Theodosia R. Paclawskyj, Ph.D., BCBA
Kennedy Krieger Institute and The Johns Hopkins University School of Medicine
J. Helen Yoo, Ph.D.
The Center for Autism and Related Disorders, Inc.
The reduction of severe maladaptive behaviors in individuals with developmental disabilities is essential for their successful participation in the least restrictive home, school, and community settings. Over 40 years of research in applied behavior analysis have resulted in the development of assessment and treatment procedures that can result in significant improvement for a large percentage of individuals. Treatment to remediate skills and performance deficits best predicts successful long-term outcome (Horner, Sprague, & Flannery, 1993). However, deficits in social competence, namely communication, social, and coping skills; also are a significant risk factor for the onset and persistence of psychopathology. Without the ability to effectively communicate needs, to appropriately initiate interaction, or to tolerate distressing emotions and develop solutions to manage stressors, an individual cannot function successfully in the community.
Teaching individuals to cope with distress is an area that is under-addressed in our clinical research. While in many cases clinicians can develop effective behavior intervention plans to reduce the incidence of maladaptive behaviors, at times the incidence of maladaptive behaviors correlates with emotional states such as anxiety or agitation, making treatment more challenging. For example, an individual may become anxious and agitated in various situations that at times result in aggressive behaviors. A behavior intervention plan may result in a decrease in aggression if sufficient reinforcement is available to the person for the display of appropriate behaviors in such settings. However, in many cases that individual's anxiety could fluctuate in intensity and still result in periodic displays of aggressive behavior. Targeting the person's anxiety in treatment could result in more beneficial outcomes as the stimulus for aggression is removed.
Reduction of anxiety through behavioral methods can be highly successful for typically functioning individuals (Craske, Rapee, & Barlow, 1992). However, anxiety disorders in persons with MR are a significantly neglected area of research and care (Reiss, 2001), and the existing treatment research relies heavily on case reports (Hagopian & Ollendick, 1997; Ollendick, Oswald, & Ollendick, 1993). For the typically functioning population, participation in treatment for anxiety involves consent to therapeutic interventions such as graduated exposure and desensitization that involve a temporary increase in anxious responding before improvement. This can be verbally mediated with persons from the general population who can understand the rationale for treatment, but becomes more challenging for individuals with impaired cognitive abilities.
Relaxation training is a more socially valid intervention for persons with disabilities with significant levels of anxiety, both with and without co-occurring maladaptive behaviors. Generally speaking, it is a therapeutic intervention that is perceived as neutral or even pleasant by the participant. The intention of relaxation procedures is to produce an overall decrease of muscle activity resulting in a physiological relaxation response of decreased emotional arousal and reduced activity in the various organ systems (e.g., cardiovascular, respiratory, digestive) that are overactivated during a state of tension (Luiselli, 1980). Observable signs of tension to be considered can range from rapid breathing, trembling, and sweating to overt agitation such as tantrums, screaming, yelling, swearing, foot stomping.
The primary challenge for clinicians working with persons with developmental disabilities is identifying a method that is appropriate for persons who may not be able to provide subjective reports on their internal states. Behavioral Relaxation Training (BRT) (Poppen, 1998) is a method that counters this difficulty. BRT focuses on the training of overt behaviors wherein a relaxed state can be objectively assessed by an observer, making it very amenable to applied behavior analytic methodology. The procedures of BRT involve modeling both relaxed and unrelaxed behaviors across 10 areas of the body (head, mouth, hands, feet, body, breathing, throat, eyes, shoulders, and vocalizations). After observing relaxed and unrelaxed postures, the person is encouraged to imitate the appropriate behaviors. The rationale behind BRT is that engaging in these motoric responses produces the relaxation response (Poppen, 1998). Scoring of relaxed behaviors can be accomplished through the Behavioral Relaxation Scale (BRS), a reliable and valid measure for recording the presence of relaxed motoric responses (Poppen & Maurer, 1982; Schilling & Poppen, 1983).
To date, twelve studies have been conducted to evaluate the teaching and treatment applicability of BRT with individuals with mental retardation, although only one-third used controlled methodology to demonstrate treatment effects. Two of these examined the effects of BRT on anxiety (Lindsay, Baty, Michie, & Richardson, 1989; Lindsay, Fee, Michie, & Heap, 1994) and two evaluated the impact of BRT on cognitive performance (Lindsay & Morrison, 1996; Morrison & Lindsay, 1997). All utilized adult participants diagnosed with moderate to severe mental retardation. These studies demonstrated that BRT could be acquired rapidly and result in more favorable relaxation scores than other forms of relaxation; additionally, participants demonstrated improvement in short-term memory and attention.
The remaining studies, although lacking experimental control, nonetheless suggested positive outcomes. Several examined the feasibility of BRT as a relaxation procedure and in comparison to abbreviated progressive relaxation (e.g., Lindsay & Baty, 1989; Lindsay, Richardson, & Michie, 1989; Lundervold, 1986). The remaining studies examined BRT as a treatment component for phobias (Lindsay, Michie, Baty, & McKenzie, 1988), chronic headaches (Michultka, Poppen, & Blanchard, 1988), and seizures (Kiesel, Lutzker, & Campbell, 1989). These were conducted using single-case design, and are the only examples of BRT used in a treatment context.
Given the demonstrated effectiveness of BRT in producing an observable relaxed response in persons with mental retardation, there appears to be significant potential for its use within the context of behavioral treatment of maladaptive behavior, especially in persons with high levels of agitation. The training process is amenable to persons with developmental disabilities as no verbal reporting is required from the patient. In addition, BRT requires little instructional control beyond brief verbal prompts to imitate specific behaviors and modeling of those behaviors. The minimum prerequisite for training is the ability to imitate motor responses, thereby allowing training to be conducted with individuals with more cognitive impairments (Poppen, 1998). However, addressing anxious and agitated behavior in an efficacious manner requires consideration of the length of time spent in treatment. Identifying the most rapid method of instruction in BRT, would provide considerable clinical benefit. Therefore, the purpose of this paper is to describe the methodology we developed in our efforts to train participants diagnosed with developmental disabilities and severe behavior and psychiatric disorders in BRT.
In the Neurobehavioral Unit at the Kennedy Krieger Institute we have provided training in BRT to 19 participants referred either for outpatient consultation, clinic-based services, or inpatient treatment for agitated or anxious behaviors co-occurring with self-injury, aggression, or other disruptive behaviors. Participants who received training were referred from 3 primary sources: (1) the current clinician who made a clinical judgment that training was appropriate, (2) the screening process for admission into the Neurobehavioral Unit inpatient or outpatient programs, or (3) from institute psychiatrists.
Prior to instruction, an assessment to identify items that were highly likely to serve as reinforcers was conducted using the stimulus choice methodology developed by Fisher et al. (1992). Next, a baseline assessment was conducted to determine the length of time the patient could typically spend in-seat (in the same cushioned chair that would be used for training sessions) and the degree to which they maintained a relaxed posture without formal instruction. The latter was determined through the use of the Behavior Relaxation Scale (Poppen & Maurer, 1982), a reliable and valid scoring system to evaluate the presence of relaxed and non-relaxed responses in the body.
During training sessions, participants were taught between 1-3 behaviors at a time, depending on the individual's ability to follow single vs. multi-step instructions. The instructor and a co-therapist first modeled the target behavior(s); the instructor then used a graduated prompt hierarchy of verbal, gestural, and physical prompts to have the patient imitate the target response. The patient received a reinforcer as identified from the stimulus choice assessment contingent on correct imitation and maintenance of the correct response. A target length of time to maintain the correct relaxed posture was determined by taking the mean in-seat duration from baseline sessions and rounding up to the nearest whole minute interval. The criterion for mastery of each individual response was defined as a mean correct response rate of at least 80% across three consecutive sessions. Instruction proceeded until at least 8/10 behaviors were mastered, after which generalization sessions occurred for most participants in locations outside of the therapy room.
Anecdotal observation indicated that training the 10 behaviors specified in the BRT procedure appeared more difficult when taught in an unspecified order, especially when behaviors involving fine motor skills (e.g., keeping eyes lightly closed) were interspersed with gross motor behaviors (e.g., keeping torso in contact with the back of a cushioned chair). Consequently, clinicians were instructed to begin training the 10 behaviors in a structured order of large-to-small muscle groups: body, head, shoulders, feet, hands, throat, mouth, eyes, and finally breathing and quiet.
Our data demonstrate significant improvements in skill acquisition when the structured training sequence was utilized. Nineteen participants were compared with results depicted in Table 1. The largest proportion (47%) consisted of individuals diagnosed with moderate mental retardation; the remaining participants were diagnosed with mild (37%), severe (11%), or unspecified mental retardation (5%). Ten participants were taught using the structured order and 9 using a random order. Of those taught in a random order, two did not master BRT.
As a group, participants were taught to engage in BRT for 2-10 minutes (m=7) and required 12-520 minutes (m=124 minutes) to achieve mastery, defined as 3 consecutive sessions with at least 80% of behavioral criteria met. Those participants trained using the structured sequence displayed more generalization across untrained behaviors (m=4) than those trained in a random order (m=1). That is, training in the structured order on average required teaching only 6/10 responses. Total time to mastery, however, was unaffected by teaching order and may reflect the variability in age and functioning levels of the different participants.
Our current clinical data demonstrate the following: children with developmental disabilities can learn BRT fairly quickly and to a reasonable degree of success. Fundamental techniques of instruction such as a graduated prompt hierarchy, in vivo modeling, and continuous reinforcement for correct responding resulted in successful acquisition of relaxation skills in 89% (17/19) of our participants. However, when a structured teaching order was employed, more participants demonstrated generalization across untrained behaviors; that is, on average, only six out of ten target behaviors needed to be taught. While total teaching time did not vary between groups, use of the structured teaching order was preferred by therapists, especially as the responses involving large muscle groups (e.g., body position) were simpler to model and prompt than the behaviors requiring fine motor responding (e.g., eye and mouth positions).
The majority of these participants were taught BRT in the context of a consultative evaluation and, despite the abbreviated time frame for training, the participants were able to acquire relaxation skills in only two hours on average. We are currently collecting additional treatment data to evaluate the impact of BRT on standard of care treatment of maladaptive behaviors in children with developmental disabilities. In our initial sample, 3 out of 4 participants demonstrated further improvements in maladaptive behaviors when BRT was included into an operant-based behavioral intervention. With additional clinical research, we hope to be able to identify the clinical indicators that suggest BRT as an appropriate component of intervention for individual treatment.
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