Monday, September 22, 2008

What's In a Reward? A reward by any other name. . .

With apologies to Shakespeare, the concept of reward has been restricted, much as the definition of a flower has been restricted to those colorful parts of plant anatomy that assure generational propagation. Some flowers are clearly not roses, dahlias, daffodils, etc.

Negative reinforcement or reward is something that psychologists learn about in school but hardly ever apply. Those who are not trained, or those who forget their training often make the error of thinking that negative reinforcement equals punishment. Here's the boring definition, "Negative reinforcement is anything (an event or object) which, by its removal, increases the likelihood that the behavior which it follows will happen again."

Darlene was an adolescent with Trisomy 21 (Langdon-Down Syndrome). She was not doing her work at school, saying "No" each time that she was given a task. Many times, she would push the person offering her a task. Few people would guess that she had rewarding "Nos." The task given to the paraprofessional (1975 to 1977) was to get her to do anything. We started with something simple, a board having large easy to grasp pegs. Sitting together, with Darlene saying "No" many times, the therapist takes her hand places a peg in it, and rapidly guides the hand to place the peg in the board. He then moves to the far end of the table. Darlene laughs.

Within two weeks Darlene was completing an entire pegboard in order to get the therapist to move away. This was negative reinforcement in action. There are obvious ways to enhance the negative reinforcing value in cases like this. One would be to work out heavily in a fitness center, getting all full of perspiration. Don't shower. Perhaps your Darlene will work twice as hard to move you away. Another way makes use of the negative reinforcement value of garlic breath, ordinarily an occupational hazard for psychologists and therapists.

Let's consider the case of Jean. This 19 year old loved to shake his hand in front of his face. Way back in 1978, he was a resident of a facility for severely and profoundly developmentally delayed people. He had a goal to be able to work at a sheltered workshop task or tasks. The psychologist, Dr. Paul, was a well trained behaviorist. He tried every thing that he could think of to get Jean to stop shaking his hand in front of his face in order to work. His attempts included rewarding competing behavior (actions that could not be completed unless he used his hands), rewarding progressively lower rates of hand shaking, and others. Nothing worked. Paul ate lunch with the psychologist and informed him of the bad news. He was discharging Jean to his living unit where he would spend his days shaking his hand in front of his face. I asked Paul if he had tried to put gloves on Jean's hands. It did not make sense to him. It did not make sense to any one at the facility. However, they reluctantly agreed to a trial run.

A large number of staff members gathered in the dayroom of Jean's living unit. Jean came in, accompanied by staff members. He leaned against the wall shaking his hand in front of his face. The only time that this did not happen for more than a few minutes was when he slept. A staff member brought in a pair of gloves. As soon as the gloves were placed on his hands, he stopped shaking them in front of his face.

It did not take long for Jean's improvement to become dramatic. He was soon at the work training facility assembling pens. The gloves sat on the table in front of him. He never needed them as long as they were visible.

A parent of a recently evaluated adolescent revealed a similar treatment for head banging. Her adopted son used to bang his head against the same place on the wall near his bead. Bucky was profoundly visually impaired. His mother desperately wanted him to stop hitting his head on the wall. She came up with the idea of gluing foam ceiling tiles over the area around the bed. The ceiling tiles glued to the wall stopped the way that the head banging sounded and felt to Bucky. He stopped banging. What is more surprising, he never tried a different area of wall for the head banging activity.

Within the past few months (2009), I had the chance to evaluate a 2 - 3 year old boy who lived in a very rural part of the state. His home was the only one on the narrow road. The little fellow was born with some problems that interfere with swallowing and with breathing, so he continues to survive with a tracheotomy tube. He is fed through a tube in his stomach wall. There is a full time nurse in his home to suction fluid accumulation from the trache.
One of the problems that I needed to address with Rocko was his hand biting behavior. He bit his hand so hard on several occasions that it bled. One of the major university medical hospitals solved the problem with prevention. They have his arms in removal, semi-flexible restraints that keep his hands away from his mouth. I observed that Rocko would bang his hands on surfaces. Sometimes, he would strike flat surfaces with the palms of his hands. Sometimes, he would strike the surfaces with the heel of his hand. He also held his fingers pointing downward and struck his finger tips on flat surfaces. It seemed to me that this indicated that his hand biting was not at all related to oral stimulation. His goal was to stimulate his hands. I recommended providing hand stimulation and pressure along with a consultation with an Occupational Therapist. I'll let you know what happens.

This is all about thinking in ways that are different. There is an old saying, "If you keep doing what you've always done, you'll get what you've always gotten." That much is true for behavior change. If you use the same way of thinking, without trying to change it, you may never be a person who changes behavior.

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