In operant conditioning, behavioral change is brought about by the manipulation of

Operative Repair

Sometimes a perineal fistula, if it opens in good position, can be treated by simple dilation. Hegar dilators are employed, starting with a No. 5 or 6 and letting the baby go home when the mother can use a No. 8. Twice-daily dilatations are done at home, increasing the size every few weeks until a No. 14 is achieved. By 1 yr of age, the stool is usually well formed and further dilation is not necessary. By the time No. 14 is reached, the examiner can usually insert a little finger. If the anal ring is soft and pliable, dilation can be reduced in frequency or discontinued.

Occasionally, there is no visible fistula, but the rectum can be seen to be filled with meconium bulging on the perineum, or a covered anus is otherwise suspected. If confirmed by plain x-ray or ultrasound of the perineum that the rectum is <1 cm from the skin, the clinician can do a minor perineal procedure to perforate the skin and then proceed with dilation or do a simple perineal anoplasty.

When the fistula orifice is very close to the introitus or scrotum, it is often appropriate to move it back surgically. This also requires postoperative dilation to prevent stricture formation. This procedure can be done any time from the newborn period to 1 yr. It is preferable to wait until dilatations have been done for several weeks and the child is bigger. The anorectum is a little easier to dissect at this time. The posterior sagittal approach of Peña is used, making an incision around the fistula and then in the midline to the site of the posterior wall of the new location. The dissection is continued in the midline, using a muscle stimulator to be sure there is adequate muscle on both sides. The fistula must be dissected cephalad for several centimeters to allow posterior positioning without tension. If appropriate, some of the distal fistula is resected before the anastomosis to the perineal skin.

In children with a high lesion, a double-barrel colostomy is performed. This effectively separates the fecal stream from the urinary tract. It also allows the performance of an augmented pressure colostogram before repair to identify the exact position of the distal rectum and the fistula. The definitive repair or posterior sagittal anorectoplasty (PSARP) is performed at about 1 yr of age. A midline incision is made, often splitting the coccyx and even the sacrum. Using a muscle stimulator, the surgeon stays strictly in the midline and divides the sphincter complex and identifies the rectum. The rectum is then opened in the midline and the fistula is identified from within the rectum. This allows a division of the fistula without injury to the urinary tract. The rectum is then dissected proximally until enough length is gained to suture it to an appropriate perineal position. The muscles of the sphincter complex are then sutured around (and especially behind) the rectum.

Other operative approaches (such as an anterior approach) are used, but the most popular procedure is by laparoscopy. This operation allows division of the fistula under direct visualization and identification of the sphincter complex by transillumination of perineum. Other imaging techniques in the management of anorectal malformations include 3D endorectal ultrasound, intraoperative MRI, and colonoscopy-assisted PSARPs, which may help perform a technically better operation. None of these other procedures or innovations has demonstrated improved outcomes.

Antecedent strategies

In operant conditioning models, one can support behavior change through altering antecedents or consequences. Simply put, the principles involve evoking behavior (via antecedents), reinforcing behavior (via consequences), and repeating (Sandoz & Boone, 2016) through providing continued opportunities to practice. Antecedent control strategies involve the prevention of undesired behavior, or the evocation of adaptive behavior. In terms of supporting adaptive behavior, it’s always easier and faster to employ antecedent control strategies in a sensitive and responsive way. Antecedent control procedures, specifically, prompting, are also critical in the shaping of novel or complex behavior.

Two concepts from Vgotskyian psychology can be useful in putting antecedent control strategies into a developmental context and in supporting parents in finding natural opportunities within everyday life to shape behavior. These two concepts are the zone of proximal development and scaffolding. The zone of proximal development is the distance between a child’s independent developmental level—what he can do by himself—and the child’s developmental potential—what she can do with guidance from adults or collaboration with peers (Karimi-Aghdam, 2017).

The interaction with others, the interaction that allows a child to reach beyond their developmental level to their developmental potential, is called scaffolding. For example, if a parent is taking a young child on an airplane, he might prepare by playing games involving taking a trip on an airplane, talking through the rules immediately before getting onto the plane, and bringing plenty of toys and snacks. By doing so, the parent is scaffolding his child’s ability to be cooperative on the airplane, providing the necessary support so that the child can do something that she cannot do alone. Or, in the case of an adolescent, if a parent would like to have a challenging conversation about spending or excessive screen use, she might choose an environment and time of day in which the teen is most comfortable, and with some privacy, to initiate the talk so that it is more likely to be heard. Scaffolding can also involve providing verbal contingency to help bolster motivation: “Honey, just one more store—and then we can go get your favorite snack. I know you can do it.” This statement may serve as an SD for reinforcement, if the child persists. After all, context matters, and so does the child’s current emotional and motivational state.

Scaffolding may include prompts, simplifying a task, breaking a task into steps, or providing just enough assistance. It is important that the scaffolding given is just enough that it allows the child to perform the behavior but does not involve the parent taking over from the child. An example of this comes from family-based treatment of child anxiety and OCD. Often, parents of anxious children accommodate their avoidance-based behaviors, and allow escape from anxiety-evoking situations. Thus family-based approaches teach parents to shape more approach-based behavior in the context of fear-eliciting situations. Often, because this is a new behavior for a child, scaffolding is needed: parents are taught to model this approach in the face of anxiety, to prompt by using encouraging words, and to engage in verbal behavior that supports the child’s self-efficacy, even when frightened (Freeman et al., 2008).

There are a number of ACT techniques that constitute antecedent strategies, especially with regard to employing augmentals. As mentioned previously, a value, a core component of ACT, is a type of motivative augmental. For example, if a parent has the goal of using verbal praise consistently, but is finding it difficult because she is feeling overwhelmed or exhausted, a clinician might encourage a parent to touch upon their values to support effective action. The clinician might frame giving consistent verbal praise in the context of the parent’s values by saying “Praising Rex’s sitting down to do his homework, and staying on task, is a step toward shaping better harmony in your family.” In addition, the ACT skills of present moment awareness and flexible perspective taking may be used to bring into awareness particular antecedents that may be helpful as SD for sensitive and responsive parenting behavior. That is, with psychological presence in the present moment and flexible perspective taking, parents can better track aspects of their child’s behavior or the wider context, that signal which parenting behavior might be most effective in that moment (SD). Parents may notice, for example, that as they are in public and their adolescent’s friends are present, that now is not the best time to praise their child as their child will be likely to find that embarrassing and unpleasant.

In addition, the same ACT skills can support parents in noticing their own intentions in a particular moment, to reconnect with their parenting values before responding and to notice the thoughts, feelings and behavioral tendencies that arise due to their own learning history without immediately acting on them. For example, a parent with a history of pregnancy or infant loss might notice a rising feeling of anxiety as they watch their toddler boldly exploring the playground and confidently approaching the big slide. The parent may notice the rising feelings of anxiety, and the behavioral tendency to “protect” their child by curtailing their exploration, and, at the same time, make a rational risk assessment, and in the service of supporting the child’s exploration, refrain from bringing the child’s exploration of the big slide to an end. Instead, the parent might decide that standing close enough to catch in the event of a fall is protection enough, and choose to do so while actively expressing delight and pride in their toddler’s achievements (and while also accepting the ongoing feeling of anxiety as it waxes and wanes).

Operant Conditioning

The operant conditioning formulation proposed byFordyce (1976, 2000) has contributed substantially to our understanding of chronic pain and has had a significant impact on treatment and rehabilitation. The operant model distinguishes between the private pain experience and observable and quantifiable pain behavior (i.e., overt communications of pain, distress, and suffering such as moaning, grimacing, or intake of medication). It is such behavior rather than pain per se that is assumed to be amenable to behavioral assessment and treatment.

The operant conditioning model proposes that acute pain behavior may come under the control of external contingencies of reinforcement and thus develop into a chronic pain problem. Pain behavior may be positively reinforced (e.g., by attention from a spouse or health care providers). Pain behavior may also be maintained by the termination of unpleasant states, such as a reduction in pain level by analgesic medication or inactivity or the avoidance of undesirable activities such as work or unwanted sexual activity (negative reinforcement). In addition, “well behavior” (e.g., functional activities, including working, homemaking activities, and self-care) may not be sufficiently reinforcing, and the more rewarding pain behavior may therefore be maintained (i.e., punishment type 2).

These principles suggest that if behavior signaling pain results in positive consequences or the removal of negative consequences, this pain behavior will increase in frequency. The patient may receive attention (often sympathy) and may be relieved of responsibilities when such behavior is emitted. Complaining leads to increased attention and efforts to provide assistance, thereby positively reinforcing patients’ pain complaints. Health care providers may provide analgesic medication in response to pain behavior, and medication then becomes contingent on pain. Thus, patients’ complaints and other behavior have a powerful ability to elicit responses from others. For example,Turk and Okifuji (1997) showed that physicians prescribe opioid medication based on patients’ complaints and patients’ reports of the cause of their symptoms, not on the basis of the presence of actual physical pathology. These results were replicated byMartell and colleagues (2007). Attention and legitimized abdication of responsibility are potentially rewarding experiences. Consequently, the pain behavior originally elicited by organic factors may come to be controlled totally or in part by reinforcing environmental events.

Similar to respondent pain, in which pain behavior is first directly related to the presence of antecedent nociception (and only later dependent on CSs), operant pain (i.e., pain behavior) occurs originally as a consequence of acute pain stimuli. Later, pain behavior may be emitted in the absence of nociception. Specifically, the operant conditioning model suggests that maintenance of pain behavior may occur through a process of reinforcement and operant or instrumental learning. The model does not directly concern itself with pain since pain is not directly observable, but rather with the overt manifestations of pain, distress, and suffering. Because of the consequences of specific behavioral responses, it is proposed that pain behavior may persist after the initial cause of the pain is resolved or greatly reduced. In a classic or respondent conditioning model, anticipation of nociception or fear of injury may be factors that maintain the maladaptive behavior, whereas in the operant model, receipt of positive and avoidance of or escape from negative reinforcers serve to maintain the maladaptive pain behavior. The respondent approach focuses on pain-eliciting stimuli; the operant approach is centered on pain-related responses.

Conclusion

Drawing upon theories of operant conditioning and social learning, behavioral approaches to the treatment of DBDs in young children have demonstrated great success (Dretzke et al., 2009). Evidence-based BPT programs in particular are dominant in this arena, with many weaving together early influences of Hanf’s two-stage model and Patterson’s coercive process. The five well-supported BPT models described in this chapter, PCIT, HNC, Triple P, IY, and PMT-O, harness the power of the family environment to create change in the caregiver–child relationship. PCIT, in particular, employs an innovative use of technology, principles of play therapy and attachment theory, parallel therapeutic processes, the idea of over-practice, and a data-focused, mastery-based treatment progression to achieve its impressive effects at reducing disruptive behavior and improving the caregiver–child relationship. Continued study, particularly in the areas of dissemination and implementation, a common elements approach, and client attrition is needed to ensure that these effective treatments are available to the children and families who need them most.

Operations for the hand and fingers

Dual Conditioning Models

A combination of classical and instrumental conditioning was described by O.H. Mowrer (1947) as a ‘two factor theory’ of learning. Mowrer observed that animals (and humans) learn to respond based on both stimulus–stimulus relationships (i.e. classical conditioning) and stimulus–response–consequence relationships (i.e. instrumental conditioning). Twenty years later, D'Amato et al. (1968) elaborated the two factor model and applied it specifically to the learning of avoidance behavior. D'Amato and colleagues observed that animals learn to avoid both stimuli that elicit anticipatory anxiety as well as those that signal objective danger and that their avoidance behavior was associated with negative reinforcement resulting from a reduction in anticipatory anxiety as well as in objective danger.

An additional extension of conditioning theories of particular relevance to PTSD is provided by Bouton's (2002) research with animals on mechanisms of a second form of learning related to fear: extinction. Bouton observed that animals do not ‘un-learn’ or ‘forget’ fear established by classical conditioning, but they can learn that a stimulus that previously was associated with danger no longer signals an actual threat. For example, if rodents repeatedly experience an unpleasant shock to their feet preceded by a particular sound or light and they will tend to show signs of fear by ‘freezing’ behaviorally and of avoidance if they are able to terminate or escape the shock by doing certain behaviors that signal that the shock will not occur. If the avoidance behavior is prevented and a new series of experiences occurs repeatedly in which the warning signal occurs and is not followed by the shock, the animal may learn that the former warning signals no longer indicate imminent danger and may cease to ‘freeze’ when those signals occur. This new learning, that what formerly signaled danger no longer does so, is extinction. Bouton also noted, however, that extinction learning is easily reversed under several circumstances: the conditioned fear (‘freezing’ behavior) may resume when the warning signal occurs if: (a) a period of time passes without any exposure to the warning signal (‘spontaneous recovery’); (b) the animal's environmental context changes, particularly in ways that are similar to the context in which the original fear conditioning took place (‘renewal’); (c) the shock is administered again, whether preceded (‘reacquisition’) or not (‘reinstatement’) by the warning signal.

Applied to PTSD, the dual conditioning models suggest the hypothesis that PTSD symptoms involve both classically conditioned anxiety (i.e. distress elicited by stimuli associated with memories or reminders of traumatic experiences) and instrumentally conditioned avoidance (i.e. negative reinforcement as a result of relief from PTSD memories and stress reactions; Foa and Kozak, 1986). Further, recovery from PTSD requires new learning that reminders or memories of the traumatic event are tolerable and need not be avoided – i.e. extinction of the learned fear. The PTSD treatment models with the strongest evidence of efficacy were derived initially from these animal research dual conditioning models of PTSD (see Chapters 7 and 8Chapters 78).

Operant Conditioning Procedures

The mobile conjugate reinforcement procedure is an operant conditioning task that was originally developed by Carolyn Rovee-Collier (Rovee and Rovee, 1969). In this task, infants learn to kick their foot to produce movement in an overhanging mobile, which is attached to their foot by a ribbon. The term “conjugate reinforcement” refers to the fact that the rate and vigor of reinforcement (i.e., movement in the mobile) is directly proportional to the rate and vigor of the infants responding (i.e., kicking). In other words, the more or harder the infant kicks, the more the mobile moves.

Infants are typically trained in the mobile procedure in two 15-min sessions that take place on consecutive days. During each session, infants are placed on their back in their crib and a mobile is suspended from a flexible mobile stand. Each training session begins with a period of nonreinforcement (see Fig. 3, left panel). During this period, a ribbon is tied around the infant's ankle, but rather than being attached to the active mobile stand, it is attached to an empty mobile stand. In this way, the mobile is visible to the infant, but kicks do not produce movement in the mobile. The purpose of this nonreinforcement phase is to measure the infant's baseline kick rate, before the contingency between foot kicks and mobile movement is introduced. Following this baseline phase, there is a period of reinforcement. During this phase, the ribbon is attached to the stand containing the mobile, and the infants' kicks produce movement in the mobile (see Fig. 3, center panel). Each training session ends with another brief period of nonreinforcement. During this period, the ribbon is again attached to the empty mobile stand, and infants do not receive reinforcement for foot kicks. The period of nonreinforcement at the end of each session provides a measure of immediate retention. Learning in the mobile conjugate reinforcement paradigm is operationally defined as a kick rate that exceeds the baseline kick rate by a factor of 1.5 during two out of any three consecutive minutes of reinforcement. A number of studies have shown that infants as young as 3 months meet or exceed this kick rate within the first session of training (see Fig. 3, right panel).

The mobile conjugate reinforcement paradigm can be used to study memory simply by inserting a delay between the end of the final training session and the beginning of the test that is scheduled days or weeks later. Memory in the mobile conjugate reinforcement task is assessed during another period of nonreinforcement at the outset of the test session. Retention is inferred on the basis of two relative response measures. First, the baseline ratio expresses the degree to which the infant's kick rate during the test exceeds his or her kick rate prior to learning. Memory is typically inferred if the baseline ratio is significantly greater than 1.0. Second, the retention ratio expresses the degree to which the infant's kick rate during the test matches his or her kick rate at the end of training, prior to the retention interval. Retention ratios that approach 1.00 indicate that little or no forgetting has occurred over the delay.

Although the mobile conjugate reinforcement task is suitable for use with infants from 2 to 6 months of age, it is necessary to adjust the task to account for age-related changes in motor skill and speed of learning. Because they are more likely to roll over during the training and test sessions, 6-month-old infants are placed in an infant seat during each session. Furthermore, the duration of the training sessions varies slightly as a function of age. For example, while 3-month-old infants are typically trained in two sessions that are 15-min in duration, 6-month-old infants only require 6-min training sessions to learn the same task, so their training sessions are typically abbreviated.

Research conducted using the mobile conjugate reinforcement paradigm has clearly documented that the duration of infant memory increases linearly as a function of age (Hartshorn et al., 1998b). For example, 2 month olds exhibit memory for 1 day, 3 month olds exhibit memory for 8 days, and 6 month olds exhibit memory for 14 days (see Fig. 4, open circles). The duration of retention in an analogous task, the train task, continues to improve over the next 12 months.

Although infants eventually forget in the mobile conjugate reinforcement paradigm, Rovee-Collier and her colleagues have shown that the memory may still be retrieved and expressed if infants are exposed to a brief reminder treatment prior to the test. In the initial demonstration of this phenomenon, Rovee-Collier found that when 3-month-old infants were briefly exposed to the moving mobile 24 h prior to the test, forgetting was alleviated after a 2- to 4-week delay (Rovee-Collier et al., 1980). During the reminder treatment, infants were placed in an infant seat to restrict movement of their legs. During the test, however, infants were again placed supine in the crib. In the absence of a reminder treatment, infants did not kick during the test; when infants were given a reminder, their kick rate during the test was virtually identical to their kick rate at the end of the final training session 2 to 4 weeks earlier. Furthermore, infants continued to exhibit memory in the task for several days after the reminder treatment.

Subsequent research has shown that if 6-month-old infants are given a 2-min exposure to the moving mobile 20 days after the conclusion of training, they also exhibit retention when tested 24 h later (Hill et al., 2004), and will continue to remember for 14 days (Hildreth et al., 2003), the same length of time that 6 month olds typically remember the task in the first place. Taken together, these studies show that although forgetting occurs very rapidly at 3–6 months of age, the memory is not always permanently lost and, given the appropriate conditions, the memory can be restored, allowing infants to profit from their prior experiences over very long delays.

Research using the mobile conjugate reinforcement paradigm has also shown that young infants form remarkably detailed memories of the mobile that is present during training as well as detailed memories of the context in which training occurs. Studies in which researchers have manipulated aspects of the mobile or the testing environment have shown that relatively small changes in the cues that are available at retrieval will disrupt infants' memory for the mobile task. For example, 3- to 6-month-old infants will not exhibit retention if they are trained with one mobile and tested with a different mobile (Hayne et al., 1986). In fact, at 2 and 3 months of age, memory for the mobile is so specific that infants do not exhibit retention if more than one out of the five objects that make up the mobile is changed during the test.

Memory performance by 3–6 month olds is also highly context-specific; memory retrieval is impaired if aspects of the incidental learning environment are changed between training and the test. Rovee-Collier has shown that infants do not exhibit retention if they are trained in one room of their house but are tested in another (Hayne et al., 1991), or if they are trained in the presence of one distinctively colored crib bumper but are tested with a different crib bumper (Borovsky and Rovee-Collier, 1990). These results suggest that young infants encode a considerable amount of detail about the mobile and the testing environment, however, the specificity of the memory representation prevents infants from generalizing their memories if aspects of the cue or context are manipulated. In the end, the highly specific nature of infants' memories may actually work against them because, in the real world, cues and contexts rarely occur the exact same way twice. As we will see below, a major hallmark of memory development during the second year of life is an increase in the flexibility of memory retrieval.

Cues

Through associative learning processes (e.g. classical and instrumental conditioning), cues/stimuli which often co-occur with alcohol and drinking episodes can become conditioned stimuli, alerting the individual to the possible availability of alcohol. These cues, e.g. the sight of a local bar or a bottle of your favorite wine on a shop shelf, can trigger alcohol seeking and consumption independently of the pharmacological effects of alcohol (e.g. priming). A variety of studies have shown that the opioid system may be important in cue-induced alcohol behavior. Animals can show a conditioned place preference (CPP), for environments that have previously been associated with alcohol and its effects. Lesions of the β-endorphin fibers innervating the nucleus accumbens can facilitate the extinction of the CPP when animals are placed in the environment in an alcohol free state. Opioid antagonists (e.g. naltrexone) can reduce cue-induced relapse in animals (Liu & Weiss, 2002) and can increase periods of abstinence in humans (O'Malley et al., 1992). Dopamine has also been implicated in this area. In humans, reduced DA-D2 receptors have been associated with increased neural activation within the anterior cingulate and regions of the prefrontal cortex in response to alcohol (compared with control) stimuli. Additionally, correlations were found between decreased DA-D2 receptors and reported craving in detoxified AUD patients, and craving was predictive of relapse risk (Heinz et al., 2004, 2010). Imaging studies have shown that, compared with control cues, alcohol cues trigger greater activity in the anterior cingulate, medial prefrontal cortex and putamen in AUD patients relate to controls. Interestingly, the degree of activation in these areas predicted craving and was positively related to alcohol intake when patients relapsed, even though craving was not (Grusser et al., 2004).These areas have also been highlighted as important in other substance-induced relapse (e.g. cocaine) as well as the basolateral amygdala (BLA), the hippocampus, and the core of the nucleus accumbens (Stewart, 2008).

Behavioral psychology, with its subsets of behavior modification and operant conditioning, is a field that is ripe for use and abuse in the realm of violence, peace, and conflict. Perhaps the least subtle or most ‘directive’ of all the fields of psychology, in its purest form behaviorism rejects all cognitive explanations of behavior and focuses on studying and modifying observable behavior by means of systematic manipulation of environmental factors. In its application, behavior modification and other aspects of the behavioristic approach are generally considered best for use on animals and children (who tend not to resent or rebel against such overt manipulation as reinforcers and token economies), and for the preparation of individuals to react immediately and reflexively in life-threatening situations such as: children in fire drills, pilots repetitively trained to react to emergencies in flight simulators, and law enforcement and military personnel conditioned to fire accurately in combat situations.

Learning to Imitate by Operant Conditioning

Skinner proposed that imitation is simply a special case of operant conditioning where the stimulus and response happen to match. He noted that pigeons can be conditioned to peck a key when they see other pigeons peck. If a pigeon (P-1) pecks a key and an observer pigeon (P-2) is reinforced with food for pecking upon seeing this event, P-2 will eventually be shaped to peck when seeing P-1 pecking. Note that P-2 did not produce this act because it was motivated to match the other animal's behavior. All that has happened is that the behavior of P-1 became a discriminative cue for eliciting a conditioned response in P-2. P-2 could be conditioned to perform a mismatched act just as easily. The similarity of the stimulus and response plays no role.

Strong operant conditioning theorists hold that there can be no infant imitation without a prior period of shaping that binds the discriminative cue to the response. For example, when a young infant sees a mother perform a simple act such as shaking a rattle, the infant at first does not know what movements to use to copy this act. Rather, the parent needs to shape the child's response through operant conditioning. Mom shakes the rattle, and the infant responds with random motor acts. Mom selectively reinforces those acts that are similar to her own shaking movements. Over time, the mother's motions come to serve as a discriminative cue (a red light would do as well) that elicits the reinforced act (the baby's rattle shaking).

Infants and young children may learn certain acts in this way, but there are two drawbacks to this theory as a complete account of imitation. First, it cannot easily explain the imitation of novel acts—acts that the caretakers have not explicitly shaped up. Second, most ethnographic reports of parent–child interaction do not report the type of extensive shaping procedures needed to account for the range of acts infants and young children can imitate.