Functional behavioral assessment (FBA) is the process of identifying

09_234_05_Grow.qxd 4/28/09 5:59 AM Page 70 Treatments for Attention- Maintained Problem Behavior: Empirical Support and Clinical Recommendations Laura L. Grow James E. Carr Linda A. LeBlanc ABSTRACT: Designing treatments to address the function of problem behavior is currently considered best practice. One of the most common behavioral functions is that of contingent social attention. The present article describes several functionbased treatments for attention-maintained problem behavior, and it discusses the unique challenges associated with this behavioral function in school settings. Clinical recommendations are provided for selecting and modifying treatments based on individual student needs. Functional behavioral assessment (FBA) is the process of identifying environmental events associated with problem behavior, which allows school psychologists to generate hypotheses about behavioral function (Asmus, Vollmer, & Borerro, 2002; Gresham, Watson, & Skinner, 2001). This information can be used to design treatments that alter important environmental antecedents or consequences to produce positive behavior change. Before the development of FBA, treatments often consisted of selecting arbitrary reinforcers or punishers to overpower preexisting reinforcers for problem behavior (Pelios, Morren, Tesch, & Axelrod, 1999). Treating problem behavior based on its operant function has several advantages. First, research suggests that Address correspondence to Laura Grow, MS, Department of Psychology, Western Michigan University, 1903 West Michigan Avenue, Kalamazoo, MI 49008 5439. E-mail: laura.l.grow @wmich.edu. 70 Journal of Evidence-Based Practices for Schools Vol. 10, No. 1

09_234_05_Grow.qxd 4/28/09 5:59 AM Page 71 Treatments for Attention-Maintained Problem Behavior 71 treatments based on FBA outcomes are more effective in reducing problem behavior and increasing appropriate behavior than are treatments selected without knowledge of behavioral function (e.g., Iwata, Pace, Cowdery, & Miltenberger, 1994). Second, knowledge of behavior function allows the clinician to avoid irrelevant or contraindicated treatments that might otherwise be reasonable treatment options. For example, guided compliance is a commonly recommended treatment for escape-maintained noncompliance. If noncompliance is maintained by attention, however, guided compliance may be contraindicated because the copious attention provided contingent on problem behavior might actually further reinforce the behavior. Over the past two decades, research on FBA and function-based treatments in school settings has become increasingly important (Ervin et al., 2001). The 1997 amendment to the Individuals With Disabilities Education Act mandates FBA when suspension or a change in placement occurs because of behavioral difficulties (Drasgow, Yell, Bradley, & Shriner, 1999). Specific assessment methods are not mandated by the act, but they do allow the individualized education plan team to determine methods for assessing behaviors of concern. FBA methods include interviews (Sturmey, 1994), rating scales (Paclawskyj, Matson, Rush, Smalls, & Vollmer, 2000), descriptive assessments (Mace, Lalli, & Pinter-Lalli, 1991), and functional analyses (Iwata, Dorsey, Slifer, Bauman, & Richman, 1982/1994). These methods vary in terms of the resources required to complete the assessment, as well as the quality of information they provide. Thus, it is not uncommon for clinicians to use a range of methods during the FBA process. Indirect FBA (e.g., rating scales, interviews) involves obtaining information from knowledgeable informants, such as teachers and other caregivers, to identify the form of the behavior (e.g., tantrums, self-injury), the settings in which behavior is likely to occur, and the events that precede and follow occurrences of problem behavior (O Neill et al., 1997; Sturmey, 1994). Direct observation is not required, but reliance on an informant s ability to accurately report critical events can render the validity of verbal report suspect and make it difficult to conclusively determine the function of problem behavior. Alternatively, descriptive assessment methods (e.g., ABC assessment) involve direct observation of problem behavior and proximal environmental events (Mace et al., 1991). Although such methods are an improvement over indirect methods because they include direct behavioral observation, the data they yield can only suggest, rather than identify, a behavioral function. By contrast, functional analyses are able to conclusively identify causal relations between problem

09_234_05_Grow.qxd 4/28/09 5:59 AM Page 72 72 LAURA L. GROW ET AL. behavior and environmental events (Iwata et al., 1982/1994) because the clinician directly tests several hypotheses regarding behavioral function. Functional analyses are not particularly viable when behavior occurs at low rates (Hanley, Iwata, & McCord, 2003), which suggests that indirect methods and direct observation may be better suited as assessment tools for low-rate behavior. Epidemiological analyses indicate that the most common functions identified via FBA are social negative reinforcement (i.e., escape from tasks or interactions), social positive reinforcement (i.e., access to attention or tangibles), and automatic reinforcement (i.e., sensory reinforcers such as visual stimulation; Iwata, Pace, Dorsey, et al., 1994). A recent review of 790 published functional analysis data sets identified escape from instruction (34%) and attention from others (25%) as the two most commonly identified functions of problem behavior (Hanley et al., 2003). Cipani and Spooner (1997) provided a detailed review of four treatments for escape-maintained problem behavior; however, no similar review exists for attention-maintained problem behavior. A review specific to the treatment of attention-maintained problem behavior is warranted because of the numerous and unique treatment challenges that may arise with this function. School settings provide many contexts in which social interaction with others must be delayed or restricted (e.g., during structured work time, waiting for a turn), and this restriction on social attention can act as an establishing operation and so momentarily increase the value of attention as a reinforcer for problem behavior. In addition, attention is a relatively ubiquitous consequence for problem behavior in school settings. Erickson, Stage, and Nelson (2006) found that teacher and student attention was the best predictor of problem behavior in classrooms for students with emotional and behavioral disturbances. Many individuals in a school setting are potential sources of attention (e.g., peers, teachers, administrators), which can make it more difficult for the school psychologist to identify the important sources of reinforcement for attention-maintained behavior than for escape-maintained behavior, for example. In addition, the nature of public school settings can make it difficult to prevent attention for problem behavior if many students are around. The present article summarizes the empirical support and provides clinical implementation guidelines for several interventions for attention-maintained problem behavior. The selection of interventions was based on the level of available support for their use and their direct relevance for attention-maintained problem behavior.

09_234_05_Grow.qxd 4/28/09 5:59 AM Page 73 CONSEQUENCE-BASED INTERVENTIONS One approach to designing interventions for attention-maintained problem behavior is the modification of consequences for appropriate and inappropriate behavior that is, consequence-based interventions. Consequence-based interventions involve arranging immediate access to reinforcers (e.g., attention) contingent on appropriate behaviors and extinction of problem behavior. Extinction is discussed first because it is often used in conjunction with other consequenceand antecedent-based interventions. Extinction Treatments for Attention-Maintained Problem Behavior 73 Procedures. Extinction involves terminating the response reinforcer contingency that maintains problem behavior, which should result in a decreased probability of responding (Lerman & Iwata, 1996). Extinction typically involves withholding the reinforcer (i.e., not delivering it) immediately following the problem behavior, and it sometimes results in a behavioral pattern characterized by an initial increase in behavior, followed by a gradual reduction in behavior. The current literature suggests that attention extinction can be used to decrease a range of problem behavior, including destructive behavior (LeBlanc, Hagopian, Marhefka, & Wilke, 2001), aggressive behavior (O Reilly, Lancioni, & Taylor, 1999), inappropriate sexual behavior (Fyffe, Kahng, Fittro, & Russel, 2004), and self-injury (Yang, 2003). For attention-maintained problem behavior, extinction involves discontinuing all forms of attention (e.g., verbal comments, eye contact, exaggerated facial expressions) immediately following problem behavior (Ducharme & Van Houten, 1994). This intervention has sometimes been referred to as planned ignoring (Hall & Hall, 1998). Although extinction has been demonstrated to be effective in reducing problem behavior, there are some issues that should be considered before this intervention is selected. Clinical considerations. School psychologists should consider several ethical and practical issues before implementing extinction. First, implementing extinction as the sole treatment for problem behavior may be unethical if the student has few or no other responses for obtaining attention from others. The exclusive use of extinction as treatment for problem behavior has been criticized because although the contingency for problem behavior is eliminated, the motivation to gain access to attention is still present (LaVigna & Donnellan, 1986); thus, the student is left without a way to gain access to attention. School psychologists

09_234_05_Grow.qxd 4/28/09 5:59 AM Page 74 74 LAURA L. GROW ET AL. should implement extinction with a behavioral acquisition component if the student has a limited behavioral repertoire. Extinction-based treatment of attention-maintained problem behavior can be complicated by the many potentially appealing aspects of interactions with others, including the source of the attention (e.g., teachers, peers, relatives). Furthermore, eye contact, physical interaction, verbal statements, and even slight changes in expression may function as possible maintaining reinforcers in classrooms. Piazza et al. (1999) demonstrated that attention maintained the aggressive and destructive behavior of two boys with developmental disabilities, but physical attention was the critical feature for one boy whereas verbal interaction was the critical feature for the other. LeBlanc et al. (2001) determined that the aggressive behavior of a teenager with mental retardation was attention maintained but that aggression was more probable with males, whose attention was more highly valued. For students in a classroom, peer attention may be more reinforcing than teacher attention (Broussard & Northup, 1995; Northup et al., 1995; Northup et al., 1997). If problem behavior is maintained by peer attention, common classroom reinforcers should be provided when peers appropriately ignore problem behavior. These findings suggest that it may be necessary to consider the individuals who provide attention for problem behavior, as well as the reinforcing features of attention. Although extinction can be quite successful in reducing attentionmaintained problem behavior, there are times when it might be inappropriate to ignore problem behavior or when extinction-related increases in problem behavior are intolerable. Hagopian, LeBlanc, and Maglieri (2000) illustrated an instance in which extinction could not be considered as a treatment, because of the severe consequences of ignoring the problem behavior. In this study, a young adult with mental retardation and congenital hydrocephalus frequently complained about his shunt, although no medical cause for the complaints was found. A series of analyses suggested that the complaints were maintained by attention, but the consequences of ignoring an accurate complaint were too severe to permit extinction. Similarly, Fyffe et al. (2004) determined that inappropriate sexual behavior (i.e., contact with others groins, buttocks, breasts) was maintained by attention, but they determined that ignoring the behavior would be inappropriate because of the nature of the behavior problem and its impact on the victim. Other problem behavior, such as elopement (e.g., running in a busy parking lot), high-intensity self-injurious behavior, and lifethreatening behavior (e.g., pica), are ill-suited to extinction treatment, owing to safety concerns.

09_234_05_Grow.qxd 4/28/09 5:59 AM Page 75 Recommendations. Extinction has been repeatedly demonstrated as one of the most powerful interventions for reducing problem behavior. However, in a number of scenarios, the implementation of extinction might be problematic for example, for students with limited behavioral repertoires, for behavior maintained by idiosyncratic forms of attention, and for problem behavior that is dangerous or life threatening. In addition, extinction may be inappropriate if classroom staff are intolerant of extinction bursts or if limited staff training resources are available to ensure proper procedural fidelity. Consequently, extinction should be selected as an intervention for attention-maintained problem behavior only after these scenarios are carefully considered. When problem behavior cannot be fully ignored or when an increase in problem behavior might prove intolerable even for a short time, the following recommendations are offered: First, minimize rather than eliminate attention following problem behavior. For example, instead of delivering a reprimand with a concerned expression, a teacher might block the behavior while looking away with a neutral expression (e.g., Kodak, Northup, & Kelley, 2007; Piazza et al., 1999). Second, teach coping strategies to staff to help them tolerate temporary increases in behavior (e.g., recruiting support from others, relaxation strategies), or explore reinforcement-based interventions as a substitute for, or in conjunction with, extinction to minimize negative side effects, such as bursts, aggression, and emotional behavior (e.g., Ducharme & Van Houten, 1994; Goh & Iwata, 1994; Lerman & Iwata, 1995; Lerman, Iwata, & Wallace, 1999; Sajwaj, Twardosz, & Burke, 1972). Third, staff resources and management (e.g., performance feedback, retraining) may be needed. Those who implement extinction should be trained to identify effects and safely handle increased problem behavior. Finally, consider providing extra classroom staff for a short period if increases in problem behavior are likely, because extinction is most effective when implemented with fidelity (Lerman, Iwata, Shore, & Kahng, 1996). Differential Reinforcement Treatments for Attention-Maintained Problem Behavior 75 This section discusses two interventions based on differential reinforcement. Differential reinforcement of alternative behavior (DRA) and functional communication training (FCT) were selected for review for several reasons. Increasing and maintaining an alternative appropriate behavior is an inherent feature of both interventions. It may be beneficial to teach students new behaviors or strengthen

09_234_05_Grow.qxd 4/28/09 5:59 AM Page 76 76 LAURA L. GROW ET AL. appropriate repertoires. This approach is consistent with the positive behavior support model of teaching replacement behaviors (Woods & Goldstein, 2003). Note that FCT is a subset of DRA; however, important distinctions between the two interventions warrant discussing them separately while recognizing their similar frameworks. DRA. DRA is a consequence-based intervention that has been shown to be effective in reducing problem behavior maintained by attention in the classroom (e.g., Wright-Gallo, Higbee, Reagon, & Davey, 2006). During DRA, problem behavior is placed on extinction, and attention is provided for some alternative appropriate behavior or class of behavior, such as on-task behavior. In a classroom setting, teachers can implement differential reinforcement for a variety of appropriate schoolrelated behavior. DRA can be individualized to include behaviors that comprise goals in the student s individualized education plan. If a student s problem behavior is maintained by peer attention, the school psychologist should consider incorporating peer attention as part of the DRA package. Broussard and Northup (1997) showed that four children diagnosed with attention-deficit/hyperactivity disorder engaged in peer attention-maintained disruptive behavior. Disruptive behavior decreased when peers implemented extinction for disruptive behavior and provided attention for appropriate behavior. With this approach, it may be necessary to implement a contingency management system to ensure that peers are differentially attending to appropriate behavior. Before implementing DRA, school psychologists should identify alternative behavior that will result in attention. Alternative behavior could be determined by examining the student s individualized education plan or by interviewing the teacher. School psychologists should consider selecting an appropriate classroom behavior (e.g., ontask behavior, cooperation with peers, remaining silent during seatwork). For students who have good language skills, rules or contingency contracting may enhance the effects of DRA. For example, when DRA is first implemented, school psychologists and teachers could tell the student, If you complete this worksheet, you can read with a friend in the back of the classroom. During the initial phase of DRA, the student should come into frequent contact with attention for appropriate behavior (Hanley, Iwata, & Thompson, 2001). Assess the student s current level of performance of the appropriate behavior before determining how frequently attention should be provided. Generally speaking, the student should receive more attention for appropriate behavior than what is currently being provided. For example, if the student receives attention after

09_234_05_Grow.qxd 4/28/09 5:59 AM Page 77 Treatments for Attention-Maintained Problem Behavior 77 completing problems during math class, attention should be provided after every problem is completed during the initial phase of DRA. When the student s appropriate behavior has been assessed, the school psychologist should identify the terminal goal for DRA (Hanley et al., 2001). For example, a goal might be for the student to complete all math problems during class without exhibiting problem behavior. Following reductions in problem behavior, the amount of appropriate behavior that is required to get attention should be gradually increased until some final goal is met. If increases in problem behavior are observed, the amount of appropriate behavior that is required should be reduced until problem behavior decreases to acceptable levels. When treatment gains are observed, the amount of appropriate behavior should be increased. LeBlanc, Hagopian, Maglieri, and Poling (2002) provide a more detailed description of methods to reduce the intensity of differential reinforcement interventions. FCT. DRA involves reinforcement of a range of appropriate alternative behavior, whereas FCT involves the reinforcement of a specific communicative response (e.g., touching a card, exchanging a card, raising a hand; Carr & Durand, 1985; Durand, 1990). Following the identification of attention as a reinforcer for problem behavior, an alternative behavior should be selected. Next, training trials should be conducted to establish and maintain the communicative behavior. Teachers and school psychologists should implement extinction for problem behavior during training to facilitate acquisition of the communicative behavior (Kelley, Lerman, & Van Camp, 2002; Shirley, Iwata, Kahng, Mazaleski, & Lerman, 1997). The training of a communicative behavior is often conducted using a discrete-trial format in which the following occur: First, attention is briefly withheld before training or diverted during training (e.g., the teacher reads a magazine); second, the communicative behavior is prompted; third, attention is delivered immediately following the communicative behavior; and, fourth, prompts are gradually faded over time. Before implementing FCT, school psychologists should consider several critical issues before selecting the appropriate communicative behavior. The student s individual characteristics, such as learning history and current behavioral repertoire, should be considered before selecting the form of the communicative behavior including vocal responses, signs, gestures, picture exchanges, among others. If a student already uses a specific mode of communication (e.g., vocal responses), school psychologists should select a communicative behavior in the same mode. Otherwise, one should determine whether the student is physically capable of performing the new communicative

09_234_05_Grow.qxd 4/28/09 5:59 AM Page 78 78 LAURA L. GROW ET AL. behavior (Bourret, Vollmer, & Rapp, 2004). In addition, one should ensure that the school personnel who will be providing attention for communicative behavior are taught to recognize it and provide attention as immediately as possible. School psychologists should also evaluate the response effort of the communicative behavior before implementing FCT. Research suggests that FCT is more effective when the communicative behavior requires less effort to perform than that of the problem behavior (e.g., Horner & Day, 1991; Richman, Wacker, & Winborn, 2001). The school psychologist or teacher can introduce prompts to condition the communicative behavior. Prompts can be introduced and faded using a variety of methods, such as least-to-most prompting or errorless prompting (Demchak, 1990). For least-to-most prompting, teachers should provide a graduated prompting sequence (verbal, gestural, and physical prompts) to teach the communicative behavior. Teachers should initially provide attention if the student performs the communicative behavior following any of the prompt levels. Over time, teachers should limit their attention to communicative behaviors that are performed without the use gestural or physical prompts. For errorless prompting, teachers should use the least amount of physical guidance necessary to ensure that the student correclty performs the communicative behavior. After several trials, teachers should fade prompts by gradually reducing the amount of physical guidance. Teachers should terminate training trials, regardless of the training method, when the student consistently performs the communicative behavior independently (i.e., without prompting). When the communicative behavior has been taught, everyone in the student s environment should be trained to provide enthusiastic attention for the communicative behavior and to ignore instances of problem behavior. Attention should be provided following each instance of communicative behavior (i.e., on a continual reinforcement schedule) during the initial phase of FCT. However, there may be situations when attention is unavailable or the student requests attention more often than what is reasonable in a classroom setting. In these situations, school psychologists should consider establishing periods when attention is unavailable. The student can be taught to determine when attention is available and unavailable through the use of visual signals present during those periods (Hanley et al., 2001; Tiger & Hanley, 2004). For example, teachers could wear a green necklace when attention is available and wear a red one when attention is unavailable. Over time, the amount of time that the red necklace is worn should

09_234_05_Grow.qxd 4/28/09 5:59 AM Page 79 Treatments for Attention-Maintained Problem Behavior 79 be gradually increased. Over time, this strategy will help students learn appropriate instances to request attention. For additional recommendations on schedule thinning, see Tiger and Hanley (2004). Clinical considerations for differential reinforcement. School psychologists should determine which contingencies to place on problem behavior during FCT and DRA including ignoring the behavior (extinction), delivering a mild aversive consequence (punishment), and continuing to provide attention (reinforcement). Hagopian, Fisher, Sullivan, Acquisto, and LeBlanc (1998) showed that extinction or punishment (e.g., time-out) was necessary to reduce problem behavior and increase appropriate behavior during 21 implementations of FCT. It may be useful for school psychologists to use a least restrictive alternative approach for selecting consequences for problem behavior that is, punishment of the problem behavior would be considered only after extinction had been shown insufficient in producing clinically significant reductions. Both DRA and FCT are most successful with extinction for reducing problem behavior (Hagopian et al., 1998; McCord, Thomson, & Iwata, 2001), suggesting that if extinction is not feasible or justifiable as discussed in the previous section, other treatment options should be considered (e.g., noncontingent reinforcement [NCR]). Recommendations. Differential reinforcement interventions have been effective in reducing problem behavior while simultaneously increasing appropriate behavior. Both DRA and FCT are especially useful for students with few, if any, appropriate behaviors in their repertoire. On the surface, differential reinforcement appears to be a relatively straightforward method for addressing attention-maintained problem behavior that is, ignore problem behavior and attend to appropriate behavior; however, these interventions can fail if certain variables are not adequately addressed before treatment. The form of the alternative or communicative behavior should be carefully selected such that the student easily performs the behavior, others reliably respond to it, and it requires less response effort than that of the problem behavior. In addition, an extinction or punishment contingency should be concurrently applied to the problem behavior. Finally, additional procedures to reduce the intensity of the intervention will be needed if the frequency of attention delivery is too cumbersome or the student is engaging in unacceptably high levels of the alternative or communicative behavior. If the requirements of DRA or FCT cannot be satisfied, an antecedent-based intervention might be warranted.

09_234_05_Grow.qxd 4/28/09 5:59 AM Page 80 80 LAURA L. GROW ET AL. ANTECEDENT-BASED INTERVENTIONS Another approach to designing interventions for attention-maintained problem behavior is to address antecedent events that immediately precede the behavior. That is, the goal of an antecedent-based intervention is to restructure the environment such that antecedents that reliably occur with problem behavior are eliminated or changed such that the behavior is less likely to occur. If limited access to social attention serves as an establishing operation, antecedent strategies can be used to abolish those effects by increasing the overall level of available attention before the occurrence of problem behavior (Kern & Clemens, 2007; O Reilly, Edrisinha, Sigafoos, Lancioni, & Andrews, 2006). As such, NCR is discussed as it applies to the treatment of attention-maintained problem behavior, and other antecedent-based strategies are briefly reviewed. NCR Procedures. NCR involves the response-independent delivery of reinforcers that have been shown to maintain problem behavior (Vollmer, Iwata, Zarcone, Smith, & Mazaleski, 1993). For example, if an FBA identifies attention as the maintaining reinforcer for problem behavior, NCR would involve delivering attention to the student, regardless of the occurrence of problem behavior. Noncontingent attention has been successfully applied to reduce disruptive behavior (Jones, Drew, & Weber, 2000), self-injurious and aggressive behavior (Kahng, Iwata, Thompson, & Hanley, 2000), excessive medical complaints (Hagopian, Crockett, van Stone, DeLeon, & Bowman, 2000), and elopement (Kodak, Grow, & Northup, 2004). For attention-maintained problem behavior, NCR typically involves providing brief statements of praise on a fixed-time schedule (e.g., every 5 minutes; Vollmer & Wright, 2003). Rasmussen and O Neill (2006) illustrated the successful use of the fixed-time delivery of attention to reduce the verbal disruptive behavior of a student with emotional and behavioral disturbances in classroom settings. During the initial phase of NCR, attention is delivered on a fairly dense schedule such that the student receives more free attention than that which he or she received for the problem behavior in baseline (Carr & LeBlanc, 2006). School psychologists should determine the initial schedule of attention delivery by using information from behavioral observations of the student (i.e., his or her problem be-

09_234_05_Grow.qxd 4/28/09 5:59 AM Page 81 Treatments for Attention-Maintained Problem Behavior 81 havior) before treatment. The initial schedule of attention delivery should be smaller than the average amount of time between attention deliveries in baseline. When problem behavior decreases following the initial NCR schedule, the schedule should be gradually thinned until some terminal goal (e.g., attention delivery every 20 minutes) has been reached (for more detail, see LeBlanc et al., 2002). For some students, peer attention will function as a more potent reinforcer than teacher attention. In this situation, NCR should include peer-delivered attention. Jones et al. (2000) assessed the disruptive behavior of a child diagnosed with attention-deficit/hyperactivity disorder. Functional analysis indicated that the participant s behavior was maintained by peer attention rather than teacher attention. Another student was taught to deliver noncontingent attention to the participant, which resulted in a reduction in disruptive behavior. Clinical considerations. The school psychologist should evaluate several considerations before selecting NCR as a treatment for attentionmaintained problem behavior. One consideration is that NCR is most effective when used in conjunction with extinction. However, some studies have shown significant reductions in problem behavior in the absence of extinction (e.g., Hagopian, Crockett, et al., 2000; Lalli, Casey, & Kates, 1997). As mentioned earlier, certain types of problem behavior may be nearly impossible to ignore (e.g., aggression toward peers, elopement, life-threatening behavior). In situations in which extinction is not possible because of ethical or practical reasons, NCR without extinction may be a desirable option. NCR without extinction involves the response-independent delivery of attention, as well as the contingent delivery of attention, following problem behavior. However, teachers should use only the least amount of contingent attention necessary to ensure the safety of the student. For example, if a student is engaging in high-intensity self-injurious behavior, a teacher might physically block the behavior (i.e., a form of attention) but minimize facial expressions and verbal comments. Minimizing the amount and intensity of attention delivery may reduce the reinforcing effectiveness of attention such that the problem behavior is less likely to occur. Although NCR may be used in conjunction with extinction, combining NCR and DRA/FCT might be contraindicated. Noncontingent attention is effective in reducing the reinforcing effectiveness of attention and so can be classified as an abolishing operation (Michael, 2000). In addition to reducing the effectiveness of attention as a reinforcer, NCR may have an abative effect on all behavior that has produced

09_234_05_Grow.qxd 4/28/09 5:59 AM Page 82 82 LAURA L. GROW ET AL. attention in the past. Previous research has shown that dense schedules of NCR can reduce appropriate behavior during DRA/FCT (Goh, Iwata, & DeLeon, 2000; Marcus & Vollmer, 1996), which suggests that DRA/FCT should be combined only if thin NCR schedules are used. As an alternative, NCR and DRA/FCT could be used with different activities during the school day. For example, NCR could be implemented during recess, whereas DRA/FCT could be used during independent seatwork. Another consideration is that a dense schedule of noncontingent attention (e.g., continual access to attention) may be required during the initial phases of NCR. However, over time, continual or dense schedules of attention may be impractical to maintain. After behavior has been reduced to clinically significant levels, schedule thinning can be used to reduce the frequency of attention delivery to a more practical level (e.g., Kahng, Iwata, DeLeon, & Wallace, 2000). For example, if the initial schedule of attention delivery is every 10 seconds, teachers should slowly increase the amount of time between attention deliveries, to eventually reach a more practical level (e.g., every 15 minutes). When the schedule is thinned, teachers might observe brief increases in problem behavior. If problem behavior persists, teachers should return to the last schedule of attention that was associated with low levels of problem behavior. An additional consideration is that teachers may find it difficult to provide scheduled attention in certain situations, such as in instructing a group of students or helping another student with academic work. In these situations, using an arbitrarily selected reinforcer to compete with attention-maintained behavior might be useful. For example, teachers could provide a highly preferred toy instead of attention during times when attention is unavailable. Although some studies have demonstrated the effectiveness of using arbitrarily selected reinforcers during NCR (e.g., Fischer, Iwata, & Mazaleski, 1997), this approach should be considered only during times when attention is unavailable. A stimulus preference assessment should be conducted to identify a potent, high-quality reinforcer when attention is impractical or impossible to deliver (for a review of preference assessment procedures, see Hagopian, Long, & Rush, 2004). Although NCR is associated with fewer negative side effects when compared with other treatments such as extinction, inadvertently reinforcing problem behavior during NCR may occur (Vollmer, Ringdahl, Roane, & Marcus, 1997). For example, if problem behavior accidentally precedes delivery of attention, teachers may inadvertently

09_234_05_Grow.qxd 4/28/09 5:59 AM Page 83 Treatments for Attention-Maintained Problem Behavior 83 reinforce the behavior. This side effect is unlikely to occur, but it can be minimized by delaying attention delivery if problem behavior occurs just before a scheduled delivery (e.g., Britton, Carr, Kellum, Dozier, & Weil, 2000). For example, if a student engages in self-injurious behavior immediately before attention delivery, teachers can delay attention for 10 seconds to eliminate the possibility of accidentally reinforcing the behavior. Recommendations. NCR has been shown to be an effective form of treatment for attention-maintained problem behavior, although the successful implementation of NCR requires attention to several procedural details. During the initial phases of NCR, teachers should deliver attention more frequently than they did for problem behavior before treatment was implemented. If peer attention is used during NCR, school psychologists should train several students to deliver enthusiastic attention to the student with problem behavior during group activities. It may be necessary to provide common classroom rewards for providing noncontingent attention to the student with problem behavior. After problem behavior has been reduced to clinically acceptable levels, schedule thinning should be used to make NCR more practical. Because of the possibility of accidentally reinforcing problem behavior during NCR, scheduled attention deliveries could be delayed if they are immediately preceded by problem behavior. NCR is most effective when it is used in conjunction with extinction that is, attention is provided noncontingently and not for problem behavior; however, NCR without extinction may be appropriate when fully ignoring problem behavior is unethical or impractical. NCR can be combined with DRA/FCT; however, appropriate behavior may occur less frequently if dense NCR schedules are used. Alternatively, NCR and DRA/FCT can be implemented in different settings across the school day. Finally, arbitrary reinforcers selected through a preference assessment can be delivered during NCR when attention is difficult or impossible to deliver. Additional Antecedent-Based Strategies School psychologists may recommend restructuring the classroom routine so that activities that involve attention delivery (e.g., small group learning, circle time) are interspersed with activities that do not involve attention, such as individual seatwork (Kern & Clemens, 2007). For example, if a school psychologist determines that the classroom is arranged in a way that requires the student to endure

09_234_05_Grow.qxd 4/28/09 5:59 AM Page 84 84 LAURA L. GROW ET AL. extended periods with few opportunities to access attention, additional activities that involve attention can be interspersed during that period. Research also suggests that problem behavior can be reduced by providing noncontingent attention immediately before situations in which problem behavior occurs (O Reilly et al., 2006). One strategy for prompting positive peer interactions is classwide peer tutoring (CWPT; Greenwood, 1991, 1997; Mortweet et al., 1999). CWPT is a teaching strategy that can be used to teach academic material in a variety of subjects. Typically, students are grouped into tutor learner pairs. Students practice the academic material while providing praise and points for accurate responding. Students alter roles so that each student has an opportunity to function as both the learner and the tutor. Although CWPT has not been explicitly implemented for the purpose of reducing attention-maintained problem behavior, there may be benefits of its use in the classroom for this purpose. Kamps, Barbetta, Leonard, and Delquadri (1994) evaluated peer interactions and reading skills during CWPT with children with autism and their typically developing peers. When CWPT was implemented, peer interactions increased during the tutoring sessions and across activities in the classroom, suggesting that CWPT may increase the opportunities for students to positively interact with one another. CWPT has also been used as an intervention strategy for classroom behavior for children with attention-deficit/hyperactivity disorder (e.g., DuPaul, Ervin, Hook, & McGoey, 1998) and mild mental retardation (Mortweet et al., 1999). The inclusion of CWPT may increase the amount of peer attention that naturally occurs in the classroom context, which may reduce the likelihood of attention-maintained problem behavior. In addition, appropriate behavior (e.g., on-task behavior) may increase as a result of CWPT, and teachers should be prepared to provide attention for those behaviors. A FRAMEWORK FOR SELECTING TREATMENTS FOR ATTENTION-MAINTAINED BEHAVIOR Figure 1 depicts an algorithm for selecting treatments, and it includes the key considerations discussed in the present article. The answers to the questions contained in the algorithm help to narrow treatment options. Figure 2 illustrates the algorithm as it applies to a specific problem behavior. The starting point is an FBA that identifies an attention

09_234_05_Grow.qxd 4/28/09 5:59 AM Page 85 Treatments for Attention-Maintained Problem Behavior 85 Figure 1. An algorithm for selecting treatments for attention-maintained problem behavior. function for disruptive behavior. In cases in which the disruptive behavior is unsafe, NCR without extinction may be warranted. Although attention is still provided for disruptive behavior, the amount of attention should be minimized. If problem behavior is safe and ethical to ignore, whether extinction bursts are tolerable in the classroom should be determined. If increases in disruptive behavior significantly interfere with classroom activities, NCR without extinction may be a reasonable option. If extinction bursts can be tolerated, whether the student s appropriate behavior needs strengthening should be determined. If the student s current appropriate repertoire is strong, extinction may be considered. If the student s appropriate behavior repertoire is limited, identify areas of appropriate behavior that should be selected. If the student has deficits in areas of communication, FCT with extinction may be useful for teaching and maintaining requests

09_234_05_Grow.qxd 4/28/09 5:59 AM Page 86 86 LAURA L. GROW ET AL. Figure 2. An illustration of the treatment-selection algorithm. for social interaction. Other students might benefit from DRA with extinction if they fail to complete tasks, engage with their peers, or remain in their seats. CONCLUSION Approximately one quarter of problem behavior is maintained by social positive reinforcement in the form of attention (e.g., Hanley et al., 2003; Iwata, Pace, Dorsey, et al., 1994). Treatment of attention-maintained problem behavior can be particularly challenging in classroom environments because it often involves planned ignoring of problem behavior. The treatments discussed in the present review, as well as the numerous variables that should be considered during treatment

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