Types of Motivating Operations in Interventions With Problem Behavior

Abstract

A motivating operation (MO) alters both the effectiveness of a stimulus as a reinforcer and the current frequency of all behavior that has been reinforced by that particular stimulus. This article reviews studies that have manipulated a MO during interventions with school-age participants with intellectual disabilities and problem behavior. A systematic review was conducted using the following major electronic databases: PsychInfo, Education Resources Information Center, Science Direct, Blackwell, SAGE, and Medline. A total of 31 published articles representing 55 participants was examined. Findings from this study suggest that the modification of a MO usually has an effect on the problem behavior by either establishing or abolishing its motivation. Furthermore, a relationship was found between the type of MO and the behavioral function identified. The theoretical and practical implications of these findings, limitations of this study and potential issues for future research are discussed.

Keywords

motivating operations setting events problem behavior behavioral function intellectual disabilities

Introduction

The problem behavior of people with intellectual disabilities¹ (IDs) has a negative impact on their own lives and their environment (Heyvaert, Maes, & Onghena, 2010). It deeply affects their health and quality of life (Langthorne, McGill, & O’Reilly, 2007) as well as their caregivers and families (Emerson, 2001). Thus, problem behavior is one of the biggest challenges to improving participation and inclusion of people with ID in the community (Carr, Ladd, & Schulte, 2008; McAtee, Carr, & Schulte, 2004).

Problem behavior can manifest in many different ways. As Kiernan and Kiernan (1994) noted, the behavior may be in the form of aggression, stereotypic behavior, tantrums, self-injurious behavior, challenging social behaviors, and so on. The prevalence of problem behavior has been a concern and an issue of study (Cormack, Brown, & Hastings, 2000; Emerson et al., 2001).

Since the 1980s, an important shift has taken place in the understanding and conceptualization of problem behavior (Emerson & Einfeld, 2011). Applied behavior analysis is an approach that has had a major impact on this change. One of the main contributions of this approach is its emphasis on the environmental determination of behavior (Emerson & Einfeld, 2011). When the focus is challenging behavior, the emphasis lies on the function of the behavior rather than its form (Iwata, Dorsey, Slifer, Bauman, & Richman, 1994). The behavior does not occur randomly; it is displayed in the context of multiple interacting variables (environmental, individual, motivational, instructional, and biological). This complexity adds new challenges to the understanding and treatment of problem behavior. Therefore, one way to understand and treat problem behavior is through a behavioral functional assessment, “a set of assessment procedures that results in the identification and description of the relationships between the unique characteristics of the individual and the contextual variables that trigger, motivate, and reinforce behavior” (Steege & Watson, 2009, p. 7). Intervention plans can be designed and developed based on this knowledge (Riffle, 2011).

Several reviews on the assessment and treatment of problem behavior have been published recently. These reviews were generally designed to acknowledge the challenge that problem behavior poses for the professionals and families it affects. In general, these reviews have focused their efforts on evaluating the benefits of functional assessment as well as the effects of different treatments or interventions (e.g., Brosnan & Healy, 2011; Denis, Van den Noortgate, & Maes, 2011; Hanley, Iwata, & McCord, 2003; Heyvaert et al., 2010; Matson & Neal, 2009). For example, Hanley et al. (2003) reviewed a total of 277 studies that conducted a functional analysis and identified the relationship between environmental variables and problem behavior. Functional analysis is a specific approach to functional assessment involving “an experimental analysis of the function of the behavior under contrived test conditions” (Cipani & Schock, 2007, p. 43). Hanley’s review demonstrates that there is a voluminous database of articles that have used functional analysis involving different topographies of problem behavior and different participant characteristics. Furthermore, their review provides guidelines for better practices. More recently, Heyvaert et al. (2010) completed a meta-analysis to examine the effects of different interventions on problem behavior. The authors included articles that have conducted contextual, psychotherapeutic, and biological interventions among persons with ID. In short, previous research has provided important evidence to guide the assessment and treatment of problem behavior.

One way to address problem behavior is through working with the antecedents and consequences of problem behavior (McGill, Teer, Rye, & Hughes, 2005). As Steege and Watson (2009) noted, two different types of antecedent variables can be identified: discriminative stimuli and motivating operations (MOs). A discriminative stimulus is an event whose presence is correlated with a changed availability of reinforcement and, therefore, with a change in the frequency of behaviors producing such reinforcement (Carr et al., 2008), whereas a MO alters the effectiveness of reinforcement (Steege & Watson, 2009). There is a growing body of evidence exploring how the problem behavior of people with ID can be influenced by antecedent events (e.g., Call, Wacker, Ringdahl, & Boelter, 2005; Garbutt & Furniss, 2007; O’Reilly, Lacey, & Lancioni, 2000; Roscoe, Carreau, MacDonald, & Pence, 2008; Simó-Pinatella, 2008). Although the needs and characteristics of people with ID may make them more likely than other groups to develop specific problem behaviors (Langthorne et al., 2007; McGill, 1993), antecedent interventions may help to reduce the incidence of such behaviors. MOs, in particular, may alter the stimulus control found in the typically understood three-term contingency of discriminative stimulus, behavior, and reinforcer (Edrisinha, O’Reilly, Sigafoos, Lancioni, & Choi, 2011).

In the literature, the variables that influence the three-term contingency have been referred to by various terms, such as setting events (Morris & Midgley, 1990) or contextual variables (McAtee et al., 2004). Although some of these terms are generally understood to be environmental variables that are developed within different theoretical systems (Kennedy & Meyer, 1998), in this article, we refer to these variables as MOs. Furthermore, MOs are understood to be those variables that “alter (a) the effectiveness of reinforcement or punishment (the value-altering effect) and (b) the frequency of operant response classes related to those consequences (the behavior-altering effect)” (Laraway, Snycerski, Michael, & Poling, 2003, p. 412). MOs may increase (establish) or reduce (abolish) the effectiveness of reinforcement. At the same time, they may increase (evoke) or reduce (abate) the behavior that produces reinforcement (Laraway et al., 2003; McGill, 1999; Michael, 1982; O’Reilly et al., 2008).

In the literature, three main categories of MO have been recognized: biological, social, and physical (Carr, Smith, Giacin, Whelan, & Pancari, 2003). As Barratt, Hughes, and McGill (2012) suggested, the biological category involves fatigue, pain, or illness, whereas the social category includes nonpreferred activities, lack of choice, communication difficulties, and the presence or absence of particular people (Carr et al., 2003). Finally, the physical category includes environmental aspects such as noise, temperature, or environmental enrichment. However, a review of the different indirect assessment tools that are used to gather information indicates that there is no consensus regarding the three categories noted (e.g., Crimmins, Farrell, Smith, & Bailey, 2007; Dunlap et al., 2010; McAtee et al., 2004; Steege & Watson, 2009); rather, a wide range of categories are used. For example, for interview-based assessments, different categories are considered, as in the Ecological Interview (McGill et al., 2005) and the Functional Assessment Interview (O’Neill et al., 1997). The Ecological Interview includes 10 categories (physical setting, time of day, day of week, time of year, weather conditions, activities, the presence of particular clients, the presence of particular staff, social context, and personal context), whereas the Functional Assessment Interview includes two main categories (physiological setting events, and environmental and social setting events). Less extensive differences are apparent on existing checklist or assessment forms. For instance, the Contextual Assessment Inventory (McAtee et al., 2004) has four categories (social/cultural context, nature of the task or activity, physical environment, and biological context), and the Antecedent Variables Assessment Form (Steege & Watson, 2009) also includes four unique categories (environmental variables, instructional variables, social variables, and transition variables).

Although there are similarities between the categories used by these assessment tools, there is no general agreement about the MO categories that should be considered when assessing the problem behavior of people with ID. Therefore, an understanding of MO must be advanced. As there are no recent reviews, this article is an attempt to contribute a review of the overall knowledge obtained from recent extensive empirical studies. Specifically, this review has the following two specific objectives: (a) to conduct a systematic review of studies that have conducted a functional assessment and a subsequent MO-based intervention of problem behavior in school-age children with ID, and (b) to identify those types of MOs that have been investigated, and the extent to which consistent relationships have been established between types of MO and the function of problem behavior.

Method

Procedure

A comprehensive review of the literature was conducted using the following major electronic databases: PsychInfo, Education Resources Information Center (ERIC), Science Direct, Blackwell, SAGE, and Medline (Ebsco and PubMed). The search was conducted using a combination of the following search terms: “motivating operations, setting events, antecedent variables, establishing operations, contextual assessment, contextual intervention, functional assessment and functional analysis” and “problem behavior, challenging behavior, behavior modification, mental retardation and intellectual disabilities.” The search was limited to publication dates within the last 10 years (January 2000 to December 2010). The first author selected articles by choosing those that included an evaluation and/or treatment of problem behavior using antecedent modification in the title or abstract. In the case of ambiguous abstracts, the full article was reviewed. The initial electronic search resulted in 360 potential articles. The electronic review was carried out from October 2010 to March 2011. The first three authors independently reviewed the abstracts of potential articles as to whether the articles met the inclusion criteria described in the following section. Articles that were judged to meet the inclusion criteria by all three reviewers were included in the review. Articles that were ambiguous with regard to the inclusion criteria were included for further review. A total of 36 articles were selected after three rounds of meetings between investigators. A manual search was conducted using the reference section of the 36 selected articles to find additional MO articles that were missed in the initial electronic search. In addition, the three journals (Journal of Applied Behavior Analysis, Behavior Modification, and Behavioral Interventions) that contained the highest number of articles selected (see Table 1) were also manually searched.

Table 1.

Journals That Publish Motivating Operations Assessment and Intervention Studies

Name of the journal	Number of citations	Percentage of sample
Journal of Applied Behavior Analysis	17	47.22
Behavior Modification	5	13.88
Behavioral Interventions	5	13.88
Research in Developmental Disabilities	4	11.11
Journal of Early and Intensive Behavior Intervention	2	5.55
Education and Treatment of Children	1	2.77
Journal of Positive Behavioral Interventions	1	2.77
Journal of Research in Special Educational Needs	1	2.77
Total	36	100

Finally, to identify additional articles missing from the initial electronic search, two strategies were used. First, the journals listed in Table 1 were hand searched to identify literature reviews published between 2005 and 2011 that involved problem behavior and IDs. The reference sections of these reviews were consulted. Second, a list of authors of published empirical studies on MOs was created, and each author was searched individually to identify other potential studies. The manual search identified one missing article.

Inclusion and Exclusion Criteria

Articles included in this review were required to meet all of the following selection criteria: (a) were published between 2000 and 2010, (b) involved a process of functional assessment plus an intervention focused on the modification of a MO, (c) were empirically based, (d) included child participants (under 18 years old), (e) included participants who had IDs, and (f) were peer-reviewed articles. Therefore, descriptive studies that only conducted a functional analysis (with or without modification of one of the conditions) but that did not carry out a subsequent intervention (e.g., English & Anderson, 2004; Lang et al., 2008) were excluded. Also excluded were those articles that focused on the evaluation of precursors of problem behavior (e.g., Najdowski, Wallace, Ellsworth, MacAleese, & Cleveland, 2008), those in which the intervention focused on functional replacement (e.g., Luiselli, Ricciardi, Schmidt, & Tarr, 2004; O’Reilly, Murray, Lancioni, Sigafoos, & Lacey, 2003), and those in which the participants had developmental delays and/or disruptive behavior but not IDs (e.g., Boelter et al., 2007). Articles that focused their interventions on the effects of medication (e.g., Carr & Blakeley-Smith, 2006; Dicesare, McAdam, Toner, & Varrell, 2005) were also excluded as were those that used only an AB design in the intervention (e.g., DeLeon, Fisher, & Marhefka, 2004).

After the inclusion and exclusion criteria were considered, 31 articles were chosen for the review.

Data Extraction and Interrater Agreement

All articles that met the selection criteria were analyzed in the following terms: (a) participants’ characteristics (age and disability), (b) research design, (c) setting, (d) participants’ problem behavior, (e) behavioral function, (f) nature of MO, and (g) the establishing or abolishing effect of the MO. For articles that included only some participants under 18 (e.g., Ringdahl, Winborn, Andelman, & Kitsukawa, 2002), or one participant with IDs and another with developmental delays (e.g., Van Camp et al., 2000), data were extracted only for the participants who met the selection criteria.

Each reviewer independently summarized the articles, and interrater agreement was established for each variable. Agreement was calculated by dividing the number of agreements by the number of total variables observed (e.g., participants, setting, problem behavior) and multiplying the result by 100. The initial agreement between raters was 96.66%. Specific disagreements were discussed until unanimous agreement was achieved.

Results

Table 2 summarizes the 31 selected papers according to the features mentioned above. All results are explained below according to participants, design, problem behavior, behavioral function, MOs, and the establishing or abolishing operation.

Table 2.

Summary of Reviewed Studies

	Participants
References	Age and gender	Disabilities	Design	Setting	Problem behavior	Behavioral function	MO	Establishing or abolishing effect
Ahearn (2003)	1 boy; 14 years old	Autism, profound range of ID	Multiple baseline design	NS (room)	Feeding problems	NS	Adding condiments on the consumption of previously rejected food (vegetables)	EO
Buckley and Newchok (2006)	1 boy; 7 years old	Autism	Reversal design	Special school	Tantrum	Escape	Music	EO
Butler and Luiselli (2007)	1 girl; 13 years old	Autism	Reversal design	Special school	SIB, aggression, tantrum	Escape	Altering the instructional requests	AO
Carey and Halle (2002)	1 boy; 12 years old	Severe mental impairment	Multielement design and alternating treatment design	Ordinary school	SIB	Multiple functions (escape and access to an activity)	Presence of music	As an AO in demand condition
Carter and Wheeler (2007)	1 boy; 9 years old	CDD, severe ID	Reversal design	Ordinary school	SIB, aggression	Escape	PSCs
							a. Contingent reinforcement (access to preferred items)	AO
							b. Contingent reinforcement (access to preferred items) with delivery of auditory cue	AO
Cautilli and Dziewolska (2004)	1 boy; 9 years old	Mild impairment, oppositional defiant disorder	Reversal design	Family home and ordinary school	Aggression, property destruction	Escape	Sleep deprivation	EO
Chung and Canella-Malone (2010)	3 girls and 1 boy; 11, 11, 16, and 14 years old, respectively	Multiple disabilities, autism, ID	Multielement design	Special school	Stereotypic behavior	Automatic reinforcement	PSCs No interaction Attention Response blocking Attention with response blocking	Some conditions acted as an AO for some individuals and others as an EO
Kuhn, Hardesty, and Luczynski (2009)	1 boy; 9 years old	Disruptive behavior disorder, stereotypic movement disorder with self-injury, ID (unspecified)	Multielement design	Inpatient unit or facility	Aggression, destructive behavior, SIB	Attention	Noncontingent attention condition	AO
							Contingent attention condition	AO
							Contingent attention plus contingency modelling condition	EO
Lang et al. (2009)	1 girl; 8 years old	Autism	Alternating treatments design	School (NS)	Stereotypic behavior, tantrum	Automatic reinforcement	Pre-session with free access to stereotypy	AO
							Pre-session without free access to stereotypy	EO
Lang et al. (2010)	2 boys and 2 girls; 4, 7, 4, and 5 years old, respectively	Autism	Alternating treatments design	Special school	Stereotypic behavior, tantrum, destructive behavior, aggression	Automatic reinforcement	Pre-session with free access to stereotypy	AO
Lanovaz, Fletcher, and Rapp (2009)	3 boys; 7, 7, and 5 years old, respectively	Autism	Reversal design	Family home	Stereotypic behavior	Automatic reinforcement	Structurally matched stimuli and music	AO to immediate vocal stereotypy
							Structurally matched stimuli	AO to immediate vocal stereotypy for all participants and subsequent vocal stereotypy for one participant
							Structurally unmatched stimuli	AO to immediate vocal stereotypy for two participants and does not decrease subsequent vocal stereotypy for all participants
LeBlanc, Hagopian, Marhefka, and Whike (2001)	1 girl; 11 years old	Profound ID	Reversal design	Inpatient unit or facility and family home	Aggression, destructive behavior	Attention	Therapist gender (female)	AO
							Type of attention (physical and verbal attention)	AO
Levin and Carr (2001)	2 boys and 1 girl; 6, 5, and 6 years old, respectively	Autism, food selectivity problems, moderate-to-severe range of ID	Reversal design and multiple baseline design	Special school	Feeding problems	Access to tangible	Access to nonpreferred food items	EO
Lomas, Fisher, and Kelley (2010)	3 boys; 8, 8, and 9 years old, respectively	Asperger syndrome, ADHD, autism	Multielement design and Reversal design	Intensive day-treatment program	Aggression, destructive behavior, tantrum, SIB	Multiple functions (access to tangibles and escape), escape	Delivery of praise and preferred food items on a variable time	AO
McComas, Hoch, Paone, and El-Roy (2000)	3 boys; 8, 8, and 9 years old, respectively	Developmental disabilities, autism	Multielement design	Special school	Destructive behavior	Escape	Method of instruction (instructional strategy, choice of sequence of tasks and nonrepeated tasks)	AO
McComas, Thompson, and Johnson (2003)	4 boys; 11, 10, 11, and 12 years old, respectively	Down’s syndrome, mild-to-moderate ID, vision and hearing impairments, language impairments, autism, moderate-to-severe developmental disabilities	Multielement design	Ordinary school	Aggression, destructive behavior	Attention, escape, multiple function (attention and escape)	Pre-session attention, pre-session no attention	Attention acts as AO for attention-maintained problem behavior, no influence on escape-maintained problem behavior
McGinnis, Houchins-Juarez, McDaniel, and Kennedy (2010)	3 boys; 6, 6, and 6 years old, respectively	Developmental disabilities	Multielement design	Center Behavior Analysis Clinic	Aggression, destructive behavior, tantrum, SIB	Attention	Pre-session attention deprivation	EO
							Pre-session of low level of attention	AO
							Pre-session high level of attention satiation	AO
O’Reilly et al. (2007)	1 boy; 14 years old	Autism, severe disabilities	Multielement design	Special school	SIB, aggression	Access to tangibles	Pre-session access to tangible	AO
							Pre-session no access to tangible	EO
O’Reilly and Lancioni (2000)	1 girl; 4 years old	Moderate level of intellectual disability	Reversal design	Family home	SIB, aggression	Escape	Sleep deprivation	EO
O’Reilly et al. (2009)	2 boys; 8 and 5 years old, respectively	Autism	Multielement design	Special school	Tantrum, destructive behavior	Multiple functions (access to tangible and escape), escape	Pre-session access to tangible (satiation condition)	AO
O’Reilly et al. (2006)	1 boy; 14 years old	Autism	Multielement design	Special school	SIB, aggression	Access to tangible	Pre-session access versus no access to reinforcer	Restricted access functioned as an EO
							Pre-session access versus no access extinction	Restricted access functioned as an EO
O’Reilly et al. (2008)	1 boy; 16 years old	Developmental disabilities, autism	Multielement design	Day service	SIB, aggression	Multiple functions (access to tangible and attention)	Pre-session access to tangible items	AO
							Pre-session no access to tangible items	EO
Pace and Toyer (2000)	1 girl; 9 years old	Severe ID	Reversal design	Outpatient setting	Pica	NS	Vitamin supplement	AO
Piazza, Adelinis, Hanley, Goh, and Delia (2000)	3 boys; 6, 8, and 17 years old, respectively	ADHD, profound and severe ID	Multielement design, reversal and multielement design	Inpatient unit	Aggression, SIB, disruptive behavior	Automatic reinforcement	Matched stimuli	AO
							Unmatched stimuli	EO
Rapp (2004)	1 boy; 10 years old	Down’s syndrome, moderate ID	Multielement design	Short-term residential facility	Stereotypic behavior	Automatic reinforcement	Prior access to stereotypy	AO
							Environment enrich with music + guitar	EO
Rapp (2005)	3 boys; 9, 9, and 11 years old, respectively	ADHD, moderate ID, autism, unspecified ID, pervasive developmental disorder, Down’s syndrome	Multiple-probe design and reversal design	Short-term residential facility	Stereotypic behavior	Automatic reinforcement	Visual and audio stimulation (television)	As an AO in some forms of stereotypy and EO for others. No clear effect for two participants
Reed, Dolezal, Cooper-Brown, and Wacker (2005)	1 boy; 4 years old	Bronchopulmonary dysplasia, immune deficiency, gastroesophageal reflux, developmental delays	Reversal design	Inpatient unit or facility	Feeding problems	NS	Sleep disruption	EO
Ringdahl, Winborn, Andelman, and Kitsukawa (2002)	1 boy; 5 years old	Mild to moderate range of ID	Reversal and multielement design	Inpatient unit or facility	Aggression	Attention	Attention only condition	EO
							Attention enriched condition	EO (access to alternative stimuli may be AO for attention)
Roantree and Kennedy (2006)	1 boy; 10 years old	Severe ID	Reversal design and multielement design	NS (room)	Stereotypic behavior	Attention	No pre-session attention	AO
							Noncontingent pre-session attention	EO
Thiele, Blew, and Luiselli (2001)	1 boy; 17 years old	Severe ID	Reversal design and multiple baseline design	Community-based group home	Tantrum	Attention	Preferred staff (noncontingent social reinforcement)	AO
Van Camp et al. (2000)	1 boy; 8 years old	Moderate ID, hydrocephalus	Multielement design and reversal design	Ordinary school	SIB	Access to tangible	Bumble Ball with vibration, the sound and the plastic protrusions	No effect
							Bumble Ball without vibration	AO
							Bumble Ball without vibration and no protrusions	No effect

Note: MO = motivating operation; ID = intellectual disabilities; NS = not specified; EO = establishing operations; SIB = self-injury behavior; AO = abolishing operation; CDD = childhood disintegrative disorder; PSC = pre-session condition.

Participants

The 31 articles included 55 participants. A total of 15 studies were single-participant studies with one participant (e.g., Ahearn, 2003), whereas 16 studies included more than one participant (e.g., Lang et al., 2010). As indicated earlier, data were obtained only for those participants in each study who met the selection criteria.

The mean age of participants was 9.01 years (range 4-17 years). A total of 44 participants (80%) were boys, and 11 were girls (20%). All participants were diagnosed with an ID. In addition to ID, some participants were diagnosed with autism (n = 24), autism and food selectivity problems (n = 3), Down’s syndrome (n = 3), multiple disabilities (n = 3), attention deficit hyperactivity disorder (ADHD; n = 3), pervasive developmental disorder and Down’s syndrome (n = 1), Asperger syndrome and ADHD (n = 1), oppositional defiant disorder (n = 1), disruptive behavior disorder (n = 1), bronchopulmonary dysplasia (n = 1), childhood disintegrative disorder (n = 1), vision and hearing impairments (n = 1), and hydrocephalus (n = 1).

Designs

For the present review, all of the designs evaluated were for single-participant research. The designs most frequently used were reversal design (n = 17), multielement (n = 16), multiple baseline (n = 3), alternating treatments (n = 3), and multiprobe design (n = 2). It is important to note that nine studies used more than one design.

Setting

A high percentage of the studies included (45.16%) were conducted at the participants’ school (n = 14). Of these studies, nine were conducted in special schools (64.28%; e.g., Butler & Luiselli, 2007) and four were conducted in ordinary schools (28.57%; e.g., McComas, Thompson, & Johnson, 2003). The remaining study (Lang et al., 2009) did not specify the type of school at which the intervention was conducted. Nonschool settings in which studies were conducted included an inpatient unit or facility (n = 4), family home (n = 2), and short-term residential facility (n = 2). One study each was conducted at the following locations: an outpatient setting, day service, intensive day-treatment program, community-based group home, and Center Behavior Analysis Clinic. Two studies were conducted in more than one setting: school and family home (Cautilli & Dziewolska, 2004), and inpatient unit or facility and family home (LeBlanc, Hagopian, Marhefka, & Whike, 2001). Finally, although two of the studies indicated that the assessment and treatment of the problem behavior was conducted in a room, the room’s location was not specified (Ahearn, 2003; Roantree & Kennedy, 2006).

Problem Behavior

The most common problem behaviors in the studies were aggression (n = 15), self-injurious behavior (n = 12), tantrums (n = 8), destructive behavior (n = 8), and stereotypic behavior (n = 7). Other problem behaviors included feeding problems (n = 3), pica (n = 1), property destruction (n = 1), and disruptive behavior (n = 1). Specifically, focusing on the study participants, the most common problem behaviors were aggression (n = 22), stereotypic behavior (n = 17), destructive behavior (n = 17), self-injurious behavior (n = 14), and tantrums (n = 11). Other problem behaviors among the participants included feeding problems (n = 5), disruptive behavior (n = 2), pica (n = 1), and property destruction (n = 1).

Because some studies included participants with more than one problem behavior and/or multiple participants with multiple behaviors, the total number of behaviors is not equal to the total number of participants.

Behavioral Function

The four most commonly found behavioral functions were all found in the reviewed articles. Problem behavior was maintained by automatic reinforcement (n = 7 studies), escape (n = 6), attention (n = 6), and access to tangible reinforcement (n = 4). Problem behavior was maintained by multiple functions in two studies (Carey & Halle, 2002; O’Reilly et al., 2008). In three studies (Lomas, Fisher, & Kelley, 2010; McComas et al., 2003; O’Reilly et al., 2009), different participants’ problem behaviors were maintained by different functions. In three of the selected articles, the function of the problem behavior was not specified.

Across participants, problem behavior was maintained by automatic reinforcement (n = 19, 34.54%), escape (n = 12, 21.81%), attention (n = 9, 16.36%), and tangible reinforcement (n = 6, 10.9%). Problem behavior was maintained by multiple functions for six participants (10.9%), and the behavioral function was not specified for three participants (5.45%).

Behavioral function was established by an experimental functional analysis in more than half of the selected articles (58.06%). The other two strategies used were direct observation (12.9%) and direct observation with indirect assessment (12.9%). Some studies (16.12%) did not specify how function was identified.

MO

The articles reviewed in this study included many different MOs. To identify the categories of MO that are empirically supported, the first author generated (from Table 2) an initial pool of MOs and grouped all items into four categories (social context, activity or nature of the task, characteristics of the environment, and personal context). The second author grouped all MOs into these four categories separately. Then, the first and second authors identified subcategories to precisely identify the types of MO included in this review. Any discrepancies were discussed until a consensus was reached.

Generally, the MOs were classified as follows: social context variables (n = 8), involving attention from others (e.g., Chung & Cannella-Malone, 2010) and factors related to others’ characteristics (e.g., gender; LeBlanc et al., 2001); activity or nature of the task (n = 2), involving instructional requests (e.g., Butler & Luiselli, 2007), presentation of work, and the method of instruction (McComas, Hoch, Paone, & El-Roy, 2000); characteristics of the environment (n = 12), involving factors related to objects or activities (e.g., Levin & Carr, 2001) and environmental enrichment (e.g., Rapp, 2005); and personal context (n = 4), involving physiological states (Cautilli & Dziewolska, 2004). Only two studies included more than one MO. In one such study, Lomas et al. (2010) observed the effects of “delivery of praise” and “preferred food items on a variable time.” In the other study, Carter and Wheeler (2007) considered the effects of “having access to preferred items” and “following systematic presentation of work tasks.”

The categories mentioned above do not differ greatly from those offered by indirect assessment tools (e.g., Contextual Assessment Inventory). Given the importance that establishing the function of problem behavior has for treatment efficacy, the association of function with antecedent variables might be of significant practical interest. Therefore, the type of MO altered or modified, according to the function of the behavior, was investigated.

For each of the four MO categories (social context, activity or nature of the task, characteristics of the environment, and personal context), Table 3 shows the different types of MOs that were explored according to behavioral function. That is, to provide more precise information about the MOs used in the selected articles, Table 3 summarizes the different MOs involved in this review and their apparent effect on each participant.

Table 3.

Effect of Different Types of MOs on Participants’ Problem Behavior in Relation to Its Function

As Table 3 shows, some categories occur more frequently than others. Most of the interventions involved an alteration of the social context or characteristics of the environment MOs. A small number of interventions took place involving a MO of the participant’s personal context, and very few interventions considered the activity or nature of the task.

Table 3 also shows that some MOs were investigated for one specific behavioral function but not for others. For example, MOs such as access to stereotypy or method of instruction were investigated for participants whose problem behavior was maintained by automatic reinforcement or escape, respectively, but not the other way around.

MOs were frequently investigated in relation to specific behavioral functions rather than broadly investigated across functions. For example, a pre-session condition with free access to stereotypy (e.g., Lang et al., 2010) and a pre-session condition with access to (or deprivation of) attention (e.g., Chung & Cannella-Malone, 2010) were well investigated for children whose problem behavior seemed to be maintained by automatic reinforcement. Similarly, this can be seen in those whose problem behavior was maintained by access to tangible reinforcement and attention. For studies involving problem behavior maintained by attention, most of the MOs investigated were those that involved access to or lack of attention (e.g., McComas et al., 2003). For studies involving problem behavior maintained by access to tangible reinforcement, the MOs used were those involving access or lack of access to tangible reinforcement (e.g., O’Reilly et al., 2007). Unlike the behavioral functions noted above, a broader range of MOs were investigated with respect to escape-maintained behavior (e.g., O’Reilly & Lancioni, 2000). Very few interventions included biological MOs or MOs that involved changes to instructional methods (e.g., McComas et al., 2000).

Establishing or Abolishing Operation

Although there were some exceptions (e.g., Van Camp et al., 2000), the majority of the MOs had a clear effect (establishing or abolishing) on the problem behavior in the predicted direction (Table 3). The MO had mixed results on the participant’s problem behavior in only two studies (Lanovaz, Fletcher, & Rapp, 2009; Rapp, 2005).

The findings in Table 3 suggest that MOs’ effects vary depending on the function of the problem behavior. MOs involving access or lack of access to a behavior producing automatic reinforcement (e.g., stereotypy) had predictable establishing or abolishing effects. Specific types of stimulation produced mixed effects consistent with research on matched/unmatched stimuli (e.g., Piazza, Adelinis, Hanley, Goh, & Delia, 2000). MOs involving changes in the level of attention had abolishing effects for some automatically maintained behaviors and establishing effects for others (e.g., Chung & Cannella-Malone, 2010).

The modification of instructional variables produced the clearest (abolishing) effects for escape-maintained behavior (e.g., McComas et al., 2000). In marked contrast, changes in the level of attention did not appear to function as MOs for escape-maintained behavior (e.g., McComas et al., 2003). Although the effects were somewhat mixed, providing access to different types of tangible reinforcement did appear to have an abolishing effect on some participants’ escape-maintained behavior (e.g., Carter & Wheeler, 2007). For two participants, sleep disruption had an establishing effect on escape-maintained problem behavior (e.g., O’Reilly & Lancioni, 2000).

Predictably, changes in the level of attention had a generally consistent effect on attention-maintained behavior, with deprivation of attention having an establishing effect and access to attention having an abolishing effect (e.g., McGinnis, Houchins-Juarez, McDaniel, & Kennedy, 2010). The only other possible MO investigated was access to tangible reinforcement, which had an establishing effect for one participant and a mixed effect for another.

Changes in the availability of tangible reinforcement produced predictable MO effects on tangibly maintained behavior (e.g., O’Reilly et al., 2007), but no other possible MOs were investigated.

Three general points are noteworthy from an inspection of Table 3. First, most putative MOs were only investigated with respect to problem behaviors in one or two specific behavioral functions. For example, alterations to instructional variables were only investigated with respect to escape-maintained behavior. Second, as a result of this restriction, evidence of the “matching” of type of MO to function remains limited. To reach a conclusion that MOs are predictably matched to behavioral function, it would be necessary to demonstrate, for example, that alteration of instructional variables, while having a predictable effect on escape-maintained behavior, did not have a consistent effect on behavior serving other functions. There appears to be better evidence regarding the matching of attentional variables and attention-maintained behavior, although no studies examine the impact of alterations to the availability of attention on tangibly maintained behavior. Third, the information in Table 3 suggests that alterations in access to tangible reinforcement may have a more general effect across behaviors serving different functions, at least for those functions that are social in nature.

Discussion

This article provides one of the first reviews of the effects of MOs on the problem behaviors that people with ID display. Given the lack of precision and agreement regarding the differentiation of MOs from other antecedent events, caution is necessary when interpreting the results of the review.

Nevertheless, the review suggests that antecedent interventions involving MOs have a clear effect on problem behavior. That is, when an antecedent event that serves as a MO is changed or modified, the problem behavior that arises in individuals with ID can be reduced or increased. Collectively, the 31 studies used different types of MOs. According to the categorization suggested in the “MO” section, variables related to the social, environmental, and personal contexts were the most used among the selected articles. In all of the studies evaluated, modification of the MO had either an establishing or an abolishing effect on at least one participant’s behavior. The MO’s establishing or abolishing effect on the behavioral function is frequently predictable (e.g., the MO “attention deprivation” may increase the occurrence of problem behavior maintained by attention, whereas “attention satiation” may decrease it), although the generalizability of this conclusion is limited by the lack of an investigation of the effect of the same MOs across problem behaviors serving different functions. As noted in the study by Chung and Cannella-Malone (2010), a MO may act as an abolishing operation for one person but as an establishing operation for another. In Chung and Cannella-Malone’s (2010) study, a pre-session noninteraction acted as an abolishing operation for two participants but as an establishing operation for the other two participants. Interestingly, the use of pre-sessions as MOs was one of the most frequently used strategies in the reviewed studies.

Of the 55 participants included in this review, most presented a mild-to-severe ID, and many of the participants also displayed autism. Few studies included people with profound or multiple ID, even though this is a population with a high risk of displaying problem behavior. In general, the more severe the disability, the higher the likelihood of present challenging behavior (Cormack et al., 2000; Emerson et al., 2001). Of the participants in the reviewed studies, 80% were males. These results are consistent with other literature reviews on problem behavior (e.g., Campbell, 2003; Heyvaert et al., 2010) where most of the participants were males.

Most of the assessments and interventions took place in a very controlled setting. A majority of the studies were carried out in special schools, or inpatient units or facilities, whereas few interventions were conducted in ordinary settings (e.g., mainstream school).

A wide range of problem behaviors were included in the studies as a whole. The most frequent behaviors were aggression, stereotypic behavior, destructive behavior, self-injurious behavior, and tantrums. These behaviors are generally considered the most challenging behaviors for professionals and families.

Finally, almost all studies specified the function of the problem behavior. The behavioral functions found were, in order of prevalence among participants, automatic reinforcement, escape, attention, access to tangible reinforcement, and multiple functions. Curiously, this prevalence order differs from the order usually found in the literature (e.g., Iwata, Pace, et al., 1994). The higher prevalence of automatically reinforced behavior reported in this review may reflect the challenge that such behaviors pose to professionals and researchers, with, therefore, greater investment in a search for their controlling variables. Although behavioral function was not specified for three participants, this likely would not have a major effect on the results of this study.

The analysis of MOs presented in this article was designed to enhance the understanding of MO types and effects. The first attempt at MO classification did not differ from those noted in existing indirect assessment tools, such as the Contextual Assessment Inventory. However, the second attempt (based on the effect of different MOs in relation to behavioral function) suggested interesting relationships between type of MO and behavioral function. Further pursuit of this approach may have a number of benefits. First, it may allow the development of new systems of assessment, relating the function of behavior to the MO. Second, it could help to determine which MOs are more associated with each behavioral function. Third, once the function of problem behavior has been identified, this approach may enable professionals and families to develop more specific and effective intervention strategies (involving MO modification) than those currently used.

Although more research is needed to explore those MOs that have an impact on each behavioral function, the first analysis presented in this review enables researchers to take a qualitative step in problem behavior treatment. That is, professionals may attend to those variables (MOs) that influence the problem behavior according to their function when designing intervention plans. There are a range of strategies available to identify the function of the behavior from the indirect (e.g., Questions About Behavioral Function; Matson, Bamburg, Cherry, & Paclawskyj, 1999; Matson & Vollmer, 1995) to the experimental (e.g., Functional Analysis; Iwata, Dorsey, et al., 1994). Similar tools could be designed that allow professionals to identify the MOs influencing problem behavior serving different functions.

A number of limitations to this review should be noted. First, studies that involved medication or people older than 18 years were not included. The effects of medication can alter people’s behavior and their response to specific environmental situations (Mace et al., 2009). Moreover, certain substances (e.g., methylphenidate) can act as a MO for problem behavior (e.g., Carr & Blakeley-Smith, 2006; Dicesare et al., 2005). The literature contains a large number of articles that focus on MOs in an adult population with ID. The focus on children in this review stemmed from a professional interest in focusing on the variables that are most relevant to educational settings and to the management of problem behavior in such settings. Second, although the inclusion of unpublished studies could provide significant data to the present study, this systematic review was limited to peer-reviewed published studies. Unpublished data are usually incomplete and their accuracy may be difficult to assess (McAuley, Pham, Tugwell, & Moher, 2000). Therefore, this systematic review provided us with a useful and rigorous summary of published studies. Third, deciding which studies met the inclusion criterion of having carried out an intervention was a difficult task. Many studies reported an experimental design as in the multielement presentation of conditions in “analogue” assessment, but this was not considered to constitute an intervention. Finally, one of the most difficult challenges for this review concerned those empirical studies that treated some antecedent variables as MOs, even though they might be acting as discriminative stimuli (or vice versa). It is believed that the second and third limitations have been addressed through independent examination by the first three authors of all potential articles using well-defined inclusion and exclusion criteria.

This review has a number of implications for further research and practical interventions. First, despite the significant efforts made in defining MOs so far (Laraway et al., 2003; McGill, 1999; Michael, 2000; Wahler & Fox, 1981), variation in different authors’ classification of antecedents as discriminative stimulus and/or as MOs may lead to misunderstandings about what was really assessed and treated, and about how the intervention results are interpreted. More consistent usage of existing definitions and terminology is required. Further work may also be required to define, with greater operational clarity, the conditions necessary for the classification of an antecedent event as a MO or as a discriminative stimulus. Second, behavioral assessment and intervention require a significant time commitment from professionals. Antecedent interventions (especially those that focus on MOs) may be less time-consuming for professionals compared with other types of treatments (Luiselli, 2006; McLaughlin & Carr, 2005). However, the articles reviewed do not make a significant contribution to how professionals can use antecedent-based interventions in a school setting or an inclusive community. More research is necessary on the practical implementation of such interventions in such settings. In addition, further research could also focus on the duration of the intervention, a variable that may influence the MO’s effect on the problem behavior. The need to conduct a meta-analysis of the effects of the MO should be a priority because such an analysis would provide increased rigor and new perspectives.

Antecedent interventions should also be accessible to children and young people who have the most severe IDs, including profound ID and multiple disabilities. The quality of life experienced by these people depends crucially on their physical and emotional well-being (Petry, Maes, & Vlaskamp, 2009).

Conclusion

This article reviews studies that treat problem behavior in school-age children with IDs by modifying a MO. This study highlights the importance of the relationship between behavioral function and type of MO. It also emphasizes the need for consistent classification of MOs and discriminative stimuli.

Footnotes

Acknowledgements

Thanks to the support provided by the Commission for Universities and Research of the Ministry of Innovation, Universities and Enterprise of the Autonomous Government of Catalonia, and the European Social Fund.

Declaration of Conflicting Interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Notes

Bios

David Simó-Pinatella is a doctoral student at the Ramon Llull University, Barcelona, Spain. His current research interests lie in the applied analysis of problem behavior, motivating operations, and the design and development of intervention plans for people who display problem behavior.

Josep Font-Roura is the principal of CPT l’Estel (special education school) and professor at the Faculty of Education, Vic University, Barcelona, Spain. His research focuses on quality of life, problem behavior, and literacy of people with intellectual disabilities.

Joaquima Planella-Morató, PhD, is a full professor at the Faculty of Education, Vic University, Barcelona, Spain. Her research interests focus on the childhood development and early intervention planning of children with intellectual disabilities.

Peter McGill is reader in the Clinical Psychology of Learning Disability at the Tizard Centre, University of Kent, Canterbury, UK. His interests include applied behavior analysis and the design and delivery of services to people with severe intellectual disabilities and challenging behavior.

Elisabeth Alomar-Kurz, PhD, is a full professor at the Ramon Llull University, Barcelona, Spain. She is also coordinator of master studies on “Special Education: Diversity and Inclusive Education.” Her research focuses on inclusive education (services and supports planning) and quality of life of children with intellectual disabilities.

Climent Giné, PhD, is the dean of the Faculty of Psychology, Education and Sport Sciences Blanquerna at the Ramon Llull University, Barcelona, Spain. His research focuses on family quality of life and supports for people with intellectual disabilities.

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