Applied Behavior Analysis Treatment of Violence and

Aggression in Persons with Neurodevelopmental Disabilities

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Editor
James K. Luiselli

Applied Behavior Analysis Treatment of

Violence and Aggression in Persons
with Neurodevelopmental Disabilities
1st ed. 2021
Editor
James K. Luiselli
Melmark New England, Andover, MA, USA

Advances in Preventing and Treating Violence and Aggression

ISBN 978-3-030-68548-5 e-ISBN 978-3-030-68549-2
https://doi.org/10.1007/978-3-030-68549-2

© Springer Nature Switzerland AG 2021

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Preface
Applied behavior analysis (ABA) is a scientific approach to
understanding and changing human behavior, grounded in operant
learning theory, and dedicated to technologically sound procedures that
are empirically evaluated, replicable, and socially valid. From inception,
and spanning five decades of treatment research, ABA has contributed
greatly to improving the lives of persons who have neurodevelopmental
disabilities including those who demonstrate violence and aggression.
This volume should be in the Springer Series, Advances in Preventing
and Treating of Violence and Aggression, addresses the most
contemporary ABA practices for assessment, intervention, training, and
supervision (https://www.springer.com/series/15332 / Advances in
Preventing and Treating Violence and Aggression). Section chapters
summarize the research foundation of many methods and procedures
that clinicians, psychologists, behavior analysts, and related
professionals can implement effectively with children, youth, and adults
in multiple service settings. As well, the chapters highlight the
multidisciplinary context of ABA treatment in the current day.
I am grateful to Dr. Peter Sturmey, Series Editor, for supporting a
book devoted to ABA. Notably, the book was completed at the height of
the 2020 COVID-19 pandemic and only possible due to the skilled
production staff at Springer, dedicated chapter authors, and support of
my colleagues at Melmark New England. And to my family, Tracy,
Gabrielle, and Thomas, thanks for everything you teach and give me so
generously.
James K. Luiselli
Andover, MA, USA
Contents
Part I Measurement and Assessment
Measurement and Data Recording of Aggression
Amanda N. Zangrillo, Seth G. Walker, Henry S. Roane,
William E. Sullivan, Dominik L. Keller and Nicole M. DeRosa
Functional Behavior Assessment
Jill M. Harper, Juliya Krasnopolsky, Melissa C. Theodore,
Christen E. Russell and Eris J. Dodds
Functional Analysis of Violence–Aggression
Ashley M. Fuhrman, Brian D. Greer and Wayne W. Fisher
Behavioral Risk Assessment of Violence-Aggression
Joseph N. Ricciardi
Social Validity Assessment
James K. Luiselli
Part II Intervention, Training, and Supervision
Communication-Focused Treatment of Violence-Aggression
Valdeep Saini and William E. Sullivan
Behavioral Treatment of Sexual Offending
Duncan Pritchard, Heather Penney, Veda Richards and
Nicola Graham
Inpatient and Residential Treatment of Violence Aggression
Nicole L. Hausman, Michael P. Kranak, Molly K. Bednar and
Louis P. Hagopian
Training and Performance Management of Care Providers
Raymond G. Miltenberger, Jennifer L. Cook and Marissa Novotny
Mindfulness Care Giving and Support for Anger and Aggression
Management
Nirbhay N. Singh, Giulio E. Lancioni and Yoon-Suk Hwang
Index
Part I
Measurement and Assessment
© Springer Nature Switzerland AG 2021
J. K. Luiselli (ed.), Applied Behavior Analysis Treatment of Violence and Aggression in Persons with
Neurodevelopmental Disabilities , Advances in Preventing and Treating Violence and Aggression
https://doi.org/10.1007/978-3-030-68549-2_1

Measurement and Data Recording of

Aggression
Amanda N. Zangrillo1 , Seth G. Walker1, Henry S. Roane2,
William E. Sullivan2, Dominik L. Keller1 and Nicole M. DeRosa2
(1) Munroe-Meyer Institute, University of Nebraska Medical Center,
Nebraska Medical Center, Omaha, NE, USA
(2) State University of New York Upstate Medical University, Syracuse,
NY, USA

Amanda N. Zangrillo
Email: [email protected]

Abstract
A foundation of ABA treatment is objective, reliable, and valid
measurement of client responses preceding, during, and following
intervention. This chapter reviews measurement and data recording
methods for documenting the effects of behavioral treatment with
persons who demonstrate aggression. The authors describe design and
implementation of these methods within clinical and research settings
including operational definitions, construction of measurement
protocols, assessing reliability, and summarizing data outcomes.

Keywords Aggression – Measurement – Data analysis

Measurement and Data Recording of Violence-

Aggression
Violence-aggression includes those acts that are intended to cause
physical harm (National Collaborating Centre for Mental Health, 2015).
The current chapter adopts an operant account of violence-aggression
in which the intent of behavior is not an assumed variable of interest.
Henceforth, we refer to violence-aggression by the term “aggression.”
Aggressive behaviors are commonly observed in young children,
specifically in early childhood, when children are beginning to interact
with peers outside of their family and navigate their social world
(Fletcher, 2011). Aggressive behaviors are considered a part of typical
development in children, although there are a number of differing
definitions of what constitutes “normal” behavior across cultures
(Hirschi, 1969). Developmentally, one expects these behaviors to
reduce between the ages of 3- and 5-years-old due to the improvement
of the child’s language skills and emotional regulation (Underwood,
2003). Additional risk factors, such as age, sex, language abilities,
adaptive functioning, cognitive abilities, genetic or biological
determinants, prescribed medications, and educational history, may
further impact the development of or persistence of aggression. Of
particular note, individuals with autism spectrum disorder and other
neurodevelopmental disabilities demonstrate a relatively high
prevalence of aggressive behavior (Hill et al., 2014; Kanne & Mazurek,
2011; Schroeder et al., 2014). Among those who develop aggressive
behaviors, there is a risk of lower quality of life, increased stress,
reduction in access to services and supports, and caregiver burnout
(Fitzpatrick, Srivorakiat, Wink, Pedapati, & Erickson, 2016). Thus, the
development of efficacious treatment for individuals displaying
aggression is critical to long-term success, growth, and development of
individuals with neurodevelopmental disabilities.
Various disciplines have sought to explain the development,
subtyping, and definition of aggression. Although not the focus of this
chapter, it is quite important that readers understand the complex
interplay between biological, psychobiological, and environmental
variables impacting how various disciplines view aggressive behavior. A
host of explanatory mechanisms for the occurrence of aggression have
emerged over the last century. Theoretical perspectives for the causal
determinants of aggression have included contributions from
unresolved unconscious states, instinctual drives, and social learning
theory (Roane & Kadey, 2011). Although these perspectives warrant
discussion, the present chapter focuses on environmental influences, or
an operant-behavior perspective, on the occurrence of aggression.
Regardless of the one’s perspective on aggression, such behaviors
are considered “aberrant” or of clinical significance warranting
intervention when they: (1) increase in intensity or severity to cause
physical or emotional harm; (2) impact participation in home, school,
and community activities or placements; and (3) persist beyond the
“normative” developmental window. To differentiate normative and
clinically significant levels of aggression, clinicians may evaluate the
behavior using interviews, checklists, questionnaires, and rating scales.
These indirect measures of clinical significance can support a clinician’s
decision for intervention and the severity of the aggression observed or
reported, relative to established norms; however, indirect measures do
not yield individualized operational definitions that would inform
accurate, reliable, and valid measurement. The use direct assessment
methodologies, which is one key feature of applied behavior analysis,
provides means for an objective measure of aggression.
For nearly 50 years, the field of applied behavior analysis has
provided a framework for the assessment and treatment of socially
relevant behavior. This technology has been applied across different
settings, ages, and topographies of behavior with the purpose of both
increasing prosocial behaviors (e.g., language skills) and decreasing
problematic or destructive behaviors (e.g., violence-aggression). In
general, the primary components of a behavior-analytic framework
include: (1) identifying and defining the behavior targeted for change,
(2) measuring the occurrence of the target responses during baseline
and treatment, and (3) analyzing the immediate and long-term effects
of treatment on the target response. The measurement of the target
response is of particular importance in: (1) developing a valid baseline
measure, (2) evaluating the effectiveness of treatment programming,
and (3) discontinuing ineffective treatment programming (Cooper,
Heron, & Heward, 2020).
In this chapter, we discuss key considerations in the development of
accurate, reliable, and valid measurement systems specifically for the
purpose of evaluating the efficacy of behavior-analytic interventions in
the treatment of aggression. We review (1) development of operational
definitions, (2) construction of measurement protocols, (3) means for
assessing interobserver agreement, and (4) summarizing and
displaying data outcomes. To assist in conceptualizing each area, the
chapter begins with a case example to illustrate each step in the
development of measurement and data collection systems.

Case Example
Quinn is a 15-year-old female diagnosed with moderate intellectual
disability and autism spectrum disorder (ASD). Quinn was born
prematurely at 35 weeks’ gestation. She experienced neurotypical
development of motoric milestones (i.e., rolling over, sitting up,
crawling, walking); however, she experienced a significant regression in
language, communication, and social behaviors at approximately
18 months of age. Quinn communicates using single words and
gestures. Her caregivers noted “red flags” related to her aggression
beginning at about 2 years of age and felt that this was the point where
her aggression increased in intensity and severity. Caregivers reported
that Quinn rapidly developed an intense interest in water play and
extreme food selectivity. She typically only consumes brand-specific
chicken fingers, cheese pizza, and crunchy carbohydrate-rich foods
(e.g., crackers and chips). Quinn is of a large stature due to her high
caloric intake and low caloric output (i.e., many of Quinn’s preferred
activities are sedentary). She is placed in a special-purpose private
school program where her individual education program goals are
focused heavily on decreasing aggressive behavior, increasing
functional communication, and increasing compliance with and
acquisition of daily living activities. She is supported by a 1:1 aide for
her academic activities. Quinn’s aggression impacts their ability to care
for Quinn while keeping themselves and her infant sibling safe.
Behavior also impacts the family’s participation in community events
and significantly impacts Quinn’s participation in her academic
programming. Specific referral concerns include frequent bouts of
verbal threats and cursing, spitting at others, scratching, and biting
others, which results in significant redness, swelling, and breaks in the
skin.
Development of Operational Definitions
Once in possession of a set of terms we may proceed to a kind of
description of behavior by giving a running account of a sample of
behaviors as it unfolds itself in some frame of reference. This is a
typical method in natural history…It may be classified as a
narration…From data obtained in this way it is possible to classify
different kinds of behavior to determine relative frequencies of
occurrence. But although this is, properly speaking, a description
of behavior, it is not a science in the accepted sense. We need to go
beyond mere observation to a study of functional relationships.
We need to establish laws by virtue of which we may predict
behavior, and we may do this only by finding variables of which
behavior is a function.
—B. F. Skinner (1938, p. 8)

Applied behavior analysis typically uses direct observation to

identify the occurrence of behaviors of interest. Direct observation
produces two distinct advantages for addressing behaviors such as
aggression, namely allowing for data collection in virtually any applied
setting, and providing a more thorough detection and recording of the
range of responses that research participants and therapy clients
exhibit (Page & Iwata, 1986).
An initial step in developing any data collection system includes
operationally defining target responses. Well-developed operational
definitions include four critical characteristics. First, they are objective,
which means the definition only includes aspects of the behavior that
can be observed and are not based on assumptions. Second, they are
clear so that others understand what the behavior “looks like.” Third,
the operational definition must specify when an occurrence of the
target response begins and when it ends. Finally, the definition must
include examples and non-examples of the behavior that further clarify
the definition.
Using the hypothetical example of Quinn, an operational definition
of biting might be written as “Upward and downward motion of the
mandibles which results in contact between Quinn’s teeth and
another’s body or clothing.” In this operational definition, the target
behavior is described to include that Quinn must open and close her
mouth (i.e., jaws) such that her teeth come into contact with any part of
someone’s body or clothing. It does not specify if a specific body part is
targeted by Quinn’s aggression. Moreover, the definition highlights that
the behavior must include movement of the jaw and contact with her
teeth, thereby disqualifying any behavior that does not involve those
components.
The four core characteristics of operational definitions ensure that
there is agreement among professionals about what behaviors are to be
included in the measurement (Hawkins & Dobes, 1977). To inform
development of operational definitions, clinicians may use indirect
assessment strategies such as interviews and/or direct assessment
strategies such as observation of the individual engaging in aggression.
Table 1 provides a list of common topographies of aggression (e.g.,
hitting, biting, kicking, pinching, and scratching (Brosnan & Healy,
2011)) and sample operational definitions that may be used to describe
these behaviors.
Table 1 Sample operational definitions

Response Sample operational definition

topography
Hitting/punching Contact of hand (open or closed) or arm (with or without another object)
from a distance of 6 in. or greater against any part of the therapist’s body
Example: Client slaps the therapist on their face
Nonexample: Client high-fives the therapist
Kicking/stomping Contact of foot, leg, or knee with any part of the therapist’s body (includes
stepping on therapist’s foot) from a distance of 6 in. or greater
Example: Client kicks the therapist on their shin
Nonexample: Client trips over the therapist’s foot
Pushing/pulling Applying force to the therapist’s body, attempting to move the therapist, or
pulling any part of the therapist’s body (including hair)
Example: Client pushes the therapist by placing their hands on their
shoulder and applying force, which moves the therapist away from the
client
Nonexample: Client takes the therapist’s hand and attempts to pull them
toward an activity as they appropriately ask for the therapist to join them
in the activity
Grabbing Applying force to the therapist’s body, putting at least one hand around any
part of a therapist’s body such that the skin is either indented or reddened
Response Sample operational definition
topography
(this includes choking; may also include clothing)
Example: Client grabs the therapist’s shirt and refuses to release their grip
on the therapist
Nonexample: Client grabs the therapist’s hand to walk with them when
transitioning and does so without causing the therapist’s hand to indent or
become red
Throwing Projecting any object at, or in the general direction of, the therapist
(includes spitting)
Example: Client throws a chair at the therapist
Client projects their spit toward the therapist’s face
Nonexample: Client throws a chair at the wall when the therapist is in the
room. The chair is not thrown in the direction of the therapist
Client spits on the floor
Pinching Closure of client’s thumb and at least one other finger around therapist’s
skin such that the skin is either indented or reddened (may occur through
therapist’s clothing)
Example: Client closes with force their thumb and pointer finger around
the skin of the therapist’s hand
Nonexample: Client closes their thumb and pointer finger around the
therapist’s shirt as they state “this shirt is nice.” No force is used in by the
client when pinching the shirt
Scratching Contact of client’s fingernails against or along therapist’s skin
Example: Client drags their fingernails with force across the therapist’s
arm, which results in red marks on the therapist
Nonexample: Client scrapes their fingernails across the therapist’s hand
when attempting to take an object from the therapist after it is offered to
them
Head butting Contact between client’s head and any part of the therapist’s body from a
distance of 6 in. or greater
Example: Client hits their head against the therapist’s arm with force
Nonexample: Client turns their head and bumps their head into the
therapist’s arm. This is not done with force
Biting Closure of client’s teeth around any part of the therapist’s body
Example: Client closes their teeth around the therapist’s hand
Nonexample: Client puts their mouth around the therapist’s fingers when
offered food, but does not bite down on the food until the therapist has
removed their fingers from the client’s mouth
Verbal aggression Vocalizations made by the client toward the therapist that are intended to
harm or threaten to harm the therapist, such as cursing, screaming, threats
Response Sample operational definition
topography
of violence-aggression
Example: Client screams when they are turned toward the therapist
Client states “F*%#* off ”
Client states “I’m going to punch you” when they are turned toward the
therapist
Nonexample: Client makes a high-pitch scream when playing with a toy,
but is not turned toward the therapist
Aggression with a Client grabs an object and uses the object to hit or attempt to hit the
weapon therapist
Example: Client picks up a book and hits the therapist forcefully with the
book
Nonexample: Client picks up a pencil and places it in the therapist’s hand

Construction and Selection of Measurement

Protocols
The operational definition is the foundational unit of behavior analysis.
After a target response is operationalized, practitioners can construct
and select the most appropriate measurement system(s). At this point
the practitioner can identify the impact of environmental changes on
the target response and thus, begin to understand functional relations
that may be present in the environment. There are many properties of
responses under consideration, and only a limited number of response
properties can be captured by a given measurement procedure. Below
we discuss three critical characteristics of measurement strategies:
accuracy, validity, and reliability.
Accuracy describes the degree to which the measurement strategy
reflects the true exhibition of the target response (Kahng, Ingvarsson,
Quigg, Seckinger, & Teichman, 2011). The second characteristic of
measurement is validity, the extent to which the measurement
procedure records what it purports to measure (Kahng et al. 2011). The
last characteristic, reliability , refers to consistency in outcomes
obtained and consistency in outcomes between two independent
observers. All measurement strategies vary across these three critical
characteristics. In combination with careful consideration of the
applied setting, resource availability, and the target response,
practitioners can arrive at selection of a measurement strategy.
Common indirect and direct measurement strategies employed in
behavior-analytic research and practice are discussed below.

Indirect Measurement Strategies

Depending on the applied setting and resources available, indirect
measures may appeal to researchers and practitioners due to ease of
implementation and lower resource need relative to direct measures.
However, ease of implementation comes at a potential cost in the areas
of accuracy and validity, particularly if implemented in isolation. These
procedures also may be implemented using a pencil and paper,
meaning they require minimal technology and instrumentation in order
to conduct measurement. Given that aggression in individuals with
neurodevelopmental and related disorders is the behavior of interest
for the present chapter, we will only review measures that best capture
the relevant dimensions of that topography (e.g., event recording, rating
scales, and permanent products).
A wide variety of established and validated interviews, checklists,
questionnaires, and rating scales that are relevant to an assessment of
aggression exist in the literature. Researchers and clinicians may use
this measurement strategy that infers the repeatability, temporal
extent, and intensity of a target response based on the reporter’s
perception of occurrence. Examples of checklists or rating scales
include the Child Behavior Checklist (Achenbach & Rescorla, 2001),
Behavior Problems Inventory (Rojahn, Matson, Lott, Esbensen, &
Smalls, 2001), Aberrant Behavior Checklist (Aman & Singh, 1994), and
Behavior Assessment System for Children (Reynolds & Kamphaus,
2004).
Permanent-product recording is another indirect measurement
strategy that infers the repeatability and intensity of a target response
based on the impact it has on the environment. To use permanent-
product recording, the general strategy is to document the change in
the environment after the target response has occurred, for example,
damage to property in the form of broken furniture and glass.
Note that permanent-product data are not a direct measure of the
target response and require a degree of inference, which sacrifices
some accuracy and validity of these data. The tactics of measuring
permanent products vary depending on the topography of interest. For
example, when collecting the pictorial examples of a sustained bite
mark provided in Fig. 1, permanent-product data would include tissue
damage that resulted from the bite mark; however, additional
information of the aggressive act, such as the number of bites
(frequency) that occurred would not be represented.

Fig. 1 Pictorial example of sustained bite marks

We may also rely on other adaptations of established measures for
recording damage produced by a response. For instance, self-injurious
behavior may be measured via description of surface tissue damage via
the Self-Injury Trauma (SIT) Scale (Iwata, Pace, Kissel, Nau, & Farber,
1990). Although the SIT Scale may be used to document the surface
tissue damage targeted toward implementers of behavioral
interventions that is not its original intention.

Direct Measurement Strategies