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A review of literature related to behavior modifi
cation as a treatment method is presented along
with definitions of the terms used in behavior
modification. Implications for the use of the
methods in physical therapy are made, particularly
as they relate to cerebral palsy. A case study is
presented which describes how behavior modifica
tion was used by physical, occupational, and
speech therapists in the treatment of a cerebral
palsied child. Conclusions are drawn which relate
the specific programs given to basic principles of
behavior modification.
Behavior Modification Downloaded from https://academic.oup.com/ptj/article/51/10/1083/4588739 by guest on 14 September 2022
in the Treatment of D uring the past few years be
Children with havior modification has become a frequently
used method of treatment for mentally retarded
and psychiatric patients. Remarkable success
Cerebral Palsy with these patients has been reported. Although
little has been written on the use of behavior
modification in the treatment of cerebral palsy,
this technique probably has much to offer in
the training of children with cerebral palsy.
Behavior modification is a method of chang
MARY L. KOLDERIE, M.A. ing the overt behavior of an organism by using
principles of learning theory. Simply stated,
behavior modification may be defined as chang
ing the rate at which an organism emits a re
sponse by administering a reinforcement after
the response has been emitted.
Behavior modification is not a haphazard
giving of rewards to a subject. Definite prin
ciples and techniques support the application of
behavior modification. Michael and Meyerson
state: "A behavioral approach to human control
does not consist of a bag of tricks to be applied
mechanically for the purpose of coercing unwill
ing people. It is part of a highly technical sys
tem, based on laboratory investigations of the
phenomena of conditioning, for describing be
havior and specifying the conditions under
which it is acquired, maintained, and elimi
1
nated."
Miss Kolderie, who was a graduate student at the
University of Minnesota, Minneapolis, Minnesota, when
the study was conducted, is currently Instructor, Depart
ment of Physical Therapy, School of Allied Health Sci
ences, The University of Texas Medical Branch, Galveston,
Texas 77550.
Volume 51 / Number 10, October 1971 1083
In behavior modification the emphasis is on neutral stimulus then becomes a conditioned
observable actions of the subject. "A behavior stimulus. The stimulus which initially does have
system attempts to specify, without reference power to elicit the response is called the uncon
to unobservable, hypothetical innerdetermin ditioned stimulus. The organism is reinforced
ing agents, the conditions and the process by by pairing the conditioned stimulus with the
which the environment controls human be unconditioned stimulus. Classical conditioning
1
havior." is associated with reflex activity and with in
3
Gelfand and Hartmann list the following as voluntary muscles.
essential aspects of a properly applied program Operant Conditioning
2
of behavior modification. First, a baseline of
the behavior must be made by careful observa In operant or instrumental conditioning, the
tion and recording. The treatment procedures organism must first make a response (perform Downloaded from https://academic.oup.com/ptj/article/51/10/1083/4588739 by guest on 14 September 2022
must be described in specific detail. During an operation on the environment) before re
therapy, continuous collection of data con ceiving a reinforcement. No stimulus elicits the
cerning the rate of emission of the behavior response as in classical conditioning; however,
is essential. Reinforcement contingencies must a discriminative cue or stimulus that indicates
be systematically varied in order to ascertain to the organism when responses will be rein
if the behavior is really under control of the forced may be used. Most behavior modifica
therapist or is occurring by chance. The be tion programs fit into the operant conditioning
3
havior that the therapist wishes to modify must paradigm.
be clearly and objectively defined and must be Reinforcement
objectively measured. To evaluate the long
range effects of the behavior modification pro Reinforcement is an event that changes the
gram, a followup study should be done to see probability that a response will be emitted in
whether the behavior is persistent. the future. Reinforcers can be presented or
withdrawn and the rate of responding can in
TERMS USED IN BEHAVIOR MODIFICATION crease or decrease. A stimulus which does not
change the rate of responding is not considered
To facilitate a clearer understanding of the a reinforcer, but a neutral stimulus. The Table
application of behavior modification, the follow shows the various combinations of presentation
ing terms are defined. or withdrawal and how each relates to changing
the rate of behavior. Considerations of the be
Classical Conditioning haviors of a child eating dinner serve as ex
In classical or respondent conditioning, a amples of the combinations in the Table.
stimulus elicits the response from the organism. 1. Presentation of a reinforcer increases the
If a neutral stimulus, that is, one that does not rate of desired behavior. The child eats
elicit the response, is paired with one that does, all his food and receives a reinforcer of
it acquires the power to elicit the response. The ice cream for dessert.
TABLE
TYPES OF REINFORCEMENT
Response Rate Presentation of Reinforcement Withdrawal of Reinforcement
Positive Reinforcement Negative Reinforcement
Response rate Subject views reinforcement as pleasant. An aversive stimulus is withdrawn when sub
increases Reinforcement is given after subject responds, ject emits response.
Punishment Punishment
Response rate An aversive stimulus is presented after sub A reinforcer, which subject views as pleasant,
decreases ject emits response. is withdrawn after subject responds.
1084 PHYSICAL THERAPY
2. Withdrawal of a reinforcer increases the interval schedule, a reinforcement is given after
rate of desired behavior. Mother nags at Y amount of time has elapsed. (The subject
the child to eat his food. When the child must first emit a response to receive a reinforce
eats, the mother stops nagging. ment. ) In a variable interval schedule, the time
3. Presentation of a reinforcer decreases the lapse between individual reinforcements varies,
rate of undesired behavior. Child spills but on the average it is Y amount of time.5
his milk and is spanked. Intermittent reinforcement has the fol
4. Withdrawal of a reinforcer decreases the lowing advantages: the behavior is not con
rate of undesired behavior. Child spills stantly interrupted by the subject partaking of
his milk and does not receive ice cream his reinforcement (in the case of food or water),
for dessert. it yields higher rates of responding, and it be
5
Whether a reinforcer is pleasant or aversive comes more resistant to extinction. The transi Downloaded from https://academic.oup.com/ptj/article/51/10/1083/4588739 by guest on 14 September 2022
must be defined by the effect it has on changing tion from continuous to intermittent reinforce
the rate of responding. Some stimuli used as ment must be gradual to prevent extinction from
reinforcers may be pleasant for some subjects, occurring during the nonreinforced trials.5
aversive for some, and have no effect on others. Regardless ©f the schedule ©f reinforcement,
A specific food is an example of such a stimulus. the reinforcement must follow the response as
In administering a behavior modification pro closely as possible in order that the organism
gram, the specific reinforcer must be carefully learns that the reinforcement is contingent on
selected. The reinforcer must appeal to the a specific behavior.4
4
child. A good idea is to try various reinforcers Extinction
to see which is the most effective for the indi When a behavior that has been reinforced is
vidual child. Examples of reinforcers for chil no longer reinforced, the frequency with which
dren are candy, ice cream, praise, being allowed it is emitted decreases until the behavior is no
to play with a favorite toy, and being allowed longer emitted. This principle is used in be
to engage in a desirable activity. havior modification when the goal is to elimi
A primary reinforcer is a stimulus which has nate some undesirable behavior. To eliminate
reinforcing power for the organism from the behavior in this manner, the theraoist must
beginning. Examples are food, water, and elec first analyze the behavior to find what in the
tric shock. A secondary reinforcer is one that environment is reinforcing it. All reinforce
acquires power by being paired with a primary ment must be eliminated because partial rein
reinforcer. Examples are money, points, praise, forcement of the undesirable behavior will
and verbal disapproval. Often a behavior modi 3
fication program will begin with pairing a pri strengthen it.
mary reinforcer with a neutral stimulus. As Behavior Shaping and Successive Approximation
the neutral stimulus acquires the power of a Often the organism is not capable of emitting
secondary reinforcer, the primary reinforcer is the final desired behavior; thus, if the experi
gradually eliminated. menter waited for him to do so, the subject
Schedules of Reinforcement would never receive a reinforcement. The ex
Usually in the initial period of a behavior perimenter, therefore, reinforces a behavior
modification program, reinforcement is given on which in some way resembles the final behavior.
a continuous schedule—every response is rein Each time he requires the behavior to be closer
forced. After the program is in progress, one to the final behavior before giving the reinforce
of four types of intermittent schedules is used. ment. In this manner, the therapist guides or
5
In a fixed ratio schedule, a reinforcement is shapes the final behavior of the subject.
given after X number of responses. In a varia Chains of Behavior
ble ratio schedule, the actual number of re
sponses emitted before a reinforcement is given Many behaviors are complex, but can be
varies each time, but over a period of trials the divided into smaller components. One com
average number of responses is X. In a fixed ponent of a chain is taught and reinforced first,
Volume 511 Number 10, October 1971 1085
then other components are added to it before a program is responsible for the change. The
reinforcement is given.5 contingencies are then reversed to the desired
3
Generalization of Behavior behavior.
If behavior modification is to have long last BEHAVIOR MODIFICATION IN CEREBRAL PALSY
ing effects, the change in behavior must not be
come conditioned to the specific treatment situa Denhoff and Robinault state: "Cerebral palsy
tion. The subject must generalize the new or is a manifestation or group of manifestations of
modified behavior to various situations where impaired neurological function due to aberrant
4
it is appropriate. structure, growth, or development of the central
nervous system." 6 They prefer the term cere
Stabilization of Behavior bral dysfunction to cerebral palsy because it is a
If the subject retains the new or modified more inclusive term. Cerebral dysfunction may Downloaded from https://academic.oup.com/ptj/article/51/10/1083/4588739 by guest on 14 September 2022
behavior and does not regress to previous un involve problems in any or all of the following
desirable behaviors after the completion of the areas: neuromotor, sensory, intellectual, be
behavior modification program, the behavior havioral, hearing, and sight.
has stabilized. To facilitate stabilization, inter Behavior modification can help children with
mittent schedules of reinforcement are used. To cerebral dysfunction develop independence
evaluate the stability of the behavior, studies within the limits of their capabilities. It is not
should be done after a lapse of time. recommended as the only method to be used
Deprivation in the treatment of children with cerebral palsy;
it should be used in conjunction with other
Deprivation means that the subject has not methods. The application of behavior modifi
received any of the specific reinforcers used in cation to the learning of motor skills and speech
his training for a period of time. Frequently is described below.
animals are deprived of food for twentyfour Motor Skills
hours prior to training to ensure that they will
be more motivated to work for food.5 The development of motor skills is the area
Satiation of greatest concern to the physical therapist in
the habilitation of the child with cerebral dys
Satiation is the opposite of deprivation. When function. In treating these children, one should
a subject is satiated, the frequency at which the emphasize abilities rather than disabilities.
behavior is emitted decreases. To avoid satia Denhoff and Robinault state: "It is well known
tion of the child, the experimenter should use that the full potentialities even of the normal in
a variety of reinforcers or an intermittent sched dividual are rarely, if ever, developed. In the
ule of reinforcement. presence of physical handicaps it is the well
Baseline spring of latent abilities that must be tapped if
the patient is to realize to the full the life he is
Before the behavior modification program is capable of enjoying."
initiated, a record is made of how frequently A welladministered behavior modification
the behavior in question is emitted. The final program has great potential for developing these
rate of performance is compared with this base latent abilities. Much of the training of motor
line. skills in cerebralpalsied children depends upon
Reversal of Contingencies motivating the child to develop his capabilities.
The potential for performing the motor skill
In order to ensure that the change in the must be present before behavior modification
rate of behavior is the result of the behavior can be effective in the development of this
modification program, the reinforcement is skill.
varied from the desired behavior to the unde A nineyearold mentally retarded girl was
sired behavior. If the rate of the desired be 7
taught to walk by using food as a reinforcer.
havior decreases and the rate of the undesired Although the girl had no physical handicaps,
behavior increases, the behavior modification she could not walk; impoverished environmental
1086 PHYSICAL THERAPY
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