Which of the following describes maladaptive behavior?

Operant Conditioning

The operant conditioning formulation proposed byFordyce (1976, 2000) has contributed substantially to our understanding of chronic pain and has had a significant impact on treatment and rehabilitation. The operant model distinguishes between the private pain experience and observable and quantifiable pain behavior (i.e., overt communications of pain, distress, and suffering such as moaning, grimacing, or intake of medication). It is such behavior rather than pain per se that is assumed to be amenable to behavioral assessment and treatment.

The operant conditioning model proposes that acute pain behavior may come under the control of external contingencies of reinforcement and thus develop into a chronic pain problem. Pain behavior may be positively reinforced (e.g., by attention from a spouse or health care providers). Pain behavior may also be maintained by the termination of unpleasant states, such as a reduction in pain level by analgesic medication or inactivity or the avoidance of undesirable activities such as work or unwanted sexual activity (negative reinforcement). In addition, “well behavior” (e.g., functional activities, including working, homemaking activities, and self-care) may not be sufficiently reinforcing, and the more rewarding pain behavior may therefore be maintained (i.e., punishment type 2).

These principles suggest that if behavior signaling pain results in positive consequences or the removal of negative consequences, this pain behavior will increase in frequency. The patient may receive attention (often sympathy) and may be relieved of responsibilities when such behavior is emitted. Complaining leads to increased attention and efforts to provide assistance, thereby positively reinforcing patients’ pain complaints. Health care providers may provide analgesic medication in response to pain behavior, and medication then becomes contingent on pain. Thus, patients’ complaints and other behavior have a powerful ability to elicit responses from others. For example,Turk and Okifuji (1997) showed that physicians prescribe opioid medication based on patients’ complaints and patients’ reports of the cause of their symptoms, not on the basis of the presence of actual physical pathology. These results were replicated byMartell and colleagues (2007). Attention and legitimized abdication of responsibility are potentially rewarding experiences. Consequently, the pain behavior originally elicited by organic factors may come to be controlled totally or in part by reinforcing environmental events.

Similar to respondent pain, in which pain behavior is first directly related to the presence of antecedent nociception (and only later dependent on CSs), operant pain (i.e., pain behavior) occurs originally as a consequence of acute pain stimuli. Later, pain behavior may be emitted in the absence of nociception. Specifically, the operant conditioning model suggests that maintenance of pain behavior may occur through a process of reinforcement and operant or instrumental learning. The model does not directly concern itself with pain since pain is not directly observable, but rather with the overt manifestations of pain, distress, and suffering. Because of the consequences of specific behavioral responses, it is proposed that pain behavior may persist after the initial cause of the pain is resolved or greatly reduced. In a classic or respondent conditioning model, anticipation of nociception or fear of injury may be factors that maintain the maladaptive behavior, whereas in the operant model, receipt of positive and avoidance of or escape from negative reinforcers serve to maintain the maladaptive pain behavior. The respondent approach focuses on pain-eliciting stimuli; the operant approach is centered on pain-related responses.

Difficulties in Adaptive Behavior and Social Emotional Development

Maladaptive behavior and social skill deficits that persist across time are a central concern among individuals of all ages with PAE in both clinical and longitudinal prospective samples. Mental health problems have been reported for a very large majority of individuals diagnosed with FASD in natural history research, and there are elevated rates of psychiatric disorders in childhood and beyond. Clinical studies of children with FASD use terms such as impulsive, distractible, and “always on the go” to describe behavior in the preschool and elementary years. In addition, while younger children with FASD have been clinically described as engaging, verbal, apparently alert, and bright-eyed, they likely appear more functional than they actually are. Clinicians note these children seem to lack social boundaries (e.g., by showing indiscriminate affection or seeking physical proximity to strangers). There is wide variability in the level of these deficits, ranging from subtle to severe. However, a recent meta-analysis of Child Behavior Problem Checklist findings across multiple studies revealed greater odds of scoring in the clinical range on internalizing, externalizing, and total behavior problems for children with FASD, and somewhat higher scores on these ratings for groups with PAE compared to those without PAE. Poorer scores were also seen among those with FASD for total competence, and the school competence subscale. For school-aged children and adolescents with FASD, the meta-analysis showed the greatest deficits on individual “syndrome” scales assessing thought problems (or odd behavior), rule-breaking behavior, aggressive behavior, attention problems, and social problems.

Indeed, adaptive behavior and social skills among preschool and young school-aged children with FASD are reported as lower than expected for age and intellectual level. Although decreased performance has been described across most adaptive domains including daily living, social, communicative, and, to a lesser extent, motor function, the development of social and interpersonal relationships appears to be especially problematic for those affected by PAE. A comprehensive review of cross-sectional, clinical, and longitudinal studies of social skill deficits completed by Kully-Martens et al. (2012) summarized the different types of social skill impairments described among children affected by PAE across a variety of social skill domains and social contexts. They concluded that social deficits were beyond the degree of deficit expected based on other cognitive, attention, and behavior problems that often co-occur among children with FASD, and that underlying brain-based impairments along with complex environments contributed to these deficits. A small literature suggests that the social problems of those with FASD are different from those with autism spectrum disorders. Social problems in association with FASD are described in young children and persist through adulthood, and after age 8 years appear greater even than clinic-referred peers with behavior or adjustment problems. This is likely the result of the lifelong neurological impairment of children born alcohol affected as well as the complex environments in which many of these individuals are raised.

Humanitarian Principles and Codes of Conduct

The four humanitarian principles—humanity, neutrality, impartiality, and independence—are the bedrock of humanitarian action.Table e3.2 provides definitions of these principles, to which all humanitarian responders must adhere. Violations of the humanitarian principles can impede access to affected populations and create security risks for aid workers.

Nongovernmental organizations (NGOs) use codes of conduct to specify behavioral, professional, interpersonal, and ethical standards for their personnel. The most widely used code of conduct is the one inBox e3.1, prepared by the International Federation of Red Cross and Red Crescent Societies and International Committee of the Red Cross for disaster responders.19 Humanitarian response often requires long work hours in uncomfortable and insecure settings. Personnel must maintain appropriate conduct despite working in a high-stress setting. Maladaptive coping behaviors such as drug and alcohol abuse, inappropriate relations with national staff or locals staff, and security protocol violations put individuals and organizations at risk. Codes of conduct help establish behaviors necessary to ensure an ethical and effective response. Responders should be aware of, and abide by, the codes of conduct for their individual organizations.

4.1.2 Maladaptive behavior

Because maladaptive behavior, particularly severe aggression and self-injury, are likely to lead to costly out-of-home placement and to have a significant impact on the individual, accurately assessing the prevalence and causes as well as effective treatment is critical to serving this population. Cooper et al. (2007; Study 4, Table 9.1) found that prevalence rates for maladaptive behavior of any kind ranged from 0.1% when DSM-IV-TR or DCR-ICD-10 criteria were used to 22.5% when clinical diagnoses were used. Again, estimates vary drastically, depending on the screening criteria and assessment methods. Table 9.3 shows the variability of overall behavior problems as a function of assessment criteria.

Table 9.3. Varying prevalence estimates of problem behaviors across studies and assessment methods

The range of prevalence rates for specific types of behavior problem were as follows: Aggressive behavior ranged from 6.4% [Holden & Gitlesen, 2006 (Study 14, Table 9.1)] to 32% [Lowe et al., 2007 (Study 17, Table 9.1)]; self-injurious behavior ranged from 4.4% [Holden & Gitlesen, 2006 (Study 14, Table 9.1)] to 21% [Lowe et al., 2007 (Study 17, Table 9.1)]; and destructive behavior ranged from 2.3% [Holden & Gitlesen, 2006 (Study 14, Table 9.1)] to 19% [Lowe et al., 2007 (Study 17, Table 9.1)].

2 PERSONALITY/PSYCHOPATHOLOGY

Examining maladaptive behavior, Dykens and Clarke (1997) found that hyperactivity was the most striking problem in a sample of 146 individuals with 5p- syndrome aged 4 to 40 years. Seen in up to 85% of the group, hyperactivity was pervasive across males and females, children and adults, those with relatively high versus low adaptive levels, and those with translocations versus deletions. Further, hyperactivity was significantly elevated in persons with 5p- syndrome relative to two other comparison groups of subjects with mixed etiologies.

Persons with 5p- syndrome also appear vulnerable to other problems, with 50 to 70% of the Dykens and Clarke (1997) sample showing aggression, temper tantrums, self-injurious behavior, general irritability, and stereotyped movements. Many of these problems were inversely correlated with cognitive-adaptive level.

Unlike early work that depicted most persons with 5p- syndrome as profoundly withdrawn, we observed withdrawal and autistic-like symptoms primarily in subjects with translocations as opposed to deletions. Controlling for the lower cognitive-adaptive level of the translocation group, those with translocations were more withdrawn, isolative, unresponsive to others, and difficult to reach, with fewer communicative gestures or responses to others. In contrast, those with deletions are often described as quite social; they readily approach peers and adults, often try to engage others, and seemingly show joint attention.

Though behavioral studies in 5p- syndrome are just underway, next steps need to build on these findings by relating hyperactivity and other salient problems to the size and location of the deletion on chromosome 5p. Early reports hinted that larger deletion sizes correlated with more severe levels of delay (Wilkins et al., 1983), yet this finding has yet to be replicated, with some individuals showing large deletion sizes and only mild levels of cognitive or language delay (Church et al., 1995; Smith, Field, Murray, & Nelson, 1990). Expanding such genotypephenotype studies to include maladaptive behavior may shed further light on these contradictory findings.

2.3.1.4 Communication

Like maladaptive behavior, communication deficits are not solely descriptive of autism, although the disorder is characterized by social communication deficits and in many cases, significant delays in functional language.

The intervention work on communication skills is particularly difficult to navigate because first, the theoretical frameworks differ widely. Second, underlying philosophies vary from a communication/language disorder intervention approach, to behavioral approaches like discrete trial teaching, and developmental approaches (e.g., sign language, milieu-based instruction, social and scripted language interventions, the picture exchange communication system). Third, many studies are not specific to autism. Although all participants in reviewed studies have a communication disorder, children with a variety of diagnoses are included. Thus the samples are heterogeneous and provide little autism specific directions for treatment.

In sum, no particular treatment seems to facilitate language growth over another. Direct comparisons were not made from one treatment to another; thus, conclusions were impossible. Further, it was impossible to identify which approach might work better for certain types of children (e.g., children in need of complex language systems, children with rudimentary language skills, and nonverbal children). Indeed, the literature provides little direction in terms of service delivery models or the intensity of services that are more likely to maximize communication intervention efforts. What seems to emerge are several characteristics of effective communication interventions. These include prompting, modeling, time delay, reinforcement, routines, and visual supports.

With regard to methodology in the communication research, many of the studies are quasi-experimental. Thus, although overall positive change was reported, the findings remain significantly limited, without control group comparisons to demonstrate true treatment effects. Thus, despite the generally positive conclusions, communication research to date is lacking in rigorous evidence-based study designs that demonstrate ecological validity.

IV.C. Extinction

Many maladaptive behaviors are maintained by consequences that follow from them. For example, temper tantrums or interrupting others during conversations are often unwittingly reinforced by the attention they receive. When there is interest in reducing behavior, extinction can be used by eliminating the connection between the behavior and the consequences that follow. Extinction refers to withholding reinforcement from a previously reinforced response. A response undergoing extinction eventually decreases in frequency until it returns to its prereinforcement level or is eliminated.

Extinction has been successfully applied to diverse problems. As an illustration, extinction was used to reduce awakening in the middle of the night among infants. Nighttime waking, exhibited by 20 percent to 50 percent of infants often is noted as a significant problem for parents. Parents may play a role in sustaining night waking by attending to the infant in ways that reinforce the behavior. In this program, parents with infants (8 to 20 months old) participated in an extinction-based program to decrease nighttime awakening. Waking up during the night was defined as a sustained noise (more than one minute) of the infant between onset of sleep and an agreed-upon waking time (such as 6:00 a.m.). Over the course of the project, several assessment procedures were used, including parent recording of sleep periods, telephone calls to the parents to check on these reports, and a voice-activated recording device near the child's bed. After baseline observations, parents were instructed to modify the way in which they attended to night wakings. Specifically, parents were told to ignore night wakings. If the parent had a concern about the health or safety of the child, the parent was instructed to enter the room, check the child quietly and in silence with a minimum of light, and to leave immediately if there was no problem.

The program was evaluated in a multiple-baseline design across seven infants. (Figure 4) shows the frequency of night wakings each week for the children during the baseline and intervention periods. As is evident in the figure, the frequency decreased during the intervention period. Followup consisted of assessment approximately three months and then two years later, which showed maintenance of the changes. The figure is instructive for other reasons. Two weaknesses of extinction programs were evident. First, extinction effects tend to be gradual.

Second, during extinction the behavior may momentarily recover (i.e., emerge for one or two occasions) even though it has not been reinforced, a phenomenon referred to as spontaneous recovery. (Figure 4) shows both the gradual nature of extinction and repeated instances of spontaneous recovery during the intervention and followup phases. The prospect of accidental reinforcement (e.g., attention to the behavior) during these periods requires special caution on the part of parents.

A related issue pertains to Child 3 (in Figure 4), who did not profit from the program. Parents reported difficulty in distinguishing the usual night wakings from those associated with illness of their child. Additional data revealed that these parents attended relatively frequently to nonillness awakenings during the intervention but improved during the first followup phase. The parents cannot be faulted. The pattern of behavior and eventual improvement draw attention to the difficulty in ignoring behavior and discriminating when behavior does and does not warrant attention. In any case, the demonstration is clear in showing that extinction generally was quite effective in decreasing night waking among infants.

Typically, extinction is used in conjunction with positive reinforcement. The main reason is that the effectiveness of extinction is enhanced tremendously when it is combined with positive reinforcement for behavior incompatible with the response to be extinguished. Also, the gradual effects of extinction, the emergence of the undesired behavior (spontaneous recovery), and untoward side effects are mitigated when extinction is combined with positive reinforcement. A limitation of extinction is that it is not always easy (without functional analysis) to identify what reinforcers are maintaining behavior, especially if the reinforcers are quite intermittent and hence not evident each time the behavior occurs. As with the use of punishment, extinction by itself does not teach the positive behaviors to be developed and may be associated with undesirable side effects. For all of these reasons, extinction usually is combined with positive reinforcement for appropriate or prosocial behavior.

Many reports have shown the successful application of extinction alone or in conjunction with other procedures (particularly reinforcement). Hypochondriacal complaints, vomiting, obsessive comments, compulsive rituals, and excessive conversation in the classroom are among the diverse problems that have been treated with extinction and reinforcement. Such applications are particularly noteworthy because they reveal that a number of maladaptive behaviors may be maintained at least in part by their social consequences.

Reiss Screen for Maladaptive Behavior

The Reiss Screen for Maladaptive Behavior (RSMB) is one of the older and well-established scales evaluating psychopathology in individuals with ID. The RSMB (Havercamp & Reiss, 1997; Reiss, 1988) was developed to meet the need for a standardized screening instrument to be used by nonprofessionals for mental health disorders in persons with ID, not as a stand-alone diagnostic tool. The RSMB is completed by caregivers to rate an individual’s severity of psychopathology on 36 items, and a high score indicates a need for referral for more detailed evaluation (Havercamp & Reiss, 1997). Reiss and Valenti-Hein (1994) investigated the RSMB by evaluating 583 children and adolescents with ID.

Walsh and Shenouda (1999) found strong convergent validity between the RSMB and the Abberant Behavior Checklist (Aman, Singh, Stewart, & Field, 1985) using a sample of 284 individuals. Specifically, RSMB subscale scores correlated with Irritability, Lethargy, and Hyperactivity subscales on the Abberant Behavior Checklist.

Gustafsson and Sonnander (2002) investigated the psychometric properties of the Swedish version of the RSMB. The authors found moderate-to-low interrater agreement and good internal consistency. Additionally, the authors found that mental health concerns most common in their sample included anxiety, depression, self-injurious behaviors, and adjustment problems (Gustafsson & Sonnander, 2002).

Introduction

Many adolescents engage in maladaptive behaviors. Some of these behaviors are directly and immediately harmful, to the point of even being life-threatening. One of the most dangerous maladaptive behaviors is nonsuicidal self-injury (NSSI). NSSI is perhaps best known as a symptom of borderline personality disorder (BPD) but typically occurs independent of this diagnosis and is thereby discussed as a distinct behavior problem here.

NSSI is a serious problem for several reasons. First, it is accompanied by immediate risk of serious physical injury and inadvertent death. Second, NSSI increases the likelihood of attempting suicide, in which the self-injurious behavior is actually intended to end one's own life. Third, some evidence suggests an increase in the rate of NSSI in recent years. This behavior is particularly concerning during adolescence since it emerges and is most common during this developmental period. Understanding NSSI in the context of adolescence therefore plays a crucial role in treating and preventing this behavior in the future.

1.1 Stress, Addiction, and Kappa Opioid Receptors

Stress is known to promote maladaptive behaviors that often increase vulnerability to the development of affective disorders—such as anxiety and depression—and addiction to drugs and alcohol. Exposure to stressful adverse events often leads to negative affective states, which can contribute to the development of alcohol and substance use disorders, and these addictive disorders can in turn promote the development or worsening of affective disorders. While many neurobiological systems are involved in mediating stress effects, the dynorphin/KOR system plays critical role in behavioral stress responses. Human and rodent literature has shown that exposure to adverse events, particularly during adolescence, increases the vulnerability to alcohol and substance use disorders in adulthood (Burke & Miczek, 2014; Butler, Karkhanis, Jones, & Weiner, 2016; Dube et al., 2001, 2003; Karkhanis, Rose, Weiner, & Jones, 2016). Further, rodent studies have shown that stress results in increased dynorphin release (Chartoff et al., 2009; Shirayama et al., 2004) and anxiety-like behaviors (Karkhanis, Locke, McCool, Weiner, & Jones, 2014; Valdez & Harshberger, 2012; Van't Veer & Carlezon, 2013). Finally, repeated or prolonged activation of KORs often results in addiction-related behaviors including excessive drug seeking (Groblewski, Zietz, Willuhn, Phillips, & Chavkin, 2015). Clinically, stress is closely associated with craving and relapse risk (Sinha et al., 2009; Sinha, Fuse, Aubin, & O'Malley, 2000). For example, cocaine-dependent abstinent patients with a variant in the KOR gene oprk1 exhibited heightened stress response and limbic brain activation, as well as increased cocaine craving, and relapse risk (Xu et al., 2013).