Behavior problems

J Dev Phys Disabil (2013) 25:91–104
DOI 10.1007/s10882-012-9305-1
ORIGINAL ARTICLE
Development of a Combined Intervention to Decrease
Problem Behavior Displayed by Siblings with Pervasive
Developmental Disorder
Niamh M. Doyle & Nicole M. DeRosa &
Henry S. Roane
Published online: 12 October 2012
# Springer Science+Business Media New York 2012
Abstract Approximately 10–20 % of children with pervasive developmental disor-der
are likely to have a sibling with that disorder. Under such circumstances, care-givers
may be faced with simultaneously implementing separate interventions for
their children. Merging different treatments to decrease both children's problem
behavior may permit for more fluid parent responses and increased procedural
integrity. The current study describes one approach to treating problem behavior
displayed by siblings with autism. Separate functional analyses identified a different
maintaining reinforcer for each child's aggression. These behaviors were initially
treated separately using functional communication training and delay fading. To
ensure that the caregiver would be able to manage these siblings' behaviors concur-rently,
a protocol using differential reinforcement of other behaviors was imple-mented
that was based on the separate functions of each child's behavior.
Keywords Parent training . Group contingency . Problembehavior
Recent studies have indicated that caregivers of children with pervasive developmen-tal
disorders (PDDs) often experience symptoms of anxiety and depression (Griffith
and Richard 2010; Quintero and McIntyre 2010). Such symptoms can and often are
exacerbated if the child also engages in problem behavior (e.g., aggression, disrup-tion,
self-injurious behavior [SIB]). Parent training focusing on the implementation of
behavioral interventions for problem behavior has reportedly been effective in dimin-ishing
the negative experiences associated with caring for children with a variety of
N. M. Doyle : N. M. DeRosa : H. S. Roane
SUNY Upstate Medical University, The Kelberman Center, Syracuse, NY, USA
N. M. Doyle (*)
Department of Pediatrics, Upstate Medical University, 600 E. Genesee Street, Suite 124, Syracuse, NY
13202, USA
e-mail: doylen@upstate.edu

92 J Dev Phys Disabil (2013) 25:91–104
diagnoses, including autism (Farley et al. 2005; Pelham and Fabiano 2008). Several
studies have examined the effectiveness of parent training in regard to both increasing
children’s adaptive behavior skills, as well as decreasing problem behavior (Ben
Chaabanne et al. 2009; Lerman et al. 2000; Meaden et al. 2009; Moes and Frea 2002;
Smith and Lerman 1999). However, the effectiveness of parent training for caregivers
in multiplex families (e.g., families with more than one child diagnosed with autism)
has not been well studied.
Approximately 10–20 % of children with autism also have a sibling diagnosed
with the disorder (Constantine et al. 2010). Given that destructive behavior (e.g., SIB,
aggression, or disruption) is common among children with developmental disabil-ities,
parents of multiplex families may have to simultaneously implement separate
behavior interventions. Additionally, group comparisons suggest that non-disabled
siblings of children with autism may display characteristics of the disorder, as well as
engage in severe problem behavior (Constantine et al. 2010; Petalas et al. 2009;
Rodriguez et al. 1993; Ross and Cuskelly 2006). The implementation of separate
interventions for more than one child may result in increased symptoms of anxiety
and/or depression for caregivers, as well as potentially result in poor procedural
integrity of one or both behavior interventions.
The implementation ofmultiple treatmentsmay be similar to treating problem behavior
that is maintained by multiple reinforcement contingencies (e.g., Borrero and Vollmer
2006; Day et al. 1994; Ingvarsson et al. 2008; Lalli and Casey 1996; Smith et al.
1993). More specifically, implementing multiple treatments can often be associated
with several different procedural variables, such as different discriminative stimuli,
communicative responses, prompting procedures, and contingencies for appropriate
and problem behavior. Previous treatments for multiply controlled problem behavior
have included separate interventions for each reinforcement contingency (Borrero
and Vollmer 2006; Day et al. 1994; Smith et al. 1993) or treating both functions
through the use of a highly preferred stimulus (e.g., food; Ingvarsson et al. 2008).
Several authors have examined an alternative treatment approach for implement-ing
multiple treatments simultaneously that involves merging the establishing oper-ation
(EO) for multiple maintaining variables into a single context (Bachmeyer et al.
2009; Call et al. 2005). An EO is an environmental event that (a) increases the
effectiveness of a stimulus as a reinforcer and (b) increases the probability of the
occurrence of behaviors that have produced that reinforcer in the past.
Bachmeyer et al. evaluated individual and combined function-based extinction
procedures for children whose inappropriate mealtime behavior was maintained
by both positive and negative reinforcement. Attention extinction alone did not
reduce problem behavior or increase acceptance of foods, while escape extinc-tion
increased acceptance and reduced problem behavior, but not to clinically
acceptable levels. Therefore, the combination of attention and escape extinction
was evaluated and found to be effective in reducing inappropriate mealtime
behavior, as well as maintaining high and stable acceptance. Call et al. com-pared
single-antecedent functional analysis test conditions and combined-antecedent
test conditions. In that study, problem behavior was only observed
during the combined-antecedent test conditions, suggesting false-negative results
from the single-antecedent assessment. Treatments derived from the results of the
combined-antecedent functional analysis were effective in reducing occurrences of

J Dev Phys Disabil (2013) 25:91–104 93
problem behavior. Both of these studies demonstrate that interventions, which targeted
multiple reinforcement contingencies, can be effective in reducing targeted problem
behavior when implemented by trained therapists within analog settings. However, it
remains unknown if the effectiveness of such combined interventions maintains when
implemented by caregivers.
The purpose of the current study was twofold. In Study 1, we sought to evaluate
differential treatments for siblings diagnosed with PDD whose problem behavior was
maintained by different functional reinforcers. Second, we examined the integration
of the two different behavioral interventions, using procedures similar to that of
Bachmeyer et al. (2009) and Call et al. (2005), such that a combined treatment could
be implemented for both children by their caregiver.
General Procedures
Participants and Settings
Molly was an 8-year-old girl who had been previously diagnosed with a variety
of behavior disorders, including PDD-Not Otherwise Specified (PDD-NOS),
Attention Deficit/Hyperactivity Disorder, and Oppositional Defiant Disorder.
She was referred to an outpatient clinic for the treatment of aggression. She
attended the clinic 3 days per week, for one 1.5-h appointment per day. Her
brother Sam was 7-years old and had been previously diagnosed with PDD-NOS
and Disruptive Behavior Disorder. He was referred to the same outpatient
clinic for the treatment of aggression and disruption. Sam attended the clinic on
the same schedule as Molly, though his initial treatment evaluation occurred
following the conclusion of Molly’s admission. Both Molly and Sam partici-pated
in Study 1 and Study 2.
During Study 1, sessions occurred in individual treatment rooms (4 m×4 m) for
both Molly and Sam. The rooms were equipped with a one-way observation window
as well as various materials that depended on the condition in effect (e.g., table,
chairs, preferred toys). During Study 2, sessions were conducted in a play area with
both children and a therapist or the participants’ mother present. Baseline sessions in
Study 1 were 5 min in duration, whereas treatment session durations varied according
to individual protocols (described below). In Study 2, baseline sessions were 5 min in
duration and treatment sessions varied based on the delay interval in place. For both
participants, 3 to 5 sessions were conducted daily.
Response Measurement and Reliability
Aggression for both children was defined as contact, or attempted contact of hands,
feet or legs against another person from a distance of 15 cm or greater; applying, or
attempting to apply, force to a person’s body (e.g., pushing or pulling a person off
balance or in a direction opposite of the person’s original movement); throwing an
object at a person; pulling on another person’s hair; and pinching, scratching, or
biting another person. Sam’s disruptive behavior was defined as throwing an object at
a wall or a stationary object from a distance of 30 cm or greater; kicking or hitting

walls or windows; and turning or attempting to turn over furniture. The target
communication response for Molly was a card exchange which consisted of Molly
removing a card with the words, “Play, please” written on it, from the wall and
placing it in the therapist’s hand. The communication response for Sam was vocally
saying the phrase, “May I play with the ball, please.” For both participants, the
targeted communication response was taught prior to their respective initial treatment
analysis using the procedures described by Worsdell et al. (2000).
Frequency data were collected for all dependent measures using laptop computers
equipped with data-collection software. For the purpose of data analysis, all frequency
data were converted to a response rate (responses per min; rpm). A second observer
independently collected interobserver agreement (IOA) data during 33.9 % of all
sessions. Exact agreement was calculated by partitioning each session into 10-s intervals
and dividing agreements by total agreements plus disagreements and multiplying by
100. An agreement was scored when both observers recorded the occurrence of a
response in the same 10-s interval, and a disagreement occurred when they did not.
During Study 1, the mean IOA for Molly’s aggression and communication was 98.3 %
(range, 83.3 % - 100 %) and 99.9 % (range, 96.7 % - 100 %), respectively. The mean
IOA for Sam’s aggression, disruption, and communication during Study 1 was 94.3 %
(range, 68.3 % - 100 %), 99.7 % (range, 96.7 % to 100 %), and 98.3 % (range, 88.3 % -
100 %), respectively. During Study 2, IOA for Molly’s aggression averaged 99.3 %
(range, 89.2 % - 100 %), IOA for Sam’s aggression averaged 99.4 % (range, 89.2 % -
100 %), and IOA for Sam’s disruption was 100 %.
Study 1: Individual Treatment Evaluations
Method
Preference Assessment Prior to each participant’s functional analysis, a paired-stimulus
preference assessment (Fisher et al. 1992) was conducted separately for
Molly and for Sam. During the preference assessment, a therapist presented a pair of
items to the participant and instructed him/her to make a choice (e.g., “Molly, would
you rather play with the ball or play on the computer?”). Following a selection, the
participant was allowed to engage with the selected item for 30 s. The assessment
continued until each toy was presented with every other toy one time. A hierarchy of
preference was determined based on the percent of trials during which Molly and
Sam selected each item. Results of this assessment were used in the subsequent
functional analysis and treatment evaluations.
Functional Analysis A functional analysis (FA), based on the procedures described
by Iwata et al. (1982/1994) with modifications as described by Fisher et al. (1996),
was conducted with each sibling. Molly and Sam were both exposed to demand,
tangible, ignore, and toy play conditions. Additionally, Molly was exposed to a
diverted attention condition, whereas Sam was exposed to a “standard” attention
condition. During the demand condition, a therapist and the participant were seated at
a table with instructional materials. The therapist instructed the participant to com-plete
instructions using a three-step prompting hierarchy (successive verbal, gestural,
and physical prompts) with no more than 5 s between each prompt. Praise was

delivered contingent on compliance following either the verbal or gestural prompt.
Contingent on a targeted response (e.g., aggression), a 20-s break from instructional
demands occurred. Prior to each tangible session, the participant received approxi-mately
2 min of pre-session access to his or her preferred item. Thereafter, the
therapist removed the toy from the participant and kept it within sight but out of
reach. The occurrence of a targeted response resulted in 20-s access to the preferred
item. During the ignore condition, a therapist and participant were in the room with
no materials present. The therapist did not interact with the participant throughout the
session and no consequences were provided contingent on a targeted response.
During the toy play condition, the therapist and participant were in the room with
the participant’s highly preferred toy. The participant had access to the toy and the
therapist interacted with the participant throughout the session, providing praise
statements approximately every 30-s. No demands were delivered and no consequen-ces
were provided contingent on a targeted response. During the diverted attention
condition for Molly, two therapists and the participant were in the room with a low
preferred toy. The two therapists engaged in a conversation with each other while
Molly had access to a low preference toy. Contingent on a targeted response one
therapist provided 20 s of attention in the form of verbal reprimands (e.g., saying,
“Molly, stop that. We’re trying to talk.”). During Sam’s attention condition, a
therapist was in the room with Sam, and Sam had access to a low preference toy
while the therapist was reading. Contingent on a targeted response Sam received 20-s
of attention in the form of verbal reprimands (e.g., saying, “Sam, it’s not nice when
you throw something at me. You might break the window.”).
Initial Treatment Analysis—Molly The initial treatment for Molly’s aggression was
evaluated using a reversal (ABCBD) design, including baseline, functional commu-nication
training (FCT), FCT+extinction (EXT), and FCT+EXT+Toys conditions.
Baseline sessions were identical to the diverted attention condition of the FA. During
all subsequent treatment conditions a card with the words, “Play, please”, was
attached to the wall. Contingent on a card exchange, Molly received access to adult
attention (e.g., saying, “Great job handing me the card, let’s play.”) and interactive
play for 20 s on a fixed-ratio (FR) 1 schedule of reinforcement. During the FCT
condition, aggression also resulted in access to attention (e.g., saying, “Molly you
shouldn’t hit me that hurts.”) for 20 s on an FR-1 schedule. During the FCT+EXT
condition, aggression was placed on EXT (i.e., no longer produced access to atten-tion)
such that only card exchanges produced adult attention and interactive play.
Aggression remained on EXT, card exchanges were reinforced with 20 s of attention
on an FR-1 schedule, and Molly had continuous access to her most preferred toy (i.e.,
a game played on a laptop computer) throughout the FCT+EXT+Toys condition.
During the second exposure to the FCT-only condition, delay fading for the commu-nication
response was introduced and remained in place throughout subsequent
sessions. Delay fading consisted of increasing the duration of time (initially up to
40 s) before the “Play, please” card was presented (as described by Roane et al. 2004)
and Molly was able to engage in a communicative response to gain access to
attention. Subsequent delay fading in the FCT+EXT and FCT+EXT+Toys condi-tions
progressed to a 346-s and an 1,800-s delay, respectively. Throughout delay
fading, the reinforcement interval remained constant at 20 s.

Initial Treatment Analysis—Sam The treatment analysis for Sam was evaluated
within a reversal (ABABAB) design, including baseline and FCT conditions.
Baseline sessions were identical to the tangible condition of the FA. During the
FCT condition, both appropriate communication and problem behavior (combined
aggression and disruption) were reinforced on an FR-1 schedule. Reinforcement
included 20-s access to a toy ball (Sam’s most preferred item as determined by the
initial preference assessment). In addition, a multiple-schedule procedure (Hanley et al.
2001) was used during the FCT condition to increase the delay to reinforcement.
During the multiple schedule, the presentation of a red piece of construction paper
(approximately 21 cm×27.5 cm) signaled that communication was on EXT while
problem behavior was reinforced. After a designated period of time, the red-card
interval ended and an identically sized green card was presented. The green card
signaled that both communication and problem behavior were reinforced. The cards
were alternated across sessions such that longer delays occurred prior to the green card
being presented (i.e., communication resulting in reinforcement). During the final FCT
phase, delays to reinforcement for successive sessions increased to variable durations
that averaged 300 s (range within session0180 s to 420 s), 450 s (range within session0
330 s to 570 s), and 600 s (range within session0480 s to 720 s). Throughout delay
fading for Sam, the reinforcement interval remained constant at 20 s.
Results
Results of Molly’s FA indicated that her aggression was maintained by access to adult
attention (data from the FA are available upon request). Figure 1 displays the results
for Molly’s treatment evaluation. During baseline, Molly engaged in moderate to high
rates of aggression (M01.1 rpm; range, 0.4–2.6 rpm). During the initial FCT phase,
Molly continued to engage in moderate to high rates of aggression (M01.3 rpm;
range, 0.3–3.8 rpm); thus EXT for problem behavior was implemented during the
third phase. During FCT+EXT, rates of aggression immediately decreased to near-zero
levels and generally occurred at relatively low to moderate rates throughout the
remainder of the phase (M00.3 rpm; range, 0–1.6 rpm). However, per caregiver
request a return to the FCT condition was implemented. Specifically, Molly’s mother
stated that she would be unable to ignore Molly’s aggression. When the EXT
component was removed, rates of aggression continued to remain low (M00.3 rpm;
range, 0–1.3 rpm), so delay fading was initiated. Consistent reductions in aggression
were not maintained when FCT was implemented in the absence of EXT while delay
fading occurred (M00.6 rpm; range, 0–2.8 rpm). Therefore, FCT+EXT was re-implemented
with inclusion of delay fading, starting with a 5-s delay, which was
again associated an inconsistent pattern of responding (M00.5 rpm; range, 0–
3.2 rpm). The final phase, FCT+EXT+Toys, began with a delay of 231 s.
Aggression decreased to zero following the initial session. A return to a 346-s delay
initially resulted in elevated rates of aggression, which decreased to zero and
remained at near-zero rates with increases in the delay up to 1,800 s (M00.3 rpm;
range, 0–3.5 rpm across all FCT+EXT+Toys sessions).
Results of Sam’s FA indicated that his problem behavior (aggression and disrup-tion)
was maintained by access to tangible items (data available upon request). The
treatment analysis for Sam is depicted in Fig. 2. During baseline, Sam engaged in

Fig. 1 Results of the initial treatment analysis for Molly. Arrows denote the session at which a given delay
interval was introduced. The accompanying numbers represent the duration of each delay (in seconds)
relatively stable rates of problem behavior (M02.0 rpm; range, 1.9–2.2 rpm).
Implementation of FCT with a 5-s delay resulted in problem behavior immediately
decreasing to near-zero across the first 3 sessions. Following a brief increase in
problem behavior, low rates of aggression were observed across the remainder of
the condition (M00.6 rpm; range, 0–2.9 rpm). Variable, but generally higher levels of
problem behavior occurred during the reversal to baseline (M02.3 rpm; range, 0–
8.0 rpm). When the FCT condition was introduced with delay fading, problem
behavior immediately decreased and maintained at near-zero levels, with few excep-tions
up to a 300-s delay interval (M00.3 rpm; range, 0–3.2 rpm). During the final
return to baseline, problem behavior increased to moderate levels (M01.0 rpm; range,
0.1–2.4 rpm). The final FCT phase resulted in the maintenance of near zero-rates of
problem behavior up to a 600-s delay to reinforcement (M00.3 rpm; range, 0–
2.3 rpm).
Study 2: Combined Treatment Evaluation
The FAs for both participants revealed different maintaining reinforcement contin-gencies
for their respective problem behavior. Subsequent to the FAs, an effective
treatment was developed for both participants. In addition, delay fading was

Fig. 2 Results of the initial treatment analysis for Sam. Arrows denote the session at which a given delay
interval was introduced. The accompanying numbers represent the duration of each delay (in seconds)
conducted for both participants such that there was a delay to reinforcement of at least
600 s. Despite these outcomes, the treatments were distinct for each participant. Such
a scenario may be impractical for caregivers (e.g., the caregiver would have to
implement separate treatment procedures for each child, possibly at the same time).
For that reason, the purpose of Study 2 was to merge the treatment contingencies for
both participants such that their mother could implement an effective, integrated
treatment.
Method
During baseline, we attempted to develop a condition that would combine the
relevant EOs for each participant (Bachmeyer et al. 2009; Call et al. 2005). Recall
that the EO for Molly’s aggression was attention deprivation, whereas the EO for
Sam’s problem behavior was restriction of preferred items. Thus, in the combined
baseline condition, we restricted access to attention for Sally and restricted access to
the preferred item for Sam. Specifically, throughout baseline Molly had access to
Sam’s toy but the attention of the therapist was diverted toward Sam (i.e., the adult
engaged in a conversation with Sam while Molly played with Sam’s preferred toy).
Contingent on problem behavior Sam received 30-s access to his preferred toy or

Molly received 30-s of attention from the therapist. There was no other attention
available to Molly and no alternative toys for Sam to engage with during the
combined baseline condition. The reinforcement contingencies operated indepen-dently
for both participants, and both reinforcers could be delivered simultaneously.
One concern in developing a treatment in this baseline context was that both
participants could request reinforcement at the same time, which might have resulted
in high rates of reinforcement and caregiver engagement (which could interfere with
the caregiver’s ability to engage in other household-related responsibilities).
Therefore, after consultation with the participants’ mother, we evaluated a combined
differential reinforcement of other behavior (DRO) contingency as a treatment.
During the DRO condition, which was first implemented with Molly, a therapist
informed Molly of the contingency prior to each session by stating, “I am going to set
the timer for 10 min. If you can play for 10 min without hitting, kicking, throwing
things, or biting, you can have the laptop computer. If you hit, kick, throw things, or
bite I will reset the timer for 10 min.” Molly was prompted to repeat the rules and
then a timer was set for 10 min and placed within view of both participants. If Molly
met the DRO contingency, she received 1-min access to the laptop and attention (e.g.,
praise, interactive play) from the therapist. Contingent on the occurrence of aggres-sion
by Molly, the therapist would reset the timer and would explain why the timer
was being reset. Whilst the DRO contingency was in place for Molly, Sam remained
in baseline contingencies (i.e., if Sam engaged in problem behavior he gained 30-s
access to his preferred toy).
Once decreased rates of aggression were observed for Molly, the DRO contingen-cy
was applied to Sam’s behavior. The DRO contingency for Sam was identical to
that described previously for Molly, with two exceptions. First, the pre-session rules
were modified to include a revised description that stated if either Molly or Sam
engaged in one of the targeted topographies of problem behavior, then the timer
would be reset. Second, the DRO contingency addressed problem behavior displayed
by either child. That is, contingent on problem behavior by either participant, the
therapist reset the timer and explained to both participants why the timer was being
reset; thus, the DRO contingency affected both participants such that problem
behavior exhibited by one participant reset the DRO interval for both participants
(i.e., a group DRO contingency; e.g., Kamps et al. 2011). If both children success-fully
completed the DRO interval, Molly gained access to the laptop and adult
attention for 1 min and Sam gained access to his preferred toy for 1 min.
The combined treatment was evaluated within a multiple-baseline across participants
design. Initially both participants were exposed to baseline sessions. Following success-ful
implementation of the combined DRO procedure with a therapist, the participants’
mother was trained to implement the treatment contingency as described above.
Results
Figure 3 displays the results of the combined treatment. During baseline, Molly (top
panel) engaged in moderate rates of aggression (M01.1 rpm; range, 0–1.8 rpm).
During implementation of the DRO contingency for Molly, aggression decreased
throughout the course of the treatment (M00.07 rpm; range, 0–0.2 rpm). Throughout
baseline, Sam (bottom panel) engaged in somewhat variable, yet moderate rates of

Fig. 3 Results of the combined treatment analysis for Molly (top panel) and Sam (bottom panel)
problem behavior (M01.5 rpm; range, 0–2.3 rpm). Upon implementation of the
combined DRO contingency, Sam’s problem behavior immediately decreased (M0
0.06 rpm; range, 0–0.1 rpm).
Following decreases in problem behavior for both participants under the combined
DRO treatment, the treatment was withdrawn and the baseline contingencies were re-implemented
for both participants simultaneously. At this point, the participants’
mother implemented all sessions. During baseline, increases in problem behavior
were observed for both Molly (M00.8 rpm; range, 0.4–1.6 rpm) and Sam (M0
2.1 rpm; range, 0.5–6.4 rpm). Upon implementation of the combined DRO treatment
by the mother, both participants’ problem behavior dropped to near-zero (M0
0.08 rpm; range, 0–0.1 rpm and M00.08 rpm; range, 0–0.5 rpm for Molly and
Sam, respectively).
Discussion
In the current investigation we evaluated a procedure for simultaneously implement-ing
an intervention that addressed the function of two siblings’ problem behavior. In
Study 1, individual treatments were evaluated for each participant based on the results

of an FA. Although both effectively reduced the occurrence of problem behavior,
additional concerns led to the development of a combined treatment. Thus, the
relevant EOs for both participants were combined to develop a single baseline
condition. A DRO procedure was then superimposed on this baseline to address the
problem behavior of both children by affecting access to their functional reinforcers.
Results indicated that the combined DRO effectively maintained low rates of problem
behavior. Moreover, reductions in problem behavior maintained when the partici-pants’
mother served as the therapist.
Previous studies have demonstrated that parent training focusing on interventions for
the treatment of problem behavior can be successful across several clinical populations
(Farley et al. 2005; Pelham and Fabiano 2008). However, the existing literature is
limited with respect to parent-training studies that have focused on the simultaneous
implementation of separate behavior interventions for more than one child within a
single household (i.e.,multiplex families). The current investigation offers a preliminary
method for addressing problematic behavior that can occur in multiplex families.
To date, there have been several studies that have merged multiple treatments into
a single, multi-component intervention (Bachmeyer et al. 2009; Call et al. 2005).
Such studies have done so by introducing multiple EOs concurrently and developing
a function-based treatment that addressed all relevant operant variables. However,
these previous analyses have focused on an intervention for a single individual whose
problem behavior was maintained by multiple environmental variables. The current
investigation extended this work by demonstrating that multiple treatments can be
combined into a single treatment to effectively reduce the occurrence of problem
behavior for two individuals. Additionally, the effects of the combined treatment were
maintained when the siblings’ mother implemented the procedures.
Although reductions in targeted problem behavior were maintained when the
participants’ mother implemented treatment, data on procedural integrity were not
collected and it is therefore unknown, aside from anecdotal observation, whether or
not the mother implemented procedures correctly. Also, all sessions were conducted
within an analog setting and the long-term effects of the combined treatment within
the home setting are unknown. Data on procedural integrity and generalization into
community or home settings represent a critical advancement for future research.
The generality of the current results is also limited by other factors. For example,
this investigation reported results for one set of siblings. The current participants
displayed many diagnostic and behavioral features that may have impacted the
efficacy of the combined treatment. For example, both children were diagnosed with
similar disorders, which reflect a similar level of impairment (in the present cases,
relatively mild). Siblings who display more varied clinical presentations would
presumably be difficult to treat in a combined manner (e.g., one sibling might be
able to attend to discriminative stimuli better than another). Also, the current partic-ipants
displayed problem behavior that was topographically similar. Thus, the rele-vant
types of problem behavior that a caregiver would need to attend to could affect
treatment outcomes. As an illustrative example, previous research has shown that
observers’ record of behavior degrades as the number of target behaviors under
observation increases (cf., Kazdin 1977). It is likely that additional topographies of
behavior across siblings could negatively impact a caregiver’s ability to implement
specific contingencies with a high degree of integrity.

Perhaps a more limiting concern is that, although the current participants displayed
behavior that was sensitive to different reinforcement contingencies, both exhibited
problem behavior that was maintained by positive reinforcement. If both negative and
positive reinforcement were involved that could possibly cause greater difficulties in
treatment design and implementation by a caregiver. It should be noted, however, that
several previous investigations have developed procedures for combining EOs that
address different reinforcement contingencies (Bachmeyer et al. 2009; Call et al.
2005; Smith et al. 1993).
There are a few other variables that impact the current results. First, the combined
DRO procedure was implemented following successful (individual) treatment with
FCT. It is therefore unknown if similar results would have been obtained without such
a history. Also, the FCT and DRO procedures for Molly produced differential
reinforcement of her functional reinforcer (attention), yet both also utilized access
to a highly preferred reinforcer. It is possible that the use of the preferred toy alone
would have been sufficient to decrease the occurrence of Molly’s problem behavior
(Fischer et al. 1997; Hanley et al. 1997). Finally, the baseline and treatment con-ditions
were implemented simultaneously for Molly and Sam when their mother
began conducting sessions. As such, this aspect of the combined treatment analysis
did not afford a demonstration of experimental control in and of itself. However, the
initial effects of the combined DRO procedure were demonstrated in accordance with
a multiple baseline across participants design, and the removal and subsequent
reintroduction of the baseline and treatment conditions with the mother serving as
the therapist approximated a reversal design (i.e., successive introduction and remov-al
of the independent variable).
In considering future directions for studies on multiplex families and the difficul-ties
inherent in managing multiple problem behaviors, the importance of including
caregivers in all aspects of treatment should not be underestimated. If the intention is
to have caregivers independently manage behavior, then training them in defining
behaviors, collecting data, identifying the functions of the behavior as well as
implementing a function-based treatment should be the ultimate goal of clinicians.
Previous research has demonstrated that various professional and para-professionals
can be trained in such skills in a relatively time efficient manner (e.g., Phillips and
Mudford 2008; Wallace et al. 2004). In addition, previous research has suggested that
caregivers of single children with disabilities suffer high levels of anxiety and
depression (Hastings 2003; Quintero and McIntyre 2010). Collecting data on care-giver
mental health in multiplex families would be of great interest, particularly
comparing pre- and post-treatment data.
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