Addressing challenging behaviour in children with Down syndrome: The use of
applied behaviour analysis for assessment and intervention
Kathleen Feeley and Emily Jones
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 characteristics
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 syndrome
Feeley KM, Jones EA. Addressing challenging behaviour in children with Down syndrome: The use of
applied behaviour analysis for assessment and intervention. Down Syndrome Research and Practice. 2006;11(2);64-77.
Children with Down syndrome have a propensity to engage in behaviours that can be particularly
problematic for family members and caregivers, as well as professionals who work with them.
Such behaviour, referred to by Doss and Reichle (1991) as challenging behaviour, is defined
as that which results "â€¦in self-injury or injury of others, causes damage to the physical environment,
interferes with the acquisition of new skills, and/or socially isolates the learner" (p. 215).
The presence of challenging behaviour, along with characterisations such as "stubborn," have
long been noted in the literature (Gibson, 1978). More recently, parent and teacher ratings
indicate that children with Down syndrome show higher rates (than typically developing children)
of attention problems, social withdrawal, noncompliance, and compulsions (such as arranging
objects and repeating certain actions) (e.g., Coe et al., 1999;
Evans & Gray, 2000) and high
rates of self-talk (Glenn & Cunningham, 2000). Additionally, behaviours associated with anxiety,
depression, and withdrawal, have been noted to increase with age (Dykens & Kasari, 1997).
There are specific physical characteristics of Down syndrome (e.g., those associated with sleep
disorders) (Richdale, Francis, Gavidia-Payne & Cotton, 2000;
Stores, 1993) as well as a higher
incidence of illness (Roizen, 1996) that may significantly impact the behavioural repertoires,
including increasing the likelihood of challenging behaviour, in children with Down syndrome.
Researchers have also demonstrated that challenging behaviour, particularly avoidance behaviour,
appears consistently in very young infants with Down syndrome (Wishart, 1993a,
when presented with task demands just slightly above their current level of ability, children
with Down syndrome demonstrate a unique pattern of behaviour involving opting out of learning
opportunities and misusing social behaviours. It appears that the presence of the extra chromosome
associated with Down syndrome affects the likelihood of challenging behaviour beginning in infancy.
In turn, these behaviours can have catastrophic effects; interfering with learning in children
with Down syndrome, not only at the foundational level during infancy, but throughout life.
These characteristics that impact the behaviour repertoire reflect a unique pattern of strengths
and weaknesses evident in individuals with Down syndrome and have been described as a distinct
cluster of behaviours termed a behavioural phenotype.
Dykens (1995) defined behavioural phenotype
as "â€¦the heightened probability or likelihood that people with a given syndrome will exhibit
certain behavioural and developmental sequela relative to those without the syndrome" (p. 523).
This does not mean that all children with Down syndrome will demonstrate all of the characteristic
behaviours; rather, there will be in an increased likelihood.
The early developing avoidance behaviour reported by Wishart and colleagues along with reports
of other challenging behaviour is believed to be part of this phenotype in very young children
with Down syndrome (Fidler, 2005). Thus, it is of utmost importance to intervene on the behaviours
characteristic of this behavioural phenotype early on so that they do not result in pronounced
deficits within the child's later development.
Challenging behaviour not only precludes individuals with Down syndrome from learning opportunities
within their environment, but also prevents them from accessing more typical educational and
community environments as they approach preschool and school age. When placement in a general
education or community 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 & Archer, 2002; Cunningham, Glenn, Lorenz, Cuckle & Shepperdson, 1998). Therefore,
interventionists who are likely to encounter behaviour that may be associated with later negative
outcomes must be prepared to address such behaviour so that children with Down syndrome benefit
from learning opportunities and are less likely to be precluded from general education/community
Fortunately, the methodology of applied behaviour analysis, demonstrated effective across a
wide range of populations, with various disabilities, can be utilised to address the unique
characteristics of challenging behaviour demonstrated by children with Down syndrome. With thousands
of studies demonstrating the positive impact of interventions based on the principles of behaviour
analysis on the lives of individuals with disabilities, both researchers and practitioners have
long relied on this scientific literature to address the challenging behaviour of individuals
with developmental disabilities. Recently, the technology of Positive Behaviour Support
(Carr et al., 2002) has emerged as an application of the principles of behaviour analysis to
not only address skill repertoires, but also redesign individuals' living environments with
the goal of achieving enhanced quality of life and decreases in problem behaviour (Carr et al.,
To date, researchers have not specifically applied the principles of behaviour analysis and
positive behaviour support to meet the unique behavioural challenges presented by individuals
with Down syndrome. However, in an extensive review of the literature, we identified a small
number of studies utilising behavioural assessment strategies, as well as several intervention
studies that addressed severe challenging behaviour in individuals with Down syndrome. The focus
of these investigations was not on the unique characteristics of individuals with Down syndrome,
rather the focus was a particular form of challenging behaviour (e.g., aggression, self-injury)
or a particular intervention strategy (e.g., reinforcement) and involved either a sole participant
who had Down syndrome or several participants, only one or two of whom had Down syndrome.
In this paper, we briefly describe applied behaviour analysis and its applications in assessing
and addressing challenging behaviours prevalent in children with Down syndrome. We then draw
upon the existing literature as well as our clinical experience and ongoing research to provide
suggestions regarding behaviourally based applications to ameliorate specific challenging behaviours
associated with Down syndrome in an effort to intervene as early as possible on this aspect
of the behavioural phenotype characteristic of children with Down syndrome.
Applied behaviour analysis
Based upon the seminal work of Baer, Wolf and Risley (1968), applied behaviour analysis emphasises
interventions addressing socially significant age-appropriate behaviours with immediate importance
to the individual using precise measurement of those behaviours in need of improvement. Generalised
behaviours, that is, behaviours that are maintained over time, appear in other environments,
and extend to other behaviours, are targeted. A functional relationship between changes in behaviour
and the intervention being implemented is demonstrated. Interventions, derived from the basic
principles of behaviour (e.g., reinforcement, extinction), are described so that they can be
easily replicated, and their effectiveness is measured by improvement in the individual's performance.
Functions of challenging behaviour
It has long been established that challenging behaviour is directly related to environmental
variables (e.g., how the behaviour is consequated). From a behaviour analytic perspective, challenging
behaviours are maintained because they are positively reinforced (i.e., result in the delivery
of a preferred item/activity) and/or are negatively reinforced (i.e., result in the removal
of a nonpreferred item/activity). O'Neill, Horner, Albin, Storey and Sprague (1997) described
these two major functional categories of behaviour as either to obtain or to escape/avoid.
That is, behaviour may function to obtain consequences such as attention (e.g., from a parent
or teacher) and access to objects (e.g., snacks, toys) or activities (e.g., recess, trip to
the park). Behaviour may also function to escape/avoid consequences such as attention (e.g.,
interactions with peers) and objects (e.g., certain foods) or activities (e.g., academic tasks).
In addition to the functions of obtain or escape/avoid,
O'Neill et al., (1997) further categorise
the functions of challenging behaviours in terms of socially or nonsocially motivated
behaviours. Socially motivated behaviours involve those in which the child seeks to escape/avoid
or obtain something from another individual in their environment. Behaviours serving a social
function in children with developmental disabilities are often related to impairments in communication
skills (Carr & Durand, 1985;
Durand & Carr, 1991; 1992). Nonsocially motivated behaviours involve
those in which the child seeks to escape/avoid or obtain internal stimuli (i.e., sensory stimulation)
and, thus, do not involve consequences related to another individual. These nonsocially motivated
behaviours are often referred to as 'self-stimulatory' behaviours.
The work of Wishart (1993a;
1993b) and Wishart and Duffy (1990) suggests that certain functions
of challenging behaviour may be more characteristic of children with Down syndrome and part
of the characteristic behavioural phenotype. In particular, both escape and attention seeking
functions seem prevalent in Wishart's reports of performance during assessment tasks. Specifically,
Wishart and colleagues (Pitcairn & Wishart, 1994;
Wishart, 1986; Wishart & Duffy,
1990) report avoidance
behaviours ranging from disruptive tantrum behaviours (e.g., sweeping test items off the table)
to charming or 'cute' behaviours (e.g., clapping, blowing raspberries) that might distract the
evaluator during task demands. The overlapping attention seeking function of such task avoidance
behaviours was also noted by Kasari and Freeman (2001) who confirmed the higher frequency of
these 'charming' behaviours in older children with Down syndrome (6-10 years). In fact, in their
study, children with Down syndrome engaged in higher rates of looking to the experimenter during
a task situation that may have been related to the significantly longer latency to start and
complete tasks, when compared to typically developing children and children with mental retardation
not related to Down syndrome.
As a result of these findings, it seems that both escape and attention seeking behaviours may
be particularly prevalent in children with Down syndrome. To determine the extent to which an
individual child possesses these specific characteristics (increased likelihood of engaging
in escape/avoid or attention motivated problem behaviour) of the behavioural phenotype, interventionists
can conduct a functional behaviour assessment. Not only will this enable interventionists to
explore this aspect of the behavioural phenotype, but specific antecedents and consequences
associated with the challenging behaviour can be determined.
Functional behaviour assessment
While certain functions (e.g., escape, obtain attention) may be associated with Down syndrome,
challenging behaviour can serve a variety of functions within and across individual children.
Therefore, the foundation of addressing challenging behaviour is determining the function a
specific challenging behaviour serves for a particular child (i.e., to obtain or escape/avoid;
socially or non-socially motivated). This is accomplished via the functional behaviour assessment
process in which the relationship between events in a person's environment and the occurrence
of challenging behaviour is determined in an effort to identify factors maintaining that behaviour.
(The reader is referred to O'Neill et al.'s  practical handbook for a detailed discussion
of functional behaviour assessment procedures.)
The first step in the functional assessment process consists of an interview to identify the
behaviour of concern; related environmental/medical factors; and when/where/with whom and during
which activities the behaviour occurs most/least. The goal is to identify factors that are related
to the occurrence of challenging behaviour.
In the past, when addressing challenging behaviour, the field of applied behaviour analysis
concentrated on the immediate antecedents and consequences. However, several behaviourists have
recognised that events occurring more distally in time or not directly related to the immediate
antecedents or consequences affect the likelihood of challenging behaviour (Michael, 1982;
2000; Wahler & Fox, 1981). Such variables have been referred to as motivating operations (Michael,
2000) as well as setting events (Wahler & Fox, 1981). Specifically, motivating operations refer
to antecedents that affect an individual's behaviour by changing the value (increasing or decreasing)
of a consequence (reinforcer or punisher) which, in turn, changes the likelihood the individual
will engage in a certain behaviour (either increasing or decreasing the likelihood). For example,
a child may be motivated to follow the directions (immediate antecedent) of his teacher because
doing so results in a pleasant interaction (i.e., the teacher smiles and praises the child;
reinforcing consequence). However, if the child has a cold, the reinforcing value of the smile
and praise may be significantly decreased, thus, decreasing the likelihood the child will engage
in compliant behaviour in response to the teacher's requests. In this situation, the cold is
a motivating operation.
The term motivating operation has been used to describe 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 Behaviour Support literature, the term setting event is widely
used to represent the phenomena described (Horner, Vaughn, Day & Ard, 1996). Several studies
have been conducted describing a relationship between different setting events (e.g., illness,
sleep problems) in the lives of individuals with developmental disabilities and a propensity
to engage in challenging behaviour (e.g., Dadson & Horner, 1993;
McGill, Teer, Rye & Hughes,
We suggest that the propensity of individuals with Down syndrome to engage in challenging behaviour
is directly related to several motivating operations (or setting events) that are inherently
related to the presence of Down syndrome. For example,
Stores (1993) found more frequent sleep
problems, including restless sleep, 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
of sleep problems appears to be related to several physical features (specifically, upper airway
obstruction due in part to relatively small mouths and airway passages, enlarged tonsils, and
obesity) (Stores & Stores, 1996). These sleep problems were also associated with daytime problem
behaviour: specifically, irritability, hyperactivity, and stereotypies (Richdale et al., 2000;
Stores, 1993). Thus, sleep disorders may be one motivating operation that affects the likelihood
of challenging behaviour in children with Down syndrome.
There is also a high incidence of illness in children with Down syndrome (e.g., recurrent ear
infections, gastrointestinal disorders, skin conditions) (Roizen, 1996). The onset of an illness,
its presence, as well as the ending stages, may be motivating operations affecting the behaviour
of children with Down syndrome, as is often the case with typically developing children. As
the frequency and severity of these illnesses is increased in individuals with Down syndrome,
the incidence of challenging behaviour is likely to be increased as well.
It is during the interview process that environmental events including setting events/motivating
operations, antecedents, and consequences, as well as target behaviours are identified. It is
here that interventionists should closely examine the extent to which specific motivating operations
(or setting events) associated with Down syndrome affect the individual's likelihood of engaging
in challenging behaviour. Just as the function of behaviour is likely to vary across individuals,
the specific antecedents and consequences as well as the presence of motivating operations (or
setting events) are likely to be unique to each child with Down syndrome and require careful
assessment to determine which are relevant for a given child.
The second component of the functional behaviour assessment process consists of direct observation
of the individual and documentation of events that occur prior to and following the challenging
behaviour. One example is an antecedent-behaviour-consequence (ABC) analysis, in which antecedents
and consequences are documented as they occur in the natural environment. The child is observed
during his/her daily routine and the occurrence of challenging behaviours, events that precede
the specific behaviour (antecedents), and events that follow the specific behaviour (consequences)
are documented. Analysis of the pattern of antecedents and consequences results in a hypothesised
function of the challenging behaviour. See Table 1 for an ABC data sheet with guidelines regarding
information that should be included and Table 2 for an example ABC data sheet with sample behaviours.
Description of behaviour(s) that occurred
How did you respond?
Obtain attention, tangibles, access to activity
||Location of student
May need to include dimensions such as duration and intensity
How did others respond?
Escape demands, transition, or attention
||Others present (teachers, students)
What happened to the activity?
Obtain internal stimuli
||Immediate trigger (demand, removal of attention)
||Escape internal stimuli
Table 1. Sample ABC data sheet.
Child playing on floor, parent attending to sibling
Child climbs on table
Caregiver rushes over, swoops child up, telling her "No, no, honey, that's dangerous"
followed by a hug and a kiss. Caregiver puts child down with toys and plays with child
Teacher presents nonpreferred task (e.g., writing activity)
Child makes a silly face and begins to sing a rhyming song
Teacher laughs with child and joins in song, delaying the request to engage in the nonpreferred
Escape and attention seeking
Table 2. Example behaviours documented on an ABC data sheet.
Often, the function of a particular challenging behaviour for a child can be identified through
the interview and direct observation process. However, a more systematic approach may be necessary
to confirm observation findings and/or determine the function, if it has not been clearly identified.
Functional analysis consists of the systematic manipulation of controlling variables to demonstrate
the function of the behaviour (the reader is referred to
O'Neill et al., 1997 as well as
Dorsey, Slifer, Bauman & Richman, 1982 for explicit procedures). Functional analysis involves
measuring challenging behaviour as a series of conditions are introduced. Consequence conditions
include situations in which: attention is delivered contingent upon the occurrence of challenging
behaviour (attention condition); demands are removed contingent upon the occurrence of challenging
behaviour (demand condition); tangibles are delivered contingent upon the occurrence of challenging
behaviour (tangible condition); the child is left alone and no consequences are delivered by
others (alone condition); and a condition involving noncontingent delivery of preferred 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 task. The conditions in which
the challenging behaviour occurs are indicative of the factor(s) occasioning and/or maintaining
the behaviour. For example, if higher rates of challenging behaviour occur within the demand
condition than within the other conditions, escape would appear to be the function of the challenging
Once the functional behaviour assessment process is complete, and the function of the challenging
behaviour identified, intervention procedures can be developed that specifically address the
challenging behaviour and the function it serves for that individual. Interventionists should
draw from the large number of empirically validated studies demonstrating the facilitative effects
of behaviour analytic procedures.
An effective means of addressing challenging behaviour, Positive Behaviour Support (Carr et
al., 2002), is rooted in behaviour analytic strategies. Positive Behaviour Support consists
of strategies addressing multiple variables influencing the occurrence of challenging behaviour.
When utilised at an individual level, Positive Behaviour Support interventions consist of the
development of a four component approach which includes strategies to address motivating operations/setting
events and immediate antecedents, interventions to teach replacement skills (e.g., communication,
academic, social), and the development of appropriate consequence strategies (e.g., reinforcement
strategies) as outlined in Figure 1. To illustrate behavioural applications within this four
component framework, we will provide a brief description of a select few studies implemented
with children with Down syndrome, followed by additional suggestions for interventions based
upon the research literature and our clinical experience and research. The studies utilising
behavioural strategies with individuals with Down syndrome we will discuss are outlined in
Target Behaviour and Function
Cole & Levinson (2002)
7 year old boy with Down syndrome, PDD, and ADD attending a school for students with
Throwing/destroying items, hitting, and dropping to the floor
Function: No functional assessment was conducted
Choice versus no choice embedded within verbal prompts delivered during instruction
of daily routine
Challenging behaviour decreased from a range of 14.3% to 81.8% in the no choice condition
to 8.3% in the choice condition, with an increase in independent task performance
Davis, Brady, Williams & Hamilton (1992)
7 year old boy with Down syndrome, enrolled in a life skills program on an elementary
Noncompliance, kicking, screaming, spitting, stereotypic behaviour, emptying cabinets/drawers
Function: No functional assessment was conducted
The delivery of three to five high-probability requests, each followed by the delivery
of verbal or gestural (thumbs up) praise
Compliance increased from a mean of 6.7% during baseline to 100% following intervention,
with performance generalised to other adults and was maintained during follow up probes
Hall, Neuharth-Pritchett & Belfiore (1997)
9 year old boy with Down syndrome in a self contained classroom with inclusive opportunities
Aggression: hitting, destroying and throwing materials
Function: both escape and attention
Instruction of communicative replacement of raising hand and saying "done"
Aggressive/destructive behaviour decreased from 11% (of the 10 second intervals within
a 45 minute session) in baseline to 2% during intervention
Performance generalised from his special education classroom to a general education
McComas, Thompson & Johnson (2003)
Two boys with Down syndrome enrolled in special education classes within a public school:
Dan, 11 years old
Ari, 12 years old
Dan: throwing materials, hitting, and spitting
Function: attention seeking
Ari: hitting, pinching, kicking, throwing items
Noncontingent attention versus no attention during 10 minute presessions prior to engaging
in tasks likely to elicit challenging behaviour
Challenging behaviour decreased for Dan (who was attention motivated) when attention
presessions were provided
Challenging behaviour did not change for Ari (who was escape motivated)
Repp & Karsh (1994)
9 year old girl with Down syndrome placed in a segregated school
Tantrums (crying, falling to floor, kicking, hitting, throwing objects, and grabbing)
and finger stereotypies (finger flexions)
Extinction, differential reinforcement of alternative behaviour, and increased opportunities
to engage in social interactions
Challenging behaviour decreased from 41% of the day in baseline to an average of 4%
Maintenance observed at one year follow-up
Table 3. Studies examining the use of behavioural interventions to address challenging behaviour
in children with Down syndrome.
Figure 1: Components of a Positive Behaviour Support Plan with example interventions.
Addressing setting events (motivating operations)
Because the term setting event is used in the Positive Behaviour Support literature, we have
chosen to use it in our discussion of intervention strategies. One setting event that we hypothesise
may be specifically associated with Down syndrome is the tendency toward an increased desire
to escape/avoid demands and to obtain attention as suggested by Wishart's research (1993a,
1993b). McComas, Thompson and Johnson (2003) utilised a setting event intervention strategy consisting
of presessions during which attention was provided. Several children participated in this study,
two of whom had Down syndrome (11 and 12 year old boys). In one condition, attention was delivered
noncontingently (i.e., regardless of the child's behaviour) during the 10 minutes prior to engagement
in tasks likely to elicit challenging behaviours (i.e., during presessions). In the second condition,
students were ignored during the 10 minute presessions. Although, the presession condition in
which attention was provided had no effect on the challenging behaviour of the child who was
escape motivated, the child who was attention motivated engaged in challenging behaviour during
subsequent tasks almost exclusively when no attention was delivered during the presessions.
McComas et al.'s (2003) study demonstrated the effectiveness of an intervention procedure to
specifically address a setting event, in this case, the increased desire for attention. It is
important to note, attention served as a reinforcer in the target situation for only one of
the two children with Down syndrome (as confirmed by the functional assessment process), while
the challenging 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 pertinent to
all children with Down syndrome. Additionally, once the functional assessment process has been
completed (taking into account setting events), interventionists should select intervention
strategies that directly correspond to the findings. For example, as illustrated by
et al., presession attention did not affect individuals who engage in challenging behaviour
serving functions other than to obtain attention.
Other setting events, such as sleep disorders and illness, that warrant attention specifically
in children with Down syndrome, may be addressed by developing a mechanism for caregivers to
share with school personnel when a child has experienced a particular setting event. Checklists
can be designed to specifically note setting events influencing the child's challenging behaviour.
Alternatively, setting events can be reported via a note sent to school or a telephone call.
School personnel can then consider several interventions designed to ameliorate the effects
of the specific setting event (e.g., Dadson & Horner, 1993;
Horner et al., 1996). For example,
a child's illness may increase the likelihood that he/she engages in self stimulatory behaviour
(e.g., repetitive hand movements). In this case, the child might be given the opportunity to
access materials that would function as a replacement response (e.g., holding onto a small textured
toy stored within the front pocket of a sweatshirt). Another child who experiences trouble sleeping
might be more likely to desire to escape demands. In this case, the child may be given an opportunity
to rest at some point during the day, or school staff might consider reducing their demands
(e.g., requesting fewer academic tasks) on days following disrupted sleep. The effects of the
setting events may also be ameliorated through the delivery of higher rates and/or higher quality
of reinforcement. This reinforcement should be delivered before the child is likely to engage
in the challenging behaviour (Marcus & Vollmer, 1996). For example, a child can be greeted at
the bus with high rates of quality attention and, therefore, may be less likely to engage in
attention motivated challenging behaviour upon entering the classroom.
Strategies to address setting events can have substantial effects on the likelihood of challenging
behaviour. However, in many instances, it may also be necessary to consider interventions that
target immediate antecedents.
Antecedent based strategies
Intervention strategies targeting stimuli that occur just prior to the child engaging in challenging
behaviour are termed antecedent based strategies (Kern, Choutka & Sokol, 2002). These strategies
aim to prevent the occurrence of challenging behaviour by altering the antecedent situations
associated with it (e.g., decreasing the aversiveness of the antecedent stimuli). Thus, these
strategies are implemented proactively, that is, prior to the point at which the challenging
behaviour is likely to occur (identified via the functional assessment process). Four strategies
may be particularly relevant to decrease the escape and/or attention motivated challenging behaviours
often seen in children with Down syndrome: choices, high probability request sequence, collaboration,
and preferred item as distractor.
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.,
Koger, Katze & Davenport, 1995; Dunlap, et al., 1994;
Dyer, Dunlap & Winterling, 1990). In one
application with a 7 year old boy with Down syndrome,
Cole and Levinson (2002) demonstrated
the effectiveness of embedding choices within the daily routine of hand washing, a situation
during which the boy was likely to engage in challenging behaviour (e.g., throwing/destroying
items, hitting, and dropping to the floor). Rather than delivering a directive regarding how
to complete a step within the task (e.g., "Rub your hands"), the child was offered choices regarding
how the step could be completed (e.g., "Do you want to rub them together quickly or slowly?").
Challenging behaviour decreased while independent task participation increased. Thus, while
presenting tasks that trigger challenging behaviour, choices can be offered with respect to
a variety of aspects, such as location (e.g., "You can work at your desk or at the group table"),
peers ("Would you like to walk with John or Mary?"), or materials (e.g., "You can use your pencil
or my blue pen") to decrease escape motivated challenging behaviours.
Another antecedent strategy, high probability request sequence, involves the delivery
of a series of requests to which the child is highly like to comply (a high probability request)
each of which is followed by the delivery of reinforcers, then a request to which the child
is not likely to comply, that is, a low probability request (the one that triggers the
challenging behaviour) is delivered. For example,
Davis, Brady, Williams and Hamilton (1992)
successfully utilised high probability request sequence to increase compliance and decrease
challenging behaviour (screaming, hitting, kicking, spitting) in a 7 year old boy with Down
syndrome. Behaviour change generalised across classroom staff and was maintained during a series
of 4 weekly follow up probes. High probability request sequences have not only been effective
in decreasing challenging behaviours (Horner, Day, Sprague, O'Brien & Heathfield, 1991;
& Belfiore, 1990), but also increasing compliance (Mace et al., 1988;
Singer, Singer & Horner,
1987), particularly during transitions (Davis, Reichle & Southard, 2000), as well as increasing
social interactions (Davis, Brady, McEvoy & Williams, 1994;
Davis & Reichle, 1996) and communicative
behaviours (Davis, Reichle & Johnston, 1998). This strategy may be particularly effective with
a child who is not only escape/avoid motivated, but also attention motivated, because, inherent
in the high probability request sequence, each compliant response results in social reinforcement
A third antecedent strategy that may be particularly effective for children with Down syndrome
who not only desire to escape/avoid a task, but also obtain attention, is an offer of collaboration
(Davis, McEvoy & Riechle, 2005). This entails sharing the responsibility of the task with the
child. For example, during a worksheet task, the interventionist tells the child, "You do the
first five items and I'll do the last five." Over time, the amount of assistance provided by
the interventionist can be systematically faded (e.g., "You do the first six, and I'll do the
last four") until the child is performing independently.
Lastly, preferred item as a distractor (Davis et al., 2000) involves presenting a child
with a preferred item to distract them from the aversiveness of the task that triggers challenging
behaviour. The preferred item is systematically presented prior to, or simultaneous with, the
request that is likely to occasion the challenging behaviour. For example, a child can be given
a favourite toy and then requested to take a walk to another instructional area. Alternatively,
the interventionist may embed the preferred item (e.g., whistle) into the request (e.g., "Can
you hold the whistle while we walk in from recess?").
For antecedent strategies to be effective, it is essential for interventionists to be fluent
in their use, paying particular attention to implementing the strategies prior to presenting
the antecedents that are associated with the behaviour. While setting event and antecedent based
intervention strategies serve to proactively decrease the likelihood that challenging behaviour
will occur, it is important to recognise the function the challenging behaviour serves for a
particular child and teach replacement skills for the child to use to obtain what they want
through more appropriate means.
Many individuals with Down syndrome can benefit from instruction in specific skills (e.g., communication,
social, academic, etc.) that function to replace challenging behaviour with a more appropriate
means of obtaining reinforcers. One type of skill building strategy, functional communication
training, involves identifying and teaching a more appropriate communicative response
serving the same function as the challenging behaviour (Carr et al., 1994).
Several researchers (e.g., Brooks, Todd, Tofflemoyer & Horner, 2003;
Hetzroni & Roth, 2003)
have implemented functional communication training with children with Down syndrome. For example,
Hall, Neuharth-Pritchet and Belfiore (1997) determined that the aggressive and destructive behaviours
of a 9 year old boy with Down syndrome served the function of both escape (the wait) and attention
when he was required to wait after completing a task. He was taught to indicate when he was
finished by raising his hand and saying "done" which resulted in the delivery of a brief, in-seat
academic activity. Acquisition of this replacement response resulted in a decrease in aggressive/destructive
behaviours that generalised from his special education classroom to a general education classroom.
As the speech and language skills of individuals with Down syndrome are specifically impaired,
their ability to communicate desires is likely to be compromised and, thus, related to the occurrence
of challenging behaviour. Based on the extensive literature examining the effectiveness of functional
communication training (e.g., Carr & Durand, 1985;
Durand & Carr, 1991; 1992), communicative
replacement strategies can be used to address a variety of communicative functions. For example,
a child who desires to escape circle time activities can be taught to raise his/her hand to
request to leave the area. For a child who desires attention, he/she can be taught to tap an
adult's shoulder to request attention (e.g., to read a book). A child who tends to tantrum in
the presence of desired objects can be taught to appropriately request the desired object (e.g.,
point to communication symbols "want" "[item]").
When teaching a child to communicate his/her desires instead of engaging in challenging behaviour,
it is crucial to reinforce appropriate communicative behaviours with immediate access to what
the child desires (e.g., a break for a child who is escape motivated, attention for the child
who is attention motivated). Once the communicative replacement response is acquired, it is
possible to systematically teach the child to wait longer periods of time before the child can
access what they desire. This intervention is referred to as teaching tolerance for delay
of reinforcement (Carr et al., 1994). For example, once the child reliably uses the replacement
communication skill (e.g., raising his/her hand), when the child makes the appropriate request,
increasing amounts of time can be inserted before delivery of the reinforcer (e.g., tell the
child "Just one minute.").
Replacement skills are particularly important as they provide the child with a communicative
response that can be used across multiple situations to more appropriately obtain desirable
outcomes. It is equally important for interventionists to also implement effective consequence
strategies for both appropriate and inappropriate behaviour.
Effective interventions addressing challenging behaviour typically include reinforcement systems
for appropriate behaviour as well as consequences for inappropriate behaviour. For example,
Repp and Karsh (1994) conducted a study with two students, one of whom was a 9 year old girl
with Down syndrome whose challenging behaviours consisted of tantrums (crying, falling to floor,
kicking, hitting, throwing objects, and grabbing) and finger stereotypies (finger flexions)
that had resulted in her removal from an integrated educational setting. Direct observation
during baseline indicated that, although she engaged in tantrums within demand situations, she
was consistently consequated with attention rather than withdrawal of demands. Intervention
consisted of placing the tantrum behaviour on extinction (in this case, no longer providing
attention) as well as increasing the rate of reinforcement for task engagement (differential
reinforcement of alternative behaviour (DRA), that is, reinforcement of the alternative
behaviour of task engagement), along with providing increased opportunities to engage in social
interactions. This intervention package resulted in a decrease in challenging behaviour which
maintained at one year follow-up. Thus, a combination of consequence strategies for both the
challenging behaviour (i.e., extinction) and more appropriate behaviour (i.e., DRA) were important
components of effective intervention.
Repp and Karsh's (1994) study illustrates two points with respect to consequence strategies.
First, their findings that challenging behaviour, in the presence of demands, may actually serve
the purpose of accessing attention, are particularly relevant in light of Wishart's work (Wishart
& Duffy, 1990; Pitcairn & Wishart, 1994) demonstrating the propensity of children with Down
syndrome to engage in what appear to be escape motivated challenging behaviours. They do so,
however, in a very social manner (e.g., engaging in party tricks) which often results in not
only escaping/avoiding a task, but also obtaining attention. In many instances, the exact consequences
maintaining challenging behaviour may be unclear, making intervention selection difficult. However,
systematic implementation of functional assessment procedures in conjunction with carefully
chosen interventions that specifically address the escape and attention motivated functions
of behaviour can lead to significant changes in the behavioural repertoires of children with
Second, Repp and Karsh's (1994) study illustrates the use of reinforcement procedures (i.e.,
DRA) to decrease a challenging behaviour. Another reinforcement procedure, differential reinforcement
of the omission of behaviour (DRO), is particularly effective with stereotypical behaviours
(e.g., Repp, Deitz & Speir, 1974). DRO involves delivering reinforcement following an interval
of time in which the challenging behaviour did not occur. We have used this procedure with several
children with Down syndrome to successfully decrease self-stimulatory behaviours (e.g., mouthing
objects, tongue clicking, and lip licking). In all cases, functional assessment indicated the
behaviours were non-socially motivated. Each child was initially reinforced on a dense schedule
(e.g., every 30 seconds). The time interval was then quickly increased (to 1, 3, 5, and 10 minute
intervals) to the point at which, for each of the children, the behaviour completely subsided
and continued reinforcement specifically for the absence of that self-stimulatory behaviour
was no longer necessary.
Two criticisms of DRO procedures are the intervention does not leave the individual with a specific
skill, rather it only decreases the target behaviour and in some instances, the function of
the challenging behaviour is not honoured (i.e., reinforcement is delivered based on the omission
of the behaviour with no specific functional equivalent response being taught). Thus, many interventionists
prefer to implement differential reinforcement of alterative behaviours (DRA), such as
that used by Repp and Karsh (1994), in which an alternative response is consistently reinforced.
As another example, consider a child who has a tendency to place objects in his mouth to get
attention. Appropriate responses (e.g., play behaviours with the objects) can be selected
to systematically reinforce. If not readily within the child's repertoire, the child can be
prompted to perform the behaviour and then immediately provided with reinforcers. Thus, the
challenging behaviour (mouthing objects) can be replaced with an appropriate play behaviour.
In instances in which the alternative response is communicative in nature, such as within functional
communication training, differential reinforcement (DRA) is in effect.
For socially motivated behaviours, such differential reinforcement procedures are often paired
with extinction to increase their effectiveness. Extinction involves no longer delivering
reinforcement following the occurrence of challenging behaviour. Using the previous example,
the target behaviour (i.e., mouthing objects) would no longer be reinforced, thus, no attention
would be delivered following its occurrence (i.e., extinction). This would be paired with high
quality reinforcement (i.e., attention would be delivered following appropriate play behaviours)
delivered following the alternative behaviour. The function of challenging behaviour must be
considered, not only in consequating challenging behaviour, but also in the choice of reinforcers
to increase appropriate behaviour. In the previous example, appropriate play behaviour resulted
in attention. As another example, a student who is escape motivated can be reinforced for appropriate
task completion with the removal of one or several demands.
Reinforcement systems such as token economies, in which tokens (e.g., stickers, check
marks) are delivered for appropriate behaviour and then cashed in at some later point for backup
reinforcers (e.g., toys, food), can also be used to reinforce appropriate behaviour. Such token
systems exist in many classrooms, but often need to be individualised to meet the unique needs
of a particular child with Down syndrome. Token systems can even be used by caregivers within
the home with very young children with Down syndrome and may be particularly relevant with escape
behaviour. For example, we have used token systems consisting of cartoon character tokens (e.g.,
BarneyTM, Blues CluesTM) with children as young as two years of age to
sustain performance during tasks where escape behaviour was typically displayed.
With the development of empirically demonstrated behavioural intervention strategies, the systematic
use of consequence strategies designed to decrease behaviour (i.e., the use of punishment procedures)
is likely unnecessary. The use of positive interventions has become so widespread that private
and public policy statements specifically call for their use prior to consideration of reactive
or punishment based procedures. For example, in the United States, federal education legislation
(Individuals with Disabilities Education Improvement Act of 2004) specifically notes "In the
case of a child whose behavior impedes the child's learning or that of others, consider the
uses of proactive behavioral interventions and supportsâ€¦" (Sec. 614). However, when positive
approaches have been systematically applied with little success, the use of reactive procedures
implemented to decrease the future likelihood of challenging behaviours may be warranted. For
example, consider a child who destroys materials to escape/avoid academic demands. A multicomponent
intervention may consist of giving the child a choice of academic activities, the
use of a preferred item as a distractor (i.e., "You can use your markers to fill in these
questions."), as well as teaching the child to request assistance when the academic task becomes
difficult (functional communication training). When the appropriate behaviour(s) occur,
the child is immediately reinforced (DRA). However, in the event the target behaviour does occur,
that is, the child destroys the materials, interventionists might consider a consequence procedure
that is likely to decrease the future occurrence of the behaviour, such as the removal of a
privilege (e.g., no recess) or an added chore (e.g., cleaning the dry erase board). In these
instances, it is of utmost importance for intervention teams (including caregivers) to make
informed decisions, in addition to acquiring consent from all necessary parties and monitoring
intervention for desired effectiveness (Cooper, Heward & Heron, 1987).
As the four component approach of positive behaviour support has effectively addressed challenging
behaviour in individuals with various developmental disabilities across the age span, it is
also likely to effectively meet the needs of children with Down syndrome who engage in challenging
behaviours. Positive behaviour support interventions can be used to systematically address characteristics
specific to Down syndrome (e.g., increased likelihood of engaging in avoidant and/or attention
motivated behaviour) as well as events that occur on an individualised basis. Additionally,
as interventionists become versed in the functional assessment process and proactive interventions,
they will find themselves naturally implementing many of these strategies, likely resulting
in an overall decrease in challenging behaviours emitted by the children with Down syndrome
with whom they work. In turn, increasing the child's likelihood of success in inclusive educational
and community environments.
Recent research suggests that the presence of escape and attention motivated challenging behaviour
may be part of the behavioural phenotype (Dykens, 1995;
Fidler, 2005) that characterises Down
syndrome. That is, the disability itself is characterised by a pattern of strengths and weaknesses
that increase the likelihood of valuing certain consequences (i.e., escape and attention).
(1999) presented the idea that disabilities may function as motivating operations in his discussion
of the decrease in the reinforcing value of attention in individuals with autism and the increase
in the reinforcing value of food in individuals with Prader-Willi. Although not specifically
mentioned by McGill, the work of Wishart and colleagues (Wishart, 1993a;
1993b; Pitcairn & Wishart,
1994; Wishart & Duffy, 1990), as well as the cluster of behaviours termed a behavioural phenotype,
suggest Down syndrome should be included in the disabilities identified by McGill as motivating
The presence of these challenging behaviours, even within the first year of life in children
with Down syndrome, effectively reduces the child's learning interactions with his/her environment.
As part of the behavioural phenotype characteristic of Down syndrome, we are challenged to develop
strategies to ameliorate these tendencies at a very young age (Fidler, 2005), by first identifying
the specific behaviours in which a child engages and then teaching caregivers to respond in
such a way that these behaviours are not systematically reinforced (Gerenser, personal communication,
June 6, 2004). For example, caregivers often make simple requests of a child that are followed
by avoidance behaviour (e.g., turning away). These avoidance behaviours are likely to result
in some initial persistence on the part of the caregiver, but, in the face of further child
resistance, caregivers may 'give up' and discontinue the request. In these situations, the child,
who did not want to comply with the request, is ultimately reinforced; that is, avoidance (e.g.,
turning away) to respond results in the removal of the demand. Alternatively, caregivers can
be taught to follow through with even simple requests. Therefore, when making a request, if
the child does not respond, he/she is prompted to do so. Once the response occurs, even if prompted,
reinforcement is immediately delivered. This results in teaching the child, from an early age,
the benefits of following simple instructions and possibly curtailing a pervasive pattern of
opting out as identified by Wishart (1993a,
Another way to address escape behaviour in young children 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 specific tasks less difficult. For example, if the child
is having difficulty accessing toys in his environment, the parent might position toys so they
are in reach, thus, pulling the toy closer can be more easily accomplished. Caregivers who are
well versed in prompting strategies (e.g., the use of physical guidance or positioning of objects
to enhance performance) as well as shaping procedures (i.e., reinforcing closer and closer approximations
to the target response) can be advised to implement such strategies to enhance their child's
performance with a given task. By using prompting and shaping procedures, adults are setting
up the situation to provide the young child with Down syndrome with more successful opportunities
and then very gradually leading to more difficult tasks. This is one application of errorless
learning techniques which, as suggested by Fidler (2005), may result in children with Down syndrome
persisting in tasks during which they might otherwise demonstrate escape behaviour.
With respect to the attention seeking functions of challenging behaviour, our clinical experience
suggests that, during the toddler and preschool years, attention motivated behaviours are present
and particularly interfering. Consider, for example, getting into a forbidden area within the
home (e.g., brick fire place, steep stair case, bay window), a common behaviour in toddlers.
Many caregivers might instinctively go to the child and remove him/her from the area, but, in
doing so, inadvertently deliver attention in the form of verbal feedback (e.g., "No, no honey,
that can be dangerous.") as well as physical contact (e.g., once the parent has the child in
his/her arms, hugs and kisses are naturally delivered). Because of the positive interaction
that ultimately takes place, the child may learn that an effective way to get attention is to
move toward the forbidden area. Alternatively, caregivers can systematically respond in a way
that is not reinforcing to the child (e.g., silently go to the child without providing eye contact
and remove the child from the forbidden area) while at the same time responding in a very reinforcing
manner when the child is playing in an acceptable location (e.g., while sitting on the floor
with their toys).
Given the early presence of these challenging behaviours, it is essential for professionals
to involve caregivers during the development and implementation of interventions so that caregivers
can effectively intervene throughout the day and across multiple environments. Professionals
should be skilled at imparting intervention techniques to caregivers so they can comfortably
implement interventions during ongoing interactions with their young child with Down syndrome.
Interventionists versed in behavioural assessment and intervention strategies are likely to
have the tools necessary to address the range (in form and function) of behaviours of children
with Down syndrome that have, in the past, precluded them from learning opportunities as well
as inclusive placements. Although the interventions have not been considered in relation to
the work of Dykens (1995) on the existence of a 'behavioural phenotype', the functional assessment
process, in conjunction with interventions adhering to sound behaviour analytic principles,
appear to be a perfect match for the prevention and amelioration of challenging behaviour in
individuals with Down syndrome, particularly early in life when a pattern of challenging behaviour
seems to first emerge.
Dr. Kathleen Feeley â€¢ Assistant Professor, Department of Special Education and Literacy, C.
W. Post Campus of Long Island University, 720 Northern Boulevard, Brookville, New York 11548.
This paper is based on a keynote presentation made to the 4th International Conference on Developmental
Issues in Down Syndrome, Portsmouth UK, September, 2005. We would like to thank Dr. Joe E. Reichle
and Dr. Edward G. Carr for their scholarly critiques of the manuscript.
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