in behavior modification a research design is used to

Module 2: The Science of Behavior Analysis and Modification

Module Overview

In Module 1, we learned that psychology was the scientific study of behavior and mental processes and that behavior modification involved changing what people do, say, or think/feel. If we do end up changing the behavior, how do we know that our treatment plan was the actual cause? In Module 2, we will look closer at what makes psychology scientific and how we go about declaring with a great deal of certainty that our treatment plan was the cause of the change.

Module Outline

2.1. Science and Psychology

2.2. behavioral assessment, 2.3. establishing a functional relationship and experimental designs.

Module Learning Outcomes

• Clarify what it means for psychology to be scientific by examining the steps of the scientific method, the three cardinal features of science, and the five main research methods that are used.
• Describe methods of measuring behavior.
• Clarify what is needed for a functional relationship to be established and describe designs which aid with hypothesis testing.

Section Learning Objectives

• Define the scientific method.
• Outline and describe all steps of the scientific method. Define key terms in bold.
• Clarify what the three cardinal features of science are and how they relate to behavior modification.
• List and describe the five main research methods used in psychology.

2.1.1. The Scientific Method

In Module 1, we learned that psychology was the “scientific study of behavior and mental processes.” We will spend quite a lot of time on the behavior and mental processes part, but before we proceed, it is prudent to elaborate more on what makes psychology scientific. In fact, it is safe to say that most people not within our discipline or a sister science, would be surprised to learn that psychology utilizes the scientific method at all.

As a starting point, we should expand on what the scientific method is.

The scientific method is a systematic method for gathering knowledge about the world around us.

The key word here is that it is systematic meaning there is a set way to use it. What is that way? Well, depending on what source you look at it can include a varying number of steps. I like to use the following:

Table 2.1: The Steps of the Scientific Method

Science has three cardinal features that we will see play out time and time again throughout this book. They are:

• Observation – In order to know about the world around us we must be able to see it firsthand. In relation to behavior modification, if we want to reduce a problem behavior such as a child acting out in class, we must be able to see the child fidget in his seat, distract other children as they work, talk out of turn, show hostility on the playground, throw food at lunch, etc. In Module 4, we will talk about the need to clearly define what this “problem behavior” entails so we know what we need to observe and record.
• Experimentation – To be able to make causal (defined as cause and effect) statements, we must be able to isolate variables. We have to manipulate one variable and see the effect of doing so on another variable. In order to stop the child from acting out, a teacher may use a specific strategy such as giving the child points for behaving that he can later cash in for some coveted prize. The points are part of a system that the teacher can manipulate and the problem behavior is what she is trying to affect. In this case, she is trying to reduce the distracting behavior.
• Measurement – How does the teacher know that her strategy has worked? She can measure how often the child misbehaved before the strategy in terms of the various dimensions of behavior you learned about in Module 1.3. Let’s say the child used to act out about 6 times an hour (frequency) for a few minutes at a time (duration) and become really difficult during group work compared to individual work (intensity). With her plan in place, she now measures behavior and notices a significant decline in the distracting behavior. Her plan must be working.

Behavior modification will utilize these features. Remember, behavior is what we do, say, or think and feel, and behavior must be overt or observable. This meets the first cardinal feature of science.

2.1.2. Research Designs Used in Psychology

Step 3 called on the scientist to test his or her hypothesis. Psychology as a discipline uses five main research designs. They are:

• Naturalistic and Laboratory Observation – In naturalistic observation , the scientist studies human or animal behavior in its natural environment which could include the home, school, or a forest. The researcher counts, measures, and rates behavior in a systematic way and at times uses multiple judges to ensure accuracy in how the behavior is being measured. The advantage of this method is that you see behavior as it occurs and it is not tainted by the experimenter. The disadvantage is that it could take a long time for the behavior to occur and if the researcher is detected then this may influence the behavior of those being observed. Laboratory observation involves observing people or animals in a laboratory setting. The researcher might want to know more about parent-child interactions and so brings a mother and her child to the lab to engage in preplanned tasks such as playing with toys, eating a meal, or the mother leaving the room for a short period of time. The advantage of this method over the naturalistic method is that the experimenter can use sophisticated equipment and videotape the session to examine it later. The problem is that since the subjects know the experimenter is watching them, their behavior could become artificial.
• Case studies – Psychology can also utilize a detailed description of one person, or a small group, based on careful observation. In fact, much of the work done in applied behavior analysis involves case studies. The advantage of this method is that you have this rich description of the behavior being investigated but the disadvantage is that what you are learning may be unrepresentative of the larger population and so lacks generalizability . Again, bear in mind that you are studying one person or a very small group. Can you possibly make conclusions about all people from just one or even five or ten?
• Surveys – This is a questionnaire consisting of at least one scale with some number of questions which assesses a psychological construct of interest such as parenting style, depression, locus of control, or sensation seeking behavior. It may be administered by paper and pencil or computer. Surveys allow for the collection of large amounts of data quickly, but the actual survey could be tedious for the participant and social desirability , when a participant answers questions dishonestly so that they are seen in a more favorable light, could be an issue. For instance, if you are asking high school students about their sexual activity they may not give an honest answer for fear that their parents will find out.
• Correlational Research ­– This research method examines the relationship between two variables or two groups of variables. A numerical measure of the strength of this relationship is derived, and can range from -1.00, a perfect inverse relationship meaning that as one variable goes up the other goes down, to 0 or no relationship at all, to +1.00 or a perfect relationship in which as one variable goes up or down so does the other. In terms of a negative correlation we might say that as a parent becomes more rigid, controlling, and cold, the attachment of the child to parent goes down. In contrast, as a parent becomes warmer, more loving, and provides structure, the child becomes more attached. The advantage of correlational research is that you can correlate anything. The disadvantage is that you can correlate anything. Variables that really do not have any relationship to one another could be viewed as related. Yes. This is both an advantage and a disadvantage. For instance, we might correlate instances of making peanut butter and jelly sandwiches with someone we are attracted to sitting near us at lunch. Are the two related? Not likely, unless you make a really good PB&J but then the person is probably only interested in you for food and not companionship. The main issue here is that correlation does not allow you to make a causal statement.
• Experiments – This is where the experiment comes in since it is a controlled test of a hypothesis in which a researcher manipulates one variable and measures its effect on another variable. The variable that is manipulated is called the independent variable (IV) and the one that is measured is called the dependent variable (DV) . In the example about a misbehaving child above, the strategy the teacher came up with is the IV and the distracting behavior that is measured is the DV. The teacher can make a causal statement about her strategy if the hypothesized decrease in behavior occurs. As such, she might say, “When I offered the student points for behaving correctly that were later cashed in for a prize, the student acted out less in class. Hence, my plan led to a reduction in this behavioral excess as hypothesized.” A common feature of experiments is to have a control group that does not receive the treatment or is not manipulated and an experimental group that does receive the treatment or manipulation. It is possible that the teacher had a second student in one of her other sections of the class that acted out in the same way. To know if her points system really works, she would use it with the first student but not with the second. Once her treatment phase ended, she could then compare the control group (the student not given points) against the experimental group (the student given points) to see how much behavior was occurring. We would expect no change in behavior for the control group but a decrease with the experimental group if the points system was effective, and this is what the teacher found. Again, the control group allows the researcher (or teacher) to make a comparison to the experimental group which can lead to a causal statement.
• Define behavioral assessment.
• Define target behavior and the forms it may take.
• Clarify why we need to measure behavior.
• Contrast the three phases of behavioral assessment.

Recall that one of the three cardinal features of science is measurement. Within the realm of behavior modification and applied behavior analysis, we talk about what is called behavioral assessment which simply is the measurement of a target behavior. The target behavior is whatever behavior we want to change, and from Module 1.4 we know that we can have an excess (it needs to be reduced), or a deficit (it needs to be increased).

Why might we need to measure behavior? Three reasons come to mind. First, we need to determine if a treatment is even needed. Maybe the target behavior is not occurring as frequently as we thought it was and so there is no need to try to reduce it. Or maybe we want to increase the number of times we go to the gym each week but discover we already are going three times most weeks and so strategizing to go more often is not necessary. Of course, we might also discover that we smoke more cigarettes in a day than we believed we did, and so reducing the unwanted or problem behavior is even more important.

Assuming a treatment is needed, our second reason to measure behavior will be to determine what treatment will work best. It may be that we wish to include a specific positive consequence for making the desirable behavior but learn through observation and measurement of behavior that this is something our client, or ourselves, really will not enjoy and so will not motivate behavior.

Finally, we need to know if the treatment we employed worked. This will involve measuring before any treatment is used and then measuring the behavior while the treatment is in place. We will even want to measure after the treatment ends to make sure the behavior sticks.

Our measurement therefore occurs during three phases:

• Baseline Phase – Before any strategy or strategies are put into effect. This phase will essentially be used to compare against the treatment phase. We are also trying to find out exactly how much of the target behavior the person is engaging in.
• Treatment Phase – When the strategy or strategies are being used. We measure across all treatment weeks to see if the target behavior changes in the predicted manner. In Module 15 we will discuss evaluating our plan and making adjustments as needed. Since we are measuring during the treatment phase, we can see if our strategy or a specific strategy within a group of strategies being used does not work. We can remove it, replace it, or change it to bring about the effect on behavior that we hypothesized.
• Maintenance Phase – Once the treatment phase has ended we will want to still measure our behavior to ensure that the strategies we used to bring about meaningful behavioral change withstand the passage of time and the influence of temptations in our environment. Let’s say our nutritionist gives us a sound strategy that brings about substantial weight loss. We may then reduce our visits and just check in periodically. Without those regular visits to check in we might fall back into bad habits and see our weight rebound, even if just partially. In a follow-up visit, the nutritionist could recommend a return to the full set of strategies or just a few of them until the desirable behavior and results have been re-established. Hopefully with time, the person will make a lifestyle change that keeps the weight off. Continued measurement after the treatment phase has ended can ensure the obtained success continues.
• Clarify what a functional relationship is.
• Outline four major experimental designs used in behavior modification.

As we have discussed already, scientists seek to make causal statements about what they are studying. In the realm of behavior modification, we call this a functional relationship and one occurs when we can say a target behavior (DV) has changed due to the use of a procedure, treatment, or strategy (the IV) and this relationship has been replicated at least one other time.

To make a causal statement, we already know that an experimental procedure is required. Within behavior modification, these procedures take on several different forms. In discussing each, note that we will use the following notations:

A will represent the baseline phase and B will represent the treatment phase.

• A-B design – This is by far the most basic of all designs used in behavior modification and includes just one rotation from baseline to treatment phase and then from that we see if the behavior changed in the predicted manner. The issue with this design is that no functional relationship can be established since there is no replication. It is possible that the change occurred due to an unseen and unaccounted for factor, called an extraneous variable , and not due to the treatment that was used.
• A-B-A-B Reversal Design – In this design, the baseline and treatment phases are implemented twice. After the first treatment phase occurs, the individual(s) are taken back to baseline and then the treatment phase is implemented again. Replication is built into this design, allowing for a causal statement, but it may not be possible or ethical to take the person back to baseline after a treatment has been introduced. What if you developed a successful treatment to reduce self-injurious behavior in children or to increase feelings of self-worth? You would want to know if the decrease in this behavior or increase in the positive thoughts was due to your treatment and not extraneous behaviors, but can you really take the person back to baseline? Is it ethical to remove a treatment for something potentially harmful to the person? Now let’s say a teacher developed a new way to teach fractions to a fourth-grade class. Was it the educational paradigm or maybe additional help the child has received from his/her parents or a tutor? Well we need to take the child back to baseline and see if the strategy works again, but can we? How can the child forget what has been learned already? ABAB Reversal Designs work well at establishing functional relationships if you can take the person back to baseline but are problematic if you cannot. An example of them working well includes establishing a system to ensure your son does his chores, having success with it, and then taking it away. If the child stops doing chores and only restarts when the system is put back into place, then your system works.
• Multiple-baseline designs – This design has just what it sounds like, multiple baselines, but for one of three scenarios. In an across-subjects design there is a baseline and treatment phase for two or more subjects for the same target behavior. In an across-behaviors design , there is a baseline and treatment phase for two or more different behaviors the same participant makes. And finally, the across-settings design has a baseline and treatment phase for two or more settings in the same person for which the same behavior is measured.
• Changing-Criterion Design – In this design, the performance criteria changes as the subject achieves specific goals. So the individual may go from having to workout at the gym 2 days a week, to 3 days, then 4 days, and then finally 5 days. Once the goal of 2 days a week is met, the criterion changes to 3 days a week. It has an A-B design and rules out extraneous variables since the person continues meeting the changing criterion/new goals using the same treatment plan. Hence successfully moving from one goal to the next must be due to the strategies that were selected.

You will find that your final project in this class will use a changing-criterion design as you will formulate specific goals to achieve and then develop a plan to reach them.

Module Recap

  In Module 2, we dove deeper into what science is and how psychology is scientific in its pursuit of an understanding of behavior and mental processes. Our discussion started general, then worked down to specific details about applied behavior analysis and how behavior is measured, how functional relationships are established, and what experimental designs are used to test the validity of our hypotheses.

In Module 3, we discuss why we must be willing to change.

…………………………… STOP ……………………………

Throughout this book we will discuss the process of change. Though other books and authors may use a different framework, essentially, the process is the same. It’s similar to the scientific method. The steps can be condensed down or expanded upon, but the overall process is the same.

The process of behavior modification we will discuss throughout Modules 3 to 14 are as follows:

Overall Process for Behavior Modification

Planning for Change

• Identify Target Behavior – Module 2
• Pros and Cons Analysis with Self-Efficacy – Module 3
• State behavioral definition – Module 4
• Establish goals and criterion – Module 4
• Determine plan to record data – Module 5
• Conduct a baseline phase and functional assessment, to include an identification of temptations – Module 5
• Identify strategies – Modules 6-9 for an overview of the strategies and Module 10 for strategy selection
• State plan rules, identify potential mistakes, and develop a behavioral contract – Module 11

Implementation and Behavior Change

• Implement the plan and collect data as you go – Treatment phase – Module 12
• Re-evaluate the plan and see if it is working. Make adjustments as needed – Module 13
• Once you have achieved your final goal move to maintenance phase. Engage in relapse prevention – Module 14

Without further ado, let’s begin to explore how to bring about positive behavioral change.

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Behavior Modification

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Behavior modification is a psychotherapeutic intervention primarily used to eliminate or reduce maladaptive behavior in children or adults. While some therapies focus on changing thought processes that can affect behavior, for example, cognitive behavioral therapy, behavior modification focuses on changing specific behaviors with little consideration of a person’s thoughts or feelings. The progress and outcome of the intervention can be measured and evaluated. Functional analysis of the antecedents and consequences of the problem behavior(s) must be identified. This leads to the creation of specific target behaviors that will become the focus of change. Then, certain variables can be manipulated via reinforcers and punishments to change problem behavior(s). The goal is to eliminate or reduce maladaptive behavior.

Behavior modification is a type of behavior therapy. B. F. Skinner demonstrated that behavior could be shaped through reinforcement and/or punishment. Skinner noted that a reinforcer is a consequence that increases the likelihood of behavior to recur, while punishment is a consequence that decreases the chance. Positive and negative are used in mathematical terms. Positive indicates that something is added, and negative indicates something is subtracted or taken away. Thus, positive reinforcement occurs when a behavior is encouraged by rewards. If a child enjoys candy and cleaning the room is the desired behavior, the candy is a positive reinforcer (reward) because it is something that is given or added when the behavior occurs. This makes the behavior more likely to recur. Negative reinforcement is removing a stimulus as the consequence of behavior but results in a positive outcome for the individual. For example, a fine is dropped, and a person no longer has to go to jail. The removal of the negative stimulus (the fine) results in a positive outcome for the individual, no jail time.

Conversely, positive punishment is the addition of an adverse consequence. For example, a child gets spanked when he crosses the street without holding his mother’s hand. He then no longer crosses the street alone. Spanking is positive punishment because it is a consequence added to the situation that decreases the likelihood of the child crossing the street alone. Negative punishment is taking away favorable consequences to reduce unwanted behavior. For example, if Emily doesn’t finish her homework on time, her cell phone gets taken away. She makes it a priority to finish her homework immediately after school before she does anything else. Removal of the cell phone would be a “negative” because it takes something away, decreasing the chance that she won’t finish her homework the next time.

Reinforcement and punishment both work independently, as well as together, as part of a behavior plan. Positive reinforcement works exceedingly better and faster than punishment. In child psychiatry, parents often come to the office angry and frustrated with their child because “nothing works.” They have tried multiple types of punishments when bad behavior has occurred using the removal of toys or privileges away or placing a child in time out. Often positive types are not being reinforced. One immediate benefit of behavior modification plans is the shift away from solely punishing unwanted behavior to also rewarding good behavior.

(Table 1, Scott and Cogburn, 2017)

In table 1, note that punishment and reinforcement have nothing to do with good or bad behavior, only if it increases or decreases the likelihood of the behavior to recur.

There are several schedules of reinforcement that can impact behavior. When a behavior plan is initially set up, continuous two is used to establish and reinforce the behavior. Once the behavior has been established, continuous reinforcement can change to intermittent reinforcement which is termed thinning . There are four types of intermittent reinforcement. They are:

Fixed interval where the person is reinforced by a set number of responses

Variable interval where the person is reinforced by a variable number of responses

Fixed ratio where the person is reinforced after a certain number of responses

Variable ratio where the person is reinforced after a variable number of responses. Variable ratio intermittent reinforcement is the most effective schedule to reinforce a behavior.

Fixed interval: rewarding a person at the end of each day

Variable interval: rewarding a person sometimes at the end of the day, sometimes at the end of the week, sometimes every few days

Fixed ratio: rewarding a person after completing the desired behavior four times

Variable ratio: rewarding a person after completing the desired behavior after three times, then after six times, then after two times. Gambling is a real-world example of a variable ratio of reinforcement.

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Evaluating the effectiveness of behavior change techniques in health-related behavior: a scoping review of methods used

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Susan Michie, Robert West, Kate Sheals, Cristina A Godinho, Evaluating the effectiveness of behavior change techniques in health-related behavior: a scoping review of methods used, Translational Behavioral Medicine , Volume 8, Issue 2, April 2018, Pages 212–224, https://doi.org/10.1093/tbm/ibx019

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Behavior change interventions typically contain multiple potentially active components: behavior change techniques (BCTs). Identifying which specific BCTs or BCT combinations have the potential to be effective for a given behavior in a given context presents a major challenge. The aim of this study was to review the methods that have been used to identify effective BCTs for given behaviors in given contexts and evaluate their strengths and limitations. A scoping review was conducted of studies that had sought to identify effective BCTs. Articles referring to “behavio(u)r change technique(s)” in the abstract/text were located, and ones that involved identification of effective BCTs were selected. The methods reported were coded. The methods were analyzed in general terms using “PASS” criteria: Practicability (facility to apply the method appropriately), Applicability (facility to generalize from findings to contexts and populations of interest), Sensitivity (facility to identify effective BCTs), and Specificity (facility to rule out ineffective BCTs). A sample of 10% of the studies reviewed was then evaluated using these criteria to assess how far the strengths and limitations identified in principle were borne out in practice. One hundred and thirty-five studies were identified. The methods used in those studies were experimental manipulation of BCTs, observational studies comparing outcomes in the presence or absence of BCTs, meta-analyses of BCT comparisons, meta-regressions evaluating effect sizes with and without specific BCTs, reviews of BCTs found in effective interventions, and meta-classification and regression trees. The limitations of each method meant that only weak conclusions could be drawn regarding the effectiveness of specific BCTs or BCT combinations. Methods for identifying effective BCTs linked to target behavior and context all have important inherent limitations. A strategy needs to be developed that can systematically combine the strengths of the different methods and that can link these constructs in an ontology of behavior change interventions.

Practice: When deciding what combination of BCTs to use in an intervention, assessment of likely effectiveness needs to be based on integration of findings across different methods; until a formal method for doing this is developed, conclusions need to be subject to major qualifications.

Policy : When considering components to include in behavior change strategies, policymakers need to combine evidence from the full range of methods available and make conclusions subject to major caveats; given this uncertainty, monitoring outcomes and adjusting policies in the light of experience are crucial.

Research : There is an urgent need to develop formal methods for combining evidence from different types of evaluation to arrive at judgments concerning the likely effect sizes of BCT combinations tailored to target behavior and context; this could benefit from organizing evidence using an “ontology” of behavior change interventions.

The primary practical purpose of research into behavior change is the development of interventions that will be effective, subject to other constraints such as affordability [ 1 , 2 ]. In doing so, one wants to be able to draw on research findings that identify behavior change techniques (BCTs) that, if enacted appropriately, are most likely to effect the desired change. This will depend not only on the behavioral outcome but also on the ways the BCTs are delivered and the context. This paper reviews the methods that researchers have used to identify relevant BCTs for use in behavior change interventions and analyses their strengths and limitations specifically for this purpose.

When characterizing the potentially active ingredients of a behavior change intervention, a distinction can be made between the “content” of interventions (their putative active components) and the way in which they are delivered. Content can be characterized in terms of BCTs [ 3–7 ], defined as the smallest identifiable components that in themselves have the potential to change behavior [ 8 ]. BCT taxonomies have been developed that provide a standardized method of classifying intervention content [ 9 ]. In Michie et al.’s [ 3 , 9 ] taxonomy of BCTs, 93 BCTs, in 16 groupings, were distinguished addressing the different potentially important targets of capability, opportunity, and/or motivation [ 1 , 2 ]. A key task in behavioral science can be seen as understanding the extent to which BCTs contribute to the effectiveness of interventions of which they form a part.

In health care, behavior change interventions are aimed at a range of behavioral outcomes: preventing and stopping people engaging in harmful or risky behaviors (e.g., smoking), promoting engagement with health protective behaviors (e.g., exercising or engaging with cancer screening programs), switching from more harmful to less harmful forms of a behavior (e.g., reducing excessive drinking or excessive speed while driving), promoting effective use of health care interventions (e.g., improving medication adherence), and promoting effective self-management of diseases (e.g., monitoring blood glucose concentrations). Interventions aimed at changing health professional behaviors can involve the following: ensuring that those working in health care follow evidence-based guidelines (e.g., in reducing antibiotic prescribing, improving hand hygiene) or improving the way that they follow procedures (e.g., when administering drugs or making diagnoses). In all of these cases, the theory and practice of behavior change can be improved by conducting interventions and assessing their effects. Specifying the content of behavior change interventions in terms of BCTs enables the identification of potentially effective components within complex interventions, both in primary research (e.g., [ 10–12 ]) and in evidence syntheses in systematic literature reviews (e.g., [ 13–16 ]).

Factors that complicate the process of identifying effective specific BCTs or BCT combinations include the following: (a) the effect of a single BCT may be very small, (b) many BCTs typically occur together in a given intervention, (c) BCTs may interact with each other to amplify or reduce effectiveness, (d) effectiveness of BCT depend on how they are delivered, (e) effectiveness may depend on specific features that are not captured by the BCT classification being used, and (f) all the preceding may vary across context (population and setting). Complicating matters further, methods of identifying effective BCTs that involve synthesizing findings across studies depend critically on accurate and complete descriptions of interventions, the target populations and settings, and use of comparable behavioral outcomes.

Despite this, there is evidence that the task is tractable. For example, it has been possible to identify BCTs involved in behavioral support for smoking cessation that have been associated with higher success rates of local stop smoking services in England [ 17 ]. This has formed the basis for guidance on service provision and learning objectives in training courses, and the use of this guidance and training has been found to be associated with increased success rates [ 18 ]. Progress in behavioral science and its application depends on the success of this kind of exercise. Without it, we cannot build generalizable knowledge or create new interventions that have a high likelihood of success. There have also been developments in linking the key constructs of behavior change interventions (BCTs, their mode of delivery, mechanisms of action, target behavior and context) into what is known as an ontology of behavior change interventions [ 19 ]. Linking constructs into one knowledge structure recognizes that BCTs may be differentially effective according to their mode of delivery, type of target behavior and context.

An informal assessment of the research literature shows that methods that are used to establish effectiveness of complete behavior change interventions are also often used to identify effective BCTs. In terms of primary studies, these include randomized controlled trials (RCTs) and comparative observational studies. In terms of evidence synthesis, they include meta-analyses. Other methods are also used such as meta-regressions. How far these methods can be successfully applied to identifying effective BCTs is not clear, however. We set out to establish what methods had been used and to analyze their strengths and limitations. The task is different from that of identifying effective interventions for the reasons given above. The task is essentially an identification problem in a complex environment with limited resources. We can therefore draw on concepts from signal detection theory [ 20 ] and applied research methodology [ 21 ] for criteria to use in evaluating the methods. We propose that these can be distilled to what may be termed the “PASS” criteria:

1 Practicability: How well can the method achieve the desired objectives within available time and resource constraints?

2. Applicability: How well does the method allow generalization to populations and settings of interest?

3. Sensitivity: How well suited is the method to picking up potentially effective BCTs for a given behavior and context if these are present?

4. Specificity: How well does the method identify BCTs that will not be effective for a given behavior and context?

This paper aimed to review methods used to identify effective BCTs or BCT combinations and analyze their strengths and limitations according to the above criteria.

Identification of articles

We searched the electronic databases Web of Science, PubMed, and PsycInfo using the search term <behavio*r change technique*> up to end of February 2015. Titles and abstracts were screened, and articles were selected for full-text analysis if they were written in English and contained a quantitative evaluation of the effectiveness of individual BCTs or specific BCT combinations within interventions aimed at changing health behavior. The process involved initial screening by K.S. and C.G., following which articles were identified and selected in consultation with S.M. and R.W. See Fig. 1 for a flowchart showing the process of study identification. The goal was not to find every BCT evaluation that had been conducted but to have reasonable confidence that the different methods used had been canvassed and to have a general indication as to their relative frequency of use.

Flow chart for identification of studies

Coding of methods for identifying effective BCTs

An initial coding frame was developed, informed by the BCT evaluation methods identified in the literature reviewed by the UK’s National Institute for Health and Social Care Excellence (NICE) in developing its guidance on behavior change [ 22 ]. Evaluation methods coded were as follows: experimental manipulation of BCTs including RCTs, observational studies comparing interventions with or without targeted BCTs, meta-analyses of comparisons of BCTs, meta-regressions assessing relative effect sizes of interventions with or without specific BCTs, and characterizing effective interventions in terms of their BCTs. An additional category was identified and added during the course of the current review: meta-classification and regression trees (CART). Studies were each assigned to one evaluation method category by K.S. and C.G. in consultation with S.M. and R.W.

Analysis of the strengths and limitations of the methods

The authors first engaged in a process of identifying in broad terms the strengths and limitations of the methods found in the review, specifically for the task of identifying potentially effective BCTs for particular behaviors in particular contexts, using the PASS criteria set out earlier. The process of analyzing strengths and limitations of the methods involved complex judgments, combining a range of factors. The PASS criteria were designed to provide a framework for judgments about strengths and limitations, but a degree of subjectivity was unavoidable. A 10% of the studies were selected for detailed analysis to assess how far these strengths and limitations were manifest in that study. Each study was given a rating on sensitivity, specificity, and applicability from 1 to 3 by a researcher (HKU) in terms of how satisfactory the method had proved (1 = unsatisfactory, 2 = marginally satisfactory, 3 = satisfactory). The study was also rated from 1 to 3 in terms of practicability of replication bearing in mind the time and resources required (1 = impracticable, 2 = marginally practicable, 3 = practicable). The results were checked by R.W., and minor modifications were made.

Evaluation methods used

Of the 913 studies identified by our search, 135 met our inclusion criteria, reported in 140 articles. Of the excluded studies, 136 were irrelevant to the topic of this review, and 642 were relevant to behavior change but did not include an assessment of the effectiveness of BCTs. The latter included 24 review articles that had used a taxonomy of BCTs to code intervention content regardless of effectiveness and 37 study protocols or intervention development articles.

Table 1 shows the methods found in the review to investigate effectiveness and the number of studies that used each method. References to studies categorized as using each method can be found in the online Supplementary Material. As might be expected, the most commonly used method was the use of individual empirical studies. However, studies characterizing what had been found to be effective interventions in terms of their component BCTs, meta-analyses, and meta-regressions were also common. Comparative observational studies were rare and only one example was found of use of meta-CART.

Methods used to evaluate effectiveness of behavior change techniques (BCTs)

BCTs behavior change techniques; RCTs randomized controlled trials; P Practicability; A Applicability; Se Sensitivity; Sp Specificity.

Strengths and limitations of evaluation methods used

Table 1 summarizes an analysis of strengths and limitations of the different methods using the steps described above.

Individual experimental studies can provide the strongest indication of causal relationship between specific BCTs or BCT combinations and effect sizes in a given set of circumstances, at least when there are no biasing factors such as loss to follow-up. However, this approach has major limitations. It is not feasible when comparing large numbers of individual BCTs or their combinations. Expected effect sizes of individual BCTs are usually small, so large sample sizes are required for adequate power and, even with factorial or fractionated factorial designs, the resources needed to undertake such experiments are typically prohibitive [ 23 , 24 ]. Generalization beyond the specific circumstance is likely to be limited. Effectiveness is influenced by implementation fidelity, which is often low [ 25 , 26 ]. Ethical and practical considerations often preclude random allocation of participants to experimental and comparison conditions [ 25 , 27 ].

By examining naturally occurring covariation, comparative observational studies avoid many of the problems with experimental studies, such as ethical and practical constraints in randomly allocating participants to conditions. Because they do not involve setting up interventions, but rather record inputs, processes and outcomes for interventions that are already in existence are typically much less expensive to run. Where there is naturally occurring variation within very large regional or national programs, they can involve large number of participants and thus have power to detect small effect sizes [ 17 , 28 ]. They typically involve interventions that are being delivered in the real world where fidelity is likely to be lower than in experimental studies. Their key limitation is in the confidence with which effects can be ascribed to BCTs. This can be addressed to some degree by statistical adjustment for potential confounding variables and establishing that factors that determine application of different BCTs to different members of the target group are not likely to be confounded with outcome. In addition, the quality of data is often lower than in experimental studies, with large amounts of missing data and measures that are poorly applied [ 29 ]. This can add both to random error and bias.

Meta-analyses of experimental studies can provide generalizable conclusions with a high degree of confidence in causal inference but are limited by all the factors that limit the studies that contribute to them and several others in addition [ 30 , 31 ]. Firstly, the approach is limited by the viability of assumptions underpinning the aggregation of data from those studies. For example, if a category of target behavior is chosen that is heterogeneous with regard to effectiveness of BCTs, it will produce misleading results. Equally important, a given category of BCT may be implemented very differently in one study versus another. Secondly, the approach is limited by the quality of the studies contributing to the meta-analyses and the difficulties in taking account of variations in methodological quality. The common approach of assigning a quality score and weighting studies accordingly can fail to remedy this because specific deficiencies can fatally undermine a study while only reducing its score by a certain amount. Thirdly, the approach is limited by the small number of relevant experimental studies [ 32 ].

Meta-regressions allow pooling of data from experimental studies to draw conclusions about associations between BCTs included in interventions and effect size. Their main strength is in the ability to aggregate data over many different studies to find patterns of association [ 16 , 33 ]. A major limitation is that when comparing effect sizes across studies, one is moving from an experimental to a correlational design. This means that there may be unmeasured confounding that accounts for associations observed (such as variations in combinations of BCTs, mode of delivery, population and setting) [ 34 ]. Another important limitation is that meta-regressions are reliant on descriptions of the key variables. Yet, there is good evidence that published descriptions of intervention and control conditions are very incomplete [ 34 , 35 ]. A third limitation is that one requires a large number of studies and sufficient variation among the studies in terms of intervention components and effect sizes in order to have a chance of detecting relevant associations [ 36 ]. When it comes to assessing the effect of combinations of BCTs, it is imperative to identify in advance what combinations would be expected to yield what effects. This requires use of sound theoretical principles to avoid arriving at misleading conclusions [ 14 , 37 ]. The most commonly used evaluation method is to identify BCTs present in interventions found to be effective in RCTs. This has the merit of providing a basis for developing intervention manuals or prescriptions in the future, where the intervention package can be assumed to yield an effect similar to what has been achieved in RCTs. However, it also runs the risk of including BCTs that do not add to effectiveness but happen to be included in effective interventions. A second limitation is that it does not permit relative effectiveness of BCTs to be assessed. Thirdly, it does not provide a basis for evaluating different BCT combinations.

Meta-CART has the potential to evaluate circumstance-sensitive effectiveness of BCTs and BCT combinations [ 38 ]. It uses what is essentially a correlational design similar to meta-regression but searches for regressions in particular substrata of the data set of interest, recognizing that some BCTs or BCT combinations may be effective in some circumstances but not in others. The obvious strength of this approach is that it allows for heterogeneity of BCT effectiveness. The major limitation is that it requires very large samples and many studies varying in important ways to be able to detect these effects reliably. It will be very rare that there are sufficient studies for associations to meet standard criteria of statistical significance.

Characterizing interventions found to be effective in terms of their BCTs have the key advantage that it is likely to include BCTs that have the potential to be effective but suffers from the key limitation that it may also include large numbers of BCTs that do not contribute to effectiveness but are frequently included in intervention packages.

A sample of 10% ( n = 13) of the studies was evaluated using the PASS criteria. Table 2 is an example that shows the PASS analysis results of the studies evaluated in the review. It is important to note that the ratings were not judgments of the quality of the studies but of the extent to which the studies would allow confident conclusions about the effectiveness or otherwise of specific BCTs or BCT combinations. This analysis produced results that were consistent with the more general analysis of the strengths and limitations of the different methods. Only weak conclusions about BCT effectiveness could be drawn from the studies.

PASS analysis of 13 studies in the review

Exp Experimental study; Obs Comparative observational study; Meta-an Meta-analysis; Meta-reg Meta-regression; Desc Description of intervention content of effective interventions in RCTs.

BCTs behavior change techniques; P Practicability; A Applicability; Se Sensitivity; Sp Specificity.

In this scoping review, the most commonly used method was to assess the effectiveness of specific BCTs or BCT combinations in experimental studies. Reviews that characterized the content of effective interventions in terms of their BCTs were also quite common. Analysis of the potential of different methods to identify effective BCTs relevant to specific behaviors and contexts suggested that all had important limitations. This was borne out by applying the criteria of practicability, applicability, sensitivity, and specificity to a sample of the studies in the review.

Since none of the methods adopted appear to be able, in themselves, to provide a high degree of confidence on BCT effectiveness applied to particular behaviors and contexts, the question arises as how to arrive at an appropriate level of confidence making use of all the evidence available. A method for doing this should enable a statement of the following kind: “In (an intervention type, including mode of delivery and specific implementation) for (target population and setting) seeking to achieve (behavioral objective), there is (x degree of confidence) that inclusion of (BCT or BCT combination) will increase (a measure of intervention outcome) by (amount) compared with (not including it/including another BCT or BCT combination).” An example would be as follows: “In an interactive website for UK smokers making a quit attempt, there is 95% confidence that rewarding users’ claims of abstinence from smoking with praise will increase 12-month continuous abstinence rates by at least 0.1% compared with not doing so.”

The confidence rating at the heart of these kinds of statements is a subjective confidence arrived at from statistical analyses coupled with judgments based on inference. It is apparent from the findings of this review that judgment will always be required, both for evaluating study quality and for evaluating relevance. Therefore, direct transposition of statistical confidence intervals around effect sizes in studies will never be sufficient. An example of this is that more than 100 high-quality RCTs find that nicotine replacement therapy increases 6-month continuous abstinence rates in smokers making a quit attempts by 60% compared with placebo, with the 95% confidence interval of the meta-analysis ranging from 50% to 70% [ 39 ]. However, comparative observational studies find no benefit when smokers use nicotine replacement therapy bought from a pharmacy or general store as opposed to obtaining it from a health professional [ 40 ]. Generalization beyond study populations and settings is always required and, therefore, so is judgment.

Given the findings of this review, the question arises as to how to combine evidence most efficiently to arrive at appropriate levels of subjective confidence for the particular behavior, mode, population and setting. As a starting point for this, the following sequence may be considered when assessing the effectiveness of specific BCTs in a given context for a given behavioral outcome:

1 Search for all studies that have used the BCT or BCT combination concerned for the type of behavior of interest, including the full range of methods identified in this review

(a) record the effect sizes and confidence intervals where these are available

(b) record the specific outcome measures, features of delivery, target populations and settings.

(c) record all available evidence on implementation of the BCT/BCT combination, including the specific way it is implemented and any measures of fidelity

(d) record information that is relevant to a judgment of bias, including conflict of interest statements of authors and study selection or publication bias

3. Starting with the most comprehensively relevant study (e.g., a review where all the features are closest to the specific behavior, mode, population and setting at issue), form a subjective judgment as to the range within which the effect size is likely to lie with what would be considered an acceptable level of subjective confidence (e.g., 95%), taking into account the need to generalize.

4. Then, iteratively update that range with successive studies, weighting each study according to relevance and confidence in its findings.

In essence, this approach follows Bayesian principles of establishing an initial level of confidence in a hypothesis and then updating this incrementally with new information [ 41 ]. The extent to which the new information changes the subjective confidence depends on the strength of evidence and its relevance. Strength of evidence will depend on aspects of study design, execution, and reporting. Relevance will depend on how closely the BCT/BCT combination, behavioral outcome, features of delivery, population studied, and setting match those to which one wishes to generalize. Formal methods of arriving at and updating subjective confidence have been used in other areas of policy making [ 42 ], and it could be useful to examine how far they could be applied here.

The process being proposed should be considered as ongoing, and it is worth considering how to manage it. The current system of scientific reporting is not well suited to this process since it treats studies in isolation. Even systematic reviews are treated as isolated studies rather than as a process of knowledge accumulation. Scientific papers are currently written as semi-structured narratives relating to a set of research questions. The absence of a coherent, systematic structure linking the studies together creates a dislocation between studies that impedes the efficient accumulation of evidence. Moreover, even with reporting standards such as CONSORT [ 43 ] and TIDieR [ 44 ], there remain crucial pieces of information that are typically not reported or are reported in a way that does not permit the information to be used in the knowledge accumulation process. The upcoming CONSORT extension on psychological and social interventions [ 45 ] will mitigate this problem, but there will still be important gaps. One important piece of information is the extent to which BCTs are delivered as planned, in terms of both extent and quality. We know from studies investigating behavioral support for smoking cessation and physical activity that fidelity of delivery of BCTs can be poor with often fewer than 50% of BCTs in intervention protocols delivered in practice [ 46–49 ]. This is compounded by the problem of selective reporting of intervention protocols in published reports with an analysis of studies synthesized in Cochrane reviews of behavioral support for smoking cessation finding that fewer than 50% of protocol-specified BCTs were reported in the published article [ 50 ]. Thus, one can see that there is a possibility that a different set of BCTs may be delivered in practice than are reported in the published article, with devastating consequences for the reliability of evidence syntheses (for a broader discussion of these issues, please see a discussion in Health Psychology Review, e.g [ 51–53 ].).

In terms of quality of BCTs delivered, BCTs may be delivered wholly or in part. This has been acknowledged in the coding scheme developed by Michie et al. in which BCTs were coded ‘++’ if the BCT was judged to be present beyond all reasonable doubt, with clear evidence available and ‘+’ if they were present in all probability but the evidence was not clear [ 9 ]. This distinction has been observed both in coding written materials (e.g., intervention protocols and manuals and published reports) and in recorded intervention sessions (e.g., audiotape recordings). An example of the latter is the quality of delivering “goal setting” in behavioral support for smoking cessation [ 54 ]. Analysis of session transcripts showed a large variation in how advisers enacted the protocol concerning setting a quit date, from which a reliable 10-item scale of the quality of delivery of this BCT was developed. Applying this to 85 transcribed behavioral support sessions found that higher quality goal setting increased reported quit attempts ( p < .001; OR = 2.60, 95% CI: 1.54 – 4.40) and that the scale components “set a clear quit date” (χ 2 (2, N = 85) = 22.3, p < .001) and “within an appropriate timeframe” (χ 2 (2, N = 85) = 15.5, p < .001) were independently associated with quit attempts. Although this method has been applied for only one of the 93 BCTs, it demonstrates the utility of pursuing this line of research.

To more fully understand the association between the effects of BCTs on behavior, it is necessary to codify knowledge about other aspects of behavior change interventions and include this in analyses of BCT effectiveness. One approach to the process of accumulating knowledge in this area is to construct an “ontology.” Ontologies are sets of elements or constructs and relationships between them which codify our collective knowledge, reflect consensus on concepts, terms, relationships, and specify and formalize them. Such relationships can be anything from semantic to causal. In the case of making judgments about effectiveness of BCTs/BCT combinations, each new piece of information could update an ontology expressing confidence about effect size for specified behavioral targets when implemented in specified ways, using particular modes of delivery to given target populations in defined settings. Such a “behavior change ontology” could also link BCTs to a set of mechanisms of action and a set of theories [ 55 ].

We have begun the work of extending the BCT taxonomy to build a more elaborated “Behavior Change Intervention Ontology.” This is a conceptual structure for systematically representing, sorting and linking the “elements” of behavior change interventions, that is, the content, features of delivery, target behavior, setting, and mechanism of action with effect sizes. It brings these pieces together into a framework that can encourage commonality of conceptualization and terminology across the scientific community and guide the generation, access, and application of evidence to answer the question “What works, how well, for whom, in what settings, for what behaviors, and why?”

We show the top level of such an ontology, specifying key elements and their relationships in Fig. 2 [ 56 ]. It should be noted that this ontology has been developed as a method for organizing evidence about behavior change interventions rather than as a representation of behavior in context in real time. For this purpose, additional parameters and feedback loops would need to be added to represent the temporal dimension. The Human Behavior Change project ( www.humanbehaviourchange.org ), a 4-year collaboration between behavioral, computer, and information scientists, is building the Behavior Change Intervention Ontology building on current work by Michie et al. [ 57 ]. Intervention content has been specified in terms of 93 BCTs within 16 groupings [ 3 , 9 ]. A taxonomy of modes of delivery has been developed with 39 items at 4 levels; it is currently undergoing expert validation. A simple classification of mechanisms of action drawn from theory has been developed in a multidisciplinary consensus exercise to give an integrative framework of 14 domains of theoretical constructs, the Theoretical Domains Framework [ 58 , 59 ]. A much more ambitious project is currently underway to organize the >1,700 theoretical constructs from 83 theories identified in a multidisciplinary literature review of behavior change theories [ 60 , 61 ]. These theories had a mean of 21 constructs, ranging from 5 to 84, with many being the same as or similar to those in other theories. The task of defining these constructs, and the relationships between them, within and across theories, is in progress. The current structure of types of mechanisms of action across theories has 3 levels of hierarchy within 14 domains [ 56 ]. Within theories, we have identified 14 possible relationships between constructs; these have been converted into diagrammatic specification, which is machine readable, and we are working with computer scientists to investigate extracting from these data one or more “canonical” theories to encapsulate the overlaps across the 83 theories.

Ontology of behavior change interventions[ 64 ]

Note: The diagram represents how features of an intervention (its content and the way that the content is delivered) interact with context (the features of the target population and the setting) and features of the target behavior and its measurement to produce a particular effect size. The above features are moderated and mediated by exposure and mechanisms of action, respectively.

The links between BCTs and frequently identified mechanisms of action are being investigated in a cross-disciplinary, international project funded by the UK’s Medical Research Council, described in a published protocol paper [ 62 ]. We are collaborating in a project, led by Kai Larsen, to develop a taxonomy of behaviors, which takes as a starting point the World Health Organization’s International Classification of Functioning [ 63 ].This is a mammoth undertaking, requiring expertise from both behavioral and computer sciences to build such an ontology to make sense of the vast and rapidly accelerating volume of published relevant literature. However, like an encyclopedia, it would have the considerable benefit of becoming useful almost immediately and gradually increasing in value as it grew. By linking with machine learning, it has the potential to efficiently and effectively harness evidence in real time, support the rapid testing and refinement of theories, and make evidence useable and useful to researchers, practitioners, and policymakers. The Human Behavior Change Project will develop shared concepts, terms, and relationships between those concepts to precisely specify not just the content of behavioral interventions (BCTs) but all the mediators and moderators that will allow us to understand their effects on behaviors, specified at different levels of granularity. In this way, it will revolutionize our ability to synthesize evidence about behavior change in real time and to generate new insights about behavior change. It will include a searchable, up-to-date database of evidence that will allow people to design and implement the best possible behavioral intervention for their circumstances.

To take us back to the focus of this paper, we can conclude that research evaluating the effectiveness of BCTs/BCT combinations uses a range of experimental and observational methods, each with strengths and limitations. Making judgments of the effectiveness of a BCT/BCT combination for a given behavior, delivered in a particular way, to a given target population in a given setting requires synthesis of information from diverse sources to arrive at a subjective confidence estimate. A process for achieving this is proposed together with a paradigm shift in the way research in this area is conducted, reported, and synthesized. This is ambitious, but given the importance of behavior change to the welfare of the world’s population, it is worth putting considerable resources into achieving it.

Supplementary material is available at Translational Behavioral Medicine online.

We would like to thank Dr. Harveen Kaur Ubhi for coding a subset of the review papers in terms of the “PASS” criteria and helping with the revised manuscript preparation. We would also like to thank the Medical Research Council for funding the project, which gave rise to this paper: “Methods for strengthening evaluation and implementation: specifying components of behavior change interventions” (GO901474).

Conflict of Interest Robert West has received consultancy fees from Pfizer, GSK and J&J who manufacture smoking cessation medications. Susan Michie, Kate Sheals and Cristina Godinho declare that they have no conflict of interest.

Primary Data This manuscript was prepared in accordance with the instructions for authors contributing to Translational Behavioral Medicine and has been read and approved by all authors, who are aware of this submission. The authors have full control of all primary data and agree to allow the journal to review the data if requested. Moreover, we would like to underscore that neither the present manuscript nor the data it contains is being considered for publication elsewhere, nor has it been previously published in its entirety or partially.

Ethical Approval The study described in this article did not involve human participants. Moreover, all procedures performed in this study were in accordance with the ethical standards of the institutional research committee and with the 1964 Helsinki declaration and its later amendments. This article does not contain any studies with animals performed by any of the authors.

Ethical responsibilities of authors: All authors have approved the final manuscript and agree with its submission to Translational Behavioural Medicine. All authors have contributed to the scientific work and are responsible and accountable for the results. We confirm that this manuscript has not been previously published (partly or in full) and that the manuscript is not being simultaneously submitted elsewhere. We confirm that the data have not been previously reported elsewhere and that no data have been fabricated or manipulated to support our conclusions. No data, text or theories by others are presented as if they were the authors’ own. The authors have full control of all data, which are accessible upon request.

Informed Consent For this type of study—a review paper—formal consent is not required.

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International Handbook of Behavior Modification and Therapy pp 151–173 Cite as

Experimental Design in Group Outcome Research

• Billy A. Barrios 4  

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Behavior modification research has been and continues to be the search for the answer to the question, “What treatment, by whom, is most effective for this individual with that specific problem, under which2019set of circumstances?” (Paul, 1967, p. 111). It is a question within which numerous questions are embedded; thus, the search is not for one answer but for numerous answers. And the search is a continuous process in which the answering of a specific question alters the nature of said question and all subsequent questions; consequently, the answering of a question is never precise but always provisional.

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Barrios, B.A. (1990). Experimental Design in Group Outcome Research. In: Bellack, A.S., Hersen, M., Kazdin, A.E. (eds) International Handbook of Behavior Modification and Therapy. Springer, Boston, MA. https://doi.org/10.1007/978-1-4613-0523-1_8

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Habit Formation

Understanding what makes behavior modification work, some ideas to keep in mind for maximizing the effectiveness of behavioral plans..

Posted October 2, 2018 | Reviewed by Jessica Schrader

Many people who seek out services from psychotherapists or counselors have “ behavior modification ” included as part of their treatment. This could involve a behavioral plan for children (to help increase their use of more appropriate behaviors), schedule changes to help remove triggers for problem behaviors (like changing a morning routine to break a smoking habit), or self-rewards where a person gives themselves something positive when they engage in desired behaviors (for example, watching a mindless television show to reward exercising for an hour).

“Behavior modification,” also known as “behavior management ” and “behavior analysis,” all stems from the work of B.F. Skinner . He did most of this work on animals, particularly pigeons and rats, to study how behaviors are reinforced. There also was earlier work conducted by I. Pavlov, who did much of his work on dogs, who studied how different events get associated with certain behavioral responses. There are many other names associated with behavior modification but Skinner and Pavlov are the most famous.

Noting that the most famous work creating behavior modification was done on animals is important. Researchers on behavior modification determine that behaviors follow some basic rules regardless of whether it is human behavior or animal behavior .

Using animal behavioral research also shows that behavior modification is very scientific. Studying animal behavior allows for a more rigid scientific approach because animals can be studied for longer periods of time and can be studied under a number of different types of conditions. Animals also do not typically respond as strongly, or at all, to being observed as humans do. This takes away one problem for studying human behaviors, where just being watched can strongly impact what people do.

Behavior modification programs focus on changing an individual’s environment in ways that increase the likelihood that certain behaviors will occur. Therapists and counselors could be looking to increase a desired behavior or could be looking to decrease an undesired behavior. Regardless of the specific approaches being used, “behavior change” is always the goal.

These days, there are many professional journals that focus on behavior modification techniques. Two of the most famous are the Journal of Applied Behavior Analysis (JABA) and the Journal of the Experimental Analysis of Behavior (JEAB). JABA specializes in clinical applications of behavior modification while JEAB specializes in research on how behavior modification works in animals. They both provide very important information about the complexities of behaviors.

And when you’re dealing with behavior modification, it’s that complexity that is extremely important. Because it’s all more than just reinforcing behaviors so that they occur more often. There are a lot of different factors that enter into behavior modification and make behavioral programs effective.

One major factor that often gets missed with behavior modification is change. Behavioral programs are not supposed to remain the same. When you find one type of approach that works, you’re supposed to keep it in place for a little while, but then change the program. If you have one program that works but you just keep the same, it isn’t likely to stay effective.

Most often you see this with how reinforcers are presented. You might have a kid who responds to getting praise for using positive behaviors. And that might work for a while to help the kid keep using those behaviors. But if all the adults around the kid do is keep praising those behaviors the same way time after time, the reinforcers won’t work anymore. You will see a decrease in the reinforcer’s strength.

What is needed here are changes in how the reinforcement is presented over time. Typically you would go from reinforcing the target behavior every time it occurs to every few times it occurs. For example, instead of reinforcing the behavior every time, you might reinforce the behavior ever four times it occurs. This is called a “fixed ratio” schedule (the first one is called “FR-1” for “Fixed Ratio” every 1 time the behavior occurs, and the second one is called “FR-4” for “Fixed Ratio” every 4 times the behavior occurs).

Once you have an effective “Fixed Ratio” schedule, you would then switch to what is called a “Variable Ratio” schedule. This means that the reinforcement is still presented every four times (in the case of a “VR-4” or “Variable Ratio 4” schedule) on average, but here would be variability in when the reinforcement is presented. Ultimately, it would average every four times. VR schedules are considered the most effective for keeping a behavior in place over long periods of time.

What all this means is that behavior modification programs are supposed to change. Once a reinforcement has been effective, there should be a change to the timing of the reinforcement. Keeping a plan the same for long periods of time is one way of decreasing its effectiveness over time.

Another important complex part of behavior modification is choosing what reinforcement to use. There are many types of reinforcement, and not all of them will not work for everyone. Some of the most common types of reinforcement include food, attention , avoidance (i.e., being able to avoid something the person does not want to do), fun things, and money.

Too many times professionals working on behavior modification will use the same types of reinforcement for everyone. This is a good way of ensuring that the plans will not be effective for many people. Everyone responds differently to reinforcement; thus, each behavior modification plan should use different reinforcers.

If a behavior management plan is not working, one possible reason is that the type of reinforcement is not effective. Too many times I hear professionals, clients, and parents say that, “This plan isn’t working,” when it really is the type of reinforcement that is ineffective. Professionals developing plans need to be sure that the type of reinforcement works for the person involved.

It’s also important to keep in mind that the strength of a reinforcer is not typically based just on it occurring more often. There are many different factors that determine whether a reinforcer has any strength in terms of getting a behavior to occur more often. Behavior research involving pigeons, for example, has shown that certain stimuli may gain their strength from whether they signal that a reinforcement will occur, regardless of whether the reinforcement actually occurs (Zentall, Laude, Stagner & Smith, 2015). When applied to humans, this suggests that approaches may be stronger based on what an individual expects will happen, even if that expectation does not always happen.

Animal behavioral research also shows the impact different individuals can have on behaviors. Behavior modification can change considerably based on who is around the individual at the time. Recent articles like those by Browning & Shanan (2018) show the strong impact that different individuals can have on the effectiveness of behavioral approaches.

Where this comes into place on behavior modification for people is that behavioral approaches might work differently depending on who is with the person at the time. If, for example, you have a plan for a child, it is possible that the plan works better with one parent in the room than the other. This doesn’t mean that the one parent is “better” than the other parent, but it does mean that someone should be trying to figure out what that person does that the child responds better to. This could help everyone working with the child to act in similar ways when working with the child (and keep behavioral approaches consistent, a step that is very important in keeping them effective).

Based on the material I presented in this post, here are some things to keep in mind for helping behavior modification plans to be effective:

1. Behavioral plans should not stay the same. Once there is evidence that a plan is working, then it might need to be modified so that the reinforcement is occurring on a different schedule or in some other different way. This is what helps to keep plans effective over time. If a professional develops a plan that works, that professional should also look at whether the plan needs to be changed over time.

2. Not every type of reinforcer works for every individual. When developing a behavior management plan, the first step should be deciding what reinforcer is most likely to be effective. If a plan is not working for someone, then it may be that a different type of reinforcer is needed.

3. Consistency is very important for effective behavior modification plans. Individuals tend to respond better to approaches that they have come to expect will bring about certain outcomes (even if they do not actually bring about those outcomes all the time).

4. Different people will often have different impacts on a behavioral plan’s effectiveness. If a plan seems to work better with one particular individual, try to identify what that person is doing so everyone else can consider using similar approaches.

If you are a professional developing behavior management plans, these are some ideas to consider for keeping them effective. If you are working with a therapist or counselor on a behavior modification plan, these are some things you can review with them to see how these issues are being addressed.

Browning, K. O. and Shahan, T. A. (2018), Renewal of extinguished operant behavior following changes in social context. Journal of the Experimental Analysis of Behavior. doi:10.1002/jeab.472.

Zentall, T. R., Laude, J. R., Stagner, J. P., & Smith, A. P. (2015). Suboptimal choice by pigeons: Evidence that the value of the conditioned reinforcer rather than its frequency determines choice. The Psychological Record, 65(2), 223-229.

Dr. Daniel Marston is a psychologist and author of Comparative Psychology for Clinical Psychologists and Therapists . He focuses on applying comparative psychology research to clinical practice.

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Behavior Modification: Techniques for Positive Behavior Change

What are the best strategies for enacting change?

Cynthia Vinney, PhD is an expert in media psychology and a published scholar whose work has been published in peer-reviewed psychology journals.

Principles and Techniques of Behavior Modification

Applications of behavior modification, behavior modification in organizational settings, ethical considerations in behavior modification, limitations and criticisms of behavior modification.

Behavior modification uses various motivational techniques to eliminate behavior you don’t want to see or encourage behavior you do want to see. For example, you can use positive reinforcement, like praise, to encourage behavior you want. Alternatively, you can use negative reinforcement, like nagging, to eliminate behavior you don’t want.

Behavior modification is based on B.F. Skinner’s theory of “operant conditioning.” Skinner emphasized that the best way to understand an individual’s behavior is through the consequences of that behavior.

If the consequences of an action were favorable, the action would be repeated, while if the consequences were unfavorable, the action would not be repeated. This is the basis of behavior modification.

In the following, we’ll look at the principles and techniques of behavior modification, explore some examples of behavior modification, and look at the ethical considerations and criticisms of behavior modification.

Klaus Vedfelt / DigitalVision / Getty

Behavior modification relies on ways to develop, strengthen, maintain, stop, or modify a behavior, according to Tara M. Lally, PhD , Supervising Psychologist in the Department of Psychiatry at Ocean University Medical Center. At the center of this is a stimulus, reinforcement, and punishment.

Stimulus and stimulus control

A stimulus is a catalyst that encourages a specific type of behavior. A stimulus control is “behavior that occurs more often in the presence of a stimulus than in its absence,” Lally explains. “For example, drivers stop in the presence of stop signs and we all act differently around someone we have a crush on.”

Consequences

Consequences occur after a behavior. “A consequence can be positive or negative,” Lally says. “Positive consequences could include praise or a reward and… negative consequence[s] could include the loss of something such as free time or attention.” In behavior modification, consequences take two forms reinforcement and punishment.

Reinforcement

“Skinner noted that a reinforcer is a consequence that increases the likelihood of behavior to recur,” said Lally. Reinforcement can be either positive or negative:

• Positive reinforcement occurs when someone is encouraged to continue their behavior because they receive rewards. For instance, when a child completes their homework, they could be allowed extra time to play on their tablet.
• Negative reinforcement occurs when someone is encouraged to change their behavior because something unpleasant will be taken away. For example, when a teenager does their laundry to get their parents to stop nagging them.

Punishment can be positive or negative as well. Lally notes that “punishment is a consequence that decreases the chance” a behavior will recur:

• Positive punishment presents a negative consequence in order to decrease the likelihood of a negative behavior. One example is corporal punishment, including spanking, but this is an unproductive form of behavior modification as it can increase aggression and other problems. A better example is something like having a child who hurt their sibling do the siblings’ chores.
• Negative punishment takes away a positive consequence to decrease negative behavior. For instance, parents may take away a child’s cell phone when they break their curfew.

Extinction “is the gradual weakening and eventual disappearance of a learned behavior,” according to Lally. “For example, a child that [has] tantrums for candy while checking out of the [grocery] store will begin to stop this behavior when ignored and not met with reward.”

Consistency is key when applying reinforcement and punishment. When consequences happen whenever you behave a particular way, eventually the choice will either become habit in the case of a positive behavior or go extinct in the case of an undesired behavior, as long as the consequences are applied consistently.

Behavior modification has been applied across all ages and settings where behavior change is necessary. Here are some examples.

Behavior modification in children and adolescents

Children and adolescents have already been covered here. Some additional examples include taking a child out for ice cream after they finish a challenging school assignment (positive reinforcement) and taking away a child’s toy when they fail to clean their room ( negative punishment ).

Behavior modification in adults

Behavior modification in adults is similar to children, and can result in similarly dramatic behavior modifications. For instance, an adult could use positive punishment to prevent themselves from biting their fingernails by putting a bad-tasting nail polish on.

Alternatively, a court could use negative reinforcement by dropping a fine so a person no longer has to go to jail. The consequence is good because the person doesn't have to do the undesired behavior.

Adults can use behavior modification to exercise regularly, eat healthy, work more efficiently, and numerous other things that can be positively or negatively reinforced or punished.

Behavior modification in clinical settings

In clinical settings, treatment teams may use behavior modification to reinforce prosocial behavior. They can do this through positive reinforcement. For instance, a token economy uses tokens or points that have real value, such as stickers or coins, as rewards for positive behaviors.

Behavior modification in educational settings

Educational settings have been widely studied. To manage classroom behavior modification:

• Define the problem
• Figure out a way to change the behavior
• Determine an effective reinforcer
• Apply the reinforcer consistently to modify behavior

Reinforcement and punishment are both effective as reinforcers but, in the classroom, reinforcement is preferred in helping children develop better behaviors.

For example, in third grade, a teacher decided to stop Allen from tipping back his chair. Every time she looked over, he would get a tally mark as punishment if he was leaning back. But positive reinforcement , where Allen got a tally mark as a reward every time she looked over and all four legs of his chair were down, might have been better as it would reinforce the positive behavior.

In recent years a wide variety of organizational settings have used behavior modification and most have claimed positive results. In organizational settings, behavioral modification is used as a technique for managers to motivate employees.

For example, in a field study by Luthans and Kreitner, they trained the experimental group of supervisors in the techniques of behavior modification. The trained supervisors were asked to use what they’d learned with their employees, and after 10 weeks it was found that the experimental group had reduced the frequency of complaints, increased quality indicators, and declined in individual performance problems.

Also, the group’s labor effectiveness improved significantly. The control group, whose supervisors weren’t exposed to behavior modification techniques, showed none of these improvements.

While behavior modification has a lot of promise, there are numerous ethical considerations . The most important of these from the perspective of a therapist or counselor is informed consent . According to Lally, “behavior modification… should have clear informed consent with patient autonomy driving the behavior change.” This involves agreement between the therapist and the patient that a given behavior needs to change.

“If the individual does not want to change the behavior, they cannot be manipulated to do so,” explained Lally. “However, the rewards, punishments, and perceived benefits of this behavior engagement may shift to lessen the appeal of continued behavior.” In other words, it would be easy for an unethical therapist to manipulate the patient to change behavior.

In addition, some behavior modification can result in ethical questions, especially those involving punishment, which can result in harm or negative consequences for the individual.

Behavior modification also has several limitations and criticisms. Chief among them are critiques of behaviorism, particularly that behavior modification addresses outward behavior instead of underlying psychological issues. This can lead to problems that may be suppressed and then resurface later.

In addition, Lally observes that behavior modification does not always use intrinsic motivation to get its results. For example, when using token economies, people do things for external rewards, leading to questionable long-term effectiveness, because external rewards are less reinforcing than internal rewards.

Also, Lally points out that individuals and individual differences vary, so the same intervention may have an outsized effect on one person but practically no effect on someone else.

Based on the work of B.F. Skinner, behavior modification uses reinforcement and punishment as ways of encouraging or discouraging behavior. Many people of all different ages can have undesired behaviors and behavior modification techniques can be used to eliminate undesired behaviors and champion desired behaviors.

New Directions for Women. What is Behavior Modification Therapy? 2021.

Morin A. Behavior Modification Techniques . Verywell Family . 2021.

Stevens CJ. Behavior Modification: The 4 Main Components . Care . 2021.

Scott HK, Jain A, Cogburn M. Behavior Modification . In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2024 Jan.

Mather N, Goldstein S. Behavior Modification in the Classroom . LD Online . 2001

Black JS, Bright DS. Learning and Reinforcement . Organizational Behavior . OpenStax; 2019.

Luthans F, Kreitner R. Organizational Behavior Modification and Beyond . Scott, Foresman; 1985: 150-159.

Kaur D. The Harmful Effects of Behaviour Modification . Project Haans . 2023.

By Cynthia Vinney, PhD Cynthia Vinney, PhD is an expert in media psychology and a published scholar whose work has been published in peer-reviewed psychology journals.

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• v.58(1); 2018

Behaviour Therapy and Behaviour Modification Background and Development

This manuscript is part of a special issue to commemorate professor Paul Eelen, who passed away on August 21, 2016. Paul was a clinically oriented scientist, for whom learning principles (Pavlovian or operant) were more than salivary responses and lever presses. His expertise in learning psychology and his enthusiasm to translate this knowledge to clinical practice inspired many inside and outside academia. Several of his original writings were in the Dutch language. Instead of editing a special issue with contributions of colleagues and friends, we decided to translate a selection of his manuscripts to English to allow wide access to his original insights and opinions. Even though the manuscripts were written more than two decades ago, their content is surprisingly contemporary. This manuscript is a transcription of a lecture that was published in 1980. It was Paul Eelen’s first public presentation after a two-year study in the United States, which has inspired much of his later thinking. The text can be viewed as a manifesto for behaviour therapy as it was then advancing in Belgium and the Netherlands.

This presentation was given as the introduction to the L.A.P.P. seminar day held October 27, 1980, which was themed: Behaviour modification . The lecture was published as: Eelen, P. (1980). Gedragstherapie en gedragsmodificatie: Achtergronden. Leuvens Bulletin L. A. P. P., 39 , 1–19.

Krasner, one of the promoters of behaviour modification, published an eulogy in 1976 for its alleged death ( Krasner, 1976 ). If it was a true eulogy, this seminar, is a posthumous tribute. But this eulogy was – luckily – pronounced at a time when the body was not identified. So, it was not known who or what had been buried. This brings us to one of the fundamental features of behaviour therapy: It is a house with many rooms, and, probably, there was never a prevailing approach from the start. Of course, names such as Wolpe, Eysenck, Skinner, Bandura, etc. are intrinsically associated with behaviour therapy. But none of them can be considered ‘Godfather’. Moreover, all of them represented a diverging view: Anyone who has followed the pointed altercation between Wolpe and Bandura ( Wolpe, 1978 ), is probably surprised to hear that both are members of the American Association for Behavioural Therapy, and that both have had an enormous influence on the theory and practice of behaviour therapy and behaviour modification.

Before continuing the introduction to this seminar, it is useful to reflect on the distinction between behaviour therapy and behaviour modification. Both terms are often interchangeably used. Yet some distinguish between both terms, albeit not always for the same reasons. Behaviour therapy is sometimes considered a part of behaviour modification. The distinction is then based on a difference in population. Behaviour therapy involves the treatment of patients, as is the case in psychotherapy, whereas behaviour modification can also be used outside therapy. For other authors, the distinction can be traced back to a difference in theoretical foundation. Behaviour therapy is then relatively more informed by the Pavlovian learning paradigm, whereas behaviour modification is more associated with the operant learning paradigm, in particular the Skinnerian school of learning. This distinction probably makes sense because Skinner and his followers do have a unique methodology. Nevertheless, in this presentation both terms will be used synonymously as most handbooks do. Moreover, let us not forget that Skinner was one of the first to use the term ‘behaviour therapy’.

Evidently, an introduction to a theme necessitates selection. After a general contextualisation of behaviour therapy, I will limit myself to a few comments on the primary characteristics of this approach. It will not be possible to explore the various applications that have emerged from this approach, which vary from addressing pollution problems to the treatment of patients with psychosis. The practice of behaviour modification will only be briefly discussed. The afternoon sessions will offer ample time and space to explore these aspects.

Attempt to develop an acceptable definition or description

When behaviour therapy originated – some 25 years ago – its identity was formed by opposing the conventional psychotherapeutic practices, which were dominated by the psychoanalytic model. The breakthrough of behaviour therapy was undoubtedly fostered by the discomfort with the psycho-analytical paradigm: both in terms of its theoretic underpinnings and its clinical efficiency.

As regards clinical efficiency, Eysenck’s famous article in 1952 ‘ The effects of psychotherapy ’ was a clear blow below the belt. With data that were – at first glance – indisputable, he demonstrated that traditional psychotherapy – whatever it means – had null effects. To be more precise, he provided evidence that neurotic patients fare just as well with as without therapy. What is striking when rereading this article today, is its rather moderate tone (especially for someone like Eysenck). Still, in the eyes of Bergin ( 1971 ), this article marked the beginning of ‘two decades of vitriol’. Not surprisingly, it prompted a series of emotional reactions. Nobody likes to see evidence that what they do, has no effect. In 1966 – 14 years after his first article – Eysenck still backed the same conclusion. In the meantime, he had further fuelled the polemics by demonstrating that behaviour therapy did have effects. When Bergin wrote a paper on the ‘The evaluation of therapeutic outcomes’ in 1971, he had probably hoped that his paper would only be of historical importance, and would provide a glance from a distance on the polemics that Eysenck had created. At the same time, he demonstrated the complexity of outcome research –also using data. A similar conclusion was reached in behaviour therapy. The well elaborated book of Kazdin and Wilson ( 1978 ) is just one example. Nevertheless, Eysenck did not change his opinion. Only a year ago, he confirmed that nothing in the literature provided evidence to reject his null-hypothesis ( Eysenck, 1978 ). The polemic will probably never end, at least not for Eysenck. What is clear today is that the original triumphalism – “the behaviour therapy is the only truly effective and efficient form of therapy” – is only endorsed by few. It is, however, undoubtedly the case that treatment goals are more articulated in behaviour therapy. When the ‘outcome’ question is formulated in terms of the achievement of treatment goals, extensive literature reveals that behaviour therapy is not doing a bad job. However, it remains to be debated what treatment goals exactly are.

As regards the theoretical underpinnings, it was almost standard practice in this early phase to situate and define behaviour therapy by contrasting it with other approaches, with psycho-analysis first and foremost. Usually Eysenck’s schematic overview (1959) was used to shed light on the differences between both approaches, in which he advanced a pronounced preference for behaviour therapy. However, it is seldom asked what the heuristic value of such comparisons is. These comparisons lack any persuasive power. For me personally, they bring to mind the introductory works to philosophical schools, where for example, Hegel’s system is criticized in a few paragraphs leading one to conclude that Hegel was a ‘minor habens’. Freud once claimed that his theory could only be evaluated by those who were initiated in it. This, of course, provided extra ammunition to his opponents. But his statement probably contains some truth. Some behaviour therapists have used the same argument.

The almost dogmatic aversion to anything that might be associated with the conceptual framework of psychoanalysis manifested itself in many ways. For example, Dollard and Miller’s ( 1950 ) ‘Personality and Psychotherapy’ work, which was a monumental attempt at integrating learning psychology and psychoanalysis, never became popular. It was not taken seriously by psychoanalysts because it was almost an insult to extrapolate findings from rats to humans. Just imagine a rat with an Oedipus complex! It was equally inacceptable to behaviour therapists because it appeared too much as a translation of psychoanalytic concepts into learning terms, and because it had little to bear on psychotherapeutic practice. It mainly offered a new vocabulary but did not inspire novel intervention methods. Even more so than with Dollard & Miller, the aversion was exemplified in the depreciation for Masserman’s work ( 1943 ) on experimental neurosis in cats. His experiments directly inspired Wolpe ( Wolpe, 1958 ), whose experiments – by the way – were of a far lower standard in terms of methodology and data analyses. Unfortunately, Masserman had used a vocabulary that was strongly informed by psychoanalysis. His focus was on the notion of ‘conflict’, operationalised in terms of aversive stimulation contingently following approach behaviour for food. In his experiments, Wolpe wanted to demonstrate that so-called neurotic reaction patterns can develop independently from any conflict, but simply by confronting the animal with a series of aversive stimuli (i.e. electric shock). This proved to be the case. However, Wolpe merely demonstrated that conflict is not a necessary condition. Hence, this finding does not rule out the possibility that conflict is a sufficient condition for the establishment of so-called neurosis. It is striking that the notion of ‘conflict’ is again used in recent behaviour therapy literature. Finally, I give one last example to illustrate the anti-psychoanalytic reflex in this early period. In implosive therapy, introduced by Stampfl and Levis ( 1967 ), the patient is ‘bombarded’ with the core features of his fear. Stampfl was a psychiatrist with psychoanalytic training, and Levis had been a student of Spence. A ‘happy marriage’ at first sight ( Levis, 1970 ). Lewis searched and found a fairly adequate experimental paradigm, but his view was hardly noticed in behaviour therapy because it relied too strongly on Freudian concepts.

All these anti-reactions probably may have been justified in the beginning: Others had to be persuaded of one’s merits. But, by now, the contribution of behaviour therapy is sufficiently established. Behaviour therapy is now expected to define itself in positive terms (‘What it is’) rather than in negative terms (‘What it is not’). Wolpe ( 1976 ) believed that the following definition was correct: Behaviour therapy is the whole body of “treatment methods derived from experimentally established principles and paradigms of learning (and related principles)”. Those who do not concur with this view, Wolpe called ‘malcontent’. Kirsch ( 1977 ) considered this definition as too restrictive and too dogmatic. According to him, behaviour therapy can only be defined as that what is done by therapists who identify themselves as behaviour therapists. The question is whether Wolpe’s description is actually too restrictive and dogmatic. In my view, his definition was critically commented upon because of what was believed that Wolpe deeply thought than because of what he actually wrote. As it is, his verbatim description closely followed the one of the “American Association for Behavior Therapy”: “Behavior therapy involves primarily the application of principles derived from research in experimental and social psychology for the alleviation of human suffering and the enhancement of human functioning. Behavior therapy emphasizes a systematic evaluation of the effectiveness of these applications …” (Franks & Wilson, 1975, p. 2). Such definition can hardly be called restrictive or dogmatic. In fact, the reverse is true!

In 1969, Bandura already pleaded for the abandonment of the term ‘behaviour therapy’ because it was an “ill-defined partisan label” ( Bandura, 1969 ). Probably, some day brand names for interventions will become useless, but it is highly unlikely that this will happen in the near future: At present there is a proliferation of conceptual systems, each with their own ‘label’, and, sometimes, also with their own dogma’s. Hence, the need to delineate behavioural therapy as an approach which – in principle – aims to apply insights, findings and methods from experimental psychology. Evidently, one should keep in mind that such approach only offers partial insight into the complex phenomenon of one human being influencing another human being in some way (i.e. therapy).

A couple of general characteristics

In his “History of Behaviour Modification”, Kazdin ( 1978 ) identified four characteristics, which can be found more or less in most handbooks. I want to discuss these characteristics. The first characteristic will receive the most attention because it contains the core of the development as well as the current practice of behaviour therapy.

The assumption that abnormal or problem behaviour is learned

This statement, when formulated in such a general way, is not unique for behaviour therapy. The psychogenic nature of many disorders is and remains one of Freud’s fundamental contributions. What is characteristic for behaviour therapy then is that it puts normal behaviour at the same level as abnormal behaviour, and that it assumes that both are initiated or maintained via similar learning principles. When behaviour therapy started off, learning paradigms were used to define these learning principles. They offered an acceptable frame of reference to describe the antecedent and consequent factors that influence behaviour.

It has become common practice, almost a caricature of behaviour therapy, to underline that the wisdom and techniques of behaviour therapy stems from experiments with animals, in particular rats and pigeons. Noteworthy, it is not so much the extrapolation from humans to animals that elicits resistance and opposition. For example, ethological approaches to abnormal behaviour are accepted with much more generosity. Rather, the experimental nature and particular language of conditioning seem to be rejected. The simple word ‘conditioning’ is an aversive stimulus for many, in the same way as the term ‘cognition’ is for some behaviour therapists. To a large extent, confusion has been raised by not sufficiently making a distinction between the procedures for conditioning experiments, the effects of these procedures, and the theoretic assumptions proposed to explain these effects. For example, calling a phobic reaction a conditional or conditioned response assumes, at most, an analogy between both phenomena. Fundamentally, any explanation of both phenomena remains possible, but nevertheless this analogy has heuristic value. When it is established – as a fundamental law – that a conditioned response disappears as a result of presenting the conditional stimulus only, it suggests an action plan. In addition, it suggests a notion of extinction, which possibly explains this law. However, also extinction is the result of a procedure and not an explanatory mechanism. To put it frankly: The question of why Pavlov’s dog salivates upon hearing a bell announcing the food remains open. Evidently, several explanatory models have been put forward, but most have become obsolete even though they occasionally re-emerge in the literature. For Wolpe, for instance, learning psychology ended with Hull, but not everyone in behaviour therapy agrees with this position.

Nonetheless, learning paradigms continue to play an important role in the theory and practice of behaviour therapy. Therefore, it remains valuable to reflect on their importance. We will focus on two issues: (1) Which question underlies the procedures of these paradigms? (2) To what extent are they relevant for clinical practice?

1) The value and limitations of conditioning models is determined by how we appreciate the fundamental questions underlying the used procedures. Take the example of classical conditioning : Essentially, it concerns the question of the conditions under which an organism learns an association between two events. It is a historic coincidence that Pavlov used a physiological index for this type of learning. Any other index would equally do, as long as it is demonstrated that the behaviour change can be attributed to the induced relation between the two stimuli. The historic coincidence, however, has had far-reaching consequences for the way classical conditioning has been represented. The physiological response has become isolated from the full event, the event of an organism learning a new relationship. Fortunately, this is changing. I will briefly illustrate this. Jenkins, a leading experimentalist in the field, published last year a study with the simplest design imaginable: A large room in which a lamp announces the delivery of food to a dog who freely moves around that room ( Jenkins, et al. 1978 ). Careful observation of the dogs’ global behaviour was used as the dependent variable. Seventy years after Pavlov’s first findings, this experiment might at first sight prove that this field repeats itself in an almost ridiculous way. Upon scrutiny, however, this experiment shows that we still know very little about what is actually happening. Identifying the necessary and sufficient conditions to learn associations is the first step towards a theory. For a long time, the temporal contiguity of two stimuli was viewed as the only necessary – and frequently also sufficient – condition. Therefore, the idea was that one could rely on rather simple mechanisms to develop a theory. The overall picture that emerges from such explanatory models is that of a passive organism in which associations and connections automatically strengthen. However, by now it is obvious that temporal contiguity is neither necessary nor sufficient. One of the most recent theories on classical conditioning has been proposed by Rescorla and Wagner ( 1972 ). The intuition that lies at the heart of this theory can be translated into psychological terms as follows: As soon as something happens to the animal – and this ‘something’ is a biologically relevant event such as food or pain in most experiments – which has not yet been predicted by another stimulus or a context, it is as if the animal searches for a predictor of this unexpected event. This is a fundamental why-question. It could thus be said that classical conditioning is fundamentally concerned with the question of how an animal construes a predictable world or – to put this differently using the words of Tolman & Brunswik (1935) – the focus is on the development of the ‘causal texture of the environment’. Operant learning can, mutatis mutandis, be considered as a procedure through which one studies how an organism learns a relationship between its behaviour and a particular outcome. The question here is how the organism construes a world and environment that can be perceived as controllable. The notions of ‘predictability’ and ‘controllability’ create a different frame of reference to describe both learning paradigms. They become increasingly more important, not because they sound nicer but because they create more room for a description and explanation of what is happening.

2) This brings us to the second question: what is the relevance of these learning principles as a model for behaviour modification? They have been used – and sometimes misused – to (a) explain the development of abnormal behaviour, (b) disentangle the factors that influence behaviour, and (c) develop particular therapeutic interventions.

(a) Although assessing the aetiology of the behaviour was less of a concern in the beginning of behaviour therapy, there was an emphasis on the usefulness of conditioning principles to explain the development of behaviour disorders. For classical conditioning, Watson & Raynor’s famous experiment ( 1920 ) with little Albert served – and still serves – as the primary model. This experiment is probably well-known, so only its essential elements are described here. Each time little Albert – an 11-month old baby- touched a white baby rat, a strongly aversive sound followed. In this way, Watson and Raynor wanted to demonstrate that phobic reactions can be rooted in conditioning experiences. After a while, it was noticed that the baby started to respond fearfully as soon as he saw the baby rat, and that this fear generalised to all sorts of similar objects. The scope of this experiment, however, has been greatly exaggerated. It certainly cannot be considered a prototypical explanation of the development of phobic behaviour. Also other aspects of this so-called experiment do not justify its assumed importance ( Harris, 1979 ). In addition, it is routinely overlooked that replicating the experiment did not succeed (apart from the question to what extent one should even try to replicate such an experiment). A similar objection can be made regarding the use operant learning models to explain the development of abnormal or problem behaviour. We now refer to the famous study by Ayllon et al. ( 1965 ). A chronic, psychotic patient was made to hold a broom, and to carry this broom everywhere with her, and this for a long period. This behaviour was learned by delivering cigarettes – the reinforcer – contingent upon the execution of this bizarre behaviour. Two psychiatrists who were unaware of this learning history were subsequently invited to provide a diagnosis and explanation while observing the patient through a one-way screen. Not surprisingly, their interpretation deeply contrasted with the actual reasons. One of the psychiatrists identified the broom as a phallic symbol. However, who is the fool here? The patient with the broom, the people who designed the experiment, or the psychiatrists who agreed to provide an interpretation? I would like to highlight the role of the psychiatrists by drawing the following analogy: Assume we have a video of someone peeling onions, his – or her – cheeks full of tears. If you could only see his or her face, and had no knowledge of the context, what would be your interpretation? One can only generate hypotheses based upon the frame of reference that one is familiar with. Evidently, it is a precarious exercise to make a diagnosis based upon fragmentary observations. But the researchers are also not innocent. Not so much because of ethical objections (a patient had to carry a broom for an entire year), but because of the following remark: “The etiology of so-called psychotic symptoms exhibited by hospitalised patients or those in need of hospitalisation does not have to be sought in the obscure dynamics of a psychiatric disturbance.” In other words, because a so-called symptom can be created through operant principles, any other explanation would be superfluous. This is an obvious logical fallacy: Symptom A was caused by factor X under specific conditions; So factor X always causes A (Davison, 1969). A similar logical fallacy is at stake when the successful application of a technique based on learning principles is used to conclude that behaviour was originally learned through those same principles. In fact, not many advances have been made to explain the aetiology of problem behaviours using learning principles. In fact, the idea has started to emerge that many problems may develop outside the realm of learning principles. Here, I want to come back to the notions of unpredictability and uncontrollability. It is a fascinating hypothesis that the essential feature of all procedures involved in creating a so-called experimental neurosis – we refer to the studies by Pavlov, Maier, Masserman, Wolpe, Seligman, et al. – is that the animal either loses predictability or controllability of its environment (Mineka & Kihlstrom, 1977). This might mean that a fertile ground for the development of disorders lies in those situations where no adequate cause is found for a particular event, or when one has lost grip on its environment. Also this is essentially a learning process, but in these cases learning is about the fact that there is no unequivocal relation between events, or that there is no relation between what one’s behaviour and what follows. In such situations, one might continue to search for a cause, or to attempt to obtain control. In that sense, a person with a phobia towards a particular situation, or a compulsive person involved in excessive controlling may both have found a solution for their intrinsic tension. Are we here far or not far removed from a psychoanalytic interpretation that a disorder essentially is about failing of ‘normal’ adjustment mechanisms?

(b) A second observation on the usefulness of learning paradigms and concepts concerns the identification and description of the factors that maintain problem behaviour. This is actually ‘functional analysis’, which is considered the back bone of any attempt at changing behaviour. Systematic observation and questioning are used to identify the antecedent or consequent factors that maintain the problem behaviour. Based on this functional analysis, in which one acts as an experimenter, a hypothesis is advanced from which an intervention technique is derived. In that respect, a functional analysis is not at all simple. There is no recipe book that prescribes treatments for disorders. The language from conditioning paradigms is often adopted in functional analysis, using words such as discriminative stimulus, conditioned emotional response, reinforce, etc. And ‘coverants’, a term introduced by Homme ( 1965 ) as a contraction of ‘covert operants’, is used to represent cognitions. This vocabulary may seem odd, and it may indeed be too simplistic when describing real life problems. Obviously, these terms are reductionist, but the key question is whether these schematic presentations have any heuristic value. The latter is not determined by the vocabulary, but by the adequacy of the functional relationships. This functional approach to behaviour probably differs thoroughly from a more ‘understanding’ approach. A child that does not want to go to school will by most be labelled with school phobia. Here, a behaviour therapist will take a different approach from someone who looks at this event through, for example, psychoanalytic glasses. The latter will probably offer interpretations along the lines of separation anxiety from the mother. A behaviour therapist is less likely to draw such inferences and will more likely focus his analysis and action plan on the specific problem. This might result in an analysis of the mother-child relation, but this is not necessarily so.

(c) A last observation concerns the application of learning principles in the elaboration of a technique or intervention method. In an influential article, London ( 1972 ) argued that it is illusory to present these techniques as if they go back to learning theory. Such a statement, however, identifies again a procedure with the explanation that has been offered for the effects of this procedure. After all, there simply is no unequivocal learning theory. It is obvious that in the design and application of these techniques, one has been too strict in relying on procedures that were used with animals. The use of identical procedures does not mean at all that identical psychological processes are targeted, and it is only through targeting specific processes that a procedure ultimately works. Let me illustrate this with an example. Electric shocks are frequently used in animal research. A neutral stimulus can be rendered aversive to the animal through association with an electric shock. A similar procedure has been used in some behaviour therapy techniques, e.g. in alcoholism treatments, in the hope that the same result would arise. I immediately wish to add that the use of such techniques is rare, although in the public opinion such techniques are considered quintessential for behaviour therapy. It is, however, overlooked that an electric shock is a completely different event for an animal than for a person. The traumatic quality of a shock to an animal probably not only lies in the pain, but also in the complete incomprehensibility of what is happening. This is why a discrete and typically novel stimulus that coincides with the shock in time and space is experienced as one event by the animal. This is completely different for an adult human who knows that an electric shock is not intrinsically linked to the sight of e.g. an alcoholic beverage. The person only knows that the shock is conditionally connected to a particular stimulus under certain circumstances, e.g. in the clinic. In other words, this brings us to the fundamental question of attribution. As a consequence, the key issue in using such procedures is not to explain why they are not working, but instead why they are working under specific circumstances.

Behaviour therapy is an application of findings from experimental psychology

A second characteristic mentioned by Kazdin is that behaviour therapy and behaviour modification aim to be an application of findings from experimental psychology. This is more wishful thinking than actual reality. How could it be otherwise? Who dares to claim to have an overview of what experimental psychology has accomplished and which parts are relevant? It is barely possible to keep up with the literature in one’s own domain. So, behaviour therapy will never be what it claims to be, but in doing so it remains in principle open to any new approach. As our discussion of the preceding characteristic has shown, behaviour therapy has all too often based its wisdom on a limited part of the conditioning literature, and has sometimes failed to take into account new theoretical evolutions. Authors like Bandura have greatly contributed to broadening the framework into what is called ‘social learning theory’. The conceptual framework has largely expanded, while not always providing clarifications to the same extent ( Bandura, 1977a ). In that context, it is remarkable that behaviour therapy, just like experimental psychology in general, is increasingly relying on a vocabulary from cognitive psychology. A huge shift has taken place in learning psychology: from the study of behaviour change to the analysis of memory and cognitive processes. Today the focus primarily lies on the study of the processes through which information is perceived, processed and recalled. Whether this cognitive psychology will make a contribution to behaviour change will largely depend on how well it succeeds in translating these intermediating processes into behavioural terms. The question of whether therapy or intervention should modify cognitions or behaviours, is probably a false one, resulting from creating a dichotomy between both terms. After all, it is only possible to talk about cognitions in terms of a process, of what the organism is doing. In his recent self-efficacy theory, Bandura ( 1977b ) claims that every behaviour change is in fact dependent on a change in cognition. In his view, the central cognition can be summarised with one term, the efficacy expectancy, or the expectation one is able to effectively execute a particular behaviour. Yet, according to Bandura the most efficient procedures to impact this intermediary cognition are heavily relying on the actual execution of that behaviour. Empirical verification of such a claim ultimately comes down to correlating two types of behaving: at the verbal and at the performance level. This again brings us close to the theme of last year’s seminar: the relationship between attitude and behaviour.

Direct focus on the behaviour

A third characteristic, according to Kazdin, is the direct focus on the behaviour one wants to change. This characteristic, too, has prompted a large number of comments. Behaviour therapy and behaviour modification would supposedly remain superficial, and not penetrate the real causal and intrapsychic determinants of the behaviour. In such comments, we can distinguish several components. First, what is frequently meant by ‘superficial’ is that behaviour therapy is ahistorical. In other words, the focus is solely on the ‘here and now’. This is both correct and incorrect. The aim is indeed to assess what the actual determinants of the behaviour are, but an extensive anamnesis often shows that the past continues to be actualised in one or another way. For emotional problems, it is often the case that the initial or main problem is only that what the patient is able to verbalize at a particular moment.

Undoubtedly, the comment also touches upon the fundamental issue of symptom substitution: Only changing external behaviour without reaching the deeper cause would result in the development of other symptoms. A lot has been written about this issue and it is impossible to summarize this debate in a few words. Let us repeat just this: symptom substitution is a hypothesis that first and foremost stems from a particular theoretical conceptualization of problem behaviour. To validate this hypothesis, one needs to clarify what a symptom is, and also when and in what form a substitution will take place. Failing to do so, novel problem behaviour can equally well be captured with other explanations. Bandura ( 1969 ) correctly observed that the problem of symptom substitution would never have been articulated in its current misleading form, if it was generally acknowledged that ‘behaviour’ is never eliminated in a vacuum (except through neurophysiological interventions), but always through (intentional or unintentional) manipulations of the factors that control this behaviour. It is of course possible to have different opinions on what those controlling factors are, but these differences in opinion can also occur amongst behaviour therapists. If a functional analysis hypothesises that a particular behaviour is a typical form of avoidance behaviour, the intervention will focus on the hypothetical cause of avoidance. In that case, it is not the behaviour itself that is targeted but rather the hypothetically assumed fear that sustains it.

Methodology

A final characteristic is the experimental methodology of behaviour therapy and behaviour modification. This was already highlighted throughout our discussion of the previous characteristics. As Brinkman ( 1978 ) writes, behaviour therapy and behaviour modification includes an empirical cycle. Starting with an as precise as possible behavioural observation, a hypothesis relating to the factors that influence this behaviour is formulated, and based on this analysis an intervention selected. Eventually a systematic evaluation of the intervention follows. The application of operant learning principles has contributed to an extensive N = 1 research methodology. In addition, a wealth of experimental literature using analogous samples exists. Studies to assess the value of certain intervention techniques using subjects with e.g. a fear of snakes or spiders, or with a fear of public speaking, are well-known. It is remarkable, however, that several authors are opposed to this. Wolpe, for instance, rejects most of the criticisms on systematic desensitisation as irrelevant because they primarily relies on findings from studies with analogous populations ( Kazdin & Wilcoxon, 1976 ). Some of this opposition probably stems from the fact that a majority of these studies demonstrate that several aspects of his technique are not necessary, and that the theoretical explanation offered for them is incorrect. Marks ( 1978 ), too, believes that research on clinical interventions is only valid when it is performed on clinical samples. It is impossible, however, to further this debate as long as it is not clearly specified what is typical about a so-called clinical population. If it is claimed that a critical and qualitative difference between so-called normal and abnormal behaviour exists, one of the fundamental assumptions of behaviour therapy is implicitly rejected. By the way, is the leap from so-called analogous to clinical populations larger than that from a neurotic cat to a neurotic human?

Final observations

I am well aware that I have only sketched a brief picture of what is understood by behaviour therapy or behaviour modification. On some occasions, I may have played the devil’s advocate a bit too much. Somehow, I considered this my task in introducing this seminar.

Allow me, then, to conclude with a personal plea for the contributions of behaviour therapy. I do not have abundant clinical experience. But behaviour therapy, for me, will continue to bring to mind the patient I was allowed to treat during my training with Wolpe in Philadelphia. She was a 70-year-old woman who had suffered from agoraphobia for more than 30 years and who had been declared a hopeless case by several psychiatrists. After a couple of months of behaviour therapy intervention, she undertook several flights to New York at her own initiative, and she is currently on a cruise trip to the Caribbean islands. Let me put the psychoanalysts among you at ease: She sends me platonic love letters every now and then!

Such experiences of course do not offer proof of the value of behaviour therapy. Any person can probably come forward with remarkable successes. And when one gives this success deeper consideration, one inevitably asks oneself: what happened here? Anyone who is confronted with people in need in their daily practice, or anyone who wants to clarify certain data through empirical research knows all too well that we know far too little about what is the object of our study: human behaviour.

Allow me to close with a prayer in view of this ignorance. This is probably a unicum: concluding a presentation about behaviour modification with a prayer! I discovered it thanks to the dean of this Faculty, who hung it next to his door. I recommend this as a ‘cognition’ that should be present in all those who are engaged in behaviour modification:

• God, give me the serenity to accept what I cannot change.
• Give me the courage to change what I can change.
• And most of all give me the wisdom to know the difference.

Competing Interests

The author has no competing interests to declare.

An Overview Of Behavior Modification

Behavior modification is generally thought of as the process of changing patterns of human behavior using various motivational techniques, such as negative and positive reinforcement, extinction, fading, shaping, and chaining. It can be a useful tool to encourage desirable behaviors in yourself, your children, or your employees. There are strategies that may improve the effectiveness of behavior modification, and a therapist may help you determine the best ones to achieve your desired change.  

What is behavior modification?

Many people make New Year’s resolutions, but it’s estimated that  80% of those people no longer follow their resolutions by the end of the first month. Behavior modification through extinction psychology generally focuses on changing associations with the undesired or desired behaviors to make it more likely that you will stick with your goals.

The theory behind behavior modification identifies that we can change the way we act or react by attaching consequences to our actions and learning from those consequences. The psychologist B.F. Skinner, known for his research on behavioral analysis, postulated that if the consequences of an action are unfavorable, there is a good chance the action or behavior will not be repeated, and if the consequences are favorable, the chances are better that the action or behavior will be repeated. He referred to this concept as “the principle of reinforcement.” Skinner's introduction of reinforcement in his framework became the basis of the development of many modern ideas in reinforcement psychology .

At a fundamental level, Skinner’s behavior analysis modification model can be a way to change habits by following actions with positive or negative consequences to either break bad habits or reinforce good habits.

For many disorders, such as ADHD, behavior therapy has been  shown to be effective , and it may improve both behavior and self-esteem. Behavior modification is often used to treat obsessive-compulsive disorder (OCD), attention deficit hyperactivity disorder (ADHD), irrational fears, substance use disorder, generalized anxiety disorder, and separation anxiety disorder in clinical settings. You may develop and implement a behavior modification plan on your own, or you can find a therapist who specializes in behavior modification therapy for additional guidance and support.

If you are struggling with substance use, contact the SAMHSA National Helpline at (800) 662-4357 to receive support and resources. Support is available 24/7.

Behavior modification techniques

There are several evidence-based ways to approach modifying behavior. Some of the techniques below are best implemented within specific contexts or with certain age ranges or developmental stages. Keep in mind that what works for one person will not always work for another person, and a licensed mental health care provider can provide guidance regarding behavior modification goals.

Positive reinforcement and positive punishment

In psychology, you can think about the concepts of positive and negative as mathematical symbols. You might keep in mind that taking something away is considered negative, and adding something is seen as positive. 

Generally, positive reinforcement adds a stimulus that reinforces good behavior. For example, you could positively reinforce the behavior of a student by awarding them a prize for doing well on their exam. Positive punishment , on the other hand, describes an added stimulus that decreases the likelihood of an undesired behavior occurring. For example, putting lemon juice (a stimulus) on your fingernails may discourage you from biting your nails (an undesired behavior). Positive punishment also includes corporal punishment, such as spanking, which is often seen as a harmful and unproductive form of behavior modification.

Negative reinforcement and negative punishment

As mentioned above, negative typically means that a stimulus is removed. Negative reinforcement can occur when you remove a stimulus to increase a desired behavior. 

For example, an infant’s cries (a stimulus) may be removed when a parent picks the infant up (the desired behavior). As a result, the parent may be encouraged to pick up their infant more often when they cry. 

Negative punishment can occur when a stimulus is taken away to reduce the frequency of an undesired behavior occurring. For example, a teenager’s cell phone (the stimulus) could be taken away when they stay out past their curfew (the undesired behavior).

A behavior can become extinct when a stimulus or reinforcer is removed. For example, if your child becomes accustomed to getting a new toy (stimulus) every time they throw a tantrum (undesired behavior), you might refrain from buying your child a toy when they throw a tantrum. When done consistently, your child is likely to learn that the behavior never produces the desired outcome, and the behavior may become extinct.

The process of shaping can reinforce behaviors that are closer to a desired behavior. For example, a child learning to walk typically involves several stages (sitting up, crawling, standing, walking). Parents might reinforce a child learning to walk through shaping by giving a child encouragement when they engage in new steps in this process.

Fading is usually thought of as the process of gradually shifting from one stimulus to another. For example, if a parent encourages their child to get good grades on report cards with a positive stimulus, such as rewarding money for good grades, they may eventually seek to find a more sustainable stimulus to maintain good academic performance. Fading removes the old stimulus, getting money in exchange for good grades, and replaces it with a new stimulus, such as satisfaction in learning new material.

Behavior chains can link individual behaviors to form a larger behavior. By breaking down a task into its simplest steps, a complex behavior may become more consistently achievable. 

Keys to success

Consistency can be crucial for achieving long-term behavior change. Once a desired behavior is established, consistent reinforcement is typically required to maintain it. When using behavior modification techniques for children, it may be helpful to discuss strategies with teachers, grandparents, and other caregivers to clearly establish rewards and consequences for behavior.

Applications for behavior modification

Behavior modification is often thought of as a parenting tool. However, while commonly used for children and adolescents, behavior modification can be effective for many demographics. For example, many adults use behavioral therapy to quit smoking, eat healthily, exercise regularly, and work more efficiently.

Because no two people are alike, behavior modification plans and programs are usually not one-size-fits-all. You may need to tweak or substitute elements of one plan or another to best suit your situation and your ultimate goals, and behavior modification therapy may work best in conjunction with other types of therapy.

Cognitive-behavioral therapy (CBT) is one type of therapy that a mental health professional may suggest. In CBT, you typically identify unhelpful behaviors and thought patterns and work to replace them with healthy, helpful behaviors and thought patterns. Many studies have been conducted that support the effectiveness of online CBT. For example, a recent publication considered more than 2,500 of those studies and found that online CBT therapy could be as effective as in-person therapy .

Online therapy platforms may offer CBT, and taking advantage of these services can help you understand why you engage in undesired behaviors and create a plan to modify your behavior. Online therapy tends to be more flexible, so you may be able to meet outside of standard business hours. Additionally, in-app communication may allow you to reach out to your therapist when setbacks occur, so you don’t have to wait until your session to bring up challenges.

What is behavior modification psychology? What is an example of behavior modification? What are the four types of behavior modification? What are behavior modification techniques? What is the key concept in Behaviour modification? What are the 5 behavioral changes? What is the most effective behavior modification? What are the two principles of behavior modification? What are the benefits of behavior modification? What is the first step in behavior modification?

• What Is Behavioral Learning? Medically reviewed by April Justice , LICSW
• What Is Maladaptive Behavior? Medically reviewed by Aaron Dutil , LMHC, LPC
• Relationships and Relations

PERSPECTIVE article

This article is part of the research topic.

Breakthroughs in Cryo-EM with Machine Learning and Artificial Intelligence

Machine learning approaches to cryoEM density modification differentially affect biomacromolecule and ligand density quality Provisionally Accepted

• 1 University of California, San Diego, United States

The final, formatted version of the article will be published soon.

The application of machine learning to cryogenic electron microscopy (cryoEM) data analysis has added a valuable set of tools to the cryoEM data processing pipeline. As these tools become more accessible and widely available, the implications of their use should be assessed. We noticed that machine learning map modification tools can have differential effects on cryoEM densities. In this perspective, we evaluate these effects to show that machine learning tools generally improve densities for biomacromolecules while generating unpredictable results for ligands. This unpredictable behavior manifests both in quantitative metrics of map quality and in qualitative investigations of modified maps. The results presented here highlight the power and potential of machine learning tools in cryoEM, while also illustrating some of the risks of their unexamined use.

Keywords: Cryogenic electron microscopy, CryoEM, Density modification, model building, machine learning

Received: 21 Mar 2024; Accepted: 03 Apr 2024.

Copyright: © 2024 Berkeley, Cook, Herzik and Jr.. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY) . The use, distribution or reproduction in other forums is permitted, provided the original author(s) or licensor are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.

* Correspondence: Dr. Mark A. Herzik, Jr., University of California, San Diego, La Jolla, 92093, California, United States

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