–14. Correspondence should be addressed to: I A N M . G R E Y , PhD, DClinPsych, BCBA, Department of Psychology, Trinity College, Dublin, Ireland. e-mail: [email protected]. Date accepted 18/06/04

369
