13.4 Managing Behavioral Relapse, Transition Planning, and Systematic Discharge Criteria

Behavioral Durability and the Challenge of Relapse

A central goal of applied behavior analysis is not merely achieving temporary behavior change in an analog therapy room, but establishing durable, lasting behavioral repertoires that survive across time, settings, and changing life circumstances. Too often, behavioral interventions produce dramatic initial reductions in problem behavior, only for clinicians to witness an abrupt, disheartening resurgence of the problem behavior weeks or months later.

Historically, colloquial psychology attributed such reversals to internal deficits: "the client regressed," "the intervention wore off," or "the child relapsed due to anxiety." In radical behaviorism, behavioral relapse is recognized not as an internal disease recurrence, but as a lawful operant phenomenon governed by specific environmental contingencies, context changes, and schedule shifts. Assistant behavior analysts must master the three primary mechanisms of behavioral relapse—resurgence, renewal, and reinstatement—and embed proactive mitigation architectures into every behavior plan.

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The Three Operant Mechanisms of Behavioral Relapse

+--------------------------------------------------------------------------+
|                 THE THREE OPERANT MECHANISMS OF RELAPSE                  |
+-------------------+------------------------------------------------------+
| 1. RESURGENCE     | Reappearance of an extinguished target behavior when |
|                   | reinforcement for an alternative behavior (DRA/FCT)  |
|                   | is discontinued, delayed, or thinned.                |
+-------------------+------------------------------------------------------+
| 2. RENEWAL        | Recovery of an extinguished target behavior when the |
|                   | individual transitions out of the treatment context  |
|                   | back into the baseline context or a novel context.   |
+-------------------+------------------------------------------------------+
| 3. REINSTATEMENT  | Reappearance of an extinguished target behavior      |
|                   | following the noncontingent delivery of the          |
|                   | maintaining reinforcer outside of the contingency.   |
+-------------------+------------------------------------------------------+

1. Resurgence

Resurgence (Epstein, 1983; Lieving et al., 2004; Volkert et al., 2009) is defined as the reappearance of a previously extinguished target behavior when reinforcement for an alternative behavior (e.g., a functional communication response) is discontinued, delayed, or reduced.

The Resurgence Paradigm in Clinical FCT

Consider a clinical application of Functional Communication Training (FCT):

1. Phase 1 (Baseline): Aggression ($R_1$) is maintained by task escape ($S^{R-}$).
2. Phase 2 (DRA / FCT): Aggression ($R_1$) is placed on extinction, and a functional mand (handing a "Break" card, $R_2$) is reinforced on an FR1 schedule. Aggression drops to zero, and the mand becomes robust.
3. Phase 3 (Schedule Thinning / Extinction of Alternative): The clinician attempts to thin the reinforcement schedule for $R_2$ by requiring 5 tasks before granting a break, or the teacher momentarily fails to honor the break card. As reinforcement for $R_2$ is delayed or withheld, $R_2$ undergoes extinction. Immediately, the extinguished aggression ($R_1$) surges back at high rates and intensities.

Clinical Prevention and Mitigation of Resurgence

• Criterion-Based, Micro-Step Schedule Thinning: Avoid large jumps in schedule requirements (e.g., never jump from FR1 to FR5). Thin schedules progressively: $\text{FR1} \longrightarrow \text{FR2} \longrightarrow \text{VR2} \longrightarrow \text{VR3}$.
• Multiple Schedules ($S^D / S^\Delta$ Architecture): Introduce visual discriminative stimuli to signal when mands will be reinforced versus when reinforcement is unavailable. A green card on the desk signals the mand is available on FR1; a red card signals "work time" where mands are unavailable. By teaching stimulus control, mands are not emitted during unavailable periods, preventing extinction bursts and resurgence.
• Delay-to-Reinforcement Tolerance Training: Systematically condition an omnibus tolerance response (e.g., Hanley et al.'s PFA/SBT protocol) so that delays evoke calm coping rather than alternative extinction.

2. Renewal

Renewal is the recovery of an extinguished target behavior when the context changes from the treatment setting back to the original baseline context or to an entirely novel environment. Renewal demonstrates that extinction is context-dependent: the operant response is not "erased" during extinction, but rather inhibited under the specific stimulus conditions of the treatment environment (Bouton, 2004).

The Three Types of Renewal

Behavioral researchers classify renewal into three primary environmental configurations:

• ABA Renewal: A behavior is conditioned in Context A (e.g., home), successfully extinguished in Context B (e.g., ABA clinic), and immediately re-emerges when the individual returns to Context A (home).
• ABC Renewal: A behavior is conditioned in Context A (e.g., home), extinguished in Context B (e.g., clinic), and re-emerges when tested in a completely novel Context C (e.g., general education classroom).
• AAB Renewal: A behavior is conditioned in Context A (e.g., school), extinguished in the same Context A (school), but re-emerges when the learner transitions to Context B (e.g., summer camp).

Clinical Prevention and Mitigation of Renewal

• Multi-Context Training (Programming Common Stimuli): Stokes and Baer (1977) emphasized training across diverse natural contexts. Conduct extinction and FCT across the clinic, home, classroom, and community.
• Incorporate Salient Treatment Cues: Transport physical discriminative stimuli from the treatment setting into the natural environment (e.g., using the identical visual schedule, communication binder, or token board at home and school).
• Implementer Training in Baseline Settings: Train parents, siblings, and paraprofessionals directly in the baseline setting using Behavioral Skills Training before service reduction.

3. Reinstatement

Reinstatement is the reappearance of an extinguished behavior following the noncontingent delivery of the maintaining reinforcer or an unconditioned aversive stimulus outside of the operant contingency (first described in respondent conditioning by Rescorla & Heth, 1975, and later shown with operant behavior).

Clinical Manifestation of Reinstatement

A child's severe tantruming, previously maintained by access to candy, has been extinguished; the child has emitted zero tantrums for six months. At a holiday party, a visiting relative hands the child a large bag of candy noncontingently (with zero behavioral contingency). Shortly after consuming the candy, when the candy is finished, the child's severe tantruming abruptly reappears at full baseline intensity.

Behavioral Mechanism

The noncontingent delivery of the functional reinforcer acts as an establishing operation (or contextual prime), momentarily reinstating the discriminative and motivational properties that originally set the occasion for the target operant class.

• Mitigation: Caregiver education regarding the risks of noncontingent delivery of historical reinforcers; ensuring that functional replacement responses (mands) remain highly accessible, practiced, and immediately reinforced.

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Long-Term Maintenance and Schedule Thinning

Initial skill acquisition and behavioral stabilization typically require dense, continuous reinforcement schedules (e.g., FR1). However, natural environments do not operate on continuous reinforcement. If a client is discharged while still dependent on an FR1 schedule, the intervention will collapse into schedule strain and behavioral relapse.

Systematic Schedule Thinning Protocols

1. Transition from Continuous to Intermittent Schedules: Systematically shift reinforcement from FR1 to variable schedules (Variable Ratio [VR] or Variable Interval [VI]). Intermittent schedules foster resistance to extinction, ensuring responding persists even when reinforcement is delayed or unpredictable.
2. Demand Fading and Behavioral Momentum: Gradually increase the number, complexity, or duration of tasks required between reinforcer deliveries.
3. Multiple Schedules with External Signaling: Utilize clear external signals (e.g., wristbands, colored cards, or visual timers) to transition between rich reinforcement periods and natural delay intervals.

Self-Management and Self-Monitoring

To achieve true permanence, behavioral control must shift from external clinical staff to the client's own repertoire. Self-management (Kanfer & Phillips, 1970) involves three core components:

• Self-Monitoring (Self-Recording): The client observes their own behavior and marks occurrences/nonoccurrences on a recording tool (e.g., a vibrating watch prompts the client to check: "Am I on task?").
• Self-Evaluation: The client compares their recorded performance against an objective, predetermined goal.
• Self-Reinforcement: The client recruits or self-administers the predetermined reinforcer upon meeting criterion.

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Transition and Systematic Discharge Planning

Ethical behavior analysis dictates that discharge planning begins on the first day of service intake. A behavior analyst must never establish an open-ended, indefinite therapy program that fosters perpetual dependence on clinical services (Standards 3.15 and 3.16 require service agreements to state when services will be discontinued or transitioned and require written discharge and transition plans).

+--------------------------------------------------------------------------+
|                SYSTEMATIC SERVICE FADING TO DISCHARGE                    |
+--------------------------------------------------------------------------+
| TIER 1: Intensive 1:1 Direct Therapy (e.g., 20-30 hours/week)            |
|   - FBA/FA, acquisition of FCT, initial extinction, dense FR1            |
+--------------------------------------------------------------------------+
| TIER 2: Systematic Thinning & Caregiver BST (e.g., 10-15 hours/week)     |
|   - Thin to VR/VI schedules, multi-setting generalization, parent leads  |
+--------------------------------------------------------------------------+
| TIER 3: Consultation & Monitoring Model (e.g., 2-4 hours/month)          |
|   - Direct hours faded; analyst monitors caregiver/teacher fidelity;     |
|   - Maintenance probes at 30, 60, and 90 days                            |
+--------------------------------------------------------------------------+
| TIER 4: Formal Discharge & Maintenance Summary                           |
|   - Objective criteria met; long-term crisis safety plan archived        |
+--------------------------------------------------------------------------+

Objective Discharge Criteria

Discharge criteria must be predetermined, objective, quantitative, and socially validated. Subjective impressions (such as "when the child seems ready" or "when the family feels comfortable") are unacceptable. Robust discharge criteria specify:

1. Reduction in Target Problem Behavior: e.g., "Target challenging behavior maintained at or below community/classroom normative rates ($\le 0.1$ instances per hour) across all natural settings for at least 3 consecutive months."
2. Mastery of Functional Replacement Skills: e.g., "Spontaneous, unprompted functional communication and coping responses emitted across $\ge 90\%$ of natural opportunities across home, school, and community environments."
3. Caregiver and Implementer Fidelity: e.g., "Caregivers demonstrate $\ge 85\%$ treatment integrity on behavioral maintenance protocols during unannounced fidelity checks across 3 consecutive months."
4. Schedule Thinning to Natural Levels: e.g., "Appropriate behavior maintained under natural, intermittent schedules of reinforcement without requiring specialized clinical prompt hierarchies or tangible token economies."

The Final Discharge Summary and Maintenance Plan

Upon achieving discharge criteria, the assistant behavior analyst authors a formal Discharge Summary. This document details baseline levels, terminal mastered rates, verified functional replacement topographies, caregiver training records, and a concrete Maintenance and Relapse Prevention Plan outlining specific environmental safeguards and contacts should behavioral relapse occur.

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Comparative Table: Behavioral Relapse Mechanisms Matrix

The following matrix contrasts the three primary relapse phenomena, detailing their operant mechanisms, clinical vignettes, and empirical prevention strategies: