Addressing challenging behaviour in children with Down syndrome: The use of applied behaviour analysis for assessment and intervention
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Down Syndrome Research and Practice 11(2), 64-77
64
Addressing challenging
behaviour in children with
Down syndrome: The use of
applied behaviour analysis for
assessment and intervention
Kathleen M. Feeley and Emily A. Jones
C.W. Post Campus of Long Island University, USA
Abstract – Children with Down syndrome are at an increased risk for engaging in challenging
behaviour that may be part of a behavioural phenotype characteristic of Down syndrome. The
methodology of applied behaviour analysis has been demonstrated effective with a wide range of
challenging behaviours, across various disabilities. Applications to children with Down syndrome
and the examination of behaviourally based strategies to specifically address the unique charac-
teristics of children with Down syndrome are limited. However, there are several studies in which a
subset of the participants did have Down syndrome. A handful of these studies are reviewed within
the context of functional behaviour assessment and Positive Behavioural Supports. Drawing from
these studies and the behavioural literature, as well as the authors’ clinical experience and research,
suggestions regarding early intervention for challenging behaviour with children with Down syn-
drome are provided.
Keywords: applied behaviour analysis, functional behaviour assessment, Positive Behaviour Support,
behavioural phenotype, proactive strategies, setting events, antecedent strategies, skill replacement,
reinforcement systems, consequence strategies.
Children with Down syndrome have a propensity to such as “stubborn,” have long been noted in the litera-
engage in behaviours that can be particularly problem- ture (Gibson, 1978). More recently, parent and teacher
atic for family members and caregivers, as well as profes- ratings indicate that children with Down syndrome
sionals who work with them. Such behaviour, referred to show higher rates (than typically developing children) of
by Doss and Reichle (1991) as challenging behaviour, is attention problems, social withdrawal, noncompliance,
defined as that which results “…in self-injury or injury and compulsions (such as arranging objects and repeat-
of others, causes damage to the physical environment, ing certain actions) (e.g., Coe et al., 1999; Evans & Gray,
interferes with the acquisition of new skills, and/or 2000) and high rates of self-talk (Glenn & Cunningham,
socially isolates the learner” (p. 215). The presence of 2000). Additionally, behaviours associated with anxiety,
challenging behaviour, along with characterisations
© 2006 The Down Syndrome Educational Trust. All Rights Reserved. ISSN: 0968-7912
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K.M. Feeley and E.A. Jones • Challenging behaviour in children with Down syndrome
depression, and withdrawal, have been noted to increase Archer, 2002; Cunningham, Glenn, Lorenz, Cuckle &
with age (Dykens & Kasari, 1997). Shepperdson, 1998). Therefore, interventionists who are
There are specific physical characteristics of Down syn- likely to encounter behaviour that may be associated with
drome (e.g., those associated with sleep disorders) (Rich- later negative outcomes must be prepared to address such
dale, Francis, Gavidia-Payne & Cotton, 2000; Stores, behaviour so that children with Down syndrome benefit
1993) as well as a higher incidence of illness (Roizen, from learning opportunities and are less likely to be pre-
1996) that may significantly impact the behavioural cluded from general education/community placements.
repertoires, including increasing the likelihood of chal- Fortunately, the methodology of applied behaviour
lenging behaviour, in children with Down syndrome. analysis, demonstrated effective across a wide range of
Researchers have also demonstrated that challenging populations, with various disabilities, can be utilised to
behaviour, particularly avoidance behaviour, appears address the unique characteristics of challenging behav-
consistently in very young infants with Down syndrome iour demonstrated by children with Down syndrome.
(Wishart, 1993a, 1993b). Specifically, when presented With thousands of studies demonstrating the positive
with task demands just slightly above their current level impact of interventions based on the principles of behav-
of ability, children with Down syndrome demonstrate iour analysis on the lives of individuals with disabili-
a unique pattern of behaviour involving opting out of ties, both researchers and practitioners have long relied
learning opportunities and misusing social behaviours. on this scientific literature to address the challenging
It appears that the presence of the extra chromosome behaviour of individuals with developmental disabilities.
associated with Down syndrome affects the likelihood Recently, the technology of Positive Behaviour Support
of challenging behaviour beginning in infancy. In turn, (Carr et al., 2002) has emerged as an application of the
these behaviours can have catastrophic effects; inter- principles of behaviour analysis to not only address skill
fering with learning in children with Down syndrome, repertoires, but also redesign individuals’ living environ-
not only at the foundational level during infancy, but ments with the goal of achieving enhanced quality of life
throughout life. and decreases in problem behaviour (Carr et al., 1999).
These characteristics that impact the behaviour rep- To date, researchers have not specifically applied the
ertoire reflect a unique pattern of strengths and weak- principles of behaviour analysis and positive behaviour
nesses evident in individuals with Down syndrome and support to meet the unique behavioural challenges pre-
have been described as a distinct cluster of behaviours sented by individuals with Down syndrome. However,
termed a behavioural phenotype. Dykens (1995) defined in an extensive review of the literature, we identified a
behavioural phenotype as “…the heightened probabil- small number of studies utilising behavioural assessment
ity or likelihood that people with a given syndrome will strategies, as well as several intervention studies that
exhibit certain behavioural and developmental sequela addressed severe challenging behaviour in individuals
relative to those without the syndrome” (p. 523). This with Down syndrome. The focus of these investigations
does not mean that all children with Down syndrome was not on the unique characteristics of individuals with
will demonstrate all of the characteristic behaviours; Down syndrome, rather the focus was a particular form
rather, there will be in an increased likelihood. of challenging behaviour (e.g., aggression, self-injury) or
The early developing avoidance behaviour reported by a particular intervention strategy (e.g., reinforcement)
Wishart and colleagues along with reports of other chal- and involved either a sole participant who had Down
lenging behaviour is believed to be part of this phenotype syndrome or several participants, only one or two of
in very young children with Down syndrome (Fidler, whom had Down syndrome.
2005). Thus, it is of utmost importance to intervene on In this paper, we briefly describe applied behaviour
the behaviours characteristic of this behavioural pheno- analysis and its applications in assessing and addressing
type early on so that they do not result in pronounced challenging behaviours prevalent in children with Down
deficits within the child’s later development. syndrome. We then draw upon the existing literature as
Challenging behaviour not only precludes individu- well as our clinical experience and ongoing research to
als with Down syndrome from learning opportunities provide suggestions regarding behaviourally based appli-
within their environment, but also prevents them from cations to ameliorate specific challenging behaviours
accessing more typical educational and community associated with Down syndrome in an effort to intervene
environments as they approach preschool and school as early as possible on this aspect of the behavioural phe-
age. When placement in a general education or commu- notype characteristic of children with Down syndrome.
nity setting does occur, challenging behaviour is likely
to be the cause of removal from these settings. This is
particularly unfortunate, as general education settings
have been found to lead to more positive outcomes for
children with Down syndrome (Buckley, Bird, Sacks &
© 2006 The Down Syndrome Educational Trust. All Rights Reserved. ISSN: 0968-7912
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K.M. Feeley and E.A. Jones • Challenging behaviour in children with Down syndrome
Applied behaviour analysis The work of Wishart (1993a; 1993b) and Wishart and
Duffy (1990) suggests that certain functions of chal-
Based upon the seminal work of Baer, Wolf and Risley lenging behaviour may be more characteristic of chil-
(1968), applied behaviour analysis emphasises interven- dren with Down syndrome and part of the characteristic
tions addressing socially significant age-appropriate behavioural phenotype. In particular, both escape and
behaviours with immediate importance to the indi- attention seeking functions seem prevalent in Wishart’s
vidual using precise measurement of those behaviours reports of performance during assessment tasks. Spe-
in need of improvement. Generalised behaviours, that cifically, Wishart and colleagues (Pitcairn & Wishart,
is, behaviours that are maintained over time, appear in 1994; Wishart, 1986; Wishart & Duffy) report avoidance
other environments, and extend to other behaviours, behaviours ranging from disruptive tantrum behaviours
are targeted. A functional relationship between changes (e.g., sweeping test items off the table) to charming or
in behaviour and the intervention being implemented ‘cute’ behaviours (e.g., clapping, blowing raspberries)
is demonstrated. Interventions, derived from the basic that might distract the evaluator during task demands.
principles of behaviour (e.g., reinforcement, extinction), The overlapping attention seeking function of such task
are described so that they can be easily replicated, and avoidance behaviours was also noted by Kasari and Free-
their effectiveness is measured by improvement in the man (2001) who confirmed the higher frequency of these
individual’s performance. ‘charming’ behaviours in older children with Down syn-
drome (6-10 years). In fact, in their study, children with
Down syndrome engaged in higher rates of looking to
Functions of challenging the experimenter during a task situation that may have
been related to the significantly longer latency to start
behaviour and complete tasks, when compared to typically devel-
oping children and children with mental retardation not
It has long been established that challenging behaviour related to Down syndrome.
is directly related to environmental variables (e.g., how As a result of these findings, it seems that both escape and
the behaviour is consequated). From a behaviour ana- attention seeking behaviours may be particularly preva-
lytic perspective, challenging behaviours are maintained lent in children with Down syndrome. To determine
because they are positively reinforced (i.e., result in the the extent to which an individual child possesses these
delivery of a preferred item/activity) and/or are nega- specific characteristics (increased likelihood of engaging
tively reinforced (i.e., result in the removal of a nonpre- in escape/avoid or attention motivated problem behav-
ferred item/activity). O’Neill, Horner, Albin, Storey and iour) of the behavioural phenotype, interventionists can
Sprague (1997) described these two major functional conduct a functional behaviour assessment. Not only
categories of behaviour as either to obtain or to escape/ will this enable interventionists to explore this aspect of
avoid. That is, behaviour may function to obtain conse- the behavioural phenotype, but specific antecedents and
quences such as attention (e.g., from a parent or teacher) consequences associated with the challenging behaviour
and access to objects (e.g., snacks, toys) or activities (e.g., can be determined.
recess, trip to the park). Behaviour may also function to
escape/avoid consequences such as attention (e.g., inter-
actions with peers) and objects (e.g., certain foods) or
activities (e.g., academic tasks).
Functional behaviour
In addition to the functions of obtain or escape/avoid, assessment
O’Neill et al., (1997) further categorise the functions of
challenging behaviours in terms of socially or nonsocially While certain functions (e.g., escape, obtain attention)
motivated behaviours. Socially motivated behaviours may be associated with Down syndrome, challenging
involve those in which the child seeks to escape/avoid or behaviour can serve a variety of functions within and
obtain something from another individual in their envi- across individual children. Therefore, the foundation
ronment. Behaviours serving a social function in chil- of addressing challenging behaviour is determining the
dren with developmental disabilities are often related to function a specific challenging behaviour serves for a
impairments in communication skills (Carr & Durand, particular child (i.e., to obtain or escape/avoid; socially
1985; Durand & Carr, 1991; 1992). Nonsocially moti- or non-socially motivated). This is accomplished via the
vated behaviours involve those in which the child seeks functional behaviour assessment process in which the
to escape/avoid or obtain internal stimuli (i.e., sensory relationship between events in a person’s environment
stimulation) and, thus, do not involve consequences and the occurrence of challenging behaviour is deter-
related to another individual. These nonsocially moti- mined in an effort to identify factors maintaining that
vated behaviours are often referred to as ‘self-stimula- behaviour. (The reader is referred to O’Neill et al.’s [1997]
tory’ behaviours.
© 2006 The Down Syndrome Educational Trust. All Rights Reserved. ISSN: 0968-7912
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K.M. Feeley and E.A. Jones • Challenging behaviour in children with Down syndrome
practical handbook for a detailed discussion of func- more frequent sleep problems, including restless sleep,
tional behaviour assessment procedures.) waking more than once per night, and waking prior to
5:00 am, in children with Down syndrome compared
to typically developing children. The higher incidence
Interview of sleep problems appears to be related to several physi-
cal features (specifically, upper airway obstruction due
The first step in the functional assessment process con- in part to relatively small mouths and airway passages,
sists of an interview to identify the behaviour of concern; enlarged tonsils, and obesity) (Stores & Stores, 1996).
related environmental/medical factors; and when/where/ These sleep problems were also associated with daytime
with whom and during which activities the behaviour problem behaviour: specifically, irritability, hyperactiv-
occurs most/least. The goal is to identify factors that are ity, and stereotypies (Richdale et al., 2000; Stores, 1993).
related to the occurrence of challenging behaviour. Thus, sleep disorders may be one motivating operation
In the past, when addressing challenging behaviour, the that affects the likelihood of challenging behaviour in
field of applied behaviour analysis concentrated on the children with Down syndrome.
immediate antecedents and consequences. However, sev- There is also a high incidence of illness in children with
eral behaviourists have recognised that events occurring Down syndrome (e.g., recurrent ear infections, gastroin-
more distally in time or not directly related to the imme- testinal disorders, skin conditions) (Roizen, 1996). The
diate antecedents or consequences affect the likelihood onset of an illness, its presence, as well as the ending
of challenging behaviour (Michael, 1982; 2000; Wahler stages, may be motivating operations affecting the behav-
& Fox, 1981). Such variables have been referred to as iour of children with Down syndrome, as is often the case
motivating operations (Michael, 2000) as well as setting with typically developing children. As the frequency and
events (Wahler & Fox, 1981). Specifically, motivating severity of these illnesses is increased in individuals with
operations refer to antecedents that affect an individual’s Down syndrome, the incidence of challenging behaviour
behaviour by changing the value (increasing or decreas- is likely to be increased as well.
ing) of a consequence (reinforcer or punisher) which, in
It is during the interview process that environmental
turn, changes the likelihood the individual will engage
events including setting events/motivating operations,
in a certain behaviour (either increasing or decreasing
antecedents, and consequences, as well as target behav-
the likelihood). For example, a child may be motivated
iours are identified. It is here that interventionists should
to follow the directions (immediate antecedent) of his
closely examine the extent to which specific motivating
teacher because doing so results in a pleasant interaction
operations (or setting events) associated with Down syn-
(i.e., the teacher smiles and praises the child; reinforcing
drome affect the individual’s likelihood of engaging in
consequence). However, if the child has a cold, the rein-
challenging behaviour. Just as the function of behaviour
forcing value of the smile and praise may be significantly
is likely to vary across individuals, the specific anteced-
decreased, thus, decreasing the likelihood the child will
ents and consequences as well as the presence of motivat-
engage in compliant behaviour in response to the teach-
ing operations (or setting events) are likely to be unique
er’s requests. In this situation, the cold is a motivating
to each child with Down syndrome and require careful
operation.
assessment to determine which are relevant for a given
The term motivating operation has been used to describe child.
the effect a specific event has on the quality of a future
consequence (e.g., reinforcer) and, thus, the likelihood
of the target behaviour occurring. Within the Positive Direct observation
Behaviour Support literature, the term setting event
is widely used to represent the phenomena described The second component of the functional behaviour
(Horner, Vaughn, Day & Ard, 1996). Several studies have assessment process consists of direct observation of the
been conducted describing a relationship between dif- individual and documentation of events that occur prior
ferent setting events (e.g., illness, sleep problems) in the to and following the challenging behaviour. One example
lives of individuals with developmental disabilities and is an antecedent-behaviour-consequence (ABC) analysis,
a propensity to engage in challenging behaviour (e.g., in which antecedents and consequences are documented
Dadson & Horner, 1993; McGill, Teer, Rye & Hughes, as they occur in the natural environment. The child is
2005). observed during his/her daily routine and the occurrence
We suggest that the propensity of individuals with of challenging behaviours, events that precede the specific
Down syndrome to engage in challenging behaviour is behaviour (antecedents), and events that follow the spe-
directly related to several motivating operations (or set- cific behaviour (consequences) are documented. Analysis
ting events) that are inherently related to the presence of the pattern of antecedents and consequences results in
of Down syndrome. For example, Stores (1993) found a hypothesised function of the challenging behaviour.
© 2006 The Down Syndrome Educational Trust. All Rights Reserved. ISSN: 0968-7912
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K.M. Feeley and E.A. Jones • Challenging behaviour in children with Down syndrome
See Table 1 for an ABC data sheet with guidelines regard- consequences are delivered by others (alone condition);
ing information that should be included and Table 2 for and a condition involving noncontingent delivery of pre-
an example ABC data sheet with sample behaviours. ferred items and attention (free play or control condition).
Antecedent conditions can also be manipulated, such as
task difficulty or attention provided while engaged in the
Functional analysis task. The conditions in which the challenging behaviour
occurs are indicative of the factor(s) occasioning and/or
Often, the function of a particular challenging behav- maintaining the behaviour. For example, if higher rates
iour for a child can be identified through the interview of challenging behaviour occur within the demand con-
and direct observation process. However, a more sys- dition than within the other conditions, escape would
tematic approach may be necessary to confirm observa- appear to be the function of the challenging behaviour.
tion findings and/or determine the function, if it has not
Once the functional behaviour assessment process is
been clearly identified. Functional analysis consists of
complete, and the function of the challenging behaviour
the systematic manipulation of controlling variables to
identified, intervention procedures can be developed
demonstrate the function of the behaviour (the reader is
that specifically address the challenging behaviour and
referred to O’Neill et al., 1997 as well as Iwata, Dorsey,
the function it serves for that individual. Intervention-
Slifer, Bauman & Richman, 1982 for explicit procedures).
ists should draw from the large number of empirically
Functional analysis involves measuring challenging
validated studies demonstrating the facilitative effects of
behaviour as a series of conditions are introduced. Conse-
behaviour analytic procedures.
quence conditions include situations in which: attention
is delivered contingent upon the occurrence of chal-
lenging behaviour (attention condition); demands are
removed contingent upon the occurrence of challenging
Intervention
behaviour (demand condition); tangibles are delivered An effective means of addressing challenging behaviour,
contingent upon the occurrence of challenging behav- Positive Behaviour Support (Carr et al., 2002), is rooted
iour (tangible condition); the child is left alone and no in behaviour analytic strategies. Positive Behaviour Sup-
port consists of strategies
Table 1. Sample ABC data sheet addressing multiple variables
influencing the occurrence of
Date Antecedent Behaviour Consequence Hypothesised
Function
challenging behaviour. When
utilised at an individual level,
Activity Description of How did you Obtain attention,
behaviour(s) that respond? tangibles, access to
Positive Behaviour Support
occurred activity interventions consist of the
Location of student May need to include How did others Escape demands, development of a four compo-
dimensions such respond? transition, or nent approach which includes
as duration and attention strategies to address motivat-
intensity ing operations/setting events
Others present What happened to Obtain internal and immediate antecedents,
(teachers, students) the activity? stimuli interventions to teach replace-
Immediate trigger Escape internal ment skills (e.g., communica-
(demand, removal of stimuli
tion, academic, social), and the
attention)
development of appropriate
consequence strategies (e.g.,
Table 2. Example behaviours documented on an ABC data sheet reinforcement strategies) as
outlined in Figure 1. To illus-
Date Antecedent Behaviour Consequence Hypothesised
Function
trate behavioural applications
2/5/06 Child playing Child climbs Caregiver rushes over, swoops Attention within this four component
on floor, parent on table child up, telling her “No, no, seeking framework, we will provide
attending to honey, that’s dangerous” a brief description of a select
sibling followed by a hug and a kiss. few studies implemented with
Caregiver puts child down
with toys and plays with child children with Down syn-
drome, followed by additional
2/7/06 Teacher presents Child makes a Teacher laughs with child Escape and suggestions for interventions
nonpreferred silly face and and joins in song, delaying attention
task (e.g., writing begins to sing the request to engage in the seeking
based upon the research liter-
activity) a rhyming nonpreferred task ature and our clinical experi-
song ence and research. The studies
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K.M. Feeley and E.A. Jones • Challenging behaviour in children with Down syndrome
Positive Behaviour Support Plan
Strategies to Address Antecedent Strategies Skill Building Strategies Consequence Strategies
Setting Events Choice Functional communication Differential reinforcement
Setting event checklist High probability request training of alternative behaviour
Presessions of attention Collaboration Tolerance for delay of Differential reinforcement
Decrease presence of reinforcement of the omission of
Preferred item as distractor behaviour
antecedents
Increase available Token systems
reinforcement Extinction
Figure 1: Components of a Positive Behaviour Support Plan with example interventions.
utilising behavioural strategies with individuals with the functional assessment process), while the challeng-
Down syndrome we will discuss are outlined in Table 3. ing behaviour of the other child served to escape. Thus,
although there is an increased likelihood of some setting
events in children with Down syndrome, not all may be
Addressing setting events pertinent to all children with Down syndrome. Addi-
tionally, once the functional assessment process has been
(motivating operations) completed (taking into account setting events), interven-
tionists should select intervention strategies that directly
Because the term setting event is used in the Positive correspond to the findings. For example, as illustrated by
Behaviour Support literature, we have chosen to use it McComas et al., presession attention did not affect indi-
in our discussion of intervention strategies. One setting viduals who engage in challenging behaviour serving
event that we hypothesise may be specifically associ- functions other than to obtain attention.
ated with Down syndrome is the tendency toward an
increased desire to escape/avoid demands and to obtain Other setting events, such as sleep disorders and ill-
attention as suggested by Wishart’s research (1993a, ness, that warrant attention specifically in children with
1993b). McComas, Thompson and Johnson (2003) uti- Down syndrome, may be addressed by developing a
lised a setting event intervention strategy consisting of mechanism for caregivers to share with school person-
presessions during which attention was provided. Sev- nel when a child has experienced a particular setting
eral children participated in this study, two of whom event. Checklists can be designed to specifically note
had Down syndrome (11 and 12 year old boys). In one setting events influencing the child’s challenging behav-
condition, attention was delivered noncontingently (i.e., iour. Alternatively, setting events can be reported via a
regardless of the child’s behaviour) during the 10 min- note sent to school or a telephone call. School person-
utes prior to engagement in tasks likely to elicit challeng- nel can then consider several interventions designed to
ing behaviours (i.e., during presessions). In the second ameliorate the effects of the specific setting event (e.g.,
condition, students were ignored during the 10 minute Dadson & Horner; 1993; Horner et al., 1996). For exam-
presessions. Although, the presession condition in which ple, a child’s illness may increase the likelihood that he/
attention was provided had no effect on the challenging she engages in self stimulatory behaviour (e.g., repetitive
behaviour of the child who was escape motivated, the hand movements). In this case, the child might be given
child who was attention motivated engaged in challeng- the opportunity to access materials that would function
ing behaviour during subsequent tasks almost exclusively as a replacement response (e.g., holding onto a small tex-
when no attention was delivered during the presessions. tured toy stored within the front pocket of a sweatshirt).
Another child who experiences trouble sleeping might be
McComas et al.’s (2003) study demonstrated the effec- more likely to desire to escape demands. In this case, the
tiveness of an intervention procedure to specifically child may be given an opportunity to rest at some point
address a setting event, in this case, the increased desire during the day, or school staff might consider reducing
for attention. It is important to note, attention served their demands (e.g., requesting fewer academic tasks) on
as a reinforcer in the target situation for only one of the days following disrupted sleep. The effects of the setting
two children with Down syndrome (as confirmed by
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K.M. Feeley and E.A. Jones • Challenging behaviour in children with Down syndrome
Table 3. Studies examining the use of behavioural interventions to address challenging behaviour in
children with Down syndrome
Author/ Subject/Setting Target Behaviour and Independent Variable Results
Year Description Function
Cole & 7 year old boy with Throwing/destroying items, Choice versus no Challenging behaviour decreased
Levinson Down syndrome, PDD, hitting, and dropping to choice embedded from a range of 14.3% to 81.8% in the
(2002) and ADD attending the floor) within verbal prompts no choice condition to 8.3% in the
a school for students Function: No functional delivered during choice condition, with an increase in
with emotional/ assessment was conducted instruction of daily independent task performance
behavioural disorders routine
Davis, 7 year old boy with Noncompliance, kicking, The delivery of three Compliance increased from a
Brady, Down syndrome, screaming, spitting, to five high-probability mean of 6.7% during baseline to
Williams & enrolled in a life stereotypic behaviour, requests, each followed 100% following intervention, with
Hamilton skills program on an emptying cabinets/drawers by the delivery of verbal performance generalised to other
(1992) elementary school Function: No functional or gestural (thumbs up) adults and was maintained during
campus assessment was conducted praise follow up probes
Hall, 9 year old boy with Aggression: hitting, Instruction of Aggressive/destructive behaviour
Neuharth- Down syndrome destroying and throwing communicative decreased from 11% (of the 10
Pritchett in a self contained materials replacement of raising second intervals within a 45 minute
& Belfiore classroom with Function: both escape and hand and saying “done” session) in baseline to 2% during
(1997) inclusive opportunities attention intervention
Performance generalised from his
special education classroom to a
general education classroom
McComas, Two boys with Down Dan: throwing materials, Noncontingent Challenging behaviour decreased for
Thompson syndrome enrolled hitting, and spitting attention versus no Dan (who was attention motivated)
& Johnson in special education Function: attention seeking attention during 10 when attention presessions were
(2003) classes within a public minute presessions provided
school: prior to engaging in Challenging behaviour did not
Dan, 11 years old Ari: hitting, pinching, tasks likely to elicit change for Ari (who was escape
kicking, throwing items challenging behaviour motivated)
Ari, 12 years old
Function: escape
Repp & 9 year old girl with Tantrums (crying, falling Extinction, differential Challenging behaviour decreased
Karsh Down syndrome to floor, kicking, hitting, reinforcement of from 41% of the day in baseline to an
(1994) placed in a segregated throwing objects, and alternative behaviour, average of 4% during intervention
school grabbing) and finger and increased Maintenance observed at one year
stereotypies (finger opportunities to engage follow-up
flexions) in social interactions
Function: attention
events may also be ameliorated through the delivery of rence of challenging behaviour by altering the antecedent
higher rates and/or higher quality of reinforcement. This situations associated with it (e.g., decreasing the aver-
reinforcement should be delivered before the child is siveness of the antecedent stimuli). Thus, these strategies
likely to engage in the challenging behaviour (Marcus & are implemented proactively, that is, prior to the point at
Vollmer, 1996). For example, a child can be greeted at the which the challenging behaviour is likely to occur (iden-
bus with high rates of quality attention and, therefore, tified via the functional assessment process). Four strate-
may be less likely to engage in attention motivated chal- gies may be particularly relevant to decrease the escape
lenging behaviour upon entering the classroom. and/or attention motivated challenging behaviours often
Strategies to address setting events can have substantial seen in children with Down syndrome: choices, high
effects on the likelihood of challenging behaviour. How- probability request sequence, collaboration, and pre-
ever, in many instances, it may also be necessary to con- ferred item as distractor.
sider interventions that target immediate antecedents. Offering choices (e.g., of tasks, materials, locations, etc.)
is a strategy that has been effectively used in a number of
studies to decrease challenging behaviour (e.g., Bambara,
Antecedent based strategies Koger, Katze & Davenport, 1995; Dunlap, et al., 1994;
Dyer, Dunlap & Winterling, 1990). In one application
Intervention strategies targeting stimuli that occur just with a 7 year old boy with Down syndrome, Cole and Lev-
prior to the child engaging in challenging behaviour are inson (2002) demonstrated the effectiveness of embed-
termed antecedent based strategies (Kern, Choutka & ding choices within the daily routine of hand washing,
Sokol, 2002). These strategies aim to prevent the occur- a situation during which the boy was likely to engage in
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K.M. Feeley and E.A. Jones • Challenging behaviour in children with Down syndrome
challenging behaviour (e.g., throwing/destroying items, tract them from the aversiveness of the task that triggers
hitting, and dropping to the floor). Rather than deliver- challenging behaviour. The preferred item is systemati-
ing a directive regarding how to complete a step within cally presented prior to, or simultaneous with, the request
the task (e.g., “Rub your hands”), the child was offered that is likely to occasion the challenging behaviour. For
choices regarding how the step could be completed (e.g., example, a child can be given a favourite toy and then
“Do you want to rub them together quickly or slowly?”). requested to take a walk to another instructional area.
Challenging behaviour decreased while independent Alternatively, the interventionist may embed the pre-
task participation increased. Thus, while presenting tasks ferred item (e.g., whistle) into the request (e.g., “Can you
that trigger challenging behaviour, choices can be offered hold the whistle while we walk in from recess?”).
with respect to a variety of aspects, such as location (e.g., For antecedent strategies to be effective, it is essential
“You can work at your desk or at the group table”), peers for interventionists to be fluent in their use, paying par-
(“Would you like to walk with John or Mary?”), or mate- ticular attention to implementing the strategies prior to
rials (e.g., “You can use your pencil or my blue pen”) to presenting the antecedents that are associated with the
decrease escape motivated challenging behaviours. behaviour. While setting event and antecedent based
Another antecedent strategy, high probability request intervention strategies serve to proactively decrease
sequence, involves the delivery of a series of requests to the likelihood that challenging behaviour will occur, it
which the child is highly like to comply (a high probabil- is important to recognise the function the challenging
ity request) each of which is followed by the delivery of behaviour serves for a particular child and teach replace-
reinforcers, then a request to which the child is not likely ment skills for the child to use to obtain what they want
to comply, that is, a low probability request (the one that through more appropriate means.
triggers the challenging behaviour) is delivered. For
example, Davis, Brady, Williams and Hamilton (1992)
successfully utilised high probability request sequence to Replacement skills
increase compliance and decrease challenging behaviour
(screaming, hitting, kicking, spitting) in a 7 year old boy Many individuals with Down syndrome can benefit from
with Down syndrome. Behaviour change generalised instruction in specific skills (e.g., communication, social,
across classroom staff and was maintained during a series academic, etc.) that function to replace challenging
of 4 weekly follow up probes. High probability request behaviour with a more appropriate means of obtaining
sequences have not only been effective in decreasing reinforcers. One type of skill building strategy, func-
challenging behaviours (Horner, Day, Sprague, O’Brien tional communication training, involves identifying and
& Heathfield, 1991; Mace & Belfiore, 1990), but also teaching a more appropriate communicative response
increasing compliance (Mace et al., 1988; Singer, Singer serving the same function as the challenging behaviour
& Horner, 1987), particularly during transitions (Davis, (Carr et al., 1994).
Reichle & Southard, 2000), as well as increasing social Several researchers (e.g., Brooks, Todd, Tofflemoyer &
interactions (Davis, Brady, McEvoy & Williams, 1994; Horner, 2003; Hetzroni & Roth, 2003) have implemented
Davis & Reichle, 1996) and communicative behaviours functional communication training with children with
(Davis, Reichle & Johnston, 1998). This strategy may be Down syndrome. For example, Hall, Neuharth-Pritchet
particularly effective with a child who is not only escape/ and Belfiore (1997) determined that the aggressive and
avoid motivated, but also attention motivated, because, destructive behaviours of a 9 year old boy with Down
inherent in the high probability request sequence, each syndrome served the function of both escape (the wait)
compliant response results in social reinforcement (e.g., and attention when he was required to wait after com-
praise). pleting a task. He was taught to indicate when he was
A third antecedent strategy that may be particularly finished by raising his hand and saying “done” which
effective for children with Down syndrome who not only resulted in the delivery of a brief, in-seat academic activ-
desire to escape/avoid a task, but also obtain attention, ity. Acquisition of this replacement response resulted in
is an offer of collaboration (Davis, McEvoy & Riechle, a decrease in aggressive/destructive behaviours that gen-
2005). This entails sharing the responsibility of the task eralised from his special education classroom to a gen-
with the child. For example, during a worksheet task, the eral education classroom.
interventionist tells the child, “You do the first five items As the speech and language skills of individuals with
and I’ll do the last five.” Over time, the amount of assist- Down syndrome are specifically impaired, their ability
ance provided by the interventionist can be systemati- to communicate desires is likely to be compromised and,
cally faded (e.g., “You do the first six, and I’ll do the last thus, related to the occurrence of challenging behaviour.
four”) until the child is performing independently. Based on the extensive literature examining the effec-
Lastly, preferred item as a distractor (Davis et al., 2000) tiveness of functional communication training (e.g.,
involves presenting a child with a preferred item to dis- Carr & Durand, 1985; Durand & Carr, 1991; 1992), com-
© 2006 The Down Syndrome Educational Trust. All Rights Reserved. ISSN: 0968-7912
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72
K.M. Feeley and E.A. Jones • Challenging behaviour in children with Down syndrome
municative replacement strategies can be used to address that is, reinforcement of the alternative behaviour of task
a variety of communicative functions. For example, a engagement), along with providing increased opportu-
child who desires to escape circle time activities can be nities to engage in social interactions. This intervention
taught to raise his/her hand to request to leave the area. package resulted in a decrease in challenging behaviour
For a child who desires attention, he/she can be taught to which maintained at one year follow-up. Thus, a combi-
tap an adult’s shoulder to request attention (e.g., to read nation of consequence strategies for both the challenging
a book). A child who tends to tantrum in the presence behaviour (i.e., extinction) and more appropriate behav-
of desired objects can be taught to appropriately request iour (i.e., DRA) were important components of effective
the desired object (e.g., point to communication symbols intervention.
“want” “[item]”). Repp and Karsh’s (1994) study illustrates two points with
When teaching a child to communicate his/her desires respect to consequence strategies. First, their findings
instead of engaging in challenging behaviour, it is cru- that challenging behaviour, in the presence of demands,
cial to reinforce appropriate communicative behaviours may actually serve the purpose of accessing attention, are
with immediate access to what the child desires (e.g., a particularly relevant in light of Wishart’s work (Wishart
break for a child who is escape motivated, attention for & Duffy, 1990; Pitcairn & Wishart, 1994) demonstrat-
the child who is attention motivated). Once the commu- ing the propensity of children with Down syndrome to
nicative replacement response is acquired, it is possible engage in what appear to be escape motivated challenging
to systematically teach the child to wait longer periods behaviours. They do so, however, in a very social manner
of time before the child can access what they desire. This (e.g., engaging in party tricks) which often results in not
intervention is referred to as teaching tolerance for delay only escaping/avoiding a task, but also obtaining atten-
of reinforcement (Carr et al., 1994). For example, once tion. In many instances, the exact consequences main-
the child reliably uses the replacement communication taining challenging behaviour may be unclear, making
skill (e.g., raising his/her hand), when the child makes intervention selection difficult. However, systematic
the appropriate request, increasing amounts of time can implementation of functional assessment procedures
be inserted before delivery of the reinforcer (e.g., tell the in conjunction with carefully chosen interventions that
child “Just one minute.”). specifically address the escape and attention motivated
Replacement skills are particularly important as they functions of behaviour can lead to significant changes in
provide the child with a communicative response that the behavioural repertoires of children with Down syn-
can be used across multiple situations to more appropri- drome.
ately obtain desirable outcomes. It is equally important Second, Repp and Karsh’s (1994) study illustrates the
for interventionists to also implement effective conse- use of reinforcement procedures (i.e., DRA) to decrease
quence strategies for both appropriate and inappropriate a challenging behaviour. Another reinforcement proce-
behaviour. dure, differential reinforcement of the omission of behav-
iour (DRO), is particularly effective with stereotypical
behaviours (e.g., Repp, Deitz & Speir, 1974). DRO involves
Consequence strategies delivering reinforcement following an interval of time in
which the challenging behaviour did not occur. We have
Effective interventions addressing challenging behaviour used this procedure with several children with Down
typically include reinforcement systems for appropri- syndrome to successfully decrease self-stimulatory
ate behaviour as well as consequences for inappropriate behaviours (e.g., mouthing objects, tongue clicking, and
behaviour. For example, Repp and Karsh (1994) con- lip licking). In all cases, functional assessment indicated
ducted a study with two students, one of whom was a the behaviours were non-socially motivated. Each child
9 year old girl with Down syndrome whose challeng- was initially reinforced on a dense schedule (e.g., every
ing behaviours consisted of tantrums (crying, falling to 30 seconds). The time interval was then quickly increased
floor, kicking, hitting, throwing objects, and grabbing) (to 1, 3, 5, and 10 minute intervals) to the point at which,
and finger stereotypies (finger flexions) that had resulted for each of the children, the behaviour completely sub-
in her removal from an integrated educational set- sided and continued reinforcement specifically for the
ting. Direct observation during baseline indicated that, absence of that self-stimulatory behaviour was no longer
although she engaged in tantrums within demand situ- necessary.
ations, she was consistently consequated with attention
Two criticisms of DRO procedures are the interven-
rather than withdrawal of demands. Intervention con-
tion does not leave the individual with a specific skill,
sisted of placing the tantrum behaviour on extinction
rather it only decreases the target behaviour and in some
(in this case, no longer providing attention) as well as
instances, the function of the challenging behaviour is
increasing the rate of reinforcement for task engagement
not honoured (i.e., reinforcement is delivered based on
(differential reinforcement of alternative behaviour (DRA),
the omission of the behaviour with no specific functional
© 2006 The Down Syndrome Educational Trust. All Rights Reserved. ISSN: 0968-7912
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73
K.M. Feeley and E.A. Jones • Challenging behaviour in children with Down syndrome
equivalent response being taught). Thus, many interven- widespread that private and public policy statements spe-
tionists prefer to implement differential reinforcement of cifically call for their use prior to consideration of reac-
alterative behaviours (DRA), such as that used by Repp tive or punishment based procedures. For example, in the
and Karsh (1994), in which an alternative response is United States, federal education legislation (Individuals
consistently reinforced. As another example, consider a with Disabilities Education Improvement Act of 2004)
child who has a tendency to place objects in his mouth specifically notes “In the case of a child whose behavior
to get attention. Appropriate responses (e.g., play behav- impedes the child’s learning or that of others, consider
iours with the objects) can be selected to systematically the uses of proactive behavioral interventions and sup-
reinforce. If not readily within the child’s repertoire, ports…” (Sec. 614). However, when positive approaches
the child can be prompted to perform the behaviour have been systematically applied with little success, the
and then immediately provided with reinforcers. Thus, use of reactive procedures implemented to decrease
the challenging behaviour (mouthing objects) can be the future likelihood of challenging behaviours may be
replaced with an appropriate play behaviour. In instances warranted. For example, consider a child who destroys
in which the alternative response is communicative in materials to escape/avoid academic demands. A multi-
nature, such as within functional communication train- component intervention may consist of giving the child
ing, differential reinforcement (DRA) is in effect. a choice of academic activities, the use of a preferred item
For socially motivated behaviours, such differential rein- as a distractor (i.e., “You can use your markers to fill in
forcement procedures are often paired with extinction to these questions.”), as well as teaching the child to request
increase their effectiveness. Extinction involves no longer assistance when the academic task becomes difficult
delivering reinforcement following the occurrence of (functional communication training). When the appro-
challenging behaviour. Using the previous example, the priate behaviour(s) occur, the child is immediately rein-
target behaviour (i.e., mouthing objects) would no longer forced (DRA). However, in the event the target behaviour
be reinforced, thus, no attention would be delivered fol- does occur, that is, the child destroys the materials, inter-
lowing its occurrence (i.e., extinction). This would be ventionists might consider a consequence procedure that
paired with high quality reinforcement (i.e., attention is likely to decrease the future occurrence of the behav-
would be delivered following appropriate play behav- iour, such as the removal of a privilege (e.g., no recess)
iours) delivered following the alternative behaviour. The or an added chore (e.g., cleaning the dry erase board).
function of challenging behaviour must be considered, In these instances, it is of utmost importance for inter-
not only in consequating challenging behaviour, but vention teams (including caregivers) to make informed
also in the choice of reinforcers to increase appropriate decisions, in addition to acquiring consent from all nec-
behaviour. In the previous example, appropriate play essary parties and monitoring intervention for desired
behaviour resulted in attention. As another example, a effectiveness (Cooper, Heward & Heron, 1987).
student who is escape motivated can be reinforced for
appropriate task completion with the removal of one or
several demands.
Summary
Reinforcement systems such as token economies, in which As the four component approach of positive behaviour
tokens (e.g., stickers, check marks) are delivered for support has effectively addressed challenging behaviour
appropriate behaviour and then cashed in at some later in individuals with various developmental disabilities
point for backup reinforcers (e.g., toys, food), can also be across the age span, it is also likely to effectively meet
used to reinforce appropriate behaviour. Such token sys- the needs of children with Down syndrome who engage
tems exist in many classrooms, but often need to be indi- in challenging behaviours. Positive behaviour support
vidualised to meet the unique needs of a particular child interventions can be used to systematically address char-
with Down syndrome. Token systems can even be used acteristics specific to Down syndrome (e.g., increased
by caregivers within the home with very young children likelihood of engaging in avoidant and/or attention
with Down syndrome and may be particularly relevant motivated behaviour) as well as events that occur on
with escape behaviour. For example, we have used token an individualised basis. Additionally, as intervention-
systems consisting of cartoon character tokens (e.g., Bar- ists become versed in the functional assessment process
neyTM, Blues CluesTM) with children as young as two years and proactive interventions, they will find themselves
of age to sustain performance during tasks where escape naturally implementing many of these strategies, likely
behaviour was typically displayed. resulting in an overall decrease in challenging behav-
With the development of empirically demonstrated iours emitted by the children with Down syndrome with
behavioural intervention strategies, the systematic use of whom they work. In turn, increasing the child’s likeli-
consequence strategies designed to decrease behaviour hood of success in inclusive educational and community
(i.e., the use of punishment procedures) is likely unnec- environments.
essary. The use of positive interventions has become so
© 2006 The Down Syndrome Educational Trust. All Rights Reserved. ISSN: 0968-7912
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74
K.M. Feeley and E.A. Jones • Challenging behaviour in children with Down syndrome
Future applications might position toys so they are in reach, thus, pulling the
toy closer can be more easily accomplished. Caregivers
Recent research suggests that the presence of escape and who are well versed in prompting strategies (e.g., the use
attention motivated challenging behaviour may be part of physical guidance or positioning of objects to enhance
of the behavioural phenotype (Dykens, 1995; Fidler, performance) as well as shaping procedures (i.e., rein-
2005) that characterises Down syndrome. That is, the forcing closer and closer approximations to the target
disability itself is characterised by a pattern of strengths response) can be advised to implement such strategies
and weaknesses that increase the likelihood of valuing to enhance their child’s performance with a given task.
certain consequences (i.e., escape and attention). McGill By using prompting and shaping procedures, adults are
(1999) presented the idea that disabilities may function setting up the situation to provide the young child with
as motivating operations in his discussion of the decrease Down syndrome with more successful opportunities and
in the reinforcing value of attention in individuals with then very gradually leading to more difficult tasks. This
autism and the increase in the reinforcing value of food is one application of errorless learning techniques which,
in individuals with Prader-Willi. Although not specifi- as suggested by Fidler (2005), may result in children with
cally mentioned by McGill, the work of Wishart and col- Down syndrome persisting in tasks during which they
leagues (Wishart, 1993a; 1993b; Pitcairn & Wishart, might otherwise demonstrate escape behaviour.
1994; Wishart & Duffy, 1990), as well as the cluster of With respect to the attention seeking functions of chal-
behaviours termed a behavioural phenotype, suggest lenging behaviour, our clinical experience suggests that,
Down syndrome should be included in the disabilities during the toddler and preschool years, attention moti-
identified by McGill as motivating operations. vated behaviours are present and particularly interfer-
The presence of these challenging behaviours, even within ing. Consider, for example, getting into a forbidden area
the first year of life in children with Down syndrome, within the home (e.g., brick fire place, steep stair case,
effectively reduces the child’s learning interactions with bay window), a common behaviour in toddlers. Many
his/her environment. As part of the behavioural pheno- caregivers might instinctively go to the child and remove
type characteristic of Down syndrome, we are challenged him/her from the area, but, in doing so, inadvertently
to develop strategies to ameliorate these tendencies at a deliver attention in the form of verbal feedback (e.g.,
very young age (Fidler, 2005), by first identifying the “No, no honey, that can be dangerous.”) as well as physi-
specific behaviours in which a child engages and then cal contact (e.g., once the parent has the child in his/her
teaching caregivers to respond in such a way that these arms, hugs and kisses are naturally delivered). Because
behaviours are not systematically reinforced (Gerenser, of the positive interaction that ultimately takes place, the
personal communication, June 6, 2004). For example, child may learn that an effective way to get attention is
caregivers often make simple requests of a child that are to move toward the forbidden area. Alternatively, car-
followed by avoidance behaviour (e.g., turning away). egivers can systematically respond in a way that is not
These avoidance behaviours are likely to result in some reinforcing to the child (e.g., silently go to the child with-
initial persistence on the part of the caregiver, but, in out providing eye contact and remove the child from the
the face of further child resistance, caregivers may ‘give forbidden area) while at the same time responding in a
up’ and discontinue the request. In these situations, the very reinforcing manner when the child is playing in an
child, who did not want to comply with the request, is acceptable location (e.g., while sitting on the floor with
ultimately reinforced; that is, avoidance (e.g., turning their toys).
away) to respond results in the removal of the demand. Given the early presence of these challenging behaviours,
Alternatively, caregivers can be taught to follow through it is essential for professionals to involve caregivers during
with even simple requests. Therefore, when making a the development and implementation of interventions so
request, if the child does not respond, he/she is prompted that caregivers can effectively intervene throughout the
to do so. Once the response occurs, even if prompted, day and across multiple environments. Professionals
reinforcement is immediately delivered. This results should be skilled at imparting intervention techniques to
in teaching the child, from an early age, the benefits of caregivers so they can comfortably implement interven-
following simple instructions and possibly curtailing a tions during ongoing interactions with their young child
pervasive pattern of opting out as identified by Wishart with Down syndrome.
(1993a, 1993b).
Another way to address escape behaviour in young chil-
dren with Down syndrome, especially in the presence of
slightly more difficult tasks, may be to teach caregivers to
manipulate items in the child’s environment to make spe-
cific tasks less difficult. For example, if the child is having
difficulty accessing toys in his environment, the parent
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