Beyond Intervention

Abstract

Individuals diagnosed with autism spectrum disorder (ASD) and other developmental disabilities are at risk of engaging in severe problem behavior, including aggression and self-injury. Severe problem behavior is an obstacle to proper education and integration into society. Therefore, eliminating severe problem behavior is key to long-term academic and social success. However, problem behavior can be persistent in the face of interventions and likely to relapse following successful intervention. This article describes basic and translational research relevant to understanding what influences the persistence and relapse of severe problem behavior in individuals diagnosed with ASD and other developmental disabilities. Investing in research to better understand persistence and relapse will pay dividends for clients, parents, clinicians, and society in general.

Keywords

severe problem behavior persistence relapse behavioral treatments public policy schools autism spectrum disorder

Basic research on persistence and relapse can improve treatment and reduce cost associated with severe problem behavior in children with ASD.

Key Points

Some individuals with autism spectrum disorder (ASD) and other disabilities engage in aggression and self-injury.

Treatments training appropriate alternative behavior are effective in the short term.

Translational research indicates these treatments could unwittingly enhance persistence and relapse in the long term.

Additional research needs to examine methods to mitigate persistence and relapse.

Policies need to increase funding for research on mitigating persistence and relapse.

Behavior specialists at schools can reduce inappropriate placements and likelihood of exacerbating problem behaviors.

Introduction

Persistence is a behavioral phenomenon reflecting a tendency for behavior to continue despite current interventions designed to decrease or eliminate the behavior. For example, individuals with alcoholism may continue to consume alcohol despite intervention. Interventions might be informal, such as loss of employment or family members attempting to decrease alcohol consumption. Formal interventions might include attending treatment groups like Alcoholics Anonymous or receipt of inpatient services. Treatment relapse is a general term capturing the unfortunate reoccurrence of problem behavior subsequent to successful treatment (Pritchard, Hoerger, & Mace, 2014). For example, formerly sober individuals may again consume alcohol after successful treatment.

Numerous behavioral health examples demonstrate the importance of understanding persistence and relapse. Disorders such as fear and anxiety (Vervliet, Craske, & Hermans, 2013), addictions (e.g., drug abuse, gambling, overeating, paraphilia; O’Brien, 2005), and destructive behaviors often exhibited by individuals with autism spectrum disorder (ASD) and other developmental disabilities (e.g., self-injury, aggression; Pritchard et al., 2014) are prime examples of persistent behaviors continuing despite either adverse consequences or formal intervention. Reemergence of the behavioral symptoms of these disorders after successful treatment underscores the importance of understanding the conditions under which interventions are likely to remain effective over time. Thus, individuals diagnosed with behavioral disorders face two challenges. One, their behavior must be sensitive to interventions, so maladaptive behavior does not persist, and treatment can be successful. Second, once maladaptive behavior is treated, the treatment must arrange conditions so that previously treated behavior does not reemerge.

The concepts of persistence and relapse apply widely to a range of mental and behavioral health disorders. Our expertise applies basic, translational, and applied scientific findings to improve behavioral treatments for severe behavior disorders in individuals diagnosed with ASD and other developmental disabilities. Severe problem behavior includes self-injury and aggression toward self and others, which can disrupt educational, developmental, financial, and social opportunities (Carr & Durand, 1985). The cost of caring for these individuals can be enormous to caregivers, both financially and emotionally. For example, the lifetime cost to care for an individual diagnosed with ASD is an estimated US$1,400,000 to US$2,400,000 (Knapp, 2011).

The primary approach to treating severe behavior in clinical settings is to (a) determine the reinforcing consequences (i.e., rewarding events) that maintain the behavior through an assessment called functional analysis (Iwata et al., 1994) and then (b) teach clients to engage instead in more appropriate behavior. For example, a functional analysis might determine that attention from clinicians reinforces acts of aggression, suggesting that attention from caregivers maintained the client’s aggression in natural environments (e.g., home, school). Treatment then eliminates reinforcers following instances of problem behavior and makes the rewards available only when the client engages in appropriate behavior (Petscher, Rey, & Bailey, 2009). This treatment is called differential reinforcement of alternative behavior (DRA). In this example, the client would be taught to ask or sign for attention, and attention would follow only these appropriate requests for attention. Along with others, we conduct research into the relevance of fundamental learning and behavioral processes for improving DRA treatments and designing novel treatments for severe problem behavior (e.g., Kelley, Liddon, Ribeiro, Greif, & Podlesnik, 2015; Mace et al., 2010; Podlesnik & Kelley, 2014, 2015; Podlesnik, Kelley, Jimenez-Gomez, & Bouton, in press).

This article focuses on (a) the science of persistence and relapse in relation to severe problem behavior, and (b) policy implications of the science. Specifically, we describe basic, translational, and applied research that discovers conditions under which severe problem behavior tends to persist and relapse, as well as how society might leverage the science to improve treatment. How broadly those scientific findings affect people needing state-of-the-art intervention depends, in part, on supporting research and disseminating the findings to researchers and clinicians.

Persistence of Severe Problem Behavior

Behavioral momentum theory (see Nevin & Wacker, 2013; Podlesnik & DeLeon, 2015) is a quantitative framework describing how environmental variables affect the persistence of behavior maintained by its consequences (“operant behavior”). Basic, translational, and applied research supports the predictions of behavioral momentum theory, including basic research with nonhuman and human participants. Behavioral momentum theory asserts that all reinforcers within an environmental context contribute to persistence of operant behavior within that context. Practically speaking, behavioral momentum theory predicts three outcomes (one perhaps counterintuitive) of reinforcement relevant to treating severe problem behavior.

First, the allocation of reinforcers between problem and appropriate behavior determines the frequency of problem behavior relative to appropriate behavior. Therefore, more frequent reinforcement of appropriate behavior than problem behavior will shift behavior toward the appropriate alternative. This is the logic behind DRA treatments that arrange high rates of reinforcement for appropriate behavior.

Second, historically more favorable reinforcement conditions for problem behavior make the problem behavior more resistant to treatment. The implications of this prediction for response persistence are clear. For example, laboratory models suggest problem behavior reinforced longer in a natural context (e.g., home, school) before beginning treatment will result in greater persistence in the face of ongoing treatment (e.g., Lentz & Cohen, 1980). Consider a student who engages in problem behavior for several years in a classroom. Upon implementing treatment, problem behavior likely will be more resistant to intervention compared with implementing treatment shortly after problem behavior first emerged. Thus, intervention when problem behavior first emerges results in less persistent problem behavior that is more easily treated with fewer resources and chance of injury to others.

For another example, higher rate, more immediate, higher quality, and lower effort reinforcers produce more persistent behavior (see Nevin & Wacker, 2013; Podlesnik & DeLeon, 2015, for reviews). Consider an individual whose severe self-injurious behavior requires immediate attention. In this case, the individual likely receives a lot of nearly immediate and high-quality attention following every act of self-injury. In this case, many responses will have produced attention in the same context as problem behavior. Therefore, successful treatment likely will be delayed and hard earned, due to delivery of reinforcement (e.g., attention) for problem behavior in that context.

Third, the tendency for a problem behavior to persist once the treatment becomes challenged in some way will be a function of all sources of reinforcement delivered in a context. Thus, reinforcement delivered for appropriate behavior could initially decrease problem behavior in the short term. Counterintuitively, the reinforcement for appropriate behavior also could increase the persistence of problem behavior if it increased the overall frequency of reinforcement in that environmental context. In a clinical treatment setting (Mace et al., 2010), reinforcement for the appropriate behavior occurring in the same context as problem behavior can increase the persistence of the problem behavior. Children diagnosed with developmental disabilities engaged in problem behavior, including aggression and food theft maintained by access to attention from caregivers and access to food. Treatment consisted of reinforcing appropriate behavior (appropriate toy play and requests for food), which reduced rates of problem behavior when compared with the absence of the treatment. Researchers assessed the persistence of problem behavior both with and without treatment. Specifically, Mace et al. (2010) eliminated all reinforcement for any problem behavior by blocking attempts to engage in problem behavior and discontinuing reinforcer deliveries for appropriate behavior, if in place. Attempts to engage in problem behavior persisted approximately 3 times longer and reached 4 times its previous levels following treatment compared with no treatment.

Similar findings demonstrate that the alternative reinforcement actually enhances persistence in the face of other treatment challenges, including reinforcer satiation, distraction, and yet other sources of off-task reinforcement (see Podlesnik & DeLeon, 2015, for a review). Therefore, the most common treatments for severe problem behavior successfully decrease its immediate frequency but dramatically increase its persistence.

These findings reveal that reinforcing the appropriate behavior in the same context as problem behavior enhances the persistence of problem behavior as predicted by basic research in behavioral momentum theory. In response, one focus of translational research is to develop alternative approaches to implementing DRA treatment that separates the delivery of reinforcement for appropriate behavior from the context mediating problem behavior. These include clearly signaling the availability of alternative reinforcement (e.g., Bland, Bai, Fullerton, & Podlesnik, 2016) and training appropriate behavior in contexts separate from those mediating problem behavior (e.g., Mace et al., 2010; Podlesnik, Bai, & Elliffe, 2012; Podlesnik, Bai, & Skinner, 2016).

Relapse of Severe Problem Behavior

Two types of treatment relapse identified by basic research are particularly relevant to intervention for severe behavior disorders: resurgence and renewal. Both relapse models capture different ways environmental conditions might change after successful treatment results in problem behavior reemerging. Resurgence is the return of a previously eliminated behavior when discontinuing reinforcement for a more recent behavior. Renewal is the return of a previously eliminated behavior due to change in environmental context. Much of the basic research on resurgence and renewal involves nonhuman subjects (rats, pigeons), but a recent surge in interest by applied researchers and clinicians resulted in translating basic research into useful clinical protocols (see Podlesnik et al., in press; Pritchard et al., 2014; Vervliet et al., 2013, for reviews). In this section, we focus on research having specific potential for application to severe problem behavior.

Resurgence

Resurgence describes treatment relapse during DRA treatments when clinicians or caregivers are required to implement a treatment for long periods of time. Over time, those implementing DRA treatment likely will be unable always to implement the procedure consistently with high fidelity due to distractions or other strains on resources. In these cases, failure to reinforce appropriate behavior increases risk of problem behavior reappearing. In children diagnosed with ASD, resurgence of self-injury and aggression both emerged when the child’s alternative communication response no longer reliably produced the relevant reinforcer and upon the clinicians dramatically reducing the frequency of reinforcing the alternative response (Volkert, Lerman, Call, & Trosclair-Lasserre, 2009). These findings are relevant to treatment relapse because they suggest that reductions in reinforcing alternative behavior contribute to post-intervention relapse of problem behavior. Research identifying environmental factors contributing to the likelihood of resurgence and approaches to mitigate resurgence could help avoid this phenomenon in clinical practice.

Laboratory research with humans and nonhuman animals identifies factors contributing to resurgence and its mitigation. As discussed with persistence, longer histories of reinforcement (Winterbauer, Lucke, & Bouton, 2013) and greater reinforcement rates (Kuroda, Cançado, & Podlesnik, 2016; Podlesnik & Shahan, 2009, 2010) should increase resurgence of problem behavior. In addition, greater rates of alternative reinforcement during treatment with DRA could more effectively decrease problem behavior initially at the expense of greater resurgence when withdrawing or fading out DRA treatment (e.g., Craig & Shahan, 2016; Schepers & Bouton, 2015). Thus, more effective treatments initially could result in greater relapse when attempting to remove treatment or with compromise in treatment integrity.

Basic and translational research also examines approaches for mitigating resurgence while exploring methods for gradually eliminating DRA treatment, which cannot be maintained indefinitely. For examples, extending DRA treatment (Wacker et al., 2011), training multiple alternative responses (Bloom & Lambert, 2015), and transitioning to less demanding interventions while retaining alternative reinforcement (e.g., Marsteller & St. Peter, 2014) could increase the effectiveness of DRA treatments.

Finally, changes to aspects of the environmental context following successful treatment could contribute to resurgence. With pigeons, removal of alternative reinforcement and stimuli associated with it produce more abrupt resurgence compared with only removing alternative reinforcement (Podlesnik & Kelley, 2014). These findings imply that a parent or caregiver misplacing or breaking some part of the treatment associated with alternative reinforcement—such as a communication card or device—would exacerbate the resurgence of problem behavior when the alternative response does not contact reinforcement.

Other studies using animals reveal that more global changes in environmental context contribute to resurgence (e.g., Kincaid, Lattal, & Spence, 2015). Specifically, returning to the setting in which problem behavior was established (e.g., home) following treatment in a different setting (e.g., clinic) can exacerbate resurgence, when coinciding with removal or fading of reinforcement for alternative behavior. Therefore, resurgence reveals that eliminating or reducing alternative reinforcement during DRA treatment contributes to relapse of severe problem behavior. Because changes to the environmental context exacerbate resurgence, changes to environmental context alone could contribute to treatment relapse, which is where we turn next.

Renewal

Renewal refers to treatment relapse occurring due to changes in some environmental feature. In laboratory models, a response trained to access reinforcement in one context can be eliminated when withdrawing reinforcement in a second context. Merely returning to the original training context, however, is sufficient to increase the previously eliminated response, even though reinforcement remains unavailable (see Podlesnik et al., in press, for a review). For example, a student might engage in significant problem behavior in the classroom (Context A), and a school might arrange treatment in a clinic from an outside agency (Context B). After successful intervention, the student might return to the classroom (Context A) along with the treatment in place. Studies of renewal suggest problem behavior will reemerge simply as a function of re-exposure to the original classroom context in which problem behavior was established—and in spite of the treatment remaining in place.

Basic and translational research evaluated renewal across two species—pigeons and children with ASD (Kelley et al., 2015). In both experiments, the original training context (A) resulted in reinforcement for an operant behavior, followed by eliminating reinforcement for responding in a different context (B). When returning to the original training context (A), despite reinforcement remaining unavailable, the responses increased (i.e., renewal). Moreover, other studies with nonhumans reveal renewal when transitioning to novel contexts (C), suggesting any transitions from a treatment context could provoke relapse via renewal (Podlesnik et al., in press). These findings serve as proof of concept that both nonhuman and human behaviors are sensitive to changes in environmental context between those in which problem behavior was established and treated.

Laboratory models with human and nonhuman animals reveal factors contributing to the likelihood of renewal of problem behavior, as well as factors contributing to mitigating renewal. As with resurgence, longer training durations (e.g., Todd, Winterbauer, & Bouton, 2012) and greater training reinforcement rates (Podlesnik & Shahan, 2009) enhance renewal. Treatment contexts (B) differing more dramatically from training (A) or novel (C) contexts result in greater renewal than treatment contexts sharing more features with training and novel contexts (e.g., Podlesnik & Miranda-Dukoski, 2015).

Preclinical research using laboratory models developed several techniques with empirical support for reducing renewal (see Podlesnik et al., in press, for a review). Establishing treatment effects across multiple contexts, rather than a single context (e.g., clinic), reduced renewal when assessed upon a return to the original training context (e.g., Chaudhri, Sahuque, & Janak, 2008) and when transitioning to a novel context (e.g., Bandarian Balooch, Neumann, & Boschen, 2012). Other studies reduced renewal by incorporating a cue specific from the treatment context during the return to the training context compared with no extinction cue (e.g., Collins & Brandon, 2002). Similarly, instructions to recall the treatment context when transitioning out of the treatment context could also mitigate renewal of problem behavior in individuals with sufficient language abilities (Mystkowski, Craske, Echiverri, & Labus, 2006). These techniques developed to reduce resurgence and renewal in laboratory models must be explored specifically with severe problem behavior to assess directly the relevance and feasibility of those findings for treating severe problem behavior.

How Might Policy Changes Affect Behavioral Health?

The research examining factors contributing to and mitigating resurgence and renewal just described provide a foundation for understanding factors influencing treatment relapse and developing technologies for its mitigation. In general, any scientific or policy-driven endeavor supporting basic, translational, and applied research advances understanding and treatment of severe behavior disorders. In this vein, policies should facilitate the transfer of scientific findings into specific, durable, and effective treatments for clinical populations.

Translational Research

Translational research seeks to connect “pure” science to real-world problems (Mace & Critchfield, 2010). The ultimate value in translational research is in facilitating the advancement of clinical practice through the collaboration of basic and applied scientists. In general, translational research should benefit both basic and applied sectors in any science, including behavior analysis.

The National Institutes of Health (NIH) includes the National Center for Advancing Translational Sciences (NCATS), which released a strategic plan in 2015:

NCATS is in the process of developing its first strategic plan to identify critical challenges, compelling opportunities, and emerging and unmet needs; develop and set scientific and operational goals and research priorities; and engage a diverse and broad community of stakeholders. The end result will be a living—that is, a purposely evolving—document charting an actionable path to effectively advance the NCATS mission. (https://ncats.nih.gov/strategicplan)

This is a bold and exciting initiative holding promise for providing a venue for funding translational research. However, our impression of the NCATS website is their research agenda heavily favors diseases physical in nature or requiring medication for treatment. Behavioral health disorders often do not require medication for the amelioration of symptoms and, in fact, sometimes are not good candidates for medication. Medication might not address the source of the problem, such as when severe problem behavior is maintained by consequences (e.g., adult attention), rather than a physical disease (Iwata et al., 1994). Also, it might be impractical and ineffective in the long term if medications only suppress symptoms rather than produce a sustainable intervention effect (Cox & Virues-Ortega, 2015).

Behavior analysis has recently emphasized the value of translational research (e.g., Mace & Critchfield, 2010). Some behavior analysts’ view applied research to be inherently translational, due to the reliance on basic principles for developing applied technologies (Lerman, 2003). However, recent research has focused on specific, purposeful collaborations between basic and applied researchers to address issues of clinical concern (e.g., Kelley et al., 2015; Mace et al., 2010; Nevin & Wacker, 2013; Podlesnik & DeLeon, 2015; Podlesnik & Kelley, 2014, 2015). In our view, which is supported by many others (see Mace & Critchfield, 2010, for a review), a purposeful, active, and dynamic collaboration between basic and applied researchers is preferred and necessary.

Two studies reviewed above demonstrate the potential that collaborative translational research has for improving technology development for clinical application. Mace et al. (2010) ultimately developed a novel approach to reducing the persistence of problem behavior based on basic research and theory. They developed the new approach only through purposeful collaboration between basic and applied researchers. For the other example, Kelley et al. (2015) demonstrated that renewal, commonly demonstrated in basic laboratory settings, generalized to individuals with ASD, a population with important clinical needs. These findings suggest renewal is a robust general behavioral relation (Mace, 1996) with wide ranging implications for the treatment of severe problem behavior. Specifically, behavioral clinicians should expect problem behavior to reemerge upon transitioning out of clinical treatment settings. Expecting and preparing for renewal is in stark contrast to what might currently happen in practice. If a student’s severe problem behavior returns to the classroom unchanged following treatment in a clinical facility, the school might abandon the intervention. With understanding of renewal, the return of problem behavior should be expected—and temporary, as long as the treatment remains in place. In these types of situations, risks include the student not experiencing what could have been successful treatment and the school terminating its relationship with agencies capable of addressing the problem behavior.

We envision great progress for research and practice in behavioral health, particularly for severe problem behavior, if research funding focuses on translational research in areas of response persistence and treatment relapse. For example, NCATS includes special research emphasis on preclinical innovation for improving the drug-developing process, repurposing drugs, rare diseases, genetic and rare disease information, and undiagnosed diseases, among others. Special emphasis on response persistence and relapse could lead to new lines of research and new discoveries that could positively affect clinical practice of severe problem behavior.

Support of Early Screening, Assessment, and Treatment

In addition to improving research and treatment of severe problem behavior, policy can contribute to improving identification of disorders commonly associated with severe problem behavior, such as ASD and other developmental disabilities. Early identification can reduce the likelihood individuals with ASD and other developmental disabilities engage in severe problem behavior in the first place.

Parents seek out the help of pediatricians when they have behavioral health concerns about their children (Wildman, Stancin, Golden, & Yerkey, 2004). An estimated 15% to 25% of appointments with pediatricians are for behavioral health concerns (Cooper, Valleley, Polaha, Begeny, & Evans, 2006). In addition, 50% to 80% of pediatrician appointments for medical concerns include concerns of behavioral or psychosocial health (Weller, 2010). Parents view pediatricians as the most trusted source of information for concerns related to their children, whether those concerns are medical or behavioral.

Pediatricians provide advice on a wide range of behavioral concerns, including tantrums/disruptive behavior, attention-deficit hyperactivity disorder, oppositional behavior, anxiety, depression, enuresis, sleep problems, tics/habit behaviors, social deficits/bullying, academic problems, and weight management (Wildman et al., 2004). Pediatricians may use instruments and interviews to determine whether a child is developing consistently with established developmental milestones. The Modified Checklist for Autism in Toddlers, Revised (M-CHAT-R™) is one such instrument specific to ASD and designed for use by pediatricians to evaluate the risk of ASD in children aged 16 to 30 months.

Unfortunately, there are numerous obstacles to early identification of children at risk of ASD. First, pediatricians can be ill equipped to provide further assessment or intervention when a child exhibits symptoms of ASD. Second, referral sources for children who are at risk of ASD can be difficult to find. Third, only a small percentage of children are exposed to screeners important for early identification of ASD symptoms. The American Academy of Pediatrics (AAP; Council on Children With Disabilities, Section on Developmental and Behavioral Pediatrics, Bright Futures Steering Committee, & Medical Home Initiatives for Children With Special Needs Project Advisory Committee, 2006) recommended all children be screened on a routine basis as a part of providing a care integration framework by giving pediatricians tools to identify early and make referrals to other professionals. However, only 19.5% of children in the United States aged 10 to 71 months received screening in the past year (Bethell, Reuland, Schor, Abrahms, & Halfon, 2011).

Also, a disconnect separates recommended best practices for early identification of ASD and routine practice throughout the United States (Bethell et al., 2011). A troubling potential obstacle hinders early identification and intervention for children at risk of ASD. Specifically, if 19.5% of children aged 16 to 30 months do not receive screening with the M-CHAT-R™ or other ASD screener, at-risk children will likely encounter delays to diagnosis and intervention. Low screening rates for ASD increase chances of missing targeted goals developed by the AAP (2014) and other agencies (e.g., U.S. Department of Health and Human Services). Those goals include diagnostic and intervention services before the age of 3 years, due to the clear evidence that earlier behavioral services dramatically improve likelihood of reaching targeted social and educational goals (Lovaas, 1987; Rogers & Vismara, 2008).

A potential solution might include linking pediatricians with behavioral health professionals trained in providing assessment and intervention for ASD. The behavior pediatric literature shows cost savings to pediatricians and families, and greater quality care when children are served in a medical setting that includes a behavioral health clinician (Williams, Klinepeter, Palmes, Pulley, & Foy, 2004). Inclusion of a behavioral health clinician in a pediatrician’s office is unusual, but additional research could develop methods to provide families with early access to behavioral health clinicians.

The relevant literature is clear on two points regarding early intervention. One, early identification and intervention can have profound effects on reducing the rates of ASD (Lovaas, 1987; Rogers & Vismara, 2008). Second, children who do not receive treatment that includes improving language skills are more likely to develop severe behavior disorders (Carr & Durand, 1985). Therefore, increasing screener rates could be both a primary and secondary prevention strategy—the prevention of the development of severe behavior disorders and the amelioration of ASD symptoms before they become intractable.

Bridging Gaps in the Educational System

Children enter school within two broad categories of education: general education and special education. Children diagnosed with disorders falling under federal law are guaranteed specialized services to meet their special needs through the Individuals With Disabilities Act (IDEA) or Section 504 of the Rehabilitation Act of 1973. The goal of IDEA is to guarantee children with disabilities Free Appropriate Public Education (FAPE) and the same opportunities for education as students without disabilities. In general, Section 504 forbids denying public education participation or access to the benefits presented in public school programs due to disability. Section 504 is relevant to any “local educational agency” and therefore applies to schools from kindergarten to 12th grade. Whereas IDEA is relevant to a subgroup of children meeting IDEA’s definition for “disability,” Section 504 includes a broader definition of disability to provide rights to students for extracurricular and afterschool activities (e.g., sports, music) and afterschool care. However, establishing specific policies that describe how individuals who engage in severe behavior disorders should be aided would better equip schools for appropriately assessing and intervening in these cases.

IDEA and Section 504 are routinely invoked in schools for children with disabilities, and can be particularly relevant to children who engage in severe behavior disorders. Children who engage in severe behavior are at risk of being moved to more restrictive environments, in an effort to provide a safer learning experience (Witt, 1990). IDEA consists of six primary components clarifying its purposes, which are (a) Individualized Education Program (IEP), (b) FAPE, (c) Least Restrictive Environment (LRE), (d) Appropriate Evaluation, (e) Parent and Teacher Participation, and (f) Procedural Safeguards. Children receive an IEP specifying how the curriculum will be modified in light of their established disability. Similarly, Section 504 plans identify students with disabilities, arrange evaluations for the students, and determine eligibility. Contingent on eligibility, the school designs a written accommodation plan (i.e., a “504 Plan”). Section 504 plans and IEPs are similar, but Section 504 plans are generally shorter. In both cases, parents, teachers, and school staff are a part of the process for generating the plans.

Despite the availability of IEPs and Section 504 plans for individuals with disabilities, it is exceedingly common for parents and caregivers to express dissatisfaction with the processes. Disconnects exist between what is offered as part of “free and appropriate education” and an intervention plan likely to produce meaningful outcomes for the student. To see the relevance to severe problem behavior, students who engage in problem behavior may be removed from the classroom and placed in an alternative school. The alternative school might primarily focus on behavior management rather than skill development and academic behavior. Placement decisions can easily create tension between what is considered “free and appropriate” and a “least restrictive environment” versus the outcomes sought by parents and caregivers.

Including research-informed services when students are at risk of placement changes or unfavorable learning conditions might ameliorate problems related to placement decisions. Creating policies or legislation requiring assessment and intervention by best-practice clinical teams specializing in severe problem behavior could reduce the incidence of placement in more restrictive environments. The behavioral research literature includes many examples of methods for assessing and effectively treating severe behavior problems (Beavers, Iwata, & Lerman, 2013; Hanley, Iwata, & McCord, 2003; Iwata et al., 1994). Other outcomes stemming from the availability of behavior specialists could include fewer parent complaints and lawsuits, more students retained in the LRE, and better educational opportunities for children.

Conclusion

Ample evidence supports (a) the efficacy of basic, translational, and applied behavioral research for informing clinical practice; (b) need for additional funding support for establishing new ways to assess and treat severe problem behavior in schools and communities; and (c) value in creating social policy linking scientific findings with application to problems of social significance. As the scientific community continues to examine novel and effective assessment and intervention modalities, we hope development of social policy provides a pathway for implementation. The health and happiness of children depend on it.

Footnotes

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.

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Beyond Intervention

Abstract

Keywords

Tweet

Key Points

Introduction

Persistence of Severe Problem Behavior

Relapse of Severe Problem Behavior

Resurgence

Renewal

How Might Policy Changes Affect Behavioral Health?

Translational Research

Support of Early Screening, Assessment, and Treatment

Bridging Gaps in the Educational System

Conclusion

Footnotes

Declaration of Conflicting Interests

Funding

References