Treatment Integrity, Commission Errors, and Reinstatement: A Primer PDF

Educ. Treat. Child. https://doi.org/10.1007/s43494-023-00104-x COMMENTARY Treatment Integrity, Commission Errors, and Reinstatement: A Primer Michael P. Kranak · John Michael Falligant Accepted: 29 June 2023 © Association for Behavior Analysis International 2023 Abstract In the contex...

Educ. Treat. Child. https://doi.org/10.1007/s43494-023-00104-x COMMENTARY Treatment Integrity, Commission Errors, and Reinstatement: A Primer Michael P. Kranak · John Michael Falligant Accepted: 29 June 2023 © Association for Behavior Analysis International 2023 Abstract In the context of problem behavior, treat- Unlike omitted reinforcers and resurgence, the ment integrity refers to the extent to which a behav- research base on commission errors and reinstate- ioral intervention is implemented as intended. Treat- ment of problem behavior is limited. In this article, ment-integrity errors may lead to relapse of problem we describe a few considerations relevant to reinstate- behavior. For example, omitting reinforcers can lead ment as it applies to commission errors and clinical to increases in problem behavior called resurgence. practice. Researchers have previously described the clinical implications of omitted reinforcers and resurgence, Keywords Commission errors · Procedural fidelity · including a variety of methods for mitigating resur- Treatment integrity · Reinstatement · Relapse gence. However, omission errors are not the only type of treatment-integrity errors. Delivery of unplanned reinforcers (a commission error) can lead to recur- Behavioral treatments can be highly effective in rence of problem behavior through reinstatement. reducing problem behavior displayed by individu- als with and without intellectual disabilities (e.g., Greer et al., 2016b; Kestner et al., 2023; Kestner & St. Peter, 2018). Behavioral treatments often involve Supplementary Information The online version (re)arranging an environment to reduce the likeli- contains supplementary material available at https://​doi.​ org/​10.​1007/​s43494-​023-​00104-x. hood problem behavior will occur (e.g., antecedent or environmental manipulation; Mitteer et al., 2023; M. P. Kranak (*) Romano et al., 2021) and/or creating contingencies Oakland University, Rochester, MI, USA such that reinforcers are delivered for desirable alter- e-mail: [email protected] native responses and withheld for problem behavior M. P. Kranak (e.g., functional communication training and extinc- Oakland University Center for Autism, Rochester, MI, tion; Ghaemmaghami et al., 2021). Over the course USA of treatment, the goal is often for clients to learn to J. M. Falligant engage in desirable alternative behavior (e.g., a func- Kennedy Krieger Institute, Baltimore, MD, USA tional communication response [FCR]) to communi- cate their wants and needs in lieu of problem behavior J. M. Falligant (Mitteer et al., 2022; Rooker et al., 2013). However, Johns Hopkins University School of Medicine, Baltimore, MD, USA one of the driving factors for treatment success is Vol.: (0123456789)  Educ. Treat. Child. Fig. 1  Illustrative rates of problem behavior in typical relapse zero rates. In Phase 3 (i.e., the treatment challenge), problem arrangements. Note. In Phase 1 (i.e., baseline), problem behav- behavior returns due to some type of change in reinforcement ior occurs at high and elevated rates. In Phase 2 (i.e., treat- or stimulus conditions ment), problem behavior is typically reduced to zero or near- the extent to which interventions are implemented as Relapse of Problem Behavior Resulting from prescribed. Treatment‑Integrity Errors Treatment-integrity errors could lead to relapse (see Treatment Integrity St. Peter Pipkin et al., 2010; Vollmer et al., 2008). Relapse of problem behavior broadly refers to the Treatment integrity (also referred to as procedural return of previously eliminated or decreased behavior integrity, fidelity, or adherence) refers to the degree following some type of treatment challenge. Relapse that a behavioral intervention is being implemented and treatment challenges are typically described and as intended (see Han et al., 2023; St. Peter et al., analyzed in a three-phase arrangement (Fig. 1; e.g., 2023; and Vollmer et al., 2008). In general, higher, Kestner et al., 2018; Nevin et al., 2017). Table 1 and near-perfect levels of treatment integrity are more auxiliary Figures A–G in Supplemental Information likely to lead to sustained, clinically significant reduc- contain additional information on types of relapse tions in problem behavior compared to behavioral and what typically occurs clinically when each type treatments implemented with poor integrity (Arkoosh of relapse and treatment challenge occurs. et al., 2007; Fryling et al., 2012; Wacker et al., 2017). Treatment-integrity errors take at least two forms: Even modest decrements in treatment integrity (i.e., omission and commission errors. Omission errors 80% integrity) can have deleterious effects on behav- occur when an intervention agent fails to implement ioral treatments (Jones & St. Peter, 2022). Poor treat- some aspect of treatment as prescribed (e.g., Leon ment integrity is likely to lead to relapse of problem et al., 2014). For example, a teacher might forget to behavior (Fryling et al., 2012; Mace & Nevin, 2017), put out a specific math worksheet for a student with which is concerning given that poor or inconsistent an individualized learning protocol before the stu- treatment integrity is commonplace across a variety dent returns to the classroom because the teacher of clinical contexts and situations (e.g., Cook et al., was attending to the needs of other students. One of 2015; Foreman et al., 2021). the most common types of omission errors is failing Vol:. (1234567890) Educ. Treat. Child. Table 1  Types of relapse and corresponding treatment challenges Type of Relapse Definition Related Treatment Challenge Representative References Resurgence Return of problem behavior fol- Omission error Ringdahl & St. Peter (2017) lowing a worsening of reinforce- St. Peter (2015) ment conditions for the alterna- tive communication response Renewal (ABA) Return of problem behavior fol- Context change Kimball et al. (2020) lowing a return to a familiar set- Kimball & Kranak (2022) ting or intervention agent despite no changes in contingencies Renewal (ABC) Return of problem behavior fol- Context change Kimball & Kranak (2022) lowing an introduction to a novel Podlesnik et al. (2017) setting or intervention agent despite no changes in contingen- cies Reinstatement (Response-Depend- Return of problem behavior fol- Commission error Wathen & Podlesnik (2018) ent) lowing the unplanned delivery of a reinforcer for a previous occur- rence of problem behavior Reinstatement (Response-Inde- Return of problem behavior fol- Commission error Wathen & Podlesnik (2018) pendent) lowing the unplanned delivery of a reinforcer despite no previous occurrence of problem behavior Reacquisition Return of problem behavior fol- Commission error Wathen & Podlesnik (2018) lowing a complete reintroduction of baseline contingencies (i.e., baseline contingencies have returned) In this table, we use problem behavior and communication responses in our definitions and examples because this is relevant to clini- cal practice. However, we note for readers these definitions are applicable to behavior outside of clinical settings to deliver a reinforcer when scheduled as prescribed clinical practice, there has been a wealth of research (e.g., Mitteer et al., 2022). conducted on the topic, ranging from basic (e.g., When omission errors involve the failure to deliver Craig et al., 2017), translational (e.g., Kestner et al., a prescribed reinforcer, a form of relapse known as 2018), and applied (e.g., Greer et al., 2019) studies resurgence may occur (Ringdahl & St. Peter, 2017). all focused on mitigating resurgence (see Perrin et al., Resurgence occurs when the reinforcement condi- 2022, and Podlesnik et al., 2023, for comprehensive tions (e.g., rate, magnitude) for an alternative behav- reviews, and Kranak & Falligant, 2021, for strategies ior, such as the FCR, worsen (cf. Lattal et al., 2017). for mitigating resurgence). For example, a child might appropriately request A second form of integrity error is a commission attention (e.g., vocally stating, “look at what I did!”) error. Commission errors occur when an interven- from a teacher but the teacher is unable to honor the tion agent adds a step to the procedure that is not a request (e.g., they are attending to another student) part of the protocol for the behavioral treatment (e.g., even though the schedule of reinforcement within DiGennaro Reed et al., 2011). For example, a behav- the behavioral treatment indicates this request should ioral therapist might deliver an antecedent instruction be reinforced. Thus, by their nature, these omission when the protocol does not call for one to be deliv- errors are a worsening of reinforcement conditions for ered. One type of commission error is providing a an alternative response (i.e., reduction in density of reinforcer when one should not be delivered (e.g., reinforcement for FCRs; Falligant et al., 2022b) likely providing attention for problem behavior when extinc- to occasion resurgence. As a result, given the likeli- tion contingencies should be in effect). When com- hood of omission errors and subsequent resurgence in mission errors involve the provision of an unplanned Vol.: (0123456789)  Educ. Treat. Child. reinforcer, a form of relapse known as reinstatement reinforcer delivery within the context of treatments may occur (Wathen & Podlesnik, 2018). for problem behavior. Reinstatement comes in two forms: response- independent reinstatement and response-dependent reinstatement, and is described further below in the General Overview of Reinstatement section, “General Overview of Reinstatement.” In brief, in the context of behavioral treatment and com- A primary cause of reinstatement is either the con- mission errors, response-independent reinstatement tingent or noncontingent delivery of a reinforcer for occurs when a reinforcer for a currently eliminated the currently eliminated or reduced response. To response (e.g., problem behavior) is provided non- reiterate, our focus is on recurrence of behavior that contingently (viz. independent of the occurrence of a increases in rate following the contingent delivery response), whereas response-dependent reinstatement of a reinforcer (i.e., response-dependent reinstate- occurs when the reinforcer is provided following the ment). “Response-dependent” is a less-common way occurrence of the response. In the context of commis- to describe reinstatement, and the phenomenon of sion errors, it is response-dependent reinstatement1 response-dependent reinstatement is somewhat unu- that is particularly concerning and applicable to prac- sual in the literature. However, there are some notable tice (e.g., Mitteer et al., 2021). Continuing from the exceptions of studies comparing response-dependent example above: when the teacher does not honor the and response-independent reinstatement of target child’s appropriate request, suppose the child then behavior of nonhuman animals. As a brief example, aggresses towards the teacher to get attention. At this Podlesnik and Shahan (2009) compared the response- point, rather than withhold attention for aggression, dependent and response-independent reinstatement the teacher briefly provides attention. As a result, of key pecking of pigeons. They found that reinstate- aggression is likely to occur again at higher rates and ment of target key pecking was greater (as analyzed magnitudes (viz. reinstatement). This example also by proportion of baseline target responding) follow- illustrates that situations that lead to resurgence can ing contingent reinforcer deliveries compared to simultaneously lead to reinstatement, as each instance noncontingent reinforcer deliveries. In other words, of resurgence is a possible instance for a commission response-dependent reinstatement was greater than error that could then lead to reinstatement. response-independent reinstatement. Unfortunately, there is little research on rein- Thus far, we have used the term reinstatement to statement as it relates to behavioral treatments (see refer to relapse resulting from commission errors. Kranak et al., 2022). Thus, in the following sections, However, there is an additional form of relapse that we describe a few considerations and implications is closely related to commission errors: reacquisition. of reinstatement as it relates to clinical practice (as Reacquisition results from the complete reintroduc- well as applied research). Namely, we describe (1) a tion of contingencies that previously maintained and general overview of reinstatement; (2) issues related reinforced a target response (e.g., problem behavior; to prevalence estimates for reinstatement in clini- Bouton et al., 2012; Baum, 2012). Commission errors cal practice; (3) general considerations gleaned from may entail reinforcing problem behavior follow- related relapse mitigation research that may pertain ing a period of extinction, and thus might appear to to reinstatement; and (4) ideas for future research be a reintroduction of contingencies that previously and practice related to treatment integrity and rein- maintained problem behavior. From our perspective, statement. These points are meant to focus broadly commission errors do not constitute a complete rein- on reinstatement and commission errors involving troduction of baseline contingencies in most cases, but rather a momentary re-exposure to those contin- gencies. It would be ideal if, following a commis- sion error, intervention agents would refrain from further commission errors and continue faithfully 1 implementing extinction (Mitteer et al., 2021; Mitteer Note that, for ease of interpretation, we use simply “rein- statement” to broadly refer to response-dependent reinstate- et al., 2018). We conceptualize commission errors ment within the context of commission errors. to be more like reinstatement because commission Vol:. (1234567890) Educ. Treat. Child. errors may entail a few reinforcer deliveries, often at than being used in isolation. Moreover, although the beginning of a session or phase (i.e., commission there are a few exceptions (e.g., automatically main- errors), whereas reacquisition often tends to emerge tained problem behavior, nonfunction-based interven- following sustained reinforcement throughout a ses- tions), the majority of treatments relying on alterna- sion or phase (i.e., treatment failure). That is, rein- tive reinforcement entail use of the same functional forcement will likely follow every (or nearly every) class of reinforcer that maintained problem behavior instance of problem behavior, as it did in baseline. (e.g., McCord et al., 2019). As such, reinforcers are Researchers have noted that the line between rein- typically available in the environment based on other statement and reacquisition is difficult to draw, thus, responses rather than independently of responding. this remains an empirical question to be addressed Further, an additional consideration, especially from through basic, translational, and applied studies an applied perspective, is that some treatments do not (Kranak et al., 2022; Mitteer et al., 2021). The line incorporate extinction and instead rely on manipu- between reinstatement and reacquisition is also diffi- lations of other dimensions of reinforcement (e.g., cult to draw without knowing baseline schedules of quality, magnitude; Vollmer et al., 2020; Weinsztok reinforcement and how often accidental reinforcer & DeLeon, 2022). Thus, it might be the case that, deliveries occur. We simply make this distinction to for example, when a higher-magnitude reinforcer is ground the continuum of treatment-integrity errors to delivered for problem behavior instead of the FCR, the broader relapse literature. the delivery of the higher-magnitude reinforcer could There is little extant research related to reinstate- cause reinstatement. ment and problem behavior. In fact, an overwhelm- ing majority of reinstatement research has been con- ducted with nonhuman animals (Haaker et al., 2014; The Prevalence of Reinstatement is Unknown Zuzina & Vinarskaya, 2022), and nearly all applied reinstatement research has been conducted in the Prevalence estimates and other characteristics of rein- behavioral pharmacology domain (see Bossert et al., statement have not yet been documented (which is an 2013; Shaham et al., 2003; Mantsch et al., 2016) area for future research described below). In contrast, with few exceptions (e.g., DeLeon et al., 2005). It is one area of resurgence and renewal researchers have interesting that basic researchers and those working investigated is their prevalence and defining charac- in behavioral pharmacology have explicitly called for teristics (e.g., the rate and intensity of behavior when additional research bridging the gap between basic it returns; Mitteer et al., 2022). Indeed, there have studies and those of social significance related to been many contemporary, large-N investigations reinstatement (see Krishnan et al., 2023). that have identified and quantified characteristics of There are several aspects that further illustrate the resurgence and renewal (Briggs et al., 2018; Falli- importance and applicability of response-dependent gant et al., 2021, 2022a; Haney et al., 2022; Kranak reinstatement to the treatment of problem behavior & Falligant, 2021; Mitteer et al., 2022; Muething (Wathen & Podlesnik, 2018). For example, a bar- et al., 2020, 2021, 2022). These studies have evalu- rier to studying reinstatement of problem behavior is ated the phenomenology of resurgence and renewal that a standard response-independent reinstatement across a variety of clinical contexts (e.g., inpatient or arrangement involves programming only extinction outpatient); types of disability; and severity, typogra- for the behavior in question (e.g., Pyszczynski & phy, and functional class of problem behavior. Over- Shahan, 2011; see Table 1 in Wathen & Podlesnik, all, these nine studies reported on over 400 cases and 2018). In other words, there is not typically reinforce- applications of functional communication training— ment available for alternative responses that replace relapse (i.e., resurgence or renewal) was observed in the target behavior (akin to problem behavior; Ber- the majority of applications described in these stud- nal-Gamboa et al., 2017; Gámez & Bernal-Gamboa, ies, even occurring in a high of 92% of applications 2018). However, extinction is almost always com- for one study (i.e., Kranak & Falligant, 2021). bined with differential reinforcement of alternative Given the relative consistency of prevalence esti- behavior (DRA) in the treatment of problem behav- mates of resurgence and renewal across the many ior (Greer et al., 2016b; Rooker et al., 2013) rather distinct and different elements (see Falligant et al., Vol.: (0123456789)  Educ. Treat. Child. 2022a), one could speculate reinstatement may also behavior is an opportunity for a commission error to frequently occur during behavioral treatment, particu- occur on the part of the intervention agent, leading larly when commission errors occur. It appears likely to reinstatement. For example, when a teacher tries that practitioners are going to encounter commission to implement a behavior plan in a new context (like errors (and subsequent reinstatement) during clinical a different classroom), the change in setting may practice (Suess et al., 2014). Therefore, in addition to initially evoke problem behavior. If commission taking steps to prevent resurgence and renewal, clini- errors also occur, this otherwise transient recur- cians may benefit from an awareness of situations that rence of problem behavior may persist. Therefore, might cause reinstatement and should consider strate- one approach to mitigate reinstatement is to limit gies to prevent reinstatement. the opportunities for commission errors by using strategies to reduce the likelihood of renewal and resurgence. Limiting Opportunities for Commission Errors Supplemental tactics have been identified to mitigate resurgence and renewal during behavioral In contrast to work pertaining to omission errors treatment for problem behavior. Some of these strat- and resurgence, there is a dearth of research regard- egies include teaching more than one alternative ing commission errors and reinstatement, especially response during functional communication train- with respect to ways to reduce reinstatement for prac- ing (e.g., Fuhrman et al., 2021), adding competing titioners (Kranak et al., 2022; Wathen & Podlesnik, stimuli during periods of extinction (Fuhrman et al., 2018). However, there may be steps that practitioners 2018), limiting exposure to establishing operations can take to potentially mitigate reinstatement. Recall (Fisher et al., 2018c, 2019), modifying the dura- that response-dependent reinstatement occurs when tion of extinction periods (e.g., Wacker et al., 2011), the reinforcer that maintained the target response incorporating additional discriminative stimuli dur- (i.e., problem behavior) is provided contingent upon ing periods of extinction (Craig et al., 2017; Fisher an occurrence of that response and causes it to subse- et al., 2015, 2020), conducting reinforcement sched- quently occur at high rates and intensity (presuming it ule thinning (Hagopian et al., 2011), and perform- has been reduced from baseline to treatment). ing successive generalization training in varied Despite the efficacy of behavioral interventions, contexts (Falligant et al., 2021; Kimball & Kranak, problem behavior may periodically occur through- 2022). For more detailed descriptions of factors out the course of treatment and even after treatment contributing to and strategies for mitigating renewal has successfully concluded (Wacker et al., 2017). and resurgence, the reader is referred to Kimball Relapse of problem behavior may set the stage for et al. (2023), Kimball and Kranak (2022), Kranak subsequent commission errors and reinstatement and Falligant (2021), Saini and Mitteer (2020), St. when treatment challenges occur. Two common Peter (2015), and St. Peter and Ringdahl (2017). treatment challenges that practitioners should be It might seem counterintuitive that a primary aware of here include (1) context changes and (2) recommendation to mitigate reinstatement is to decrements in the density of reinforcement for the use strategies to mitigate other forms of relapse alternative response (e.g., the FCR), each of which first rather than describe a specific reinstatement- produce two common forms of relapse: renewal mitigation strategy. However, again consider that and resurgence, respectively (Podlesnik & Kelley, response-dependent reinstatement occurs when 2015). As mentioned, results from extant literature one makes a commission error. Thus, situations indicate that both renewal (e.g., Muething et al., that cause renewal and resurgence are corollary 2020) and resurgence (e.g., Briggs et al., 2018) situations that might cause reinstatement—the only are common clinical phenomena that occur during way a commission error can occur, in the context treatment challenges across a variety of inpatient of behavioral treatment, is when problem behav- and outpatient treatment settings. Every instance of ior occurs. As such, one way to mitigate reinstate- renewal and resurgence sets the stage for response- ment is to avoid situations in which commission dependent reinstatement to occur. Put another way, errors might occur by mitigating the occurrence of every instance of renewal or resurgence of problem renewal and reinstatement. Vol:. (1234567890) Educ. Treat. Child. Specific Reinstatement‑Mitigation Strategies reinstatement) during the reinstatement test. Ber- nal-Gamboa et al. (2017) used a stimulus (called an As mentioned in the preceding section, research- extinction cue) associated with extinction to reduce ers have developed tactics to supplement behavioral reinstatement of lever pressing of rats when reinforc- treatments to mitigate renewal and resurgence. It is ers were re-presented following a period of extinc- important to note that nearly all of those procedures tion. This approach has been effective at preventing have been well-validated in applied studies and dem- or reducing other forms of relapse of problem behav- onstrations (e.g., teaching multiple response alterna- ior (e.g., Greer et al., 2019; see Kimball et al., 2023, tives; Fuhrman et al., 2021). Unfortunately, the same for a review). Further, researchers have also shown does not hold true with respect to reinstatement as that lower rates of reinforcement for target responses applied work in this area is lagging behind investiga- can result in less reinstatement compared to higher tions of resurgence and renewal. rates of reinforcement (e.g., Nevin et al., 2016; Podle- To our knowledge, no explicit strategies for miti- snik & Shahan, 2009). However, excluding the pro- gating reinstatement of problem behavior have been cedures used in Woods and Bouton (2007, which is demonstrated in the treatment of problem behavior. akin to progressive-ratio training), these approaches However, one promising strategy is progressive-ratio have been used with nonhuman animals in response- training (Kranak et al., 2022). In brief, progressive- independent arrangements, meaning only extinc- ratio training entails gradually increasing the rein- tion was arranged during Phase 2 or reinstatement forcement schedule for the target response (i.e., prob- was assessed after a subsequent period of extinction. lem behavior) in the presence of a discriminative Recall that extinction is rarely programmed as the stimulus. That is, in the presence of the discrimina- sole component of a behavioral treatment. Thus, the tive stimulus, the likelihood of a reinforcer being applicability of these potential reinstatement-mitiga- delivered for problem behavior continually decreases tion tactics requires explicit investigation when rein- over time, whereas the alternative response contin- forcement is available for an alternative response in ues to be reinforced on a constant and frequent rein- the context of DRA. forcement schedule. In general, during the reinstate- ment test, Kranak et al. (2022) found that participants Quantitative Models and Treatment Integrity engaged in less target responding in the presence of the discriminative stimulus from progressive-ratio An additional relapse mitigation strategy involves training compared to its absence. Although Kranak designing treatments based on quantitative models of et al. (2022) successfully mitigated reinstatement behavioral persistence, such as behavioral momen- using progressive-ratio training, they conducted that tum theory (BMT; Fisher et al., 2018b, 2020; Fuhr- study in a translational, proof-of-concept fashion. man et al., 2016; Nevin & Grace, 2000; Pritchard Thus, a relatively major limitation of progressive- et al., 2014). Although newer models have emerged, ratio training is that it has yet to be evaluated with BMT has been useful as a quantitative and concep- problem behavior, meaning readers should not yet use tual framework for understanding reinforcement and progressive-ratio training until more-applied data are response strength (Podlesnik & DeLeon, 2015; Smith available. & Greer, 2023). Given that resurgence and renewal Three other strategies have been used to reduce may set the stage for reinstatement following commis- reinstatement with nonhuman animals. Similar to sion errors, these models may improve the durability progressive-ratio training described above, Woods of treatment and indirectly decrease opportunities for and Bouton (2007) gradually increased the reinforce- reinstatement to occur. Using BMT to inform behav- ment schedule for lever pressing of rats and made ioral treatments allows clinicians to make specific the schedule a leaner variable-interval (VI) sched- predictions about the potential success of a treatment ule within and across sessions (though they did not based on certain factors and identified functional rela- include an alternative response). Compared to rats tions affecting relapse (e.g., rates of reinforcement for whose target responding was eliminated via extinc- problem behavior and the FCR, time spent in extinc- tion-only, rats exposed to the gradually increasing tion, and schedule-correlated stimuli; see Fisher et al., VI schedule engaged in less target responding (i.e., 2018a, for a review). For example, using BMT might Vol.: (0123456789)  Educ. Treat. Child. lead one to conduct more treatment sessions than nor- the downshift in alternative reinforcement and the mal or use leaner schedules of reinforcement during magnitude of the resurgence of the previously elimi- treatment compared to standard practice (see Fisher nated target response. These findings have been dem- et al., 2018b). Indeed, it seems that BMT-informed onstrated across a variety of research preparations treatments are not only highly successful, but also (e.g., Falligant et al., 2022b) and organisms including more durable and able to withstand treatment chal- rodents (Shahan et al., 2020) and humans (Shahan & lenges that might otherwise occasion resurgence Greer, 2021). These findings suggest that the more (Brown et al., 2020; DeLeon et al., 2005; Greer et al., pronounced the omission error, the more problem 2019, 2020; Mace et al., 2010; Pritchard et al., 2014). behavior will return—thus setting the stage for sub- Researchers have recently developed alternative sequent commission errors and reinstatement. To the quantitative and theoretical models (e.g., Resur- extent that these models are used to inform clinical gence as Choice [RaC]; Shahan & Craig, 2017) that decisions involving variables known to affect resur- could also have implications for promoting durable gence (see Kimball et al., 2023), they may prevent the behavior change and preventing relapse, including return of problem behavior that creates the necessary reinstatement. Broadly, RaC proposes that resur- conditions for reinstatement. gence is governed by the same behavioral processes Like omission errors and resurgence, these quan- that underlie choice (see Greer & Shahan for titative models can in principle also be extended to a comprehensive overview). RaC posits that alloca- illustrate the process of commission errors and rein- tion between target responding (e.g., aggression) and statement/reacquisition (or other behavioral phe- alternative responding (e.g., the FCR) occurs accord- nomena, such as extinction bursts; Shahan, 2022). ing to changes in the relative value of each response Consider the foundational tenets of many of these alternative over time. RaC and its related family of models: Behavior is distributed in proportion to rela- models—RaC in Context (­ RaC2; Shahan et al., 2020), tive value of concurrently available reinforcers. In the temporally weighted matching law (Fisher et al., general, the return of problem behavior following 2023), and an alternative account of RaC proposed omission errors can be viewed as a reallocation of by Podlesnik et al. (2022) that incorporates Davison behavior given a concurrent schedule change when and Jenkins’s (1985) contingency discriminability the appropriate alternative response “stops working” model ­(mRaC2)—appear to describe relapse phenom- as well as it was. This same reallocation framework ena well (e.g., Shahan, 2022; Smith & Greer, 2022). applies to response-dependent reinstatement when Indeed, behavioral treatments based on quantitative problem behavior “starts working” again following models such as BMT and RaC have been shown to some period of time where it had not been working prevent resurgence (e.g., Fisher et al., 2018a, b, c). (i.e., extinction). Readers interested in additional information on BMT For example, Fig. 2 illustrates a hypothetical sce- and RaC are directed to Greer and Shahan (2019), nario with RaC in which, following successful reduc- Greer et al. (2016a), and Laureano and Falligant tions in problem behavior with DRA and extinction, (2023). even a single episode with commission errors for problem behavior causes the return of problem behav- The Frequency of Treatment Integrity Errors Affects ior. During the brief sessions of this hypothetical the Severity of Problem Behavior Relapse baseline, imagine that problem behavior is reinforced on a moderately dense schedule of reinforcement and Quantitative models of behavioral persistence can be there are no consequences provided for the alternative used to predict the magnitude of relapse given the response. During the treatment phase consisting of frequency of the treatment integrity omission or com- DRA and extinction, problem behavior is placed on mission errors. As described above, even relatively extinction and the alternative response is reinforced infrequent integrity errors can seemingly increase on a dense schedule. Finally, during the third phase problem behavior relative to treatment-as-planned with commission errors, both problem behavior and (see Carroll et al., 2013, for a related discussion). the FCR are reinforced for a given number of sessions For example, consistent with the predictions of RaC, before treatment integrity is restored (i.e., problem there is an exponential relation between the size of behavior is no longer reinforced). The focal point here Vol:. (1234567890) Educ. Treat. Child. Fig. 2.  RaC-predicted relapse of problem behavior following just a single session (open circles) to five consecutive sessions commission integrity errors. Note. BL = baseline. The number (open diamonds). These results illustrate the effects of com- of sessions with reinforcement commission errors for problem mission errors during DRA on problem behavior using default behavior in the third phase (“Integrity Errors”) varies from model parameters (e.g., Greer & Shahan, 2019) is that once a commission error occurs, it is critical applied studies. For example, they serve as a means that an intervention agent begin implementing with and impetus for alerting stakeholders to the likeli- high integrity as soon as possible to recapture treat- hood of relapse, as well as for clinicians to imple- ment effects (to the extent they were lost) and prevent ment and researchers to develop of mitigation strate- additional problem behavior from occurring. In other gies (see Kimball & Kranak, 2022). Thus, one readily words, quantitative models predict that effects of only apparent area in which researchers could focus on a single session with treatment integrity errors may reinstatement might be to quantify its prevalence, persist for some time. similar to other forms of relapse, using retrospective consecutive-controlled case series studies (Hagopian, 2020). This would require a fine-grained analysis of Considerations for Future Research treatment-integrity data (which are often limited and may not distinguish between omission and commis- The contrast between the preponderance of research sion errors; St. Peter et al., 2023). To date, all large- on other forms of relapse (i.e., resurgence and N relapse prevalence studies have been retrospective renewal) compared to reinstatement may be sugges- in nature. As mentioned, it can be difficult to align tive of the challenging nature of studying reinstate- data on reinforcer deliveries and subsequent prob- ment (e.g., programming and quantifying commission lem behavior in such a way that enables identification errors, mapping treatment-integrity data onto treat- and analysis of reinstatement. Therefore, researchers ment evaluation data). Nonetheless, there are several might also consider a prospective evaluation of the areas of research that seem primed for reinstatement prevalence of reinstatement. For example, researchers and problem behavior. could provide an intervention agent with a detailed First, large-N studies of renewal and resurgence list of steps for implementing a behavioral interven- have provided invaluable information regarding the tion and then indicate on which steps they should prevalence, magnitude, characteristics, and other make an error (Fiske, 2008; see St. Peter Pipkin et al., aspects of those forms of relapse (e.g., Falligant 2010, for a translational example of this framework). et al., 2021, 2022a). Data from these large-N studies This would also then enable follow-up studies such can then be used to inform clinical practice and other as parametric analyses of commission error rates and Vol.: (0123456789)  Educ. Treat. Child. component analyses of specific types and sequences reinstatement. As similar discussions have high- of commission errors and their corresponding effects lighted the applied relevance of resurgence (St. Peter, on reinstatement. 2015) and renewal (Kimball & Kranak, 2022), we Second, as mentioned above, researchers have devel- hope the discussion contained herein (1) emphasizes oped strategies for specifically mitigating renewal and the importance of avoiding commission errors when resurgence. Although mitigating those two forms of problem behavior occurs and (2) stimulates additional relapse might conditionally mitigate response-depend- research on reinstatement and problem behavior. ent reinstatement by preventing opportunities for com- mission errors, it might be worthwhile to see if any Acknowledgements The authors thank Chris Podlesnik, Dan Mitteer, and Harriet de Wit for their correspondence during the other relapse mitigation strategies have generality for preparation of this article. mitigating reinstatement (Falligant & Hagopian, 2020; Kimball et al., 2023). This point is particularly true for Data Availability Any data or information beyond that resurgence-mitigation strategies, given the similarities described herein are available from the corresponding author between resurgence and reinstatement. For example, upon reasonable request. researchers could evaluate the effects of either baseline Declarations or treatment phase duration on reinstatement (Greer et al., 2020, 2023; Smith & Greer, 2022). Researchers Ethical Approval No human subjects were involved in the might also examine how obtained rates of reinforce- preparation of this manuscript, thus informed consent was not ment during baseline and treatment affect reinstatement necessary. (Podlesnik & Kelley, 2015; Pritchard et al., 2016). Competing Interests On behalf of all authors, the corre- Third, many of the strategies used for mitigat- sponding authors declares there are no conflicts of or competing ing other forms of relapse rely on some type of dis- interests. crimination training or incorporation of additional discriminative stimuli (e.g., Fisher et al., 2020; Fuhr- man et al., 2016; Greer et al., 2019). In their transla- References tional study on mitigating reinstatement, Kranak et al. 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