Chapter 8

Behavioral Modification

Behavioral Modification Program for a Child with ASD

Behavior modification is generally thought of as the process of changing patterns of human behavior
using various motivational techniques, such as negative and positive reinforcement, extinction, fading,
shaping, and chaining. It can be a useful tool to encourage desirable behaviors in yourself, your children,
or your employees. There are strategies that may improve the effectiveness of behavior modification,
and a therapist may help you determine the best ones to achieve your desired change.

What is behavior modification?

Many people make New Year’s resolutions, but it’s estimated that 80% of those people no longer follow
their resolutions by the end of the first month. Behavior modification through extinction
psychology generally focuses on changing associations with the undesired or desired behaviors to make
it more likely that you will stick with your goals.

The theory behind behavior modification identifies that we can change the way we act or react by
attaching consequences to our actions and learning from those consequences. The psychologist B.F.
Skinner, known for his research on behavioral analysis, postulated that if the consequences of an action
are unfavorable, there is a good chance the action or behavior will not be repeated, and if the
consequences are favorable, the chances are better that the action or behavior will be repeated. He
referred to this concept as “the principle of reinforcement.” Skinner's introduction of reinforcement in
his framework became the basis of the development of many modern ideas in reinforcement
psychology.

At a fundamental level, Skinner’s behavior analysis modification model can be a way to change habits by
following actions with positive or negative consequences to either break bad habits or reinforce good
habits.

For many disorders, such as ADHD, behavior therapy has been shown to be effective, and it may
improve both behavior and self-esteem. Behavior modification is often used to treat obsessive-
compulsive disorder (OCD), attention deficit hyperactivity disorder (ADHD), irrational fears, substance
use disorder, generalized anxiety disorder, and separation anxiety disorder in clinical settings. You may
develop and implement a behavior modification plan on your own, or you can find a therapist who
specializes in behavior modification therapy for additional guidance and support.

Behavior modification techniques

There are several evidence-based ways to approach modifying behavior. Some of the techniques below
are best implemented within specific contexts or with certain age ranges or developmental stages. Keep
in mind that what works for one person will not always work for another person, and a licensed mental
health care provider can provide guidance regarding behavior modification goals.

In psychology, you can think about the concepts of positive and negative as mathematical symbols. You
might keep in mind that taking something away is considered negative, and adding something is seen as
positive.

Generally, positive reinforcement adds a stimulus that reinforces good behavior. For example, you
could positively reinforce the behavior of a student by awarding them a prize for doing well on their
exam. Positive punishment, on the other hand, describes an added stimulus that decreases the
likelihood of an undesired behavior occurring. For example, putting lemon juice (a stimulus) on your
fingernails may discourage you from biting your nails (an undesired behavior). Positive punishment also
includes corporal punishment, such as spanking, which is often seen as a harmful and unproductive form
of behavior modification.

Negative reinforcement and negative punishment

As mentioned above, negative typically means that a stimulus is removed. Negative reinforcement can
occur when you remove a stimulus to increase a desired behavior.

For example, an infant’s cries (a stimulus) may be removed when a parent picks the infant up (the
desired behavior). As a result, the parent may be encouraged to pick up their infant more often when
they cry.

Negative punishment can occur when a stimulus is taken away to reduce the frequency of an undesired
behavior occurring. For example, a teenager’s cell phone (the stimulus) could be taken away when they
stay out past their curfew (the undesired behavior).

Extinction

A behavior can become extinct when a stimulus or reinforcer is removed. For example, if your child
becomes accustomed to getting a new toy (stimulus) every time they throw a tantrum (undesired
behavior), you might refrain from buying your child a toy when they throw a tantrum. When done
consistently, your child is likely to learn that the behavior never produces the desired outcome, and the
behavior may become extinct.

Shaping

The process of shaping can reinforce behaviors that are closer to a desired behavior. For example, a
child learning to walk typically involves several stages (sitting up, crawling, standing, walking). Parents
might reinforce a child learning to walk through shaping by giving a child encouragement when they
engage in new steps in this process.

Fading
Fading is usually thought of as the process of gradually shifting from one stimulus to another. For
example, if a parent encourages their child to get good grades on report cards with a positive stimulus,
such as rewarding money for good grades, they may eventually seek to find a more sustainable stimulus
to maintain good academic performance. Fading removes the old stimulus, getting money in exchange
for good grades, and replaces it with a new stimulus, such as satisfaction in learning new material.

Chaining

Behavior chains can link individual behaviors to form a larger behavior. By breaking down a task into its
simplest steps, a complex behavior may become more consistently achievable.

Keys to success

Consistency can be crucial for achieving long-term behavior change. Once a desired behavior is
established, consistent reinforcement is typically required to maintain it. When using behavior
modification techniques for children, it may be helpful to discuss strategies with teachers, grandparents,
and other caregivers to clearly establish rewards and consequences for behavior.

This behavioral modification program is based on training the child to behave in a more appropriate and
socially accepted manner. This should consist of an immediate correction of any aberrant behavior,
utilizing a special holding technique to overcome temper tantrums. Many of the most difficult behaviors,
if dealt with early, may become controlled, or if neglected, may lead to a wild, impulsive, uncontrollable
behavior that may require institutionalization. In many families of children with ASD, instead of the
children being taught normal, socially accepted behavior, the entire family learns abnormal behaviors
from the kids in the process of trying to accommodate them to prevent the temper tantrums. This is
why controlling the tantrums is so important. Accommodating these kids by giving in to the abnormal
behaviors only delays the tantrums and makes the abnormal behaviors the accepted standard for those
children with ASD.

Structured daily routine

A structured daily routine is important. The child will perform best under familiar conditions, including
location and activities. Later, as the situation improves, the rigid routine may be gradually modified, as
tolerated.

Temper tantrum control

Controlling temper tantrums is of extreme importance. The holding technique, as demonstrated during
the office visit, requires a gentle, yet firm hold of the child, with the back to the parent’s chest; the
child’s legs should be held between the parent’s legs. During the holding time, the parent must try to
communicate with the child, calm him/her, yet not give in to the behavior that led to the tantrum. This
procedure is not a form of punishment. It is devised to protect the child and others from the erratic
behaviors. It must be done gently, not to hurt the child, yet firmly to get a clear unequivocal message
through. It definitely is not meant to be “fun” time and a firm approach is required. Communication
must be short, clear, and firm, expressing the parent’s appropriate emotional reaction to the behaviors
that led to the tantrum. The reaction (firmness of communication) must be proportionate to the severity
of the behavior. This will also teach a child whose ability to understand emotional responses are
impaired, how one must react under different circumstances. The main objective of the holding and the
behavioral modification program is to correct inappropriate behaviors, thus trying to normalize the
child’s routines and behavior, including all social interactions as much as possible.

There are three priorities, when it comes to “insisting” with a child over behavioral issues.

1. First priority: Temper tantrums and inappropriate behavior that if left unchanged may
potentially become life threatening, such as hitting, throwing objects, jumping out of high places
or windows, running into the street, or refusing to eat, must be attended to immediately,
without compromise.

2. Second priority: “Sitting skills.” Behavior, that if left alone, will make it impossible for the child
to sit in class and, therefore, impossible to attend school with his/her peers, regardless of his
abilities or “baseline IQ.” This consists of teaching sitting skills. This may be accomplished while
sitting for dinner with the rest of the family, sitting in a restaurant or at any family or social
gathering that require sitting skills.

3. Third priority: Dealing with the repetitive ritualistic habits. Unusual “bizarre” behaviors, that
may result in social isolation or difficulties, if left unchanged. Such are inappropriate play habits,
pervasive repetition of activities, self-stimulatory behavior, hand flapping, persevering into strict
interests or production of unusual sounds. This may be done with a simple firm “stop!”
command, and by directing the attention to more appropriate behaviors.

The holding technique is very important and constitutes the frame structure for the behavioral
modification program. The holding should be done with compassion, not trying to hurt the child, but
helping him/her to adjust to a difficult situation. This is not a form of punishment. Only one parent
should communicate with a child while being held. One parent holding, while the other is smiling and
trying to console the child, will cause confusion and the wrong message to come through.

The behavioral modification teaches the child to acquire a more socially acceptable behavior, thus giving
him/her a better starting point, to enter life’s social requirements, compared to a child who still remains
with all the attended social, behavioral difficulties associated with ASD.

Communication

Communication must be short, clear, loud (not yelling). Many children with ASD have auditory
integration difficulties. Talking to them excessively will not be registered and may sound to them like
gibberish. Therefore, communication must be very simple and to the point, leaving time between words
to integrate the information. Eye contact must be worked on. As the child improves, communication
may become more fluent and elaborate.
Never smile or regard inappropriate behavior as cute or funny. Some behaviors as pulling a parent to
different locations must be discouraged. Facial expressions by the parents must be appropriate and
sometimes exaggerated to teach the socially appropriate way of expressing emotions. Proper attempts
by the child to communicate must be encouraged and pursued.

Individualization of care

The behaviors of individuals with ASD may differ in many aspects. Each child has his own strengths and
weaknesses. A good behavioral modification must be customized to each child’s specific needs. The
principle of correcting inappropriate behavior, however, applies to all.

Placement and education

The most regular, highest functioning environment, including a regular educational system, should be
attempted whenever possible. This, with independent supplementation of all the other needs, including
speech therapy, occupational therapy, and physical therapy, if needed, will result in the most favorable
outcome. When a regular educational system is unrealistic, each community may offer different options.
The parents should individually and personally check these options. Once in the program, I do encourage
parents to come in and observe first hand the quality of services provided, and how the child fits in. You
have to give it some time, but remember, be a strong advocate for your child. There is no program that
fits exactly the individual needs of every child with ASD, therefore sometimes you may have to use your
creativity, based on the knowledge of your child, to obtain the best solution. Rarely, you may have to
actively pull your child out of a program if he/she does not fit and seems to regress, and find a better
alternative. Parents must, however, be realistic about the child’s potential.

Emotional aspects

No one can clearly determine the final outcome of a child with ASD. Do not give in. Have realistic
expectations yet try to push him/her as much as possible. Try to demand from your child to behave like
any other regular child and regard them as such. Do not let the child “get away with things” because
he/she is autistic. If your expectations are set too low, it may impair the final outcome. On the other
hand, when it is clear that a child cannot perform a certain task, know where to stop. The right balance
may be sometimes difficult to determine.

The “A” word and the social stigma: The public and some professionals, unfortunately, lack education
when it comes to ASD. Do not deny the problem, try to educate yourself and deal with the specific
difficulties. On the other hand, keep the diagnosis private, if possible, to prevent expectations from
educators and the public in a way that may eventually affect your attitude and opinion as well. This
applies to mild cases of ASD.

Other treatment options

Different modalities are available. Some are controversial, some clearly ineffective. There are no studies
that unequivocally demonstrate beneficial results from vitamin or diet therapy, but there are some
anecdotal reports falsely supporting many modalities. Contrary to this, there are reports of
improvement without any “therapeutic” intervention.
Modalities that can be considered should be free of side effects. Auditory and sensory integration
training, when done properly, benefits certain children with ASD. Other modalities are discussed in the
ASD package.