Is there science behind that? Antecedent-based interventions

Elizabeth Hardesty, MA, BCBA, Breanna Roberts, MA, BCBA, and Thomas Zane, PhD, BCBA-D
Department of Applied Behavioral Science, University of Kansas

Is there science behind that Most children with autism spectrum disorder (ASD) engage in at least one form of challenging behavior throughout their lifetime (Quetsch et al., 2023; Steenfeldt‐Kristensen et al., 2020). Research shows that some challenging behavior may be triggered by specific events or situations (Melanson & Fahmie, 2023). These events or situations are commonly referred to as “antecedents” as they occur before the challenging behavior. Some common antecedents to challenging behavior include loud noises, various healthcare appointments, instructions, chores, academic tasks, hygiene tasks, and providing novel foods. These specific antecedents related to challenging behavior are usually obvious to people familiar with the individual and in many cases can be changed to make the challenging behavior less likely to occur. The strategies typically used to change antecedents are called antecedent-based interventions. In practice, it is likely that multiple antecedent-based interventions are combined into a more comprehensive intervention to decrease challenging behavior while increasing completion of tasks or instructions. In this article, we will describe various antecedent-based intervention techniques and briefly review recent research highlighting their use and effectiveness. Our goal is to equip parents, caregivers, guardians, and service providers with valuable information on antecedent-based interventions and their use in comprehensive plans to enhance support and learning for individuals with autism.

What are Antecedent-Based Interventions?

According to the National Clearinghouse on Autism Evidence and Practice, antecedent-based interventions include an “arrangement of events or circumstances that precede an activity or demand in order to increase the occurrence of an alternative socially appropriate behavior or lead to the reduction of challenging/interfering behavior” (Steinbrenner et al., 2020). In other words, the way the environment is set up can be changed to “tip the scales” towards desired outcomes and away from challenging behavior. Ultimately, antecedent-based interventions increase the likelihood of socially appropriate behavior and decrease the likelihood of challenging behavior. Antecedent-based interventions typically include one or more of the following: (a) stimulus fading or graduated exposure, (b) noncontingent reinforcement, (c) advanced notice, (d) choice-making, or (e) demand fading. Graduated exposure or stimulus fading is when the individual is gradually or slowly introduced to the task or routine. Noncontingent reinforcement is when reinforcing items are provided on a time-based schedule. This type of schedule means that an individual accesses reinforcement after a certain amount of time has passed, rather than after they have engaged in a desired behavior. In other words, breaks, preferred items, activities, or attention is given freely to decrease the motivation for challenging behavior to occur to access these activities. Advanced notice consists of giving a warning or instruction before a schedule change or transition. Choice-making provides the individual opportunities for choice and control before, during, or after an activity. Demand fading is when the task or instruction is changed to reduce the task difficulty. Examples of each of these procedures are provided in the next section.

How are Antecedent-Based Interventions Implemented with Individuals with Autism?

Some antecedent-based interventions are designed to increase tolerance and acceptance of a specific health, hygiene, academic task, or other challenging situation such as a transition or routine change. These interventions may include slowly introducing a toothbrush to an individual (graduated exposure) and slowly increasing the total amount of time they brush their teeth or slowly increasing the number of steps the person completes independently (demand fading); providing access to tablets, music, or TV shows during car rides or doctor appointments (noncontingent reinforcement); providing walk breaks during homework time (noncontingent reinforcement); giving 2-min warnings before the bedtime routine starts (advanced notice); or asking if the individual would like to wash their arms or legs first in the bath (choice and preference). These strategies are usually combined in a way that makes sense for the challenging situation. For example, if a child is struggling to sit through a dentist’s appointment, the dentist may slowly introduce the dental tools to the child by showing the tools and explaining how they will be used and provide frequent breaks and play preferred shows or music during the appointment.

Another option is to combine multiple antecedent-based interventions to decrease challenging behavior throughout an individual’s day (e.g., Ala’i-Rosales et al., 2018; Kamana et al., 2023). A package of interventions may include (a) noncontingent reinforcement by providing positive interactions every few minutes and providing free and frequent access to a variety of preferred items and activities on a specific schedule; (b) demand fading strategies by presenting instructions with “do” statements (e.g., “let’s sit down” instead of “don’t stand on the table”) and showing the person what you are asking them to do with an example; (c) advanced notice by giving an individual warnings before transitions; and (d) general strategies to decrease the future occurrences of challenging behavior by not commenting on nor talking about the challenging behavior with the individual (Ala’i-Rosales et al., 2018; Kamana et al., 2023). Of note, this last practice is a consequent-based intervention which highlights the common use of antecedent-based interventions in comprehensive plans. These general strategies may be implemented for one or more individuals with the ultimate goal to meet the needs of the person to prevent the occurrence of challenging behavior.

Is There Science Behind Antecedent-Based Interventions?

Over the years, researchers have extensively reviewed published literature on the use of antecedent-based interventions to decrease challenging behavior in specific situations. Most recently, researchers have conducted multiple meta-analyses and reviews (e.g., Chazin et al., 2021; Kupzyk & Allen, 2019; Tereshko et al., 2021). For example, Kupzyk & Allen (2019) conducted a systematic review evaluating graduated exposure results specific to addressing individuals with various intellectual or developmental disabilities engaging in challenging behavior during medical or dental procedures. Graduated exposure is a complex antecedent-based intervention in which an item is slowly introduced or re-introduced to an individual in a specific manner to teach the person to tolerate the item. Graduated exposure can be implemented before or after an individual has a negative experience with the item. Kupzyk and Allen reported the results of 32 studies that used graduated exposure. Overall, 96% of these investigations reported graduated exposure to be effective in reducing challenging behavior and increasing compliance with the medical or dental procedure. Seventy-two percent of these studies included consequent-based interventions in addition to graduated exposure. Similarly, Abdel-Jalil et al. (2024) conducted a review evaluating the effectiveness of graduated exposure to complete medical procedures for individuals with and without disabilities who were reported to have a phobia of the medical procedure. Abdel-Jalil et al. found that graduated exposure was effective in increasing the completion of the medical procedure in 70% of all participants across the studies. However, as typical in practice, graduated exposure was combined with other antecedent-based interventions or with a consequent-based intervention for 87.1% of applications. In all, more research is needed to determine whether graduated exposure alone is effective without the use of additional components.

Chazin et al. (2021) systematically reviewed 39 studies (incorporating 79 participants) that evaluated various antecedent-based interventions on the occurrence of challenging behaviors that occur because nonpreferred activities are paused or stopped. The majority (91.2%) of these investigations assessed the impact of changing only the antecedents to challenging behavior; no other interventions were included. Results of this meta-analysis showed that antecedent-only interventions were effective in reducing challenging behavior in 27 of 40 (67.5%) applications. Chazin and colleagues found noncontingent reinforcement (i.e., access to preferred items) was the most evaluated antecedent-based intervention followed by advanced notice and demand fading. Noncontingent access to preferred items was found to be effective in reducing challenging behavior in 12 of 24 (50%) applications. Demand fading and advanced notice were effective 100% of the time (across two participants). Overall, this review of noncontingent access, demand fading, and advanced notice show promising evidence in reducing or preventing the occurrence of challenging behavior. However, noncontingent reinforcement and demand fading may limit the total number of learning opportunities, as frequent breaks from instructions or only certain types of instructions are provided. Advanced notice was shown to be consistently effective; however, it may not be feasible for advanced notice to be used all the time (e.g., last-minute schedule changes) and it is unknown if challenging behavior might occur more frequently if advanced notice were used inconsistently. Therefore, more research is needed to determine the best way to fade these interventions such that the individual can contact the same number of learning opportunities as their peers or tolerate last-minute schedule changes.

Tereshko et al. (2021) conducted a systematic review of antecedent-based interventions used in treating food selectivity. Antecedent-based interventions represented in the review included stimulus fading with various prompting procedures. A total of 21 articles were reviewed involving 31 children, of whom 10 were diagnosed with ASD. Fourteen of 21 studies (67%) included a treatment package consisting of multiple antecedent-based interventions or an antecedent-based intervention combined with a consequent-based intervention. Most of the studies in this review did not directly measure challenging behavior, however, 3 of 4 studies that did assess challenging behavior reported decreases in challenging behavior. Tereshko et al. categorized stimulus fading to be highly effective. However, current research suggests that food selectivity may require the use of a consequent-based intervention combined with an antecedent-based intervention. More research on effective antecedent-interventions specific to mealtime challenging behavior and food selectivity is required before general recommendations can be made.

The National Clearinghouse on Autism Evidence and Practice conducted a comprehensive review of research from 1990 to 2017 to identify evidence-based practices for individuals with autism (Steinbrenner et al., 2020). Among their findings, antecedent-based interventions were found to be strongly supported by 49 articles, supporting antecedent-based interventions as effective approaches. Additionally, the National Standards Project of the National Autism Center (2009) classified antecedent packages as an evidence-based practice.

Generally, there is a preponderance of data supporting the effectiveness of antecedent-based interventions for challenging behaviors. A newer area of research has begun evaluating packaged prevention strategies to reduce challenging behavior. For example, Kamana et al. (2023) trained approximately 150 group home and day service staff on a prevention package hypothesized to reduce the likelihood of challenging behavior of adults with various intellectual and developmental disabilities. The prevention package used noncontingent reinforcement which has shown potential to prevent the occurrence of challenging behavior in a laboratory model (Fahmie et al., 2018). The prevention package consisted of the following: (a) staff providing positive interactions approximately every 5 min, (b) promoting positive engagement with items or activities, (c) providing simple and clear instructions, and (d) reducing the reinforcement provided after the occurrence of challenging behavior. Results of the study indicated that staff acquired the skills in the prevention package and engaged in the prevention skills throughout the day. However, researchers did not evaluate the occurrence of challenging behavior before and after the package was taught to staff. Because the effects of the prevention package on challenging behavior cannot be directly evaluated from Kamana et al., more research on packaged prevention interventions is needed. This area of research is rife with possibilities to decrease the occurrence of challenging behavior in various settings throughout an individual’s daily life or to prevent challenging behavior from a young age. Packaged prevention strategies is a newer area of research; therefore, this should not detract from evidence supporting the effectiveness of specific antecedent-based interventions.

What Else Should We Consider?

While current research outcomes show support for antecedent-based interventions overall, most studies also included consequent interventions. Therefore, it is unknown if consequences need to be changed during challenging situations to see similar outcomes. For example, most studies included in the reviews discussed here evaluated antecedent-based interventions with differential reinforcement of an alternative behavior. Differential reinforcement of alternative behavior is a well-established behavioral procedure that usually consists of teaching a replacement skill, such as a request, for the individual to engage in and access reinforcement. More information on differential reinforcement to teach a request can be found in Cicero (2024). Recent research has shown that synchronous reinforcement (i.e., providing a reinforcer for tolerance and pausing or removing the reinforcer if challenging behavior occurs) is a relatively simple intervention that may increase compliance or tolerance in challenging situations such as during medical or dental procedures (see McHugh et al., 2022 for an example). However, further research on synchronous reinforcement is needed to better understand when it is most effective.

What is the Gist?

Overall, there is a large body of research supporting antecedent-based interventions in a variety of applications and settings. Antecedent-based interventions are considered evidenced-based. However, more research on selected interventions is required to identify the conditions under which these interventions are effective and not effective. For example, stimulus fading may be more effective to increase food acceptance while graduated exposure may be more effective in decreasing challenging behavior during medical/dental procedures. Other areas of research should include determining parental and caregiver acceptance and use of antecedent-based interventions, as well as evaluating specifics or details of antecedent-based interventions that make them most effective, such as determining how many steps to include during graduated guidance or how to best fade demands. Another area of research should focus on which combination of antecedent-based interventions are most effective or if antecedent-based interventions can be effective without a comprehensive plan that includes consequent-based interventions. Further, there is strong theoretical support for antecedent-based intervention packages to prevent and decrease the occurrence of challenging behavior throughout an individual’s day. This line of research is long from being complete but would contribute greatly to a field of prevention, assessment, and treatment of a wide array of challenging behavior. The continued application of behavioral science research will provide the best outcomes in answering these questions.

References

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Ala’i-Rosales, S., Cihon, J. H., Currier, T. D. R., Ferguson, J. L., Leaf, J. B., Leaf, R., McEachin, J., & Weinkauf, S. M. (2018). The big four: Functional assessment research informs preventative behavior analysis. Behavior Analysis in Practice, 12(1), 222–234. https://doi.org/10.1007/s40617-018-00291-9

Chazin, K. T., Velez, M. S., & Ledford, J. R. (2022). Reducing escape without escape extinction: A systematic review and meta-analysis of escape-based interventions. Journal of Behavioral Education, 31(1), 186–215. https://doi.org/10.1007/s10864-021-09453-2

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Kamana, B. U., Dozier, C. L., Kanaman, N. A., DiGennaro Reed, F., Glaze, S. M., Markowitz, A. M., … & Erath, T. G. (2024). Large‐scale evaluation of staff training in programs for adults with intellectual and developmental disabilities. Behavioral Interventions, 39(1), https://doi.org/10.1002/bin.1971

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Tereshko, L., Leaf, J. B., Weiss, M. J., Rich, A., & Pistorino, M. (2021). A systematic literature review of antecedent and reinforcement‐based behavioral feeding interventions without the implementation of escape extinction. Behavioral Interventions, 36(2), 496–513. https://doi.org/10.1002/bin.1769

Reference for this article:

Hardesty, E., Roberts, B., & Zane, T. (2024). Antecedent-based interventions: Is there science behind that? Science in Autism Treatment, 21(11).

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Antecedent-Based Interventions: Is There Science Behind That?