/ Brhov. i-her. & Exp Psyrhrot Printed m Great Britam.

Vol. 22, No. 2. pp. 123-129.

19Yl

0

Mx).~791h/91 $3.00 + O.o(l 1991 Pcrgamon Press plc

PHONE PHOBIA, PHACT OR PHANTASY?: AN OPERANT APPROACH TO A CHILD’S DISRUPTIVE BEHAVIOR INDUCED BY TELEPHONE USAGE ROBERTA The Kennedy

Institute

L. BABBITT

and The Johns Hopkins

JOHN The University

University

School of Medicine

M. PARRISH

of Pennsylvania

School of Medicine

Summary - The clinical efficacy of a contingency management program for treating a developmentally disabled girl referred for telephone phobia was evaluated using both a multiple baseline across settings design and a reversal design. A descriptive analysis indicated that the ‘phobia’ was in all probability an operant, rather than a respondent. The treatment, consisting of differential reinforcement, extinction and time-out, was effective in reducing the frequency and intensity of disruptive behaviors in response to telephone usage. Follow-up assessments at 1, 3, and 6 months revealed that treatment gains were maintained.

matic observation of the target behavior under quasi-controlled circumstances designed to simulate naturalistic conditions (Bijou, Peterson, & Ault, 1968). The target behavior is elicited repeatedly in order to derive hypotheses regarding the function of the behavior. Based upon these hypotheses, the clinician designs an intervention package that will alter the contingencies such that the ongoing function of the problem behavior is reduced or removed. The impetus for our intrasubject experiment was the referral of a child who exhibited socalled telephone phobia. The child’s parents and the referring professional reported recurrent crying, screaming, falling to the floor, grabbing the telephone, and other disruptive behaviors contingent upon parental use of the telephone. History, coupled with a series of direct observations, did not reveal avoidance behavior that was classically conditioned. The exact etiology of the behavior could not be determined.

Given the prevalence of fears among children and the extent to which we assume that a child’s repeated crying in response to a recurrent situation is attributable to a ‘phobia’, it is not uncommon for clinicians serving children to field referrals where the chief complaint is that of an alleged ‘phobia’ (Morris & Kratochwill, 1983). Yet, upon differential diagnosis, it is sometimes found that the behaviors of concern do not meet DSM III-R (1987) criteria for phobia. Consequently, among other alternatives, the clinician may attempt to rule out that the behavior is primarily an operant and, therefore, may seek to determine whether current environmental variables maintain the problem behavior. Based upon the seminal work of Bijou and his colleagues (Bijou, Peterson, & Ault, 1968), clinicians are increasingly conducting descriptive analyses of maintaining variables (Mace, Browder, & Lin, 1987; Mace & Lalli, in press; Mace, Lalli, & Pinter-Lalli, in press; Mace & West, 1986). Descriptive analysis entails systeRequests Kennedy

for reprints should be addressed to: Roberta L. Babbitt, Institute. 707 N. Broadway, Baltimore. MD 21205, U.S.A. 123

Department

of Behavioral

Psychology,

The

ROBERTA

114

L. HABBIT1‘

Therefore, we conducted a descriptive analysis to formulate motivational hypotheses regarding the ongoing behavior. This analysis revealed that the behavior in question was indeed an operant. A data-based intervention consisting of time-out from reinforcement, differential reinforcement, and t-e-direction of the child to an activity alternative to the problem behavior was instituted in order to decrease the frequency and intensity of the target behavior.

Method Participunt Karen, a o-year-old child with spastic diplegia cerebral palsy, was referred by her parents and a Child Life Specialist for treatment of a so-called telephone phohirr. Karen received Valium as a means of diminishing muscle contracture and associated discomfort, while enhancing her range of motion. Audiological examination indicated that Karen’s hearing acuity and sensitivity to auditory stimulation were within normal limits following tympanostomy tube placement one and a half years earlier. A highly verbal and sociable child, Karen functioned within the range of Moderate to Mild Mental Retardation, as determined by her performance on the Bayley. Stanford-Binet, and the Vineland. Setting Clinic-based sessions were conducted in rooms containing a functioning telephone. Home-based sessions were held at the family residence in rooms equipped with a telephone. History and Description

of Target Behavior

Her parents reported that her ‘phobia’ had begun about one year prior to referral when her Valium dosage was repeatedly adjusted upward and downward. They were unable to

identify any other possible precipitants. Karen did not appear to be bothered by the presence of a telephone when it was not in use. However. when she heard the telephone ring. or observed an individual placing an outgoing call. she would typically cease her ongoing activity, look at the user, gasp, and then scream, cry, and attempt to terminate the call. These behaviors would subside only upon such termination. Curiously, a toy telephone. with which she played appropriately. was one of her favorite toys. Parental and teacher reports, as well as direct observations by trained clinicians, did not reveal similar reactions to other auditory stimuli. Her parents had tried a variety of strategies to alleviate Karen’s disruptive behavior, including changing tclephoncs (e.g.. different bell sounds. lowered bell signals) and limiting incoming and outgoing telephone calls until Karen was either in school OI asleep. Based upon this history and description of the target behavior, Karen’s behavior did not meet the DSM III-R (1987) criteria for Simple Phobia or Avoidant Disorder. Descriptive

Analysis

Based upon our clinical observations, in conjunction with parental report, we hypothesized that the target behavior functioned to terminate an S-delta. An S-delta is a stimulus that occurs prior to the behavior and is present only if extinction is in effect for that behavior (Catania, 1984). It appeared that Karen was responding to an interruption of the positive reinforcement she accrued from her adult care provider when that individual would withdraw from her in order to receive or place a telephone call. In response, her problem behavior resulted in an interruption of this withdrawal through termination of telephone use and a return to the preceding level of interaction between Karen and her care provider. Consequently, Karen’s ‘phobia’ was considered to be a set of disruptive behaviors that may have served to mand an increase in reinforcement density.

Phone

Ohserwtionul

Procedures

The dependent measure was the percentage of trials during which the aforementioned target behavior co-occurred either with an outgoing or an incoming telephone call. The onset of a trial was marked by use of a telephone by either a parent, sibling or staff person. The offset of a trial occurred when the telephone call was terminated. Reliuhility

of Dependent

Measures

Interobserver agreement on the occurrence of the target behavior in each setting (clinic and home) was assessed across all experimental phases. Data were collected during 61% of clinic-based sessions by the primary therapist (first author), with either a parent or another clinician serving as reliability observer. In the home setting, data were collected during 34% of sessions by a parent or Karen’s sister. Reliability was calculated by dividing the number of agreements on occurrences by the number of agreements plus disagreements and multiplying by 100. During both clinic and home observations, the mean level of interobserver agreement for the target behavior. as well as for family implementation of the protocol, was 98%. Experimentul

Design und Procedures

Experinzentul design. Functional control was demonstrated via the following two intrasubject designs: the multiple baseline across settings design and the within-series withdrawal (reversal) design. Gene& procedure. During clinic-based sessions, both parents, Karen’s sister, and the therapist served as behavior change agents. During home-based sessions, only the aforementioned family members served as therapists. Prior to the beginning of each structured session. whether conducted at the clinic or at the home, a variety of Karen’s preferred toys

Phobia

125

and a functional telephone were placed on a table. Throughout all structured sessions, Karen and the change agent were seated at the table. The change agent would receive or place telephone calls. with the direction of the call randomized across five trials per session. At least 30 seconds transpired between trials; during intertrial intervals data were recorded and. when applicable, Karen received contingent positive reinforcement. Baseline. During structured sessions, the change agent interacted with Karen as she played and then placed or received a telephone call. When Karen began to emit disruptive behavior, the change agent attended to her and terminated the telephone call prematurely, as was the common practice at home. In the home setting, upon the natural (unstructured) use of the telephone. occurrences of disruptive behavior and the family’s responses to it were recorded throughout the day by family members. During such unstructured calls, baseline contingencies remained the same as during structured calls. No differential programmed consequences were applied when Karen responded appropriately to either structured or unstructured calls. Treatment. During each treatment session, whether structured or unstructured, the following contingencies were implemented systematically: When Karen remained quiet for 5 seconds subsequent to a telephone call, the change agent provided descriptive praise and periodically prompted (i.e., instructed) her to play with her toys. The change agent continued to talk on the telephone for at least 30 seconds, while periodically monitoring and acknowledging Karen throughout the telephone call. Acknowledgements included physical reinforcement (e.g., a pat on the back), smiles, and minimal participation in Karen’s toy play. Karen’s comments and questions about the call were ignored, as were mild inappropriate behaviors (e.g., soft whining). At the conclusion of a successful trial (i.e., a trial during

126

ROBERTA

I_. BABBITT

which she did not exhibit the targeted problem behavior), Karen received descriptive praise and her choice of a preferred toy or edible reinforcer. If Karen began to cry, scream, or grab the telephone, she was told “No (crying. etc.); time-out.” The change agent first excused him/ herself to the confederate on the telephone, then guided Karen to remain seated and her chair was turned away from the table where the adult was sitting. While Karen was in time-out. disruptive behavior was ignored and the change agent continued to talk on the telephone. A contingent changeover delay was in effect, whereby the criterion for Karen to exit time-out was 10 consecutive seconds of qlliet behavior. When this criterion was met. the change agent excused him/herself to the other party on the telephone, turned Karen’s chair to face the table. re-directed her back to the toys, and then resumed the telephone conversation. This time-out procedure was repeated as often as necessary (ranging from zero to six applications per session), with the duration of timeout averaging four minutes (range = 30 seconds to 25 minutes). Integrity ofthe lmplementution Interverltio~i

of the

The fidelity of the implementation of the intervention package was also assessed systematically. The mean level of interobserver agreement for the change agents’ use of the protocol. both in clinic and at home, was 100% During the baseline, Karen’s parents’ mean use of the recommended treatment procedures was 25%. Once trained how to implement the protocol during the intervention phase, their mean correct use increased to 100%. During the reversal. they reverted back to baseline procedures, with 0% correct use of recommended skills. When the treatment phase was re-introduced. they used the protocol with 100% accuracy. At home during baseline, Karen’s family exhibited 0% of the skills. With

and JOHN

M. PARRISH

the implementation of treatment, their mean correct percent usage of the protocol averaged 100% . Fuding alld prqrumming

for generulizution.

When Karen had remained quiet without emitting any disruptive behavior across at least three consecutive sessions, treatment contingencies were faded along three dimensions. The length of each telephone conversation was gradually increased from 30 seconds to a maximum of five minutes. During telephone calls, the rate at which the change agent acknowledged Karen for behaving appropriately was decreased systematically. Finally, the frequency at which the change agent prompted Karen to engage in toy play was decreased. Thus, the amount of structure provided Karen during adult telephone usage was progressively diminished. Generalization of treatment effects was programmed not only by varying change agents, but also by implementing the treatment contingencies in new environments (e.g., different rooms. different telephones). Follow-q u.sse.wment. Maintenance of intervention effects was evaluated through direct observation in the clinic one month posttermination of treatment and through parent report via telephone at 3 and 6 months posttermination. Social vulidutiorl. At termination and at the time of each follow-up assessment, parental satisfaction with the treatment program and its effects was determined.

Results Figure I presents the percentage of trials/ opportunities during which Karen exhibited disruptive behavior during structured clinicand home-based sessions, and during unstructured uses of the telephone at home. During the clinic baseline (Figure 1, uppermost panel), Karen exhibited disruptive be-

Phone

127

Phobia

CLINIC

HOME

5

10

15

20

25

20

35

40

45

50

55

60

65

70

75

80

85 90

I.

Percentage

of trials/natural

opportunities

of disruptive

havior during 100% of the trials. Following the implementation of treatment, her disruptive behavior occurred on an average of 22% of the trials (range = 0% to 80%). Upon a return to baseline conditions, Karen again emitted disruptive behavior during 100% of the trials. With the re-introduction of treatment, Karen’s disruptive behavior decreased to a mean of 6.7% of trials (range = 0% to 20%). There was a six-month hiatus between Sessions 21 and 24, during which Karen’s mother underwent back surgery and was confined to bed. During this time, Karen stayed with different relatives and her family did not use

100

t

3 llwnuls

fOlbV+“p

SESSIONS Figure

95

behavior

during

clinic-

and home-based

trials.

the treatment recommendations consistently. When Karen’s mother was able to ambulate, we resumed active services. As before, baseline assessment revealed that disruptive behavior continued during 100% of trials, though not quite as intensely as before. When treatment was re-implemented. Karen did not exhibit disruptive behavior. Beginning in Session 27, the duration of the telephone call was gradually increased. Also, from Session 29 on, in both clinic and home settings, the frequency of prompts to engage in play was faded to an average of less than one prompt per trial. To promote generalization,

12x

ROBERTA

I_. BABRIT-I-

the sessions were conducted in new cnvironments in Sessions 33 to 36. As expected, observed decreases in disruptive behavior as a function of treatment at the clinic did not generalize to the home setting. However, as in the clinic setting. when treatment was introduced at home previously demonstrated effects were replicated. During the home-based structured trials (Figure 1, middle panel), Karen’s disruptive behavior decreased from 100% in Baseline to 5.9% (range = 0% to 60%) during the Treatment phase. Subsequent to implementing treatment during unstructured telephone usage (Figure 1, lowermost panel) as well as during structured training trials at home. disruptive behavior decreased from a mean of 87% (range = 0% to 100%) in Baseline to Y.?% (range = 0% to X0’%) in Treatment. Karen‘s responding was more variable during the unstructured opportunities than during the discrete trials. perhaps because the number of opportunities fluctuated daily, with some days totalling only one or two calls. Across all three clinic baseline phases, family implementation of the protocol averaged 31% correct (range = 0% to 53%). Following training, they implemented the prescribed treatment procedures with 87% accuracy in the first treatment phase, then with 93% and 100% accuracy during the subsequent treatment phases respectively. At home, they reported using the protocol with 97% accuracy. Follow-up datu. During the clinic-based assessment of maintenance one month posttermination, Karen’s parents implemented the prescribed treatment procedures with 100% accuracy and Karen responded appropriately to structured trials 100% df the time. At the three-month evaluation, Karen’s parents reported that they still were using the recommended protocol and that disruptive behavior had not occurred during the previous week. At the six-month check, her parents reported that they had used the protocol most of the time. but less consistently than before, and that

ad

.fOHN

M. PARRISFI

Karen had been mildly disruptive only once during the previous week. They reported that disruptive behavior typically occurred onI> when Karen was tired. ill, or when they did not use the recommcndcd procedures. L~ocir~l vdidutiorl rlutrr. When asked to express their degree of satisfaction with the training program and its effects, at termination and at each follow-up assessment. the parents revealed a high degree of satisfaction (a mean of 9 on ;I scale of l-10, with IO indicating complete satisfaction).

Discussion The results of this investigation pro\ idc additional evidence that ;I descriptive analysis of ongoing environmental conditions may reveal an operant when referral sources are convinced that the behavior of’ concern i\ ;I respondent. In the case of Karen, descriptive analyses indicated that ;I so-called rr/@onr plzohirr was in all probability a set of disruptive behaviors in response to an S-delta. More specifically. the child engaged in behaviors that perhaps had repeatedly resulted in ;I return to ;I level of reinforcement density that had been interrupted by intervening telephone usage. Had the clinicians endorsed the initial dingnostic label, the ensuing treatment protocol may have been misguided. unnecessary. and ineffective. Operating with a plausible hypothesis based upon a descriptive analysis of the presenting problem. the clinicians alternatively implemented a relatively simple. data-driven contingency management program that proved to be efficacious. Parents were apparently engaged by the systematic approach to data collection and treatment selected, offering some further evidence that data-based outcomes can be validated on an outpatient basis with parental cooperation. Parents were able to acquire the skills necessary to conduct the recommended protocol at home as well as at the clinic.

Phone

The within-series withdrawal design suggests that a demonstration of functional control was achieved. The multiple baseline design across settings indicates that, although a degree of generalization may have occurred from structured to unstructured telephone interactions in the home, it was necessary to program behavior change in each setting in order to attain desired effects. Interestingly, during follow-up Karen’s parents reported anecdotally that they had observed on some occasions an increased sensitivity on Karen’s part to loud noises made by other electrical equipment (e.g., vacuum cleaner, blender). Yet, in these situations, Karen typically reacted appropriately by saying that the noise was too loud and by removing herself to her room until the noise subsided. The parents also reported anecdotally that the treatment procedures and the resultant clinical outcome had been associated with improved family interactions and reduced stress levels at home. Acknowkdgemenrs - This investigation was supported by Grant No. MCJ000917-22-1 from the Maternal and Child Health Service of the U.S. Department of Health and

129

Phobia

Human Services. Our appreciation is extended to Katie McKew. Kathy Linthicum. Wanda Finnerty and Bridget Johnson for their assistance with making the confederate telephone calls.

References American Psychiatric Association (1987). Diagnostic and sratistical manual for mental disorders (3rd ed. Revised). Washington, D.C.: American Psychiatric Association. Bijou. S. W.. Peterson, R. F.. & Ault, M. H. (1968). A method to integrate descriptive and experimental field studies at the level of data and empirical concepts. Journal of Applied Behavior Analysis, I, 175-191. Catania. A. C. (1984). Learning (2nd ed.). Englewood Cliffs, NJ: Prentice-Hall. .’ Mace. F. C.. Browder. D. M., di Lin, Y. L. (1987). Analysis of demand conditions associated with stereotypy. Journal of Behavior Therapy and Experimental Psychiatry. 18, 25-31. Mace, F. C. & Lalli, J. S. (In press). Linking descriptive and experimental analyses in the treatment of bizarre speech. Journal of Applied Behavior Analysis. Mace, F. C.. Lalli. J. S.. & Pinter-Lalli, E. (In press). Functional analysis and treatment of aberrant behavior. Research in Developmental Disabiliries. Mace, F. C., & West, B. J. (1986). Analysis of demand conditions associated with reluctant speech. Journal of Behavior Therapy and Experimental Psychiatry. 17,2X5294. Morris. R. J. & Kratochwill, T. R. (1983). Trealing children’s fears and phobias: A behavioral approach. New York: Pergamon Press.

Phone phobia, phact or phantasy? An operant approach to a child's disruptive behavior induced by telephone usage.

The clinical efficacy of a contingency management program for treating a developmentally disabled girl referred for telephone phobia was evaluated usi...
582KB Sizes 0 Downloads 0 Views