Association for Behavior Analysis International

The Association for Behavior Analysis International® (ABAI) is a nonprofit membership organization with the mission to contribute to the well-being of society by developing, enhancing, and supporting the growth and vitality of the science of behavior analysis through research, education, and practice.


50th Annual Convention; Philadelphia, PA; 2024

Event Details

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Symposium #317
CE Offered: BACB — 
Science Can Guide Us: Assent, Countercontrol, and Treatment Refractory Behavior
Sunday, May 26, 2024
3:00 PM–4:50 PM
Convention Center, 100 Level, 114
Area: DDA; Domain: Translational
Chair: Nicholas Lowther (Judge Rotenberg Educational Center)
Discussant: Nathan Blenkush (Judge Rotenberg Educational Center)
CE Instructor: Nathan Blenkush, Ph.D.

Applied behavior analysis has directed little empirical attention to the interrelated concepts of assent, countercontrol, and treatment refractory behavior. Despite recent conceptual discussions of assent (Morris, Detrick, & Peterson, 2021), countercontrol (Spencer, King, Martone, & Houlihan, 2022), and treatment refractory behavior (Blenkush, O’Neill, & O’Neill, 2023) the field has yet to develop standardized measures for any of these concepts. To that end, we developed and tested the validity of (1) the Behavioral Assent to Treatment Scale; (2) a treatment protocol for countercontrol in residential settings; (3) an operational definition of treatment refractory behavior to include associated variables; and (4) the Refractory Behavior Index assessment tool. Across presentations, we will discuss conceptual overlap between assent, countercontrol, and treatment refractory behavior with an emphasis on empirical evaluation and clinical case analysis. We conclude that science can, and should, guide us in our attempts at tackling complex treatment issues such as assent, countercontrol, and treatment refractory behavior.

Instruction Level: Intermediate
Target Audience:

Behavior analysts interested in the limitations associated with the standard of care in applied behavior analysis

Learning Objectives: At the conclusion of the presentation, participants will be able to: (1) conceptualize and define assent, countercontrol, and treatment-refractory problem behavior; (2) list associated variables for consideration; (3) identify limitations associated with the standard of care in applied behavior analysis and regulatory restrictions in their region that might contribute to assent, countercontrol, and treatment-refractory problem behavior; and (4) understand how to utilize the Behavioral Assent to Treatment Scale (BATS) and Refractory Behavior Index (RBI) in their own practice
Behavioral Assent to Treatment Scale (BATS): A Proposed Tool to Assess and Optimize Assent
(Applied Research)
HALLE APELGREN (Judge Rotenberg Center ), John O'Neill (Judge Rotenberg Educational Center)
Abstract: Behavior analysts are obligated to consider “obtaining assent from clients when applicable” as dictated by the ethics code - section 2.11 (Behavior Analyst Certification Board, 2020). Assent is broadly thought of as client agreement or approval of treatment procedures. In behavior analysis, there is limited research describing assent procedures or studying the implications for treatment outcomes (Morris, Detrick, & Peterson, 2021). To address this gap, an assessment tool, the Behavioral Assent to Treatment Scale (BATS), will be proposed that weighs factors such as safety, risk/benefit analysis, behavioral dimensions, socially significant goals, essential/nonessential treatment progress, and legal/ethical obligations. Next, we will examine the treatment of countercontrol as a special example of the necessary risk/benefit analysis associated with client assent in applied behavior analysis. Considerations of countercontrol and assent share some common features as the former can be an indirect byproduct of a learning history which was inattentive to the latter. Here we will review the cases of individuals enrolled in a residential treatment facility and examine vital components of treatment. Pre- and post-treatment measures of assent (with interobserver agreement) will be provided as preliminary construct validation for the BATS.
Countercontrol in Residential Treatment Settings
(Applied Research)
JOSEPH TACOSIK (Judge Rotenberg Education Center), John O'Neill (Judge Rotenberg Educational Center)
Abstract: B. F. Skinner described countercontrol as a response to socially mediated aversive consequences in personal, group, governmental, religious, therapeutic, economic, and educational environments that are primarily reinforced through negative reinforcement (i.e., removal or weakening of aversive stimuli) and may be strengthened through positive reinforcement (e.g., peer approval or other attention). Residential treatment settings are inherently restrictive, potentially aversive to consumers, and thus may evoke countercontrol by clients, especially when assent/consent is withheld or provided by someone other than the individual receiving treatment (e.g., a guardian). We provide insights specific to challenges presented by countercontrol in residential treatment settings to include the following: (1) the potential for false-positive functional hypothesis results; (2) the limited control of setting events; (3) the idiosyncratic nature of conditioned aversive stimuli; (4) the various competing contingencies of reinforcement; (5) associated delayed consequences that complicate treatment; and (6) the general insensitivity of rule-governed behavior in relation to the effects of countercontrol. We will provide clinical case examples (with inter-observer agreement) of countercontrol challenges and propose a standard set of considerations for residential treatment facilities.
The Refractory Behavior Index (RBI): Identification of Treatment Refractory Behaviors
LYNDE KAYSER (Judge Rotenberg Education Center), Jessica Lindsay (Judge Rotenberg Educational Center ), John O'Neill (Judge Rotenberg Educational Center), Nathan Blenkush (Judge Rotenberg Educational Center)
Abstract: Across disciplines, the term treatment refractory refers to inadequate reductions in symptomology following appropriate treatment. In behavior analysis, treatment refractory behavior problems consist of the sustainment or worsening of maladaptive behavior topographies despite appropriate behavior analytic service delivery. To objectively evaluate and identify refractory behavioral presentations, we propose the utilization of the Refractory Behavior Index (RBI). The RBI employs a five-point scale to quantify variables that are indicative of the development of treatment refractory behavior problems. Variables are categorized across three primary domains: (1) Assessment and Intervention; (2) Quality of Treatment; and (3) Course of Behavior Problem. Based on a review of an individual’s treatment history and behavioral presentation, ratings across each domain enable an assessment of responsiveness to treatment across time and interventions. We will review the proposed definition of treatment refractory behavior in behavior analysis, discuss factors contributing to the development of behavioral resistance to treatment (including assent & countercontrol), evaluate these factors within the context of the RBI, and discuss the potential of the RBI to identify refractory behavior problems.
Quantifying Treatment Resistance: A Review of Case Examples
(Applied Research)
JESSICA LINDSAY (Judge Rotenberg Educational Center ), Lynde Kayser (Judge Rotenberg Education Center), John O'Neill (Judge Rotenberg Educational Center), Nathan Blenkush (Judge Rotenberg Educational Center)
Abstract: The purpose of this presentation is to review clinical cases, based on practical experience, that exemplify the spectrum of treatment refractory behavior. Clinical cases will be scored using the Refractory Behavior Index (RBI) to quantify resistance to treatment (with inter-observer agreement). It is hypothesized that individuals whose behaviors score low on the index are more likely to demonstrate behavioral progress following behavior analytic treatment; whereas individuals receiving high scores may exhibit challenging behaviors (including assent withdrawal & countercontrol) which persist or worsen despite behavior analytic treatment. Historical information pertaining to each clinical case will be reviewed and considered in relation to the development of treatment refractory behavior. Through widescale use, the RBI may help practitioners identify relevant risk factors, and indicate areas in need of further assessment and/or intervention. The advancement of behavior analysis relies on the ability to objectively describe and measure behavioral presentations. We will discuss how the RBI might highlight the need for and promote the develop



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