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Descriptive assessment of inappropriate vocalizations emitted by persons diagnosed with dementia. Yanerys Leon1. | Meagan K. Gregory2. | Ashley Flynn‐ ...

Received: 19 June 2017

Revised: 13 November 2017

Accepted: 16 November 2017

DOI: 10.1002/bin.1511

Brief Report

Descriptive assessment of inappropriate vocalizations emitted by persons diagnosed with dementia Yanerys Leon1

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Meagan K. Gregory2

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Ashley Flynn‐Privett3

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Aurelia Ribeiro 1

School of Behavior Analysis, Florida Institute of Technology, Melbourne, VIC, USA

Individuals diagnosed with dementia often emit disruptive inappro-

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priate vocalizations, and functional analyses of inappropriate vocal-

Department of Behavioral Psychology, Kennedy Krieger Institute, Baltimore, MD, USA

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izations in this population have produced inconclusive results. One

Florida Institute of Technology, Melbourne, VIC, USA

reason may be that researchers have not presented the relevant

Correspondence Meagan K. Gregory, Neurobehavioral Unit, Kennedy Krieger Institute, 707 N Broadway, Baltimore, MD 21205, USA. Email: [email protected]

ilar to those typically delivered in the individual's environment. The

antecedents or delivered consequences that were qualitatively simpurpose of this study was to identify environmental events that may be related to inappropriate vocalizations emitted by individuals with dementia. A 2‐part descriptive assessment was conducted (narrative and structured). Conditional and unconditional probabilities were calculated to determine antecedent and consequent events that were correlated with inappropriate vocalizations. Results showed that at least 1 antecedent event was correlated with inappropriate vocalizations, and attention was likely to follow the occurrence of inappropriate vocalizations for all participants.

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I N T RO DU CT I O N

It is estimated that 3.8 million people in the United States are currently diagnosed with dementia. Furthermore, the population of individuals over 65 years of age in America is expected to double from 35 million people in 2007 to 71 million by the year 2030, and older age is a significant risk factor for the development of dementia. Thus, the need for prevention and treatment of symptoms associated with chronic diseases of aging, including dementia disorders, will be in high demand (Plassman et al., 2007). Although the primary diagnostic feature of dementia is the development of multiple cognitive deficits, it is estimated that more than 50% of individuals with dementia exhibit problem behavior requiring intervention (Fisher, Drossel, Yury, & Cherup, 2007). Behavioral symptoms of dementia (e.g., inappropriate vocalizations and sleep disturbances) have been correlated with early nursing‐home placement, decreased quality of life for the individual and caregiver, and increased caregiver stress (Gitlin, Kales, & Lyketsos, 2012). Once institutionalized, inappropriate vocalizations in particular can evoke agitation in other residents and result in staff burnout and turnover. Previous research suggests that pharmacological interventions are only moderately effective at managing this behavior

Behavioral Interventions. 2018;33:69–78.

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(Reeves & Perry, 2013) and can have severe side effects, resulting in a Federal Drug Administration warning to medical providers of individuals with dementia and a need for nonpharmacological interventions (Gitlin et al., 2012). Although research indicates that functional analysis (FA) methods can be used successfully to assess the environmental variables that maintain inappropriate vocalizations, and effective function‐based treatments can be developed based on the results of a functional analysis, there has been little research published in behavior analytic journals addressing problematic speech emitted by older individuals with dementia. Buchanan and Fisher (2002) assessed the variables maintaining disruptive vocalizations emitted by two individuals with dementia. Two different functional analyses were conducted for Participant 1, and both were undifferentiated. For Participant 2, higher levels of vocalizations occurred in the contingent attention condition relative to the alone condition. A treatment of noncontingent reinforcement (attention alone, attention + music for the respective participants) produced modest decreases in inappropriate vocalizations. In a similar investigation, Beaton, Peeler, and Harvey (2006) examined irrational speech emitted by a 75‐year‐old female diagnosed with probable Alzheimer's disease. Following an undifferentiated FA, a modified FA consisting of fixed time (FT) 15 s attention, FT 30 s attention, and ignore conditions was conducted. Irrational statements were lowest in the ignore condition, slightly higher in the FT 30 s condition, and highest in the FT 15 s condition. These results suggest that social interactions may have served as discriminative stimuli for inappropriate vocalizations. Trahan, Donaldson, McNabney, and Kahng (2014) evaluated the differential impact of antecedents and consequences on bizarre speech emitted by three adults with dementia. Following inconclusive FAs during which bizarre speech was highest in the control condition, Trahan et al. (2014) found that manipulating certain antecedents (i.e., the presentation of open‐ended vs. yes‐no questions) produced differentiated FA outcomes, whereas modifying social consequences did not. These results corroborate the findings of Beaton et al. (2006), which suggested that social interaction may occasion disruptive vocalizations. However, the impact of consequences on the maintenance of disruptive vocalizations remains unclear. Collectively, these results highlight some of the difficulties with using “standard” FA contingencies to assess inappropriate vocalizations by older adults. One reason for this may be because researchers have not presented the relevant antecedents or delivered consequences that were qualitatively similar to those typically delivered in the individual's environment. For example, reprimands may not be delivered often, but agreement may commonly follow certain types of inappropriate vocalizations, such as perseverative speech, in an attempt to reassure the individual. Given these difficulties, descriptive assessment (DA) could be used to identify naturally occurring environmental events correlated with inappropriate vocalizations, which could later be tested in an experimental functional analysis. For example, following an inconclusive FA of hand‐mouthing emitted by a preschooler, Tiger, Hanley, and Bessette (2006) incorporated stimuli observed to be correlated with problem behavior during the descriptive assessment into a subsequent FA. The modified FA produced a differentiated outcome that leads to an effective function‐based treatment. The purpose of this study was to conduct a descriptive assessment at a local senior day care facility to determine environmental events that are correlated with inappropriate vocalizations emitted by adults with dementia.

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METHOD

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Subjects and setting

Four individuals with dementia participated in this study. Subjects were included based on referral by a day program staff member who reported that the subject engaged in frequent inappropriate vocalizations that were disruptive to ongoing activities or upsetting to other consumers. Janine was a 59‐year‐old female diagnosed with early‐onset Alzheimer's disease. Most of Janine's verbal behavior consisted of unintelligible sounds. Elizabeth was a 97‐year‐old woman who was diagnosed with dementia. She would respond to “yes” or “no” questions but only nodded in response

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to open‐ended questions that required more than a yes or no response. Additionally, Elizabeth frequently yelled out, “Please!” while displaying negative affect. Monty was a 72‐year‐old man who was diagnosed with dementia with behavioral disturbances. Monty did not initiate conversation; however, when spoken to, he would shake or nod his head in response. The only verbal statement he made during our observations at the day program was, “When can I go home?” Charlie was an 88‐year‐old man who was diagnosed with dementia. Charlie would frequently greet staff members and other clients attending the facility (e.g., “Hi, good to see you,”) but was unable to talk about past events (e.g., could not state the branch of the military in which he served). All subjects attended the same day care program for seniors, which was where all sessions were conducted. The day care facility consisted of a large, open area with tables. Subjects were provided with various group activities (e.g., bingo, music, pet therapy, arts, and crafts) throughout the day.

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Response measurement and interobserver agreement (IOA)

An open‐ended narrative DA was conducted for Monty, Charlie, and Janine during their regular routine to select potential antecedent and consequent events for inclusion in the structured DA. We collected data on antecedents, target behavior(s) (i.e., inappropriate vocalizations), and consequences using 10‐s partial interval recording. Inappropriate vocalizations were selected based on staff report and experimenter observation that a specific verbal response was frequent, non‐contextual, and disruptive to staff or other consumers. Charlie's inappropriate vocalizations were defined as any instance of singing, “I'm nothing but a nothing ...” or any perseverative compliments toward staff, guests, and other clients at the center (i.e., “You're a wonderful person” and “It's an honor and a pleasure to have you here”). A compliment was scored as an inappropriate vocalization only if the same comment was directed to the same person within a 5‐min interval. For Monty, inappropriate vocalizations were defined as any occurrence of asking, “When can I go home?” Inappropriate vocalizations for Elizabeth were defined as any occurrence of yelling “Please!” Janine's inappropriate vocalizations were defined as any audible mumbling and loud whimpering. Data were collected on the following antecedent events: staff attention, client attention, divided attention, demand, materials present, and music (Charlie only). Staff and client attention was scored when a staff member or client interacted with a participant either verbally (e.g., “hi”) or nonverbally (e.g., a wave). Divided attention was scored when a client or staff member was within 1.5 m of the participant but delivered attention to someone other than the participant. A demand was scored when a client or staff member told or asked the participant to do something (e.g., “It's time to go to the bathroom”). Materials were defined as the presence of materials within reach of the subject (e.g., magazine, crosswords, coloring materials, and snack). Music was defined as any time audible music was playing (e.g., radio and musical guest). Antecedent events were scored whenever they occurred, irrespective of the occurrence of the target behavior. Data were collected on the following consequent events: acknowledgement, agreement, disagreement, walk away, other verbal statements, and presentation of materials. Acknowledgment was scored when a client or staff member responded to the content of the subject's inappropriate vocalizations in a neutral way, either verbally (e.g., “I hear you,”) or nonverbally (e.g., nods and shrugs). An agreement was scored when a client or staff member responded to the subject's inappropriate vocalization with agreement (e.g., “Yes,” or “I know”) and included answers of sympathy or verification (e.g., “Don't worry. You can go home soon.”). A disagreement was scored if a client or staff member responded to the subject's inappropriate vocalizations with opposition (e.g., “No,” or “stop”). Walk away was scored if a client or staff member left the area where the subject was located. Other verbal statements were defined as a verbal statement made by a client or staff member that was directed toward the participant and that did not meet the definition of acknowledgment, agreement, or disagreement. Other was scored for verbal statements that were unrelated to the inappropriate vocalizations. For example, if Monty asked a client sitting by him, “When can I go home,” and the client replied “Isn't that song lovely?” Other verbal response was scored. Materials were scored as a consequent event when materials followed an occurrence of the target behavior and were not present prior to the target behavior.

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Consequent events were scored if they occurred followed an occurrence of the target behavior within the same or subsequent 10‐s interval. IOA was assessed by having an independent observer collect data during at least 20% of all sessions. Sessions were divided into 10‐s intervals, and data were compared on an interval‐by‐interval basis. The number of intervals in which both observers agreed on the occurrence or non‐occurrence of the event (antecedent, consequence, or target behavior) was divided by the total number of intervals and multiplied by 100. Mean IOA coefficients across all subjects were as follows: target responses, 95% (range, 92–99%); antecedents, 93% (range, 67–100%); and consequent events, 98% (range, 82–100%).

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Procedures

During the structured DA, observers recorded the occurrence of inappropriate vocalizations and potentially relevant environmental events during continuous 10‐s intervals. Based on the procedures described by Camp, Iwata, Hammond, and Bloom (2009), a minimum of four 15‐min observations were conducted for each participant; however, observations continued until at least 10 instances of inappropriate vocalizations were observed. Charlie and Elizabeth were observed for 75 min each. Janine was observed for 90 min, and Monty was observed for 135 min. Observations occurred during both morning and afternoon activities for all participants in an effort to sample different activities and staff–participant interactions. Staff members were told to interact with subjects as they normally would, and no attempts were made to program events.

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Data analysis

Conditional and unconditional probabilities were calculated to identify correlations between inappropriate vocalizations and environmental events. For the purposes of data analysis, an antecedent was defined as an event that occurred prior to a participant's target behavior but in the same 10‐s interval as the target behavior or in the immediately preceding interval. A consequence was defined as an event occurring immediately after inappropriate vocalizations or within the next 10‐s interval (Camp et al., 2009). Note that antecedent and consequent events were scored any time they occurred; however, they were only included in the analysis if they met the above definition. The following conditional and unconditional probabilities for antecedents were calculated: staff attention, client attention, presence and absence of materials, demands, divided attention, music, and absence of all forms of attention (i.e., absence of staff and client attention and demands). We utilized data analysis procedures described by Camp et al. (2009) to determine the conditional and unconditional probabilities of environmental and behavioral events scored during the structured descriptive assessment. The conditional probability of antecedent events given the occurrence of the target behavior was calculated by dividing the number of intervals in which the antecedent and the target behavior occurred in the same interval (or if the antecedent occurred in the interval prior) by the total number of intervals in which the behavior occurred. The unconditional probability of each antecedent was calculated by dividing the total number of intervals with the antecedent by the total number of intervals. Because the participants emitted little to no appropriate speech throughout the study, many of the consequent events occurred exclusively as a response to inappropriate vocalizations (e.g., statements of agreement). Therefore, rather than calculate conditional probabilities of the different types of attention, all forms of attention (i.e., agreement, disagreement, acknowledgment, and other verbal statement) were collapsed to determine the conditional and unconditional probability of attention as a consequence for inappropriate vocalizations. The conditional probability of attention as a consequence was calculated by dividing the number of intervals across all sessions in which any type of attention followed the target behavior by the total number of intervals with the target behavior. The unconditional probability of attention as a consequence was calculated by dividing the number of intervals with attention (including those intervals during which attention was scored as a possible antecedent event) by the total number of intervals. That is, attention was always scored when it was delivered. If it followed an occurrence of the target behavior, it

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was scored as a specific consequent event (e.g., agreement). If it did not follow the problem behavior, it was scored as a potential antecedent (i.e., staff or consumer attention). Therefore, the unconditional probability of attention was calculated by all intervals in which attention occurred. In addition to the conditional and unconditional probability of attention, we calculated the proportion of each type of attention (e.g., statements of agreement and disagreement) to identify the most common topography of consequent attention. The number of intervals during which a given type of attention followed the target behavior was summed and divided by the total number of intervals during which attention was scored as a consequent event for the target behavior.

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RESULTS

Figure 1 displays the conditional and unconditional probabilities of each antecedent event. Probabilities of antecedent events related to attention are on the left panel and other antecedent events (i.e., presence and absence of materials, demands, and music [Charlie only]) are on the right panel. Antecedent events that were predictive of inappropriate vocalization were idiosyncratic across participants. For example, staff attention was predictive of inappropriate vocalizations for Janine, whereas absence of attention and divided attention was predictive of inappropriate vocalizations for Elizabeth and Monty, respectively. Additionally, absence of materials was predictive of inappropriate vocalizations for Monty and Charlie (compliment only). Client attention, presence of music or materials, and presentation of demands were not predictive of inappropriate vocalizations for any of the participants. Figure 2 displays the conditional and unconditional probabilities of attention as a consequent event on the left panel and the proportion of each category of attention as a consequent event on the right panel. The conditional probability of attention following an occurrence of the target behavior was substantially higher than the unconditional probability of attention for all participants. Acknowledgment accounted for the highest proportion of attention delivered contingent on inappropriate vocalizations and was the most frequent consequence in three of five analyses (Elizabeth, Charlie‐compliment, and Charlie‐song). Other verbal statement was the most frequent consequence for Janine's inappropriate vocalizations. Statements of agreement and statements of disagreement were the most frequent consequence for Monty's inappropriate vocalizations and were roughly equally likely (0.46 and 0.38, respectively). Data for materials as a consequent event are not presented due to their extremely infrequent occurrence (i.e., conditional probability of 0.025 for one participant and 0.0 for all others).

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DISCUSSION

We conducted descriptive assessments at a local senior day care facility to determine environmental events that were correlated with inappropriate vocalizations emitted by four adults with dementia. Although speech impairment that occurs during the progression of dementia may be, in part, due to physiological changes, at least one environmental event was correlated with inappropriate vocalizations for each participant. Absence of materials was shown to be predictive of Charlie's compliments and Monty's questioning. Other predictive events included the presence of staff attention (Charlie's compliments and Janine's inappropriate vocalizations), the presence of divided attention (Monty's questioning), and the absence of attention (Elizabeth's inappropriate vocalizations). Further, data for three of the four subjects (Janine, Charlie, and Monty) indicated that attention was significantly more likely to follow occurrences of inappropriate vocalizations than to occur independent of them. Results of this study extend the literature in several ways. First, to date, no one has demonstrated whether (or not) the environmental events known to be associated with problem behavior exhibited by other populations (e.g., individuals with intellectual disabilities) are the same events that are associated with problem behavior exhibited by individuals with dementia. Although Heard and Watson (1999) conducted a descriptive assessment of wandering emitted by persons with dementia and found that social attention and tangible items were potential sources of reinforcement, they did not report on the types of attention or tangible items that were delivered. Our

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ANTECEDENT EVENTS 1.0

1.0 Janine

Janine

0.8

PROBABILITY

PROBABILITY

0.8 CP

0.6 UP

0.4 0.2

CP

0.6 CP

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1.0

PROBABILITY

0.8

UP

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Elizabeth

0.8 0.6 CP UP

0.4 0.2

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0.0 Monty

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Monty

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0.8 PROBABILITY

0.8 CP

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UP

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CP UP

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0.0 Materials

Charlie (compliment)

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1.0 Charlie (song)

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Demand

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0.0 Staff Attention

FIGURE 1

Absence of Materials

1.0 CP

PROBABILITY

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UP

0.0 Elizabeth

1.0 PROBABILITY

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Consumer Attention

Divided Attention

Absence of Attention

Music

Materials

Absence of Materials

Demand

Conditional (CP) and unconditional probabilities (UP) of antecedent events

data corroborate the findings of Heard and Watson (1999), which suggested that social attention may be a common consequence for problem behavior in this population and extend those findings by providing a more detailed account of the types of attention that are likely to follow inappropriate vocalizations emitted by persons with dementia. Further, our results add to the literature on descriptive assessment in behavioral gerontology by describing antecedent events that may be likely to precede problem behavior in this population. Beaton et al. (2006) and Trahan et al. (2014) suggested that social interactions (i.e., attention) could be discriminative stimuli that may evoke both appropriate and inappropriate speech (Trahan et al., 2014). The results of our study showed that in some cases (e.g., Charlie's compliments and Janine's vocalizations), social interaction may occasion

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CONSEQUENT EVENTS 1.0

1.0 0.8

CP

0.8

Janine

Janine

0.6

0.6 UP

0.4

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CP

1.0 Charlie (compliment)

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0 Attention

Acknowledge

Agree

Disagree

Other Verbal Statement

Walk Away

FIGURE 2

Left panel: Conditional (CP) and unconditional probabilities (UP) of consequent attention. Right panel: Proportion of each type of attention that followed occurrences of the target behavior

inappropriate vocalizations, which may reflect an individual's attempt to continue the interaction by using a verbal repertoire reduced due to the disease process. However, there were other individuals who were more likely to engage in inappropriate vocalizations in the absence of attention (e.g., Elizabeth and Monty). In addition to identifying the presence and absence of attention as predictors, the absence of materials also was correlated with the occurrence of inappropriate vocalizations for both Monty and Charlie. It is possible that engaging with materials (often reading

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materials) may have competed with vocalizations. Trahan et al. (2014) demonstrated that antecedent events were more likely to differentially influence the occurrence of disruptive vocalizations in this population relative to consequences. Future researchers could examine the extent to which treatment planning based on the results of the descriptive assessment (i.e., removing antecedent events that are likely to evoke the target behavior) improves treatment outcomes when functional analyses are not feasible. Previous research applying FA methods to determine the reinforcers maintaining inappropriate vocalizations emitted by these individuals has produced results that are undifferentiated (e.g., Beaton et al., 2006). This could be because the relevant antecedent and consequent events were not included. That is, although the social disapproval, demand, alone, and play conditions are commonly included in an FA for severe problem behavior emitted by individuals with intellectual disabilities, those conditions may not reflect the naturally occurring contingencies responsible for occasioning and maintaining inappropriate vocalizations emitted by persons with dementia. Therefore, it is perhaps not surprising that attempts at using those conditions have produced largely undifferentiated outcomes. Nevertheless, functional analysis is a flexible tool, and as a result, conditions can be created to test any number of potentially relevant antecedent and consequent events. Descriptive assessments could be used to further identify naturally occurring environmental events that are contiguous with problem behavior, and researchers and clinicians could then conduct an FA utilizing those events. Previous research examining inappropriate vocalizations emitted by individuals with dementia has identified attention as a potential reinforcer (Buchanan & Fisher, 2002). This study found that attention frequently followed inappropriate vocalizations for three of the four participants, and it is possible that attention functioned as a reinforcer in these cases. However, previous research has demonstrated that the results of descriptive assessments often do not match the outcomes of FAs (e.g., Camp et al., 2009). That is, although DAs identify environmental events that are correlated with behavior and may provide hypotheses about the function of the behavior, they do not identify functional relations between behavior and environmental events. Functional relations can only be identified by way of an experimental functional analysis. In particular, descriptive assessments may inaccurately identify attention as a potential reinforcer (Pence, Roscoe, Bourret, & Ahearn, 2009). This may occur because many topographies of severe problem behavior (e.g., self‐injurious behavior and aggression) require immediate intervention, and thus, attention might be a programmed consequence for such behavior in community settings (Thompson & Iwata, 2001). Inappropriate vocalizations, however, do not pose an immediate threat; nevertheless, attention was much more likely to follow inappropriate speech than to occur independently. It is possible that caregiver attention may interrupt the occurrence of inappropriate vocalizations, thereby maintaining the caregiver's attending behavior by way of negative reinforcement. Although this study adds to the literature on behavioral assessment of inappropriate vocalizations emitted by persons with dementia, there are some limitations that should be noted. First, because one of the purposes of the study was to identify the most common types of attention that followed inappropriate vocalizations, we did not score occurrences of individual consequent events (e.g., agreements and disagreements) independent of the target behavior. Therefore, we were unable to calculate unconditional probabilities for each of the consequent events. As a result, it is unclear if any of the types of consequent attention were more likely to occur following an occurrence of inappropriate vocalization. Thus, rather than present conditional probabilities of those events in isolation, we elected to (a) combine all consequent attention to evaluate the conditional and unconditional probability of attention as a consequence for inappropriate vocalizations and (b) examine the proportion of each type of consequent attention, consistent with the ABC method of data analysis described by Pence et al. (2009). Our results indicate that the type of attention that was most likely to follow inappropriate vocalizations was idiosyncratic across participants. It is possible that the type of attention that follows inappropriate vocalization is related to the content of those vocalizations. For example, Monty's inappropriate vocalization consisted of asking, “When can I go home.” The two types of consequent attention that were most likely to follow that statement were agreements (e.g., “Soon”) and disagreements (e.g., “Not until 5 p.m.”). On the other hand, Elizabeth's inappropriate vocalizations consisted primarily of loud screams and yells, and the consequent attention that was most likely to follow was acknowledgment (e.g., “I hear you”). These findings are consistent with previous research that has suggested that the topography of problem behavior may influence the conditional probability of

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staff attention (Thompson & Iwata, 2001) and extends those findings by demonstrating that the form of staff attention may also be influenced by the topography of problem behavior. Given that the form of attention may differ depending on the form of the inappropriate vocalization, it may be particularly important to construct functional analysis conditions based on the results of a descriptive assessment for this particular target behavior. Future researchers could examine the extent to which different forms of attention produce differential responding emitted by individuals diagnosed with dementia. For example, Kodak, Northup, and Kelley (2007) demonstrated that different forms of attention (e.g., reprimands and unrelated comments) produced differential responding for two children with developmental disabilities whose functional analysis results suggested that attention was a reinforcer for their problem behavior. Although the results of Trahan et al. (2014) showed undifferentiated responding across consequent manipulations, those results may have been confounded with antecedent manipulations that resulted in high rates of inappropriate speech (i.e., open‐ended questions). Future researchers could further evaluate the influence of consequent events in this context by evaluating consequences identified by way of a DA in the absence of strong antecedent control. We selected particular antecedent and consequent events to examine in the descriptive assessment based on the results of a narrative DA. During these observations, demands were never issued (and were in fact an infrequent occurrence during the structured DA). Therefore, we elected to omit consequences related to the presentation of demands. Although demands were an infrequent occurrence during this study, it is possible that escape‐related consequences (e.g., escape, additional prompting, or follow through) could have differentially influenced inappropriate speech for some of the participants. Future researchers could examine the influence of demands and escape related‐consequences on inappropriate vocalizations emitted by persons with dementia. Finally, previous research has suggested that DA results can be influenced by the window‐size when utilizing partial interval recording (Vollmer, Borrero, Wright, Van Camp, & Lalli, 2001). Because we collected data using a 10‐s partial interval recording, it is possible that a response and an environmental event were anywhere from 1 s to 19 s apart. Future researchers should consider the use of real‐time recording and set windows for potential antecedent and consequent events anchored to the target behavior. ORCID Yanerys Leon

http://orcid.org/0000-0002-6145-1089

Meagan K. Gregory

http://orcid.org/0000-0001-8093-7407

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How to cite this article: Leon Y, Gregory MK, Flynn‐Privett A, Ribeiro A. Descriptive assessment of inappropriate vocalizations emitted by persons diagnosed with dementia. Behavioral Interventions. 2018;33:69–78. https://doi.org/10.1002/bin.1511

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