Keys to Compliance: Strategies for Increasing Compliance in Learners with and Without an ASD

1. Keys to Compliance: Strategies for Increasing Compliance in Learners with and Without an ASD Brittany R. Rothe, B.S., BCaBA University of Houston-Clear Lake

2. Overview • Define compliance • Determine who is concerned with compliance • Problems with noncompliance • Reasons for noncompliance • Ways to encourage compliance • Break • Consequences for compliance/noncompliance • Difficult cases • Generalization • Final considerations

3. Compliance • What is compliance? • Following instructions/directions • Independently initiating/completing a request • Within a time frame (6 s) • Noncompliance: opposite of or lack of compliance • Sometimes accompanied by problem behavior • Noncompliance—most common childhood problem • Noncompliance vs. Lack of ability

4. Compliance • Who can be noncompliant? • Typically developing learners • Learners with an Autism Spectrum Disorder (ASD) • You and me! • Noncompliance is not limited to young children

5. Compliance • Common situations/instructions for noncompliance • Schoolwork • Transitions • Activities of daily living/chores • Doctor visits • Who is concerned with compliance? • Parents/Caregivers • Teachers • Doctors/Nurses • Therapists

6. Problems with Noncompliance • Creates deficits in skill development • Academic skills • Self-help skills • Social skills • Affects family life/stress • Parents • Siblings • Leads to other behavior problems

7. Why Noncompliance? • Why does noncompliance occur? • Escape from or delay an unpreferred activity • Schoolwork • Access or maintain access to preferred items/activities • Toys, games, food • Gain attention (verbal, physical, both) • Teacher, parents, peers • Noncompliance is tricky because the reason is not always obvious • Common reactions to compliance and noncompliance

8. Treatments/Interventions • Prevention Strategies • Goals: Prevent noncompliance & encourage compliance • Consequence Strategies • Goals: Provide rewards for compliance & encourage future compliance

9. Prevention Strategies • Used alone or in combination • What works? • Simple Instruction Tips (Package) • High-Probability (High-p) Request Procedure • Time-based Rewards • Learner Choice • What doesn’t work? • Warning or advance notice (transitions or termination) • Rationales

10. Simple Instruction Tips • Deliver instruction a short distance from the learner • 1 ft. • Crouch to small learner’s level • Gently touch learner’s shoulder • Attempt to make eye contact • Avoidance in ASD • Interrupt current play/activity • Gently block hands

11. Instructions/Demands • Should be in statement form • Correct: Pick up the toys. OR Please, pick up the toys. • Incorrect: Will you/can you pick up the toys? • “Do” requests • Correct: Sit down in the chair. • Incorrect: Don’t lay on the floor. • Specific • Keep a neutral tone

12. High-p/Low-p • High-probability request procedure • High-probability request • Compliance likely • “Touch your nose” • “Clap your hands” • Imitation: “Do this” • Low-probability request • Compliance unlikely • “Give me the toy” • “Say Mom” • “Put on your shoes”

13. High-p/Low-p • How to use the high-p, low-p instructional sequence • Deliver ~3 high-p instructions • Snacks/toy rewards + praise for compliance • ~ 10 s between high-p instructions • Speed of demands • Benefits • Widely studied • Appropriate for wide variety of situations • Examples: Medical exams, educational settings, home • Weaknesses • Difficult if very few high-p

14. Modified Instructions • Know your learner • One-step vs. multiple-step instructions • Modify aspects of task that is aversive • Make task more manageable/ enjoyable • Break task into steps • Reward each step • Don’t modify instruction after giving it • Individuals will learn demands will get easier if they are noncompliant

15. Time-based Breaks • Who would benefit from breaks? • Learners who are noncompliant to escape • Will comply for some period of time • Short breaks interspersed throughout task • Example: Work for 2 min.  30 s break repeat • Length of “work” time between breaks • Based on current behavior • Determine average time before noncompliance • Considerations • Feasibility (Tracking time) • MotivAiders, timer, watch • Difficulty w/ transitions—break in work area

16. Time-based Attention/Toys • Who would benefit? • Learners who are noncompliant to gain attention or items • Will comply for some period of time • Looks procedurally similar to time-based breaks • Learner receives attention or toys instead of break • Attention: High-fives, praise, tickles, pat on the back • Small pieces of snacks • Easily removable toys

17. Common Questions: Time-based Rewards • What happens if the individual is noncompliant? • Time-based not “behavior-based” • Learner receives scheduled break/attention/toy • Why do time-based rewards work? • Decreases motivation for noncompliance • Learner already getting what they want • Do I have to do this all day/every day? • Tasks when noncompliance likely • Will I have to do this forever? • Increase work time • Based on success of learner

18. Learner’s Choice • Learner can control some aspect of instruction • Teacher/Caregiver decision • Allow learner to choose task • Order of tasks: Math or Science first • Type of tasks: Different worksheets • Allow learner to choose location • Work at the table or at the desk • Writing work • Use a colored pencil or a regular pencil • Dressing • Order of dressing, color of shirt/shorts/underwear

19. Consequence Interventions • Substantially more effective than antecedent interventions • Commonly used in combination • What works? • Extinction of noncompliance • Guided Compliance (3-step prompting) • Rewards (toys, foods, etc.) for compliance • Combining breaks with toys/activities as a reward • Not recommended • Time-out for noncompliance

20. Extinction of Noncompliance • Behavioral terminology • Learner doesn’t get what he/she wants • Break • Attention • Toys, Snacks, Activities • Consider reason for noncompliance • Not always feasible • Most effective when combined with reinforcement for compliance!

21. Guided Compliance • Also known as: “Three-step prompting” • Caregiver/Teacher guides learner through task • Step 1: Delivery of instruction • Step 2: Instruction + Model desired behavior • Step 3: Instruction + Physical guidance • Benefits • Teach learner compliance is mandatory • Gives opportunity for independence • Feasibility • Larger learners • Other challenging behaviors

22. Rewards for Compliance • “Functional” reinforcers • Reason for noncompliance • Escape (Break) • Tangible (Toys, edibles, etc.) • Attention (Praise, reprimands, physical prompts) • Use functional reinforcers for compliance • Noncompliance No break (Extinction) • ComplianceBreak (Reinforcement) • Prompted vs. Unprompted Compliance • Different rewards

23. Rewards for Compliance • Rewards should be individualized • Allow learner to choose reward • Verbal learner • Nonverbal learner • Preferences for rewards change • Frequently reevaluate rewards • Alternate highly-preferred rewards • Prevent satiation • If compliance is not increasing evaluate if reward is really a reward

24. Tips for Delivering Rewards • Praise • Enthusiastic • Specific • Physical • All Rewards • Immediate (within 5 s) • Frequent (in the beginning) • Pair praise with other rewards • Preferences for rewards may change

25. Benefits of Token Economies • Allows more time between large rewards • Tokens exchangeable for different rewards • Prevents satiation on one reward • Used across settings • Classroom setting • Easy to use with multiple students

26. Shaping Compliance • Large end goal • Correctly complete a math worksheet independently • Break into smaller steps • Sit at desk • Take out pencil • Complete 1 math problem with assistance • Independently complete 1 math problem • Complete multiple problems • Smaller steps receive rewards • Gradually increase requirement to receive reward

27. Difficult Cases • When physical guidance is not feasible: • Do not allow access to preferred items • Do not acknowledge noncompliance (reprimands) • Continue verbal/gestural prompts every 30 s • Make noncompliance “uncomfortable” • Do not “bribe” or “threaten” • Interference of other problem behaviors • Aggression, property destruction, screaming, self-injury • Treatment for other behaviors • Consider changing the reinforcement for compliance • Magnitude, Quantity, Quality….

28. Generalization • Compliance is a learned skill • Learners with ASD may have trouble generalizing skills • No experience or “history” of rewards • Compliance needs to be practiced • In different settings • With different people • Understand when compliance does not generalize • Know when follow-through is not likely • Grandma’s house • Babysitter

29. Final Considerations • ALWAYS FOLLOW THROUGH! • Don’t give a demand if you can’t follow through immediately • May want to postpone demand • Compliance will not happen overnight • May be regression before progress in the beginning • Don’t use the child’s name exclusively before demands • Labor intensive in the beginning • You will get out what you put in

30. References Carlos A. Zuluaga & Matthew P. Normand. (2008) An evaluation of the high-probability instruction sequence with and without programmed reinforcement for compliance with high-probability instructions. Journal of Applied Behavior Analysis, 41, 453-457. Coleman, C. L., & Holmes, P. A. (1998). The use of noncontingent escape to reduce disruptive behaviors in children with speech delays. Journal of Applied Behavior Analysis, 31, 687-690. David A. Wilder, Janelle Allison, Katie Nicholson, O. Elizabeth Abellon, & Renee Saulnier (2010). Further evaluation of antecedent interventions on compliance: The effects of rationales to increase compliance among preschoolers. Journal of Applied Behavior Analysis, 43, 601-613. Einar T. Ingvarsson, SungWoo Kahng, & Nicole L. Hausman. (2008) Some effects of noncontingent positive reinforcement on multiply controlled problem behavior and compliance in a demand context. Journal of Applied Behavior Analysis, 41, 435-440. Kasey M. Stephenson & Gregory P. Hanley (2010). Preschoolers’ compliance with simple instructions: A descriptive and experimental evaluation. Journal of Applied Behavior Analysis, 43, 229-247. *Kazdin, A.E. (2009). The KAZDIN METHOD for Parenting the Defiant Child: With no pills, no therapy, no contest of wills. New York, NY: Houghton Mifflin Harcourt

31. References Kelly J. Bouxsein, Henry S. Roane, & Tara Harper (2011). Evaluating the separate and combined effects of positive and negative reinforcement on task compliance. Journal of Applied Behavior Analysis, 44, 175-179. Kodak, T., Miltenberger, R. G., & Romaniuk, C. (2003). The effects of differential negative reinforcement of other behavior and noncontingent escape on compliance. Journal of Applied Behavior Analysis, 36, 379-382. Marcus, B. A., & Vollmer, T. R. (1995). Effects of differential negative reinforcement on disruption and compliance. Journal of Applied Behavior Analysis, 28, 229-230. Matthew P. Normand & Lauren Beaulieu (2011). Further evaluation of response-independent delivery of preferred stimuli and child compliance. Journal of Applied Behavior Analysis, 44, 665-669. Piazza, C. C., Moes, D. R., & Fisher, W. W. (1996). Differential reinforcement of alternative behavior and demand fading in the treatment of escape-maintained destructive behavior. Journal of Applied Behavior Analysis, 29, 569-572. Rortvedt, A. K., & Miltenberger, R. G. (1994). Analysis of a high-probability instructional sequence and time-out in the treatment of child noncompliance. Journal of Applied Behavior Analysis, 27, 327-330.