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RESEARCH ARTICLE
An Evaluation of “Balance”: a Home-Based, Parent-ImplementedProgram Addressing Emerging Problem Behavior
Kelsey W. Ruppel1,2 & Gregory P. Hanley1,2 & Robin K. Landa1,3 & Adithyan Rajaraman1,4
# Association for Behavior Analysis International 2020
AbstractPrograms that prevent the development of severe problem behavior in young children with autism spectrum disorder (ASD) arecritically needed. We describe a program designed to do this, and we report on a preliminary evaluation of its effects with four 3-and 4-year-old children with ASD. Parents served as the primary implementers, with twice-weekly coaching from a BoardCertified Behavior Analyst. Direct measures and Aberrant Behavior Checklist scores reflected decreases in emerging problembehavior. Direct measures also reflected increases in child communication, social, and cooperation skills, and parents rated theprocess as highly acceptable. A randomized controlled trial will be required to evaluate the extent to which the program preventsthe development of problem behavior in young children with ASD.
Keywords autism . early intervention . parent training . prevention . problem behavior
The average age at an autism spectrum disorder (ASD) diagnosisin the United States is 4 years 4 months (Centers for DiseaseControl and Prevention, 2019), and research focuses on ever-earlier identification (e.g., English, Tenenbaum, Levine, Lester,& Sheinkopf, 2019; Franchini et al., 2018). The AmericanAcademy of Pediatrics recommends early intervention servicesas soon as ASD is suspected (American Academy of Pediatrics,2014; Myers & Plauché Johnson, 2007). A critical function of
these services would seem to be preventing the development ofsevere problem behavior, given that it is more common in chil-drenwithASD than in typically developing children and childrenwith other disabilities (American Psychiatric Association, 2013;Bodfish, Symons, Parker, & Lewis, 2000; Farmer & Aman,2011; Mayes et al., 2012). However, most early intensive behav-ioral intervention outcome studies report little or no data on prob-lem behavior (Smith & Iadarola, 2015). To our knowledge, noprograms from any discipline have empirically demonstrated theprevention of severe problem behavior in children with ASD.
However, there is research suggesting the potential utility ofcertain procedures. The Preschool Life Skills Program (Hanley,Heal, Tiger, & Ingvarsson, 2007) focuses on systematically andexplicitly teaching children how to respond to challenging situa-tions they are likely to encounter in daily life. Target skills in-clude responding to name calls, functional communication,responding calmly to delays and denials, following instructions,and interacting with peers. It has been demonstrated to preventthe development of problem behavior in typically developingchildren (Luczynski & Hanley, 2013). The Preschool LifeSkills Program also reduces existing problem behavior andstrengthens social skills in typically developing preschoolersand children with developmental disabilities (Fahmie &Luczynski, 2018; Gunning, Holloway, & Healy, 2019;Gunning, Holloway, & Grealish, 2020; Robison, Mann, &Ingvarsson, 2020). No published studies have evaluated its pre-ventive effects for children with developmental disabilities.
Research Highlights• Parents served as the primary implementers of a skill-building package,resulting in child cooperation with multistep tasks following denial of afunctional communication response.
• Rates of problem behavior decreased among all participants.• Behavior analyst support occurred for 2 hr per week, making this packagepotentially useful where service availability is limited.
• Evaluation of the preventive effects of this package on the development ofsevere problem behavior in children with autism seems warranted.
* Kelsey W. [email protected]
1 Psychology Department, Western New England University,Springfield, MA, USA
2 Present address: FTF Behavioral Consulting, 40 Southbridge St.,Suite 202, Worcester, MA 01608, USA
3 Present address: May Institute, Worcester, MA, USA4 Present address: Psychology Department, University of Maryland,
Baltimore County, Baltimore, MD, USA
https://doi.org/10.1007/s40617-020-00490-3
Published online: 8 February 2021
Behavior Analysis in Practice (2021) 14:324–341
However, given the program’s preventive effects for typicallydeveloping children and its intervention effects for children withdevelopmental disabilities, this seems a logical next step forresearchers.
Recent research outside of that investigating the PreschoolLife Skills Program suggests some additional components thatmight enhance its effects for children with ASD. Comparativeresearch suggests that synthesized reinforcers (e.g., escape fromwork to tangibles, attention, and sensory reinforcement) producestronger treatment effects than isolated reinforcers (e.g., escapeonly or praise only; Slaton & Hanley, 2018; Slaton, Hanley, &Raftery, 2017).1 Indeed, research has shown that synthesizedreinforcers delivered continuously at first, then intermittentlyand unpredictably, establish social skills to the exclusion of prob-lem behavior in individuals with ASD (e.g., Beaulieu, VanNostrand, Williams, & Herscovitch, 2018; Falcomata, Roane,Muething, Stephenson, & Ing, 2012; Falcomata, Muething,Gainey, Hoffman, & Fragale, 2013; Greer, Fisher, Saini,Owen, & Jones, 2016; Hanley, Jin, Vanselow, & Hanratty,2014; Herman, Healy, & Lydon, 2018; Jessel, Ingvarsson,Metras, Kirk, & Whipple, 2018; Rose & Beaulieu, 2019;Santiago, Hanley, Moore, & Jin, 2016; Strand & Eldevik,2017; Taylor, Phillips, & Gertzog, 2018). Therefore, the effectsof the Preschool Life Skills Program might be enhanced by in-corporating synthesized, personalized reinforcers to shape skills.
This synthesized, personalized reinforcement interval couldbe thought of as a child-led playtime (see also Luckett, Bundy,& Roberts, 2007). A prevention program might begin bytargeting adult–child interaction during child-led play to createthe most reinforcing context possible for the child. Access to thiscontext could then be delivered contingent on the demonstrationof target skills during the remainder of the program.
The Preschool Life Skills Programmight also be enhanced bythe addition of an emphasis on developing a balance betweenchild- and adult-led activities. The National Association for theEducation of Young Children (NAEYC) recommends bothchild- and adult-led experiences (NAEYC, 2009), and yet accessto both types of experiences might be limited for children withASD. Research suggests that adults avoid adult-led activities withchildren with a history of uncooperative behavior (Carr, Taylor,& Robinson, 1991). At the same time, the quality of child-ledexperiences might be routinely compromised due to commontreatment recommendations. For example, caregivers are oftenencouraged to embed teaching into play activities for childrenwith ASD, but research suggests that childrenmay not prefer this,and that embedded teaching can even punish some children’splay (Heal & Hanley, 2011; Heal, Hanley, & Layer, 2009).Therefore, separating child- and adult-led activities and striking
a balance between the twomight improve the quality of both andensure that children access important learning opportunities.
This general framework of child-led time and adult-led time isused in other programs, such as parent–child interaction therapy(Masse, McNeil, Wagner, & Chorney, 2007). Parent–child inter-action therapy is a treatment program typically usedwith childrenwith significant, existing behavior problems. Although re-searchers have begun to experimentally evaluate its use withchildren with ASD (e.g., Ginn, Clionsky, Eyberg, Warner-Metzger, & Abner, 2017; Scudder et al., 2019; Solomon, Ono,Timmer, & Goodlin-Jones, 2008), no prevention studies havebeen published. In fact, we suspect that theremay be componentsimportant to preventing the development of problem behavior inchildren with ASD that are not included in parent–child interac-tion therapy, such as the explicit teaching of functional commu-nication and tolerance for request denials (Ala’i-Rosales et al.,2019; Fahmie, Iwata, &Mead, 2016).We also suspect that somecomponents that are included may not be optimal for childrenwith ASD, such as the recommendation that parents model, ex-pand, describe, and imitate during child-led time (Ginn et al.,2017; Masse et al., 2007; Scudder et al., 2019). These couldpresent as demands to children with ASD, decreasing the qualityof the child-led time and potentially evoking problem behavior.
Therefore, we developed a program that is the subject of thecurrent study—a home-based, parent-implemented program spe-cifically designed to prevent the development of severe problembehavior in children with ASD. It is based on the Preschool LifeSkills Program, with modifications based on recent research (i.e.,synthesized reinforcement, a focus on balance between child-and adult-led activity). Given this emphasis, we call it the“Balance Program.” It also contains modifications to make itaccessible to children not receiving intensive early interventionservices: The primary interventionists are parents, with 2 hr ofBoard Certified Behavior Analyst (BCBA) support per week,and teaching occurs in the home.
In this preliminary investigation, we evaluated the effects ofthe Balance Program using a single-subject experimental design,and we report on direct and indirect measures of emerging prob-lem behavior and direct measures of communication, social, andcooperation skills. We also report on procedural integrity, theamount and distribution of teaching and support required toachieve the observed outcomes, and the social validity of thegoals, procedures, and outcomes. Evaluating the preventive ef-fects of the Balance Program will necessitate a randomized con-trolled trial, and the present study is a precursor to such an effort.
Method
Participants
Participants were four young children and their primary care-givers (see Tables 1 and 2). Child inclusion criteria were are
1 Studies calling synthesized reinforcers into question have not included compar-ative treatment phases (Fisher, Greer, Romani, Zangrillo, & Owen, 2016; Greer,Mitteer, Briggs, Fisher, & Sodawasser, 2019), permitting the conclusion that iso-lated and synthesized functional analyses may produce different results but pre-cluding conclusions about the comparative treatment utility of those results.
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follows: (a) between 3 and 6 years old, (b) diagnosed withASD by an outside evaluator within the last year, (c) livingat home, and (d) reported by parents to engage in frequentuncooperative behavior or nondangerous problem behaviorthat appeared to be socially mediated.
We recruited participants by distributing flyers to local ser-vice providers, with the request that they offer them to familiesof young children recently diagnosed with ASD. The first au-thor screened respondents using the inclusion criteria. For thefourth criterion, the researcher asked the parent whether thechild exhibited any uncooperative or problematic behaviors,and if so, to describe the topographies, frequency, intensity,and situations in which they tended to occur. Children wereincludedwhen parent report suggested “emerging” socially me-diated behavior problems. An “emerging” behavior problemwas defined as the parent-reported daily occurrence of uncoop-erative behavior or nondangerous problem behavior. If parentsreported the occurrence of severe problem behavior (i.e., self-injury, pica, elopement, aggression resulting in injury to others,or behavior that resulted in observable damage to property),2 orif parent report suggested automatic reinforcement, we referredthe child to other programs within our clinic.
Although our participants were not referred for dangerousproblem behavior, their parents nevertheless reported that theemerging problem behavior had adverse effects on the family.Parents had difficulty running errands, completing householdtasks, and caring for siblings, and some reported persistentfamily conflict and/or mental health concerns related to par-enting issues.
Three master’s-level BCBAs participated, all of whomwere enrolled in a behavior-analytic doctoral program at thetime of the study and were supervised by the second author, adoctoral-level behavior analyst. One BCBA completed allvisits for a family.
Overview
The Balance Program was designed to fit within existing ser-vice systems for children with ASD. Practice guidelines forthe behavior-analytic treatment of ASD include at least 2 hrper week of case supervision by a BCBA (The Council ofAutism Service Providers, 2020). Therefore, the BalanceProgram involves two 1-hr visits by a BCBA per week, withthe recommendation that parents practice at least five trialswith their child twice daily between visits. To promote childskill acquisition and provide parents with immediate rein-forcement for their teaching efforts, we asked parents to teachin short, circumscribed practice sessions with short intertrialintervals (Francisco & Hanley, 2012) early in the program.We specifically suggested that they not attempt to teach allday or embed the trials in typical routines until Step 10. Tominimize demands on parents, we did not ask them to collectdata on practice sessions. We anticipated that it would beapparent from the child’s responding at the start of the nextvisit whether high-quality practice had occurred betweenvisits, and we planned to continue practicing with the parentand child at the current level until performance criteria weremet (see Appendix D).
We conducted assessments during the first and secondvisits. During subsequent visits, the BCBA taught the parentto teach the child a skill (see Tables 3 and 4). Followingmastery of all skills, there was a break of at least 1 month,after which follow-up was conducted.
2 Severe problem behavior is sometimes observed in children under 5. Forexample, Kurtz et al. (2003) reported on 30 children’s self-injury. The meanage was 2 years 9 months, and all produced tissue damage; 83% engaged inhead banging (see also Kurtz, Chin, Huete, & Cataldo, 2012). Children whoengaged in such behaviors were not eligible for the current study, given thepreventive focus of the program.
Table 1 Child characteristics
Name Age(yr:mo)
Sex Diagnosis Race/ethnicity Languagelevela
EPB Tasks
Walt 4:3 M ASD White 3 Whining, yelling, hitting Cleaning up, putting on outerwear, sharing withbrother, listening to story
Jaden 4:7 M ASD White 4 Yelling, throwing,b kicking air,stomping, squeezing parent’s face
Cleaning up, handwriting, putting on outerwear,making bed, brushing teeth
Max 4:1 M ASD White 4 Whining, yelling, throwing,b
flopping, verbal attacksCleaning up, putting on particular clothes,
playing parent-selected game, playing alone
Kelly 3:3 F ASD Black/AfricanAmerican
1 Whining, kicking air, pushingitems/people away, flopping
Cleaning up, listening to story, early VB tasks,playing alone
Tasks include those used in baseline and Steps 6 and thereafter; yr, years;mo, months;ASD, autism spectrum disorder;EPB, emerging problem behavior;VB, verbal behaviora 1 = nonverbal; 2 = one-word utterances; 3 = short disfluent sentences; 4 = full fluencyb This included small/lightweight items, such as socks or game pieces, not in the direction of another person
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Setting and Materials
BCBA visits were conducted in one room in the partic-ipants’ homes until Step 10, at which point skills werepracticed throughout the home. All materials originatedin the participants’ homes, except for video equipment,
program-related written materials, and empty bins, whichthe BCBA provided. Items related to child- and adult-ledactivities were identified via interview and sorted intotwo bins of the same size (approximately 30 cm3 or60 cm × 40 cm × 30 cm). Parents were not asked toobtain any new items for the program.
Table 2 Parent characteristics
Childname
Participatingcaregivers
Race/ethnicity Primarylanguage
Highest education Employment Otherchildren
Training/professionalexperience—early childhood
Walt Mother, mother White English College degree,postgraduate degree
Full time outsidehome
1 No
Jaden Mother, father White English College degree, highschool degree
Full time outsidehome
0, 1 Yes (general), no
Max Mother White English Some college Not employedoutside home
1 No
Kelly Mother Black/AfricanAmerican
English College degree Full time outsidehome
2 Yes (general)
ForWalt and Jaden, when a column contains one response, it applies to both parents. When a column contains two responses separated by a comma, oneresponse pertains to each parent
Table 3 Objectives by teaching steps
Parent objective Child objective Selected references
Teachingprocess
1 Present no EOs forEPB.
Play in the absence of EPB. Ghaemmaghami, Hanley, Jin, & Vanselow, 2016; Hanley et al., 2014 &repl.; Heal et al., 2009; Heal & Hanley, 2011; McLaughlin & Carr, 2005;NAEYC, 2009
2 Shape responding toname.
Stop, look, say “yes” toname call.
Beaulieu, Hanley, & Roberson, 2012, 2013; Beaulieu & Hanley, 2014;Everett et al., 2005; Hamlet, Axelrod, & Kuerschner, 1984; Hanley et al.,2007 & repl.; Kraus, Hanley, Cesana, Eisenberg, & Jarvie, 2012; Milleret al., 2017
3 Shape functionalcommunication.
Emit part of request. Carr & Durand, 1985; Ghaemmaghami, Hanley, Jin, & Vanselow, 2016;Hanley et al., 2007 & repl.; Hanley et al., 2014 & repl.; Horner & Day,1991; Reeve & Carr, 2000
4 Teach completerequest.
Emit complete request. Ghaemmaghami, Hanley, Jessel, & Landa, 2018; Hanley et al., 2007 & repl.;Hanley et al., 2014& repl.; Hernandez, Hanley, Ingvarsson, & Tiger, 2007
5 Shape tolerance. Respond to denials calmly. Carr & Carlson, 1993; Fagen & Hill, 1987; Hanley et al., 2007 & repl.;Hanley et al., 2014 & repl.; Skinner, 1953
6 Shape cooperation. Follow 1–3 instructions. Ghaemmaghami, Hanley, & Jessel, 2016; Hanley et al., 2007& repl.; Hanleyet al., 2014 & repl.; Lalli & Casey, 1996; Piazza et al., 1996;Tarbox et al., 2007
Post 7 Shape persistence. Complete all steps of anactivity.
Hanley et al., 2007 & repl.; Hanley et al., 2014 & repl.
Generality 8 Practice with newinstructions.
Complete new activities. Stokes & Baer, 1977
9 Practice without bins. Demonstrate all skills withoutbins.
10 Practice during typicalroutines aroundhouse.
Demonstrate all skills duringtypical routines aroundhouse.
EO, establishing operation; EPB, emerging problem behavior; repl., replications
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Data Collection and Response Definitions
Data Collection
The primary dependent variables were emerging problembehavior, child-led play, responding to name, functionalcommunication, tolerance responding, and cooperation.Responses per minute were used to analyze emerging prob-lem behavior; percentage of opportunities correct was usedfor responding to name, functional communication, andtolerance responding; and percentage of 20-s whole inter-vals was used to analyze play and cooperation. Data werealso collected on parent integrity of the teaching proce-dures (see Appendix A), which are reported as a percentageof 20-s intervals in which no errors were made. A checklistwas used to measure each BCBA’s fidelity to the supportprocedures (see Appendix A). In baseline, all direct mea-sures were collected in 5-min sessions. In the teaching pro-cess, data were collected from one 5-min or 5-trial sessionat the start of each visit. In follow-up, data were collectedfrom one or two 5-trial sessions at the start of the visit. Allsessions were video-recorded and scored later.
Indirect measures included a semistructured parent inter-view called the Individualized Features of ReinforcementMeeting (InFORM; see Appendix B); the AberrantBehavior Checklist, Second Edition (ABC-2; Aman &Singh, 2017); and social validity assessments (seeAppendix C). The purpose of the InFORM, administeredduring the first visit, was to identify the materials and ac-tivities to be used during teaching. The ABC-2 is a 58-itemrating scale completed by parents/caregivers and often usedin evaluations of interventions for children with ASD out-side of behavior analysis (Kaat, Lecavalier, & Aman,2014). The ABC-2 was completed by each participant’sprimary caregiver at baseline and again after Step 10.Parents completed versions of the social validity assess-ment at baseline, after Step 10, and at follow-up.
Response Definitions
The definition of emerging problem behavior was individual-ized per child (see Table 1). Hitting was rarely observed and oflow intensity—that is, distinct from “severe problembehavior.”
Child-led play was defined as the child manipulating toy(s)and/or engaging in activity-related conversation with the care-giver in the absence of problem behavior. Responding to namedefinitions were individualized per participant but generallyinvolved stopping, looking toward the parent, and/or saying“yes.” Functional communication was defined as any instanceof a request for access to items or to play the child’s way, toescape or avoid items or parental instruction, or any combina-tion thereof, emitted in the absence of emerging problem be-havior. The topography of the functional communication re-sponse (FCR) taught was individualized for each child basedon the child’s language level. A tolerance responsewas definedas any instance of an explicit and calm response to a delay ordenial imposed by the parent (e.g., “OK”). Cooperation wasdefined as behaving in accordance with the adult instruction orexpectation in place at the time. For example, if the adult askedthe child to color and left the area, the expectation that the childcolor would be considered in place until the adult returned. SeeTable 1 for participant-specific tasks.
Interobserver Agreement
Interobserver agreement was evaluated by having a sec-ond independent observer review the video recordingsand collect data on all target behaviors at a separatetime from the primary data collector. Each session wasdivided into 20-s intervals. Interobserver agreement foremerging problem behavior was calculated by dividingthe smaller total number of occurrences by the largertotal number of occurrences in each interval, addingup the proportions, dividing by the number of intervals,
Table 4 Teaching procedures
Content Process Dosage
BCBA teachesparent
How to:Initiate trialsPrompt desired child responses & fade promptsDifferentially reinforce child responding
Written, vocal description and rationaleModelingPrompting, feedback as parent
practices with child
Two 1-hr visits/week
Parent teaches child How to:Respond to name callsEmit FCREmit TRCooperate with adult-led activities of
increasing length, diversity
Adult-initiated trialsPrompting:
Three step or wait outDifferential reinforcement:
Synthesized reinforcersIntermittent, unpredictable schedule
Two 1-hr visits/week with BCBAandTwo 5-trial sessions/dayindependently
BCBA, Board Certified Behavior Analyst; FCR, functional communication response; TR, tolerance response. See Appendix A for BCBA and parentimplementation integrity checklists
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and multiplying by 100. Interobserver agreement for allother measures was calculated by dividing the numberof agreements (intervals marked with the same symbolby both data collectors) by the number of agreementsplus disagreements, and then multiplying by 100.Interobserver agreement data were collected for at least20% of sessions across all conditions and participantsand averaged at least 86% (range 67%–100%) for allparticipants and all measures.
Design
Functional control by the independent variable over childemerging problem behavior and over parent teaching behaviorwas demonstrated using a nonconcurrent multiple-baselineacross-participants design. Functional control over child skills(responding to name, FCR, tolerance responding, and cooper-ation) was demonstrated via repeatedmeasures and replicationof the effects of the independent variable on multiple depen-dent variables across points in time. The effects of the packageon the balance between child- and adult-led time were inferredrather than demonstrated.
Procedures
Natural Baseline
The BCBA distributed the materials identified in the parentinterview and directed the parent to engage with the child asthey normally would. Two or three 5-min sessions were con-ducted. These data were used to assess the balance betweentime spent on child-led and adult-led activities, prior to anyinstruction to the parent in this regard.
Prompted Baseline
The BCBA instructed the parent to allow the child to play forabout half of the time and try to have the child complete tasksfor the other half of the time. No further prompts were given.Three to five 5-min sessions were conducted. These data wereused to evaluate the parent’s ability to create balance betweenchild-led and parent-led activities when specifically asked todo so, as well as to evaluate child behavior under theseconditions.
Teaching (Steps 1–10)
Following baseline, participants moved into the teaching pro-cess. Beginning with Step 1, the BCBA taught the parent toteach each skill outlined in Table 3. At least one visit wasdedicated to each step, with progression to the next step basedon parent and child performance (see Appendices for details).
Teaching Procedures The procedures by which BCBAstaught parents and parents taught children are outlined inTable 4. Before teaching began, the BCBA described twoprompting approaches—three-step prompting (verbal,model, physical prompt; e.g., Tarbox, Wallace, Penrod,& Tarbox, 2007) and a “wait-out” (parent delivers averbal instruction, removes tangibles unrelated to theinstruction, and waits for the child to follow theinstruction; Piazza, Moes, & Fisher, 1996). Parents wereasked to select the approach they preferred. Jaden’s,Max’s, and Kelly’s parents opted to use three-stepprompting. Walt’s parents opted to use a wait-out.
Each teaching step built on the previous ones such that thechild continued to practice and, intermittently, contact imme-diate reinforcement for all previously learned skills. The orderof trial types varied across sessions such that the response thatwould result in immediate reinforcement on each trial wasunpredictable (see Appendix D).
Posttest The data from Step 7 were considered the posttest. Atthis time, all the skills had been taught and the same contextualfeatures as in the baseline were present.
Generality Steps 8, 9, and 10 were considered generality steps,as they extended the process beyond that which was assessedin baseline. Step 8 involved introducing new activities, Step 9involved items kept in their regular locations (rather thanbins), and Step 10 involved practice in new areas of the homeand during natural routines.
Performance Criteria The teaching process was consideredcomplete following two consecutive sessions at Step 10 inwhich the child displayed (a) near-zero rates of emergingproblem behavior, (b) independent skills (responding toname, funct ional communicat ion, and toleranceresponding) in most opportunities, (c) cooperation andplay in most applicable intervals, and when parent- andchild-led times each composed roughly half of thesession.
Booster and Follow-Up
The BCBA conducted a booster session between 4 and 10weeks after the last Step 10 visit, depending on the family’savailability. The BCBA observed the parent and child practiceStep 10 and provided feedback as needed. The BCBA thenreturned later the same week to record a five-trial session ofStep 10. If the child’s performance met the criteria noted pre-viously, a second session was recorded during that visit. If not,the BCBA provided feedback, asked the parent to practicewith the child, and returned to record another session whenthe family’s schedule allowed.
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Modifications
Based on Max’s and Kelly’s performance and on feedbackfrom their parents, we made modifications for these partici-pants. These are detailed in Table 5. The reasons for the mod-ifications were different for the two children, leading us tomake different changes for each.
For Kelly, we attempted a set of modifications (marked as“Modif.” phase on Figure 5) that were unsuccessful, prior tothe successful modifications detailed in Table 5 and marked as“Express” on the figure. The unsuccessful modificationsconsisted of adding BCBA practice with Kelly in the home,returning to Step 2, and reinforcing only independent re-sponses. When these modifications did not yield the desiredrates of independent FCRs over six visits, we consulted withKelly’s mother to determine which skills she most wantedKelly to learn. She indicated the FCR and cooperation.Therefore, we developed a shortened version of the programcalled “Balance Express,” which omitted responding to aname call and tolerance responding.
Results
Summary
Figure 1 summarizes data for all participants. Black sym-bols represent performance given the standard program,and gray symbols represent Max’s and Kelly’s perfor-mance with their parents, in the home, following modifi-cations. For all participants, emerging problem behavior(top-left panel) decreased from the prompted baseline topostprogram (posttest, generality, and follow-up), evengiven balance between child- and adult-led times (top-right panel) and given that social skills and cooperation
were required (third and fourth panels on the left). Allparticipants played in the absence of emerging problembehavior for most child-led intervals in all conditions (sec-ond panel on the left), although an increase in play wasobserved with Jaden after teaching. Parental integrity tothe teaching procedures improved from the prompted base-line to postprogram for all participants, with more substan-tial improvements observed for Max’s mother followingmodifications to the program (bottom-right panel).
Emerging Problem Behavior
Individual participant data are displayed in Figures 2, 3, 4 and5. Figure 6 displays emerging problem behavior data from theprompted baseline and the first three steps of teaching for allparticipants, to highlight the multiple-baseline across-partici-pants design.
During the natural baseline, all participants except Waltemitted some emerging problem behavior. Jaden and Maxemitted it following certain parent actions during play (e.g.,when parents did not follow their instructions), and Kellyemitted it during her mother’s attempts to implement adult-led time. During the prompted baseline, all parents imposedsome adult-led activities, and all participants engaged in in-creasing (Walt, Jaden, Max) or stable (Kelly) rates of emerg-ing problem behavior. With the introduction of Teaching Step1, rates of emerging problem behavior decreased to zero ornear zero and remained below the baseline average throughoutthe teaching process and follow-up for all participants, exceptfor a few isolated spikes for Max and Kelly.
Play
Walt and Kelly engaged in play in the absence of emergingproblem behavior for 100% of the child-led time in baseline
Table 5 Modifications for Max and Kelly
Child Modifications Rationale Timing
Max (1) Moved to clinic-based practice:(i) BCBA practiced Steps 8, 9 with child
Parent collected treatment integrity dataParent & BCBA discussed scores
(ii) Parent practiced Step 9 with child & BCBA,then child alone
- Low child skill emission suggests need for more practice- Low parent-reported confidence suggests need for:
More modeling by BCBAPractice under more controlled conditions
After first follow-upphase
(2) Returned to home-based practice:(i) BCBA practiced Steps 9, 10 with child beforeparent did
(3) BCBA conducted parent education modules -Parent questions suggest need for additional education
Kelly (1) Added BCBA practice with child in home - Low child skill emission suggests need for more practice After Step 9 visits(2) Eliminated response to name and tolerance
response trials- Decrease in parent time for practice for family/personal
reasons
Note. BCBA, Board Certified Behavior Analyst. All BCBA-run sessions were conducted using the same procedures parents had used. Parent educationmodules consisted of didactic instruction and discussion only, without the child present, and are detailed in Appendix E
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(Figures 2 and 5, second panels). Jaden and Max engaged inplay for the entire child-led time, but their play was sometimesaccompanied by emerging problem behavior (Figures 3 and 4,second panels; black portions of the bars reflect play in theabsence of emerging problem behavior; gray portions reflect
the time in which play was permitted, but the child either didnot play or played while emitting emerging problembehavior). In Step 1, Jaden’s and Max’s play in the absenceof emerging problem behavior increased to 100%. All partic-ipants engaged in play for all or most of the allotted time
Figure 1 Summary Data for All Participants. Note. The baseline meanwas calculated from all sessions of the prompted baseline for all measuresexcept for “Balance,” which was calculated from all sessions of thenatural baseline. The posttest mean was calculated from all sessions ofStep 7. The generality test mean was calculated from all sessions of Steps
8, 9, and 10. The follow-up mean was calculated from all sessions offollow-up. Gray symbols (Max, Kelly) represent performance in thehome, with the parent as implementer, following modifications to thepackage
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across all teaching sessions and follow-up. Because there waslittle change in the quality of play from baseline to teaching,we characterize our participants as having had initially strongchild-led play skills.
Responding to Name
Walt’s and Max’s parents did not call their names duringbaseline, and Jaden’s and Kelly’s did so infrequently.Neither Jaden nor Kelly responded to these name calls.Responding emerged only following the introduction of Step
2. Across subsequent teaching steps and follow-up,responding generally remained high for Walt, Jaden, andMax. Kelly’s responding was more variable. Following thefirst set of modifications to Kelly’s program, responding im-mediately increased and became more stable; however, it be-came variable again following the reintroduction of Step 3.
Functional Communication
All caregivers attempted to restrict access to tangibles and/orplace demands during the prompted baseline, creating
Figure 2 Individual Data forWalt. Note. Numbers in bracketsrefer to teaching steps. Nat. =natural baseline; Prompt. =prompted baseline; Teach. Integ.= teaching integrity
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opportunities for children to emit requests to retain the tangi-bles and escape the demands. However, only Max did so inthe absence of problem behavior, and he only did so on oneout of four opportunities. Responding emerged for all partic-ipants in Steps 3 and 4. Walt and Jaden emitted FCRs in mostor all opportunities across subsequent steps. Max’s andKelly’s responding was variable until modifications weremade, at which time responding for both became high andstable and remained so across subsequent phases.
Tolerance Responses
Because participants emitted few or no requests usingwords in baseline, there were few explicit request denialsby parents and therefore few opportunities to emit a tol-erance response. Tolerance responding emerged follow-ing the introduction of Step 5 for Walt, Jaden, and Maxand in the third visit at Step 5 for Kelly. Respondingmaintained in most opportunities across subsequent steps
Figure 3 Individual Data forJaden. Note. Numbers in bracketsrefer to teaching steps. Nat. =natural baseline; Prompt. =prompted baseline; Teach. Integ.= teaching integrity
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for Walt and Jaden. Max’s responding was variable untilmodifications were made, at which time it became highand stable and remained so across subsequent phases.Kelly’s responding decreased following Step 7, and thetolerance response was not included in her modifiedprogram.
Cooperation
All participants engaged in some cooperation during baseline;however, it averaged less than 50% of requested intervals forall participants. Cooperation was targeted beginning in Step 6,and it increased forWalt, Jaden, and Kelly.Max’s cooperationwas variable but increased to consistently high levels follow-ing modifications.
At follow-up, Walt and Max emitted cooperation in allrequested intervals, and Kelly emitted cooperation in 95% ofrequested intervals. Jaden emitted cooperation in 100% of
requested intervals with his father but only in 29% of intervalswith his mother.
Balance
During the natural baseline, most of the time was spent inchild-led activity for all participants. During most promptedbaseline sessions, time was either allocated disproportionatelyto child- or adult-led activity. During Step 1, time was againallocated exclusively to child-led activity by design, but thisdecreased gradually across teaching steps for all participantsuntil follow-up, at which point child- and adult-led time wereallocated more equally.
Parent Integrity to Teaching Procedures
Parent integrity to the teaching procedures increased up-on the introduction of the teaching process for all
Figure 4 Individual Data forMax. Note. Numbers in bracketsrefer to teaching steps. At parentrequest, Step 4 (gain attention)was terminated prior to mastery.Nat. = natural baseline; Prompt. =prompted baseline; Teach. Integ.= teaching integrity; BCBA =Board Certified Behavior Analyst
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participants. It remained high for Walt’s, Jaden’s, andKelly’s parents across teaching and follow-up. ForMax’s mother, it decreased upon the introduction ofStep 2 and remained variable across teaching, althoughit was generally higher than in baseline. Following mod-ifications to the program, the level of teaching integrityincreased and variability decreased.
BCBA Integrity to Support Procedures
BCBA integrity to the support procedures was scored foran average of 17% of sessions (range 14%–22%) acrossall three conditions (baseline, teaching process, andfollow-up) for all participants and averaged at least93% (range 86%–100%).
Time Requirement
The entire process, from the InFORM through follow-up, re-quired 15 one-hour BCBA visits for Walt, 20 for Jaden, 59 forMax, and 56 for Kelly.
Aberrant Behavior Checklist–2
The results for each subsection of the ABC-2 are summarizedin Table 6, with raw scores appearing first and percentileranks3 in parentheses. According to the ABC-2’s authors, ascore in the 75th percentile or above suggests the need forintervention (Aman & Singh, 2017). At baseline, both of
3 Based on 1,036 parent ratings of children under the age of 6 with an ASDdiagnosis (Aman & Singh, 2017).
Figure 5 Individual Data forKelly. Note. Numbers in bracketsrefer to teaching steps. At parentrequest, Step 4 (gain attention)was terminated prior to mastery.Nat. = natural baseline; Pr. =prompted baseline; Teach. Integ.= teaching integrity; BCBA =Board Certified BehaviorAnalyst; Modif. = modification
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Walt’s parents rated his behaviors at or above the 75th per-centile for Hyperactivity/Noncompliance and InappropriateSpeech.Max’s mother rated his behavior at the 75th percentilefor Irritability. All participants’ parents rated behaviors in allthe other categories below the 75th percentile, supporting ourdesignation of the participants’ behaviors as “emerging” (rath-er than “severe”) problems.
The ABC-2’s authors state that generally, a reduction ofone standard deviation or more might be considered clinicallysignificant (Aman & Singh, 2017). Walt’s Parent A’s ratingsmet this criterion in the areas of Hyperactivity/Noncomplianceand Inappropriate Speech, and his Parent B’s ratings met thiscriterion in all areas except Stereotypic Behavior. Max’smother’s ratings met this criterion in the areas of Irritabilityand Stereotypic Behavior.4 By contrast, Jaden and Kelly didnot meet this criterion in any area. However, their baselineratings were lower (at or below the 50th percentile), makingthis outcome unsurprising. All participants’ raw scores im-proved by at least three points in at least one category, andnone worsened by the same amount.
Social Validity
All parents rated the goals of the program as very important(M = 6.9 on a 7-point Likert-type scale), the procedures as
highly acceptable (M = 7), and their comfort implementingthe procedures as high (M = 6.7). At Step 10 and follow-up,parent ratings of their satisfaction with the effects outside ofBCBA visits varied across participants (M = 5.6, range 3–7).Generally, Walt’s and Jaden’s parents rated themselves asmore satisfied than Max’s and Kelly’s. Walt’s, Jaden’s, andKelly’s parents provided only positive responses to open-ended questions, and Max’s mother did not respond to anyopen-ended questions. (See Appendix C for participant-specific scores and comments.)
Discussion
Direct measures suggest that the Balance Program reducedemerging problem behavior, improved social and cooperationskills, and was associated with the development of balancebetween child- and adult-led activities for all participants.These outcomes were demonstrated in the home, with parentsproviding all or most of the teaching. Parents socially validat-ed the goals and procedures, and an indirect, standardizedmeasure of problem behavior detected general improvements.In other words, the Balance Program produced important childbehavior outcomes relevant to children with an ASDdiagnosis.
Our evaluation also revealed some areas for improvementand important directions for future research. First, two out offour children acquired all the targeted skills given the “stan-dard” package. Modifications to the program were associated
4 All participants displayed some restricted/repetitive behavior or interests,consistent with the diagnostic criteria for ASD. The Stereotypic Behaviorsection of the ABC-2 focuses on motor stereotypy specifically. For our par-ticipants, vocal stereotypy and restricted interests were more common.
Figure 6 Emerging problembehavior multiple baseline acrossparticipants
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with more robust performance for the other two children, andsome of these modifications might be incorporated from thebeginning for future participants. In addition, on the socialvalidity assessment, some parents provided equivocal ratingsfor the outcomes of the program outside of BCBA visits;therefore, steps might be taken to improve outcome generality.Once these areas have been addressed, future researchersmight consider a randomized controlled trial to evaluate theprogram’s preventive effects on problem behavior in childrenwith ASD.
All children in the present study acquired at least a simpleFCR, and three out of four acquired responding to their nameand tolerance to denial responses. It is likely that initial lan-guage skills are a moderator of outcomes in this program. Thethree participants who acquired responding to their name andtolerance response communicated in short, disfluent sentencesor with full vocal-verbal fluency at the start of the program,whereas the participant who did not acquire these responses(Kelly) was nonverbal at the start of the program. Kelly’sindividual data suggest that these responses were attainablefor her in isolation; in several sessions, she emitted high levelsof responding to her name, but she never emitted criterionlevels of responding to her name and the FCR in the samesession, suggesting that the desired conditional discriminationwas not established. Future researchers should evaluate theprogram with additional participants who have little verbalbehavior in baseline. If similar outcomes are observed, theprogram might prescribe a modified approach (e.g., BalanceExpress) for children with little initial language and/or parentswho foresee having limited time to dedicate to practice.
Max’s modifications also suggest revisions to the program.Max’s performance improved substantially in sessions imple-mented by the BCBA in the clinic with higher teaching integ-rity than his mother had exhibited. When his mother returned
to teaching, she demonstrated improved teaching integrity.Although the current data do not allow for conclusions aboutwhich changes were responsible for either Max’s or hismother’s improvements, his mother may have benefited fromthe higher dose of modeling from the BCBA and from theexperience of scoring teaching integrity until she did so withno errors. In future in-home applications, the BCBA couldmodel implementation or show video models and teach theparent to accurately evaluate teaching integrity.
The in-home, parent-implemented Balance Program couldalso be considered a Tier 1 intervention in a response-to-intervention model. That is, most or all children admitted toearly intervention services could receive the Balance Program,implemented by parents in the home. If the Balance Programdoes not produce the desired outcomes for a child, a Tier 2intervention would be indicated and considered. A Tier 2 in-tervention might consist of professionally implemented ses-sions a few times per week, either in the home or in a clinic. ATier 3 intervention, should it be required, might consist ofintensive outpatient or inpatient services. Therefore, under thisconceptualization, given that the Tier 1 intervention did notyield a general-enough change in Max’s behavior, Max expe-rienced a Tier 2 version of the program.
Walt’s, Jaden’s, and Max’s performances suggest a possi-ble relation between teaching integrity averaging at least 80%and robust child outcomes—child performance reachedcriteria in phases in which teaching integrity averaged 80%or higher and did not otherwise. Future implementers mightconsider adding a role-play component to the program andcoaching parents until they demonstrate at least 80% correctimplementation before beginning to teach their children a giv-en step. In other words, in future iterations, the parent-trainingprocedures might include all the steps of behavioral skillstraining (BST; e.g., Drifke, Tiger, & Wierzba, 2017;
Table 6 Aberrant behavior checklist (ABC-2) scores (with percentiles)
Name Irritability Social Withdrawal Stereotypic Behavior Hyperactivity/ Noncompliance Inappropriate Speech
Max. 45Clin. Sig. 20
Max. 48Clin. Sig. 15
Max. 21Clin. Sig. 8
Max. 48Clin. Sig. 29
Max. 12Clin. Sig. 6
Pre Post Pre Post Pre Post Pre Post Pre Post
Walt
Parent A 9 (37th) 1 (<16th) 4 (25th) 0 (<16th) 0 (16th) 1 (25th) 35 (84th) 9 (16th) 6 (75th) 0 (16th)
Parent B 18 (70th) 3 (<16th) 13 (70th) 4 (25th) 1 (25th) 1 (25th) 32 (75th) 13 (32nd) 6 (75th) 1 (32nd)
Jaden 6 (25th) 6 (25th) 9 (50th) 6 (37th) 1 (25th) 1 (25th) 19 (50th) 21.4 (50th) 2 (37th) 2 (37th)
Max 21 (75th) 12 (50th) 1 (<16th) 0 (<16th) 4 (50th) 0 (16th) 28 (70th) 19 (50th) 3 (50th) 4 (63rd)
Kelly 7 (32nd) 2 (<16th) 7 (37th) 3 (16th) 1 (25th) 2 (25th) 12 (32nd) 12 (32nd) 1 (45th) 1 (45th)
Clin. Sig. = clinically significant score per ABC-2 authors. Boldface denotes a clinically significant reduction according to criteria provided in the ABC-2manual. Post measures reported for Max were collected following Session 58. Mean scores for a sample of children with autism spectrum disorder, asrated by their parents, are as follows: Irritability = 12.8 (50th percentile); Social Withdrawal = 10 (50th percentile); Stereotypic Behavior = 5 (50thpercentile); Hyperactivity/Noncompliance = 18.7 (50th percentile); and Inappropriate Speech = 3.7 (63rd percentile; Aman & Singh, 2017)
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Sawyer, Crosland, Miltenberger, & Rone, 2015). We did notinitially incorporate role-play because of expected time con-straints in practice and because we hoped the program mightbe useful in telehealth settings, in which role-play is moredifficult. However, future researchers might consider addingopportunities for parents to demonstrate robust teaching skillsprior to practicing with their children.
Parents’ ratings of the goals and procedures of the programwere overwhelmingly positive, and parents reported that theBCBA support was enough to make them feel comfortableteaching the skills. However, parents’ ratings of the outcomesof the program outside of BCBA visits were mixed, withWalt’s and Jaden’s parents rating the outcomes more highlythan Max’s and Kelly’s. Walt and Jaden progressed throughthe program more quickly than Max and Kelly, with no mod-ifications. Some variables that might have influenced both thechild’s progress and parents’ satisfaction with outcomes out-side of visits include the amount and/or procedural integrity ofpractice outside of visits throughout the program. In the future,researchers might collect data on between-visit practice andevaluate the effects of procedural modifications on the fre-quency and quality of practice, as well as the generality ofoutcomes. Interestingly, Kelly’s mother’s open-ended com-ments on the effects of the program seem to contrast withher rankings, suggesting that future researchers might findmultiple types of social validity measures informative.
Future researchers implementing the program using asingle-subject design might also consider design modifica-tions to enhance the demonstration of functional control overall child skills by the program. In the present study, there wereno baseline opportunities for children to demonstrate some ofthe skills. Future researchers could ask parents to provide op-portunities for specific skills during the prompted baseline orafterward, as its own baseline condition, if no opportunitiesare observed in the prompted baseline.
However, even when parents did not present opportunitiesin baseline, we have several reasons to infer that childrenlacked these skills and acquired them as a function of theprogram. First, it is unlikely that a child has hadopportunities to acquire a skill if , over repeatedobservations, the parent does not provide opportunities forthe child to emit that skill. Skill acquisition requires practice;Luczynski and Hanley (2013) demonstrated that, in the ab-sence of explicit teaching, typically developing preschoolersdid not develop similar skills. The fact that the parents did notprovide baseline opportunities for commonplace parent–childinteractions suggests that parental attempts had beenextinguished by persistent child noncooperation or punishedby emerging problem behavior, as suggested by Carr et al.(1991). Finally, all parents rated the goals of the program asvery important. It seems unlikely they would have done so ifchildren had a history of reliably emitting these skills in rele-vant opportunities.
We inferred, rather than demonstrated, control by the pro-gram over the balance between adult- and child-led activities.In early teaching steps, child-led play was delivered contin-gent on relatively short responses, and a great deal of thesession was spent in child-led play by design; balance wasachieved gradually, emerging around Step 6 or later. Wedeemed it undesirable to extend participants’ baselines forthe time that would be required to demonstrate stability untilafter balance emerged for earlier participants. However, giventhe demographic and geographic differences among the fam-ilies, and the varying amounts of time between baseline anddemonstration of balance, it seems implausible that balancewould have emerged as a function of some factor other thanthe program.
There is precedent for teaching each of the skills in theBalance Program (e.g., Durand & Moskowitz, 2015; Everett,Olmi, Edwards, & Tingstrom, 2005; Hanley et al., 2014;Luczynski & Hanley, 2013); nevertheless, whittling downthe program to the behaviors that are essential for preventingthe development of severe problem behavior is an importanttask for researchers. Such an evaluation might be most pro-ductive after a demonstration of the preventive effects of theprogram via a randomized controlled trial; the question willthen be which components of the program are necessary toproduce those preventive effects. It is possible, for example,that differentially reinforcing various durations of cooperationwith personalized and synthesized reinforcers may be enough.
Future researchers, before or after a randomized controlledtrial, might also investigate the moderating role of initial playskills. All children engaged with the materials their parentshad nominated as preferred for most of the child-led time inbaseline, and no parents prompted their children to do so.Despite these robust child performances in baseline, allBCBAs conducted instruction in Step 1 to address parentbehavior—such as interfering with child toy manipulation orattempting to teach—that might have made access to the playmaterials a less potent reinforcing context. It is unclear whatthe effects of the program would have been had the partici-pants not demonstrated robust child-led play in baseline. Itseems probable that baseline play behavior moderates the ef-fects of the program; whether this is the case and how toaddress it are important research questions.
Despite the many remaining questions, the promising ef-fects of the Balance Program shown in the current study—andthe studies showing positive effects of similar skill-basedteaching programs in different service models (e.g., Hanleyet al., 2007; Hanley et al., 2014; Jessel et al., 2018; Robisonet al., 2020)—suggest that Balance may be a useful programfor professionals supporting parents of young children withASD in the home.
Supplementary Information The online version contains supplementarymaterial available at https://doi.org/10.1007/s40617-020-00490-3.
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Author Note This manuscript was prepared in partial fulfillment of thedoctoral program requirements of the Psychology Department at WesternNew England University. We thank Amy J. Henley, Rachel H.Thompson, and Jonathan W. Pinkston for their comments on earlier ver-sions of this manuscript.
Compliance with Ethical Standards
Conflict of interest During the peer review and publication process forthis manuscript, Kelsey Ruppel and Gregory Hanley received salariesfrom FTF Behavioral Consulting, an organization that offers training onthe Balance Program among other services. Neither were employed byFTF Behavioral Consulting before or during the conduct of the study.Robin Landa and Adithyan Rajaraman declare no conflict of interest.
Ethical approval All procedures performed in studies involving humanparticipants were in accordance with the ethical standards of the institu-tional review board of the university and with the 1964 Helsinki declara-tion and its later amendments.
Informed consent Informed consent was obtained from all individualparticipants included in the study.
References
Ala’i-Rosales, S., Cihon, J. H., Currier, T. D. R., Ferguson, J. L., Leaf, J.B., Leaf, R., McEachin, J., &Weinkauf, S. M. (2019). The big four:Functional assessment research informs preventative behavior anal-ysis. Behavior Analysis in Practice, 12, 222–234. https://doi.org/10.1007/s40617-018-00291-9.
Aman, M. G., & Singh, N. N. (2017). The Aberrant Behavior Checklist(2nd ed.). Slosson Education Publications.
American Academy of Pediatrics. (2014). AAP publications reaffirmedor retired. Pediatrics, 134, e1520. https://doi.org/10.1542/peds.2014-2679.
American Psychiatric Association. (2013). Neurodevelopmental disor-ders. In Diagnostic and statistical manual of mental disorders (5thed.). https://doi.org/10.1176/appi.books.9780890425596.dsm.01
Beaulieu, L., & Hanley, G. P. (2014). Effects of a classwide teacher-implemented program to promote preschooler compliance. Journalof Applied Behavior Analysis, 47(3), 594–599. https://doi.org/10.1002/jaba.138.
Beaulieu, L., Hanley, G. P., & Roberson, A. A. (2012). Effects ofresponding to a name call and group call on preschoolers’ compli-ance. Journal of Applied Behavior Analysis, 45(4), 685–707. https://doi.org/10.1901/jaba.2012.45-685.
Beaulieu, L., Hanley, G. P., & Roberson, A. A. (2013). Effects of peermediation on preschoolers’ compliance and compliance precursors.Journal of Applied Behavior Analysis, 46(3), 555–567. https://doi.org/10.1002/jaba.66.
Beaulieu, L., Van Nostrand, M. E., Williams, A. L., & Herscovitch, B.(2018). Incorporating interview-informed functional analyses intopractice. Behavior Analysis in Practice, 11(4), 385–289. https://doi.org/10.1007/s40617-018-0247-7.
Bodfish, J. W., Symons, F. J., Parker, D. E., & Lewis, M. H. (2000).Varieties of repetitive behavior in autism: Comparisons to mentalretardation. Journal of Autism and Developmental Disorders, 30(3),237–243. https://doi.org/10.1023/A:1005596502855.
Carr, E. G., & Carlson, J. I. (1993). Reduction of severe behavior prob-lems in the community using a multicomponent treatment approach.Journal of Applied Behavior Analysis, 26(2), 157–172. https://doi.org/10.1901/jaba.1993.26-157.
Carr, E. G., & Durand, V. M. (1985). Reducing behavior problemsthrough functional communication training. Journal of AppliedBehavior Analysis, 18(2), 111–126. https://doi.org/10.1901/jaba.1993.26-157.
Carr, E. G., Taylor, J. C., & Robinson, S. (1991). The effects of severebehavior problems in children on the teaching behavior of adults.Journal of Applied Behavior Analysis,24(3), 523–535. https://doi.org/10.1901/jaba.1991.24-523.
Centers for Disease Control and Prevention. (2019). Spotlight on: Delaybetween first concern to accessing services. https://www.cdc.gov/ncbddd/autism/addm-community-report/delay-to-accessing-services.html
Drifke, M. A., Tiger, J. H., & Wierzba, B. C. (2017). Using behavioralskills training to teach parents to implement three-step prompting: Acomponent analysis and generalization assessment. Learning andMotivation, 57, 1–14. https://doi.org/10.1016/j.lmot.2016.12.001.
Durand, V. M., & Moskowitz, L. (2015). Functional communicationtraining: Thirty years of treating challenging behavior. Topics inEarly Childhood Special Education, 35(2), 1–11. https://doi.org/10.1177/0271121415569509.
English, M. S., Tenenbaum, E. J., Levine, T. P., Lester, B. M., &Sheinkopf, S. J. (2019). Perception of cry characteristics in 1-month-old infants later diagnosed with autism spectrum disorder.Journal of Autism and Developmental Disorders, 49, 834–844.https://doi.org/10.1007/s10803-018-3788-2.
Everett, G. E., Olmi, D. J., Edwards, R. P., & Tingstrom, D. H. (2005).The contributions of eye contact and contingent praise to effectiveinstruction delivery in compliance training. Education andTreatment of Children, 28(1), 48–62.
Fagen, S. A., & Hill, J. M. (1987). Teaching acceptance of frustration.Teaching Exceptional Children, 19, 49–51.
Fahmie, T. A., Iwata, B. A., & Mead, S. C. (2016). Within-subject anal-ysis of a prevention strategy for problem behavior. Journal ofApplied Behavior Analysis, 49(4), 915–926. https://doi.org/10.1002/jaba.343.
Fahmie, T. A., & Luczynski, K. C. (2018). Preschool life skills: Recentadvancements and future directions. Journal of Applied BehaviorAnalysis, 51(1), 183–188. https://doi.org/10.1002/jaba.434.
Falcomata, T. S., Muething, C. S., Gainey, S., Hoffman, K., & Fragale, C.(2013). Further evaluations of functional communication trainingand chained schedules of reinforcement to treat multiple functionsof challenging behavior. Behavior Modification, 37(6), 723–746.https://doi.org/10.1177/0145445513500785.
Falcomata, T. S., Roane, H. S., Muething, C. S., Stephenson, K. M., &Ing, A. D. (2012). Functional communication training and chainedschedules of reinforcement to treat challenging behavior maintainedby terminations of activity interruptions. Behavior Modification, 36,630–649. https://doi.org/10.1177/0145445511433821.
Farmer, C. A., & Aman, M. G. (2011). Aggressive behavior in a sampleof children with autism spectrum disorders. Research in AutismSpectrum Disorders, 5(1), 317–323. https://doi.org/10.1016/j.rasd.2010.04.014.
Fisher, W.W., Greer, B. D., Romani, P.W., Zangrillo, A. N., & Owen, T.M. (2016). Comparisons of synthesized and individual reinforce-ment contingencies during functional analysis. Journal of AppliedBehavior Analysis, 49(3), 596–616. https://doi.org/10.1002/jaba.314.
Franchini, M., Duku, E., Armstrong, V., Brian, J., Bryson, S. E., Garon,N., Roberts, W., Roncadin, C., Zwaigenbaum, L., & Smith, I. M.(2018). Variability in verbal and nonverbal communication in in-fants at risk for autism spectrum disorder: Predictors and outcomes.Journal of Autism and Developmental Disorders, 48(10), 3417–3431. https://doi.org/10.1007/s10803-018-3607-9.
Francisco, M. T., & Hanley, G. P. (2012). An evaluation of progressivelyincreasing intertrial intervals on the acquisition and generalization of
339Behav Analysis Practice (2021) 14:324–341
three social skills. Journal of Applied Behavior Analysis, 45(1),137–142. https://doi.org/10.1901/jaba.2012.45-137.
Ghaemmaghami, M., Hanley, G. P., & Jessel, J. (2016). Contingenciespromote delay tolerance. Journal of Applied Behavior Analysis,49(3), 548–575. https://doi.org/10.1002/jaba.333.
Ghaemmaghami, M., Hanley, G. P., Jessel, J., & Landa, R. (2018).Shaping functional communication responses. Journal of AppliedBehavior Analysis, 51(3), 502–520. https://doi.org/10.1002/jaba.468.
Ghaemmaghami,M., Hanley, G. P., Jin, S. C., &Vanselow, N. R. (2016).Affirming control by multiple reinforcers via progressive treatmentanalysis. Behavioral Interventions, 31(1), 70–86. https://doi.org/10.1002/bin.1425.
Ginn, N. C., Clionsky, L. N., Eyberg, S. M., Warner-Metzger, C., &Abner, J. P. (2017). Child-directed interaction training for youngchildren with autism spectrum disorders: Parent and child outcomes.Journal of Clinical Child & Adolescent Psychology, 46(1), 101–109. https://doi.org/10.1080/15374416.2015.1015135.
Greer, B. D., Fisher, W. W., Saini, V., Owen, T. M., & Jones, J. K.(2016). Functional communication training during reinforcementschedule thinning: An analysis of 25 applications. Journal ofApplied Behavior Analysis, 49(1), 1–17. https://doi.org/10.1002/jaba.265.
Greer, B. D., Mitteer, D. M., Briggs, A. M., Fisher, W. W., &Sodawasser, A. J. (2019). Comparisons of standardized andinterview-informed synthesized reinforcement contingencies rela-tive to functional analysis. Journal of Applied Behavior Analysis,53(1), 82–101. https://doi.org/10.1002/jaba.601.
Gunning, C., Holloway, J., & Grealish, L. (2020). An evaluation of par-ents as behavior change agents in the Preschool Life Skills Program.Journal of Applied Behavior Analysis. Advance online publication.https://doi.org/10.1002/jaba.660
Gunning, C., Holloway, J., & Healy, O. (2019). Evaluating the PreschoolLife Skills Program to teach school readiness skills: An Irish pilotstudy. European Journal of Behavior Analysis, 20(1), 48–68.https://doi.org/10.1080/15021149.2018.1531962.
Hamlet, C. C., Axelrod, S., & Kuerschner, S. (1984). Eye contact as anantecedent to compliant behavior. Journal of Applied BehaviorAnalysis, 17(4), 553–557. https://doi.org/10.1901/jaba.1984.17-553.
Hanley, G. P., Heal, N. A., Tiger, J. H., & Ingvarsson, E. T. (2007).Evaluation of a classwide teaching program for developing pre-school life skills. Journal of Applied Behavior Analysis, 40(2),277–300. https://doi.org/10.1901/jaba.2007.57-06.
Hanley, G. P., Jin, C. S., Vanselow, N. R., & Hanratty, L. A. (2014).Producing meaningful improvements in problem behavior of chil-dren with autism via synthesized analyses and treatments. Journal ofApplied Behavior Analysis, 47(1), 16–36. https://doi.org/10.1002/jaba.106.
Heal, N. A., & Hanley, G. P. (2011). Embedded prompting may functionas embedded punishment: Detection of unexpected behavioral pro-cesses within a typical preschool teaching strategy. Journal ofApplied Behavior Analysis, 44(1), 127–131. https://doi.org/10.1901/jaba.2011.44-127.
Heal, N. A., Hanley, G. P., & Layer, S. A. (2009). An evaluation of therelative efficacy of and children’s preferences for teaching strategiesthat differ in amount of teacher directedness. Journal of AppliedBehavior Analysis, 42(1), 123–143. https://doi.org/10.1901/jaba.2009.42-123.
Herman, C., Healy, O., & Lydon, S. (2018). An interview-informed syn-thesized contingency analysis to inform the treatment of challengingbehavior in a young child with autism. DevelopmentalNeurorehabilitation, 21(3), 202–207. https://doi.org/10.1080/17518423.2018.1437839.
Hernandez, E., Hanley, G. P., Ingvarsson, E. T., & Tiger, J. H. (2007). Apreliminary evaluation of the emergence of novel request forms.
Journal of Applied Behavior Analysis, 40(1), 137–156. https://doi.org/10.1901/jaba.2007.96-05.
Horner, R. H., &Day, H.M. (1991). The effects of response efficiency onfunctionally equivalent competing behaviors. Journal of AppliedBehavior Analysis, 24(4), 719–732. https://doi.org/10.1901/jaba.1991.24-719.
Jessel, J., Ingvarsson, E. T., Metras, R., Kirk, H., & Whipple, R. (2018).Achieving socially significant reductions in problem behavior fol-lowing the interview-informed synthesized contingency analysis: Asummary of 25 outpatient applications. Journal of Applied BehaviorAnalysis, 51(1), 130–157. https://doi.org/10.1002/jaba.436.
Kaat, A. J., Lecavalier, L., & Aman, M. G. (2014). Validity of theAberrant Behavior Checklist in children with autism spectrum dis-order. Journal of Autism and Developmental Disorders, 44(5),1103–1116. https://doi.org/10.1007/s10803-013-1970-0.
Kraus, A. J., Hanley, G. P., Cesana, L. L., Eisenberg, D., & Jarvie, A. C.(2012). An evaluation of strengthening precursors to increase pre-schooler compliance. Journal of Applied Behavior Analysis, 45(1),131–136. https://doi.org/10.1901/jaba.2012.45-131.
Kurtz, P. F., Chin, M. D., Huete, J. M., & Cataldo, M. F. (2012).Identification of emerging self-injurious behavior in young children:A preliminary study. Journal of Mental Health Research inIntellectual Disabilities, 5(3–4), 260–285. https://doi.org/10.1080/19315864.2011.600809.
Kurtz, P. F., Chin, M. D., Huete, J. M., Tarbox, R. S. F., O’Connor, J. T.,Paclawskyj, T. R., & Rush, K. S. (2003). Functional analysis andtreatment of self-injurious behavior in young children: A summaryof 30 cases. Journal of Applied Behavior Analysis, 36(2), 205–219.https://doi.org/10.1901/jaba.2003.36-205.
Lalli, J. S., & Casey, S. D. (1996). Treatment of multiply controlledproblem behavior. Journal of Applied Behavior Analysis, 29(3),391–395. https://doi.org/10.1901/jaba.1996.29-391.
Luckett, T., Bundy, A., & Roberts, J. (2007). Do behavioural approachesteach children with autism to play or are they pretending? Autism,11(4), 365–388. https://doi.org/10.1177/1362361307078135.
Luczynski, K. C., & Hanley, G. P. (2013). Prevention of problem behav-ior by teaching functional communication and self-control skills topreschoolers. Journal of Applied Behavior Analysis, 46(2), 355–368. https://doi.org/10.1002/jaba.44.
Masse, J. J., McNeil, C. B., Wagner, S. M., & Chorney, D. B. (2007).Parent-child interaction therapy and high functioning autism: A con-ceptual overview. Journal of Early and Intensive BehaviorIntervention, 4(4), 714–735. https://doi.org/10.1037/h0100402.
Mayes, S. D., Calhoun, S. L., Aggarwal, R., Baker, C., Mathapati, S.,Anderson, R., & Peterson, C. (2012). Explosive, oppositional, andaggressive behavior in children with autism compared to other clin-ical disorders and typical children. Research in Autism SpectrumDisorders, 6(1), 1–10. https://doi.org/10.1016/j.rasd.2011.08.001.
McLaughlin, D. M., & Carr, E. G. (2005). Quality of rapport as a settingevent for problem behavior: Assessment and intervention. Journalof Positive Behavior Interventions, 7(2), 68–91. https://doi.org/10.1177/10983007050070020401.
Miller, M., Iosif, A.-M., Hill, M., Young, G. S., Schwichtenberg, A. J., &Ozonoff, S. (2017). Response to name in infants developing autismspectrum disorder: A prospective study. Journal of Pediatrics, 183,141–146.e1. https://doi.org/10.1016/j.jpeds.2016.12.071.
Myers, S. M., & Plauché Johnson, C. (2007). Management of childrenwith autism spectrum disorders. Pediatrics, 120(5), 1162–1182.https://doi.org/10.1542/peds.2007-2362.
National Association for the Education of Young Children. (2009). Keymessages of the position statement. https://www.naeyc.org/sites/default/files/globally-shared/downloads/PDFs/resources/position-statements/KeyMessages.pdf
Piazza, C. C., Moes, D. R., & Fisher, W. W. (1996). Differential rein-forcement of alternative behavior and demand fading in the treat-ment of escape-maintained destructive behavior. Journal of Applied
340 Behav Analysis Practice (2021) 14:324–341
Behavior Analysis, 29(4), 569–572. https://doi.org/10.1901/jaba.1996.29-569.
Reeve, C. E., & Carr, E. G. (2000). Prevention of severe behavior prob-lems in children with developmental disorders. Journal of PositiveBehavior Interventions, 2(3), 144–160. https://doi.org/10.1177/109830070000200303.
Robison, M. A., Mann, T. B., & Ingvarsson, E. T. (2020). Life skillsinstruction for children with developmental disabilities. Journal ofApplied Behavior Analysis, 53(1), 431–448. https://doi.org/10.1002/jaba.602.
Rose, J. C., & Beaulieu, L. (2019). Assessing the generality and durabilityof interview-informed functional analyses and treatment. Journal ofApplied Behavior Analysis, 52(1), 271–285. https://doi.org/10.1002/jaba.504.
Santiago, J. L., Hanley, G. P., Moore, K., & Jin, C. S. (2016). Thegenerality of interview informed functional analyses: Systematicreplications in school and home. Journal of Autism andDevelopmental Disorders, 46(3), 797–811. https://doi.org/10.1007/s10803-015-2617-0.
Sawyer, M. R., Crosland, K. A., Miltenberger, R. G., & Rone, A. B.(2015). Using behavioral skills training to promote the generaliza-tion of parenting skills to problematic routines. Child and FamilyBehavior Therapy, 37(4), 261–284. https://doi.org/10.1080/07317107.2015.1071971.
Scudder, A., Wong, C., Ober, N., Hoffman, M., Toscolani, J., & Handen,B. L. (2019). Parent-child interaction therapy (PCIT) in young chil-dren with autism spectrum disorder. Child & Family BehaviorTherapy, 41(4), 201–220. https://doi.org/10.1080/07317107.2019.1659542.
Skinner, B. F. (1953). Science and human behavior. The B. F. SkinnerFoundation.
Slaton, J. D., & Hanley, G. P. (2018). Nature and scope of synthesis infunctional analysis and treatment of problem behavior. Journal ofApplied Behavior Analysis, 51(4), 943–973. https://doi.org/10.1002/jaba.498.
Slaton, J. D., Hanley, G. P., & Raftery, K. J. (2017). Interview-informedfunctional analyses: A comparison of synthesized and isolated
components. Journal of Applied Behavior Analysis, 50(2), 252–277. https://doi.org/10.1002/jaba.384.
Smith, T., & Iadarola, S. (2015). Evidence base update for autism spec-trum disorder. Journal of Clinical Child and AdolescentPsychology, 44(6), 897–922. https://doi.org/10.1080/15374416.2015.1077448.
Solomon, M., Ono, M., Timmer, S., & Goodlin-Jones, B. (2008). Theeffectiveness of parent-child interaction therapy for families of chil-dren on the autism spectrum. Journal of Autism and DevelopmentalDisorders, 38, 1767–1776. https://doi.org/10.1007/s10803-008-0567-5.
Stokes, T. F., & Baer, D. M. (1977). An implicit technology of general-ization. Journal of Applied Behavior Analysis, 10(2), 349–367.https://doi.org/10.1901/jaba.1977.10-349.
Strand, R. C. W., & Eldevik, S. (2017). Improvements in problem behav-ior in a child with autism spectrum diagnosis through synthesizedanalysis and treatment: A replication in an EIBI home program.Behavioral Interventions, 33(1), 102–111. https://doi.org/10.1002/bin.1505.
Tarbox, R. S. F., Wallace, M. D., Penrod, B., & Tarbox, J. (2007). Effectsof three-step prompting on compliance with caregiver requests.Journal of Applied Behavior Analysis, 40(4), 703–706. https://doi.org/10.1901/jaba.2007.703-706.
Taylor, S. A., Phillips, K. J., & Gertzog,M. G. (2018). Use of synthesizedanalysis and informed treatment to promote school reintegration.Behavioral Interventions, 33(4), 364–379. https://doi.org/10.1002/bin.1640.
The Council of Autism Service Providers. (2020). Applied behavior anal-ysis treatment of autism spectrum disorder: Practice guidelines forhealthcare funders and managers (2nd ed.). https://casproviders.org/wp-content/uploads/2020/03/ABA-ASD-Practice-Guidelines.pdf
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