When providing treatment for problem behaviors, many of us have often taught our parents, supervisees, and others “It gets worse before it gets better.” I don’t know how many times I’ve said this over the years, but I can tell you it is a lot. This is a huge obstacle to successful treatment. The fact that it often gets worse initially leads to safety concerns, lack of buy-in from parents or school staff, restraints, seclusion, and potentially giving up on effective treatments. But now, I think this rule doesn’t have to be true. In fact, it might be that it is rarely true. If so, that would solve many implementation problems.
Why Do Problem Behaviors Occur?
When a child is engaging in problem behaviors, the assumption is that they are getting something out of it. In other words, the problem behavior isn’t just random, but there is a real tangible benefit for the child. Now, this doesn’t deny that some behaviors are related to emotional reactions. Just that the vast majority of problem behaviors can be understood if we understand it from the child’s point of view and figure out what benefits they are receiving from the behaviors.
BCBAs will start by trying to figure out the specifics of what kids are getting out of the problem behavior. In my view, recent research is suggesting that it is rarely just one thing. Most likely it is some combination of events like:
- Not having to do something they don’t want to do.
- Getting to do something they do want to do.
- Getting other people to act in a way they want them to act.
- Getting some physical stimulation that makes them feel good.
Why does it often get worse before it gets better?
Once we figure out the benefits the child is receiving from the problem behavior, we design a treatment to eliminate it. That treatment almost certainly has many parts, but virtually always includes not giving them what they want if they engage in the problem behaviors. In other words, the problem behavior abruptly no longer serves its purpose.
So, what happens when normally we get what we want after engaging in a behavior, and then suddenly we don’t? Think of a time when you bought something at a vending machine and nothing came out. First, you probably tried to hit the button several more times. Next, you probably hit the button harder, got angry and maybe punched the machine or complained to someone. That’s the typical reaction. First, we increase the behavior (hit the button several more times). Then we increase the intensity of the behavior (e.g., hit the button harder, got angry, and punched the machine). But eventually, you stopped trying to get your item out of the machine.
That’s what we expect when we use this procedure with kids who engage in problem behaviors.
First, they will increase the amount of the behavior. Next, they will increase the intensity of the behavior and maybe even have serious emotional reactions. But eventually, they will stop engaging in the problem behaviors.
The Conflict
This put BCBAs in a tremendous conflict. On the one hand, we want to have successful treatment in community settings like schools. This requires obvious things like the treatment be safe; strong support from teachers and families; the treatment maintains the dignity of the child. On the other hand, the research literature seems to tell us that successful treatment often requires a “burst” of responding. Without riding out the “burst,” treatment would simply not be effective in many cases. Of course, some treatment of mild problem behaviors might not have this problem. But many, many children seem to need this. What’s the BCBA to do?
False Choice?
There have been several studies suggesting different ways that treatment might be implemented without having to deal with the burst. I’m no longer convinced that going through the burst is necessary for the successful treatment of problem behaviors, as I’ve seen several successful treatments implemented without it.
It is easy to be fooled by the elimination of problem behaviors that won’t last over time. That’s not the critical factor. In my view, the key to successful treatment depends on the teaching of alternative behaviors that will naturally work in the child’s everyday life. That’s most likely to lead to success in the long run. We have always done that. What’s somewhat new is there might be a variety of ways to focus on the alternative behaviors without the need to create a burst. A few potential ideas include making reinforcement for the problem behavior not quite as good as reinforcement for the alternative behavior or simply prompting the appropriate alternative behavior contingent on problem behaviors. These procedures have the potential to dramatically increase safety. In addition, they might increase the time available for instruction if you don’t have long dramatic episodes of problem behaviors.
We don’t have enough research yet to tell us that we can always successfully treat problem behavior without a burst. It is a critical area for future research. I know several research teams are working on this problem. But for now, it is definitely worth considering all the alternatives and not just assuming it will be necessary. There is strong evidence that the burst isn’t always needed.