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Education and Training in Developmental Disabilities, 2007, 42(1), 59 – 64
Division on Developmental Disabilities Functional Analysis and Reduction of Inappropriate Spitting
Abstract: Functional analysis was used to determine the possible function of inappropriate spitting behavior ofan adult woman who had been diagnosed with profound mental retardation. Results of an initial descriptiveassessment indicated a possible attention function and led to an attention-based intervention, which wasdeemed ineffective at reducing the frequency of spitting. A follow-up functional analysis revealed an automaticfunction and an intervention of medication prescribed for gastro-esophageal reflux markedly reduced thefrequency of inappropriate spitting. The implications for using functional analysis as a means of identifyingbiological events such as medical illness are discussed. Identification of variables that influence the difficult due to the complexities of separating the stimuli from the response (Iwata, Dorsey, functional analysis procedures has become Slifer, Bauman, & Richman 1994; Vollmer).
standard practice in the literature on behav- ioral assessment (Hanley, Iwata, & McCord, tained by automatic reinforcement have been 2003). Several variations and extensions of assessed by directly manipulating various idio- syncratic stimuli that could be controlled and demonstrated to be beneficial toward clarify- ruling out competing hypotheses (Kennedy & ing ambiguous results (Kuhn, DeLeon, Fisher, & Wilke, 1999), examining low rate behaviors Inclusion of nonsocial variables in func- (O’Reilly, 1996), or examining temporally dis- tional analyses poses numerous problems such tant events (O’Reilly, 1995). Although inclu- as identifying which idiosyncratic variables sion of additional information in functional may be most relevant to the analysis, isolating analyses have been found to be beneficial to- specific nonsocial variables, and differentiat- ward providing more meaningful results, the ing the presence or absence of specific non- influence of these antecedent events on auto- social variables. Kennedy (2000) proposed a matically reinforced behavior have not been method for addressing ambiguous functional frequently examined in the literature on func- analyses when an automatic function was sug- tional analysis (Hanley et al., 2003).
gested by the results. His method involved Behaviors that are maintained by nonsocial incorporating sensory extinction procedures variables may be considered to be automati- on possible sources of automatic reinforce- cally reinforced (Vollmer, 1994). Nonsocial ment. While sensory extinction procedures have been shown to be effective in identifying maintain behaviors such as pica (Piazza, Han- specific sources of automatic reinforcement ley, & Fisher, 1996), stereotypy (Hanley, Iwata, (Rapp, Miltenberger, Galensky, Ellingson, & Thompson, & Lindberg, 2000), and eye pok- Long, 1999), the utility of these types of pro- ing (Kennedy & Souza, 1995; O’Reilly, 1997).
cedures may be limited with various sources of Although nonsocial variables may be relevantto several maladaptive behaviors, the direct automatic reinforcement. Hanley, Iwata, and manipulation of these nonsocial variables re- sponsible for behavior maintenance may be tional analyses with and without the presenceof physiological or internal states such as ill-ness or drugs in order to clarify the impact ofthese conditions on a specific behavior and to Correspondence concerning this article should be addressed to Stacy Carter, 4518 20th Street, Lub- identify a more accurate and effective treat- ment. Carr (1994) suggested that the utility of functional analysis procedures could be ex- (1996) conducted a functional analysis during tended by investigating nonsocial variables the presence and absence of allergy symptoms such as physiological or internal states. He and sleep deprivation. They distinguished the referred to these variables as biological events presence or absence of allergy symptoms and such as physical illness or drug states. Exami- sleep deprivation by interobserver agreement nation of these biological events implies the among the teachers and parents of the chil- need for incorporating medical examinations dren involved in the study rather than by med- that could be time consuming, costly, and in- ical examination. The results indicated that conclusive. Even with the numerous difficul- both biological events and conditional states ties associated with analyzing the impact of could influence the outcomes of functional biological events on problem behavior, cur- rent research has demonstrated several strate- gies for incorporating these events into a example of a biological event correlated with a life threatening behavior. Their evaluation involved directly manipulating the administra- Conducting functional analyses in the pres- tion of a multivitamin to determine the pres- ence and absence of biological events (i.e.
ence of a previously undiagnosed biological allergy symptoms, otitis media), conditional event (vitamin deficiency). They used a BAB states (i.e., sleep deprivation), and situational design to demonstrate the reductive effects of events (i.e., spending the night in a respite a multivitamin on the pica of a 9-year old facility) have been demonstrated as a benefi- female diagnosed with severe mental retarda- cial means of evaluating these types of vari- tion, iron deficiency, and anemia. Their study ables and has resulted in determining these is unique in that it demonstrated how behav- types of events to be related to the occurrence ioral techniques could be used to determine of problematic behavior (Kennedy & Meyer, the presence of an undiagnosed medical con- 1996; O’Reilly, 1996; O’Reilly, 1997). O’Reilly (1996) conducted a functional analysis during The current study examined the function of the presence and absence of a situational spitting behavior in an adult woman diag- event on the self-injurious behavior of a man nosed with profound mental retardation.
with mental retardation. The functional anal- Both descriptive assessment and functional ysis was conducted following two situational analysis procedures were conducted in an at- events (nights spent at home vs. nights spent tempt to identify an effective intervention to at a respite facility). Conducting the func- reduce the occurrence of inappropriate spit- tional analysis in the presence and absence of ting. Findings from the descriptive assessment these two situational events was beneficial to- were ultimately considered to have led to a ward determining that nights spent in a re- false identification of function. Results of the spite facility were correlated with increased functional analysis were indicative of a possi- self-injury during the next day. O’Reilly ble previously undiagnosed medical condi- (1997) used a functional analysis to determine tion. These results were also used to develop that the presence of a biological event was an effective treatment that consisted of medi- correlated with self-injury. The presence or cation for gastrointestinal reflux disorder.
absence of the biological event in this study(otitis media) could be definitively deter- mined through medical examinations and lab-oratory results. Some biological events may be Participant, Setting, and Dependent Variable difficult to determine due to the lack of avail-able laboratory tests, rapid cycling of events, Sharon was a 31-year-old female resident of a or inconclusive test results. While many bio- state developmental center. She was diag- logical events may present difficulty in pre- nosed with profound mental retardation and cisely determining their presence or absence, functioned at the profound level of adaptive the associated side effects of some of these behavior as measured by the Vineland. Sharon events may be readily apparent (i.e., runny had a verbal repertoire of approximately 20-30 nose, watery eyes, etc.). Kennedy and Meyer words/phrases that she used to name objects 60 / Education and Training in Developmental Disabilities-March 2007 or activities. Her typical daily routine con- from staff on a weekly basis throughout the sisted of self-care activities, meals, sheltered workshop activities, leisure activities, and var- ious recreational activities. A review of docu- was conducted following procedures similar to mentation over the previous ten years indi- those described by Iwata et al. (1982/1994).
including the following: noncompliance, ex- three consecutive days (day 114, 115, & 116) cessive salivation, regurgitation, tantrums, and using 10 min. sessions. The five conditions aggression. Prior to initiating this study, the manipulated during the functional analysis author consulted with Sharon’s primary care consisted of an alone condition, an attention physician regarding any possible existing med- condition, a demand condition, a play condi- ical conditions. The physician indicated that tion, and a tangible condition, which were no known medical conditions could be deter- alternated, in a multielemental design. Dur- mined from recent medical examinations that ing the alone condition, Sharon was placed in might be associated with the target behavior a room by herself and observed via a one way of inappropriate spitting. During the course mirror. During the attention condition, the of this study, the only maladaptive behavior observed and/or reported by staff involved spitting by delivering a reprimand (e.g., “Stop spitting saliva. The target behavior of inappro- spitting Sharon, it is not nice”). The demand priate spitting was defined as expelling fluid condition consisted of sheltered workshop from the mouth onto floor or location other tasks (e.g., folding paper, shredding paper) than sink or cup. One incident of inappropri- and each occurrence of inappropriate spitting ate spitting was documented each time saliva was followed by 30 s of escape from the task.
was expelled past the lips and contacted an- During the play condition, Sharon had access other surface area. A criterion of 30 s of no to her favorite activities and the experimenter occurrence of target behavior was used to dis- delivered noncontingent attention every 30 s tinguish between episodes. The distinction be- with no specified consequence for inappropri- tween episodes was necessary due to instances ate spitting. The tangible condition consisted of saliva lingering past the lips in long strands and a highly preferred object (magazine).
The experimenter held the object away fromSharon unless inappropriate spitting oc- Procedures, Conditions, Experimental Design curred. Upon each occurrence of inappropri- ate spitting, the experimenter carried the pre- were interviewed independently using a Func- ferred object to Sharon and handed it to her tional Analysis Screening Tool (FAST; item by for 30 s. After Sharon had held the preferred item inter-rater reliability ϭ 94%). An analysis object for 30 s, the experimenter took the of potential maintaining variables recorded object away from Sharon. Inter-observer reli- during direct observations in typical daily ac- ability was conducted during 100% of sessions tivities such as vocational tasks, mealtimes, self-care tasks, and leisure time was con- ducted. Throughout all phases of the study, lowing the same procedures described during direct support staff collected data on all ob- Assessment Phase 2 was conducted with Sharon.
served episodes of target behavior that oc- This functional analysis was completed on three curred during her typical daily routine Reli- consecutive days (days 274, 275, and 276) when ability data was obtained from weekly direct Sharon was receiving 30 mg Prevacid. Inter-ob- observations of Sharon by the author and an- server reliability was conducted during 67% of other trained observer, and monthly observa- tions and interviews with staff regardingimplementation of procedures. Weekly reli- ability observations and monthly interviewswith staff regarding implementation of proce- During Phase 1, staff was trained to imple- dures were 100%. Data sheets were obtained Figure 1. Functional analysis of inappropriate spitting.
social interaction, preferred materials, or pre- direct observations indicated the inappropri- ferred snacks. In addition, staff were in- ate spitting to be maintained by staff attention structed to implement an extinction (EXT) in the form of reprimands (i.e., “Stop spit- procedure which consisted of ignoring epi- ting”, “That is dirty”, etc.). Additionally, an sodes of target behavior. In Phase 2, staff con- intervention consisting of noncontingent re- tinued to implement conditions described in inforcement (NCR) and extinction was devel- oped. The initial functional analysis depicted Reglan each day. With Phase 3, staff contin- in Figure 1, resulted in the highest percentage of intervals of inappropriate spitting occur- ring the alone conditions. This represented Reglan and 30mg Prevacid. During Phase 4, an automatic reinforcement contingency for staff continued to implement conditions de- the inappropriate spitting. The intervention scribed in Phase 1 and Sharon was prescribed derived from these results consisted of addi- 30mg Prevacid (10mg of Reglan was discon- tional consultation with Sharon’s primary phy- tinued). At Phase 5, staff was told to discon- sician in an attempt to determine any existing medical conditions. The physician was unable scribed in Phase 1 and Sharon was prescribed to determine any existing medical conditions but suggested a trial of medication for gastro-esophageal reflux disorder. The results of thesecond functional analysis resulted in zero oc- Results of both FAST interviews indicated themaintaining variables of inappropriate spit- The results of the intervention procedures are ting as attention from staff. Results of the depicted in Figure 2. Phase 1 of the interven- 62 / Education and Training in Developmental Disabilities-March 2007 Figure 2. Baseline and treatment of inappropriate spitting.
tion (NCR ϩ EXT) resulted in variability of larger response class of behaviors (Hanley et episodes of inappropriate spitting with the al., 2003). The results of this study demon- range of episodes per day increasing from strate a decrease in episodes of inappropriate daily baseline occurrences. Phase 2 of the in- spitting with the introduction of medication routinely prescribed for gastroesophageal re- resulted in more stability among episodes of flux disorder (GERD). The functional analysis inappropriate spitting represented by a lower in this study was beneficial in identifying a range of daily occurrence. Phase 3 of the in- possible physiological event which may have been associated with occurrences of inappro- 30mg Prevacid) resulted in a noticeable de- crease in episodes of inappropriate spitting An important limitation of the study is the with the daily ranges from 0 to 2 occurrences.
fact that the biological event (GERD) consid- Phase 4 of the intervention (NCR ϩ EXT ϩ ered to be effecting the inappropriate spitting 30mg Prevacid) resulted in an overall de- was not directly manipulated or controlled.
crease in the frequency of inappropriate spit- Reduction in inappropriate spitting appeared ting episodes from the previous phase with to be directly associated with medication rou- similar daily ranges (0 to 2 occurrences).
Phase 5 of the intervention (30mg Prevacid) highly indicative of the presence of this disor- resulted in high stability with only two epi- der. Additional information could have been sodes of inappropriate spitting occurring obtained to clarify the presence of the disor- throughout with a daily range of 0 to 1 epi- der such as evidence of erosion of the esoph- agus, but this may only have been present inlater stages of the disorder which may nothave been an issue since the inappropriate Discussion
spitting had only recently been reported as This study demonstrates use of functional analysis procedures for assisting in diagnosis noted during routine medical examinations.
of a possible medical disorder. Utility of func- Prior to implementing medication, the pres- tional analysis procedures with the behavior of ence of a condition such as GERD could not be ruled out completely due to varying de- strated within the literature apart from a grees of the effects of this particular condi- tion, the fact that the participant was not ca- havior Analysis, 27, 197–209. (Reprinted from pable of providing self-report information, Analysis and Intervention in Developmental Disabili- and the lack of clearly identifiable symptoms to validate the presence of the disorder.
Kennedy, C. H. (2000). When reinforcers for prob- The importance of this study is the practical lem behavior are not readily apparent. Journal ofPositive Behavior Interventions, 2, 195–201.
implications of using functional analysis pro- Kennedy, C. H., & Meyer, K. A. (1996). Sleep depri- cedures toward identifying a possible medical vation, allergy symptoms, and negatively rein- condition. Identification of automatic rein- forced problem behavior. Journal of Applied Behav- forcement as the primary maintaining variable for a problem behavior could indicate the Kennedy, C. H., & Souza, G. (1995). Functional presence of a biological event that might not analysis and treatment of eye-poking. Journal of otherwise be recognizable based on the pre- Applied Behavior Analysis, 28, 27–37.
senting symptomology. Previous research in- Kuhn, D. E., DeLeon, I. G., Fisher, W. W., & Wilke, volving biological events focused on establish- A. E. (1999). Clarifying an ambiguous functional ing operations that were relatively easy to analysis with matched and mismatched extinctionprocedures. Journal of Applied Behavior Analysis. 32, define (McGill, 1999). The current study ex- tends previous research investigating biologi- McGill, P. (1999). Establishing operations: Implica- cal events acting as establishing operations by tions for the assessment, treatment, and preven- evaluating a biological state that was not tion of problem behavior. Journal of Applied Behav- clearly definable. In addition, functional anal- ior Analysis, 32, 393– 418.
ysis was demonstrated to possibly be comple- O’Reilly, M. F. (1995). Functional analysis and treat- mentary toward determining a medical diag- ment of escape-maintained aggression correlated with sleep deprivation. Journal of Applied Behavior identifying the influence of other less clearly definable biological states in conducting func- O’Reilly, M. F. (1996). Assessment and treatment of episodic self-injury. A case study. Research in Devel- tional analysis and the additional contribu- opmental Disabilities, 17, 349 –361.
tions that functional analysis may have toward O’Reilly, M. F. (1997). Functional analysis of epi- sodic self-injury correlated with recurrent otitismedia. Journal of Applied Behavior Analysis, 30, References
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