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Volume V
Issue Number 1
ISSN 1932 - 4731
Table of Contents
Pg.: 1: Generic Instruction versus Intensive Tact Instruction and the Emission
of Spontaneous Speech - R. Douglas Greer & Lin Du
Pg.: 20: Effects of Multiple Exemplar Instruction on the Transformation of
Stimulus Function Across Written and Vocal Spelling Responses by
Students with Autism - Carly M. Eby, R. Douglas Greer, Lisa D. Tullo,
Katherine A. Baker & Rebecca Pauly
Pg.: 32: .AAC Interventions: Case study of In-utero Stroke. Cindy Geise
Arroyo, Robert Goldfarb, Danielle Cahill, & Janet Schoepflin
Pg.: 48: Implications of Skinner’s Verbal Behavior for Studying Dementia Jeffrey A. Buchanan, Daniel Houlihan, & Peter J.N. Linnerooth
Pg.: 59: Using Skinner’s Model of Verbal Behavior Analysis to study
Aggression in Psychiatric Hospitals - Michael Daffern & Matthew
Tonkin
Pg.: 70: Evaluation of Two Communicative Response Modalities for a Child
with Autism and Self-Injury - Stacy E. Danov, Ellie Hartman, Jennifer J.
McComas, & Frank J. Symons
Pg.: 80: Using DRO, Behavioral Momentum, and Self-Regulation to Reduce
Scripting by an Adolescent with Autism - Vanessa Ann Silla-Zaleski &
Mary J. Vesloski
The Journal of Speech - Language Pathology
and Applied Behavior Analysis
VOLUME NO. 5, ISSUE NO. 1
ISSN: 1932 - 4731
Published: January 12, 2010
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Speech - Language Pathology and Applied Behavior Analysis
ISSN: 1932-4731
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SLP-ABA
Volume 5, No. 1
Generic Instruction versus Intensive Tact Instruction and the
Emission of Spontaneous Speech
R. Douglas Greer and Lin Du
Abstract
We isolated the effects of intensive tact instruction from increased generic instruction on the
emission of spontaneous speech (pure mands, pure tacts, intraverbals) in non-instructional settings by 3
boys with ASD, using a delayed multiple probe design across participants. The teaching procedure included
the replacement of 100 generic academic learn units with 100 learn units of tact instruction until mastery of
5 sets of 4 stimuli (20 pictures). Results showed a strong functional relationship between intensive tact
instruction and the participants’ production of pure mands and pure tacts in non-instructional settings.
Findings suggest that it is not an increase in instruction alone but the nature of intensive tact instruction that
results in more verbal operants in non-instructional settings.
Keywords: intensive tact instruction, verbal operants, tacts, mands, learn units
Introduction
The expansion of the tact repertoire appears to be critical to the acquisition of subsequent and more
complex verbal developmental stages. It is likely that direct instruction in tacts must continue until
children have acquired the verbal developmental cusp of Naming, which is defined as the capability to
acquire the listener and speaker responses to stimuli incidenta lly (Greer & Speckman, 2009; Greer, Stolfi,
& Pistoljevic, 2007; Horne & Lowe, 1996; Pistoljevic & Greer, 2006; Skinner, 1957).
Skinner (1957) described six elementary verbal functions for the speaker, including (1) echoics, (2)
mands, (3) tacts, (4) autoclitics, (5) intraverbals, and (6) textual responding. For the purposes of this
study, we focus primarily on mands, tacts, and intraverbals. Mands are speaker or substitute speaking
topographies that are emitted under conditions of deprivation or annoying conditions in the presence of a
listener who then mediates the environment for the speaker (Skinner, 1957; Greer & Ross, 2008). Tacts
are verbal operants occasioned by a discriminative stimulus in the environment and are reinforced by
generalized reinforcers particularly attention (Tsiouri & Greer, 2003).
Children with autism usually demonstrate deficits in functional communication (DSM-IV,
American Psychiatric Association, 1994) , including tacts. For example, children with autism typically do
not emit language without prompting or questioning by others and thus demonstrate few instances of
“spontaneous speech” (Krantz & McClannahan, 1998). For this reason, studies have focused on the
development of verbal skills by these children. Partington, Sundberg, Newhouse, & Spengler (1994)
implemented a procedure for transferring stimulus control from verbal stimuli to nonverbal stimuli in a
six-year-old girl with autism. As a result, the girl acquired tact responses to 19 stimuli. Partington et al.
then proposed that the reason for the failure of children with autism to acquire tacts may be tied to the
antecedent verbal behavior of others (e.g., “What is that?”) which functions to block the establishment of
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Volume 5, No. 1
stimulus control by a nonverbal stimulus. This observation is consistent with findings reported by
Williams and Greer (1993).
Several evidence-based protocols are available for inducing echoics and then mand and tact
responses for children who have no, or limited, vocal verbal operants. Included here are (1) the stimulusstimulus pairing procedure to induce echoics (Sundberg, Michael, Partington, & Sundberg, 1996), (2)
rapid motor imitatio n to induce echoics to mand and echoics to tact functions (Ross & Greer, 2003;
Tsiouri, & Greer, 2003), and (3) direct echoic to mand and echoic to tact instruction (Williams & Greer,
1993). Procedures are also available to expand repertoires such as speaker immersion (Greer & Ross,
2004; Ross, Nuzzolo, Stolfi, & Natarelli, 2006; Schwartz, 1994). However, once repertoires are
established, children need extensive instruction in order to expand their language functions or verbal
repertoires.
The primary repertoire in need of expansion is the tact repertoire because tacts are foundational to
the subsequent development of more complex verbal behavior such as Naming, say-do correspondence,
conversational units, and age-appropriate self-talk (Barnes-Holmes, Barnes-Holmes, & Cullinan, 2000;
Greer & Ross, 2008; Greer & Speckman, 2009; Horne & Lowe, 1996). Several recent investigations
suggested the importance of directly and intensely teaching the tact repertoire, especially for those
children who cannot acquire tacts through spontaneous observational learning (Williams & Greer, 1993;
Ross & Greer, 2003; Schauffler, & Greer, 2006; Tsiouri & Greer, 2003; Pistoljevic & Greer, 2006;
Pistoljevic, 2008). The protocol used in these studies is referred to as the intensive tact procedure (ITP). Using
this procedure children received at least 100 instructional trials (learn units) devoted to tacting visual stimuli,
in addition to their general educational instruction. All of these studies found that the children significantly
increased their “spontaneous vocal verbal behavior in social settings”. In all of the studies the vocal verbal
responses that were emitted in the non-instructional settings (NIS) differed from those taught during the ITP,
suggesting that ITP affected the reinforcing effects of emitting tacts.
Pistoljevic and Greer (2006) tested the effects of ITP on the number of vocal verbal operants emitted
in NIS (transition time, lunch, and free play) by three preschool boys with autism who, prior to intervention,
emitted low numbers of pure (spontaneous) tacts and mands. In these studies, the participants received 100
additional learn units daily during the ITP phase while learn units of the generic educational programs
remained constant during baseline. Results showed that the participants’ verbal operants (tacts and other verbal
behaviors) increased in NIS. However, Pistoljevic and Greer noted that the increase may have occurred simply
as a result of increasing the number of learn units received by the participants, regardless of whether the learn
units were based on ITP or any other generic educational program. They proposed that future research should
be designed to isolate the increased tact instruction from increased instruction of any kind.
Schauffler & Greer’s study (2006) found that after the implementation of ITP, the audience-accurate
tacts and conversational units increased significantly for two middle school students, while inaccurate
tacts/conversational units decreased for one student. They also found that the participants emitted accurate tacts
not taught during ITP, suggesting that ITP taught audience control. That is, rather than emitting language that was
inappropriate for school settings, the students emitted audience-appropriate language. In a recent dissertation,
Pistoljevic (2008) found that preschool participants who mastered several sets of tacts using the ITP not only
emitted more verbal operant but also acquired Naming.
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Prior research reported that by increasing the numbers of learn units presentations one may significantly
increase the instructional objectives and educational standards achieved by students (Albers & Greer, 1991;
Greer, McCorkle & Williams, 1989; Ingham & Greer, 1992; Kelly, 1997; Lamn & Greer, 1991; Selinske,
Greer, & Lodhi, 1990). It is possible then that the results of studies of ITP could be attributed to the increase in
learn units regardless of whether the learn units targeted tacts or other educational goals. None of the prior
studies isolated the increased tact instruction from increased instruction of any other kind (Schauffler & Greer,
2006; Pistoljevic & Greer, 2006). Therefore, it is possible that simply increasing the numbers of generic learn
units that students receive daily this will also affect the emission of pure tacts and pure mands in NIS. For
example, it is possible that increasing the number of learn units to target the identification of body parts,
counting, number-object correspondence, visual matching, or textual responses can lead to the same or similar
outcomes as those attributed to the ITP.
To assess whether an increase in spontaneous tacting is due to an increase in generic learn units or to
an increase in tact-specific learn units, it is necessary to control for the number of learn units in each condition.
In other words, instead of having fewer learn units in generic instruction than in ITP, baseline conditions should
include similar numbers of learn units in each condition to control for the effects of instruction. In the present
study, we compared the effects of generic instruction versus ITP on the emission of tacts in NIS by three
participants. The number of learn units was equivalent in each condition, allowing for the isolation of the tact
component that is present in ITP and missing from generic instructional programs.
Method
Participants
Three male children diagnosed with Autism Spectrum Disorders served as participants in this study.
These participants were chosen for this study because they had limited tacts in their repertoire and because they
did not emit many pure tacts and mands throughout the day, especially in NIS (transition time, free play, lunch).
Each participant’s verbal behavior achievement levels and standardized measures at the beginning of this
study are summarized in Table 1.The table indicates that Participant A was an 8-year-old male who functioned
at emergent listener/emergent speaker levels of verbal behavior. According to the Preschool Inventory of
Repertoires for Kindergarten (PIRK) (Greer & McCorkle, 2003) and assessments of verbal development
described in Greer and Ross (2008) which were conducted prior to the experiment, the following verbal
developmental cusps and capabilities were not in his repertoire: self-talk, say-do correspondence, and Naming
(the capability to acquire language incidentally). He was receiving instruction devoted to conditioning books
and toys as reinforcers for observing responses and preference in free play, mands for non-visible items, and
dictation. When assessed using the Preschool Language Scale- Fourth Edition (PLS-4) (Zimmerman, Steiner,
and Pond, 2002), he scored 50 in total language and 50 in expressive communication.
Participant B was a 5-year-old male who functioned at the emergent listener/speaker levels of verbal
behavior. According to the PIRK (Greer & McCorkle, 2003) and assessments of verbal behavior (Greer & Ross,
2008), appropriate self-talk, say-do correspondence, auditory matching and spontaneous incidental learning
were not present within his repertoire. His program included procedures to teach vocal direction following, to
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condition books and toys as reinforcers for observing responses and preference in free play, and to teach the
use of mands for accessing non-visible items. He scored 61 in expressive communication on the PLS-4.
Participant C was a 3-year-old male who functioned at the emergent listener/speaker level of verbal
behavior. According to the PIRK (Greer & McCorkle, 2008) conducted prior to the study, the following
capabilities were not within his repertoire: self-talk, say-do, auditory matching and spontaneous incidental
language learning. He was being instructed in conditioning books and toys as reinforcers for observing
responses and preferences in free play, mands for non-visible items, and dictation. His scores on the PLS-4
included a 55 in auditory comprehension, 57 in expressive communication and 51 in total language.
Table 1. Description of the Three Participants
1
P
Age
A
8
B
C
5
3
Diagnosis and Level
Of Verbal Capability
Standardized
Test Scores
-Autism
3
- emergent
listener/emergent
speaker
-Total language : 50
-Autism
3
- emergent
listener/speaker
- Expressive
Communication: 61
-Autism
3
-emergent
listener/emergent
speaker
-Total language : 51
PLS-4
- Expressive
communication: 50
PLS-4
PLS-4
- Expressive
communication: 57
2
PIRK Repertoires
Echoics, mands/tacts with autoclitic frames,
matching and pointing/ listener literacy,
visual tracking, generalized imitation, visual
instruction control, capacity for sameness,
and conditioned reinforcement for voices
Echoics, mands/tacts with autoclitic frames,
matching and pointing/ listener literacy,
visual tracking, generalized imitation,
conditioned reinforcement of books,
conditioned reinforcement of voices,
capacity for sameness, listener literacy
Echoics, mands/tacts with autoclitic frames,
matching and pointing/ listener literacy,
visual tracking, generalized imitation, visual
instruction control, capacity for sameness,
and conditioned reinforcement for voices
1
P = Participant
PIRK = Preschool Inventory of Repertoires for Kindergarten (Greer & McCorkle, 2003)
3
PLS-4 = Preschool Language Scale-Fourth Edition (Zimmerman, Steiner, and Pond, 2002)
2
All participants attended school in a suburb of New York City. Participants A and B were both enrolled
in the same class of a public elementary school. The setting was a self-contained classroom with five students,
one teacher and four teaching assistants. All students in the classroom had varying levels of verbal behaviors.
Participant C attended a privately run and publicly funded preschool using the CABAS® (Comprehensive
Application of Behavior Analysis to Schooling) educational model, which has 7 classrooms that vary in terms of
the students' levels of verbal behavior (pre-listener/ speaker through speakers and emerging self-editors). The
method of instruction employed and the measurement of the students' responses to instruction in both settings
were based on the principles of applied behavior analysis.
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Setting
The experiment was conducted in the children’s classrooms and throughout the school environment. In
Participant A’s and B's classroom, there were 5 tables, 12 adult chairs, and 6 child chairs. The classroom had
two free play areas with rugs (located at different ends of the classroom), and an extensive assortment of toys,
games, children’s books, and one plastic cottage playhouse. In one play area, there was a shelf with toys, books,
blocks, and plastic animals. A TV with DVD and tape player were placed on the top of a cabinet facing this play
area. In Participant C’s classroom, there were 4 tables, 8 adult chairs, and 7 child chairs. The toy area was
approximately 2 x 2.5 meters and was located in the corner of the classroom, sectioned off by shelves holding
books and toys. The study was conducted in several pla ces at the school. During the probes for pure tacts,
mands, and intraverbals, data were collected in three NIS, including the toy areas of the classrooms, at the table
during lunchtime, and in the hallways during the transition from the school buses. The intensive tact instruction
took place in the toy area or other places in the classroom rather than at the traditional instructional table. At this
time, other students received one-to-one instruction by other instructors in the classroom or they received
speech, physical or occupational therapy in the therapists' rooms. Participants A and B ate their lunch in the
school's lunchroom at a large rectangular shaped table near the windows. Their lunch started from 11:30 and
ended at 12:00 everyday. For Participant C, the students ate their lunch inside the classroom at a large
horseshoe shaped table near the door. Probes of the lunchtime responses were conducted when the participants
finished their lunch. The probes in each NIS were conducted during 5-minute segments, and the three 5-minute
sessions were blocked into a single 15-minute daily session.
Dependent Variable
The dependent variables in this study were pure mands, pure tacts, and intraverbals emitted by the
participants in NIS (transition, play, lunch). Pure tacts were defined as verbal operants that made contact with
the environment or identified components of the environment when there was no verbal antecedent, and were
reinforced by generalized social reinforcers (Greer, 2002). Examples of the pure tacts emitted by the
participants included "My backpack", and "It is raining". Pure mands were defined as verbal operants that
specified their reinforcers under associated motivational conditions when there was no verbal antecedent
(Greer, 2002). Examples of the pure mands emitted by the participants included "Help me, please", "Open,
please" and "Lunch box, please". Intraverbals were defined as verbal operants that did not have a point-topoint correspondence with verbal stimuli and also occurred under verbal stimulus control. For example, a
participant said “hi” in response to his teacher’s greeting (“Good morning”) while transitioning from the bus to
the classroom.
Independent Variable: The Intensive Tact Procedure
The independent variable was an intensive tact procedure (ITP), consisting of 100 extra learn
units of daily intensive tact instruction (ITI). Before the treatment, each participant’s mean number of
daily learn units was calculated for the prior month. During baseline, each participant received 100 extra
learn units to address 5 non-tact generic educational objectives. Specifically, participant A’s and B’s learn
units were increased from 300 to 400, and Participant C’s learn units were increased from 350 to 450
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during baseline. When ITI began, each participant’s total number of daily learn units remained the same
as they were in baseline, but 100 of the non-tact generic academic learn units were replaced with 100 tact
instruction learn units.
ITI targeted 20 different tacts, each in response to a pictured stimulus. The stimuli represented 5
categories (community helpers, animals, food, instruments, and transportation) with 4 stimuli in each
category. To establish that the participants did not know the tacts for these stimuli prior to the initiation of
ITI, each participant was probed with one trial for each stimulus picture. The instructor presented a
picture and (without saying anything) waited 2-3 seconds for the participant to make a response. None of
the responses were consequated during the probe. Results of the probe demonstrated that the participants
did not have any of the tacts for these stimuli in repertoire.
For ITI, the stimuli were divided into five sets corresponding to each of the 5 categories. Within
each category set, each of the 4 stimuli were represented by 5 different pictures. For example, within the
set of instruments, there were 5 pictures of pianos, 5 pictures of triangles, and so on. This resulted in 20
pictures per set.
As indicated above, participant received 100 tact learn units during ITI. A correct response was
defined as the emission of a tact within 2 to 3 seconds following the presentation of a stimulus picture by
the instructor. For example, when the instructor, without any vocal antecedent, presented the participant
with a picture of a fox, a correct response was recorded if the participant emitted the vocal response “fox”
within 2 to 3 seconds. The instructor then reinforced the participant by giving him his preferred edibles or
vocal praise (i.e. “You are so smart! It is a fox!”). If the participant did not emit any vocal response or if
he emitted one or more incorrect responses within 2-3 seconds, it was coded as incorrect and a correction
procedure was initiated in which the teacher presented the picture of the fox again, said “fox,” and
required the participant to echo the word “fox”.
When the participant mastered the items in one or more categories (100% accuracy in one session or
90% in two consecutive sessions), the 100 learn units of ITI were devoted to the rest of the categories that
were not yet mastered, which were rotated until the participant received 100 learn units of ITI. For
example, if the participant met criterion on the category of food first, he still needed to receive 100 learn
units of ITI, including 80 learn units for the remaining four categories plus 20 learn units for the mastered
set of food. A day of post probe was conducted after the participant met criterion on a set. This same
procedure was used in prior studies of the ITP (Pistoljevic & Greer, 2006; Pereira-Delgado & Oblak,
2007).
Data Collection
Design. A delayed multiple probe design across participants (Horner & Baer, 1978; Pistoljevic &
Greer, 2006; Schauffler & Greer, 2006) was used to compare the number of verbal operants (tacts, mands,
intraverbals) emitted by each participant in NIS (transition, play, lunch) before and after mastering each set
of objectives in each of two conditions: (1) baseline, during which 5 sets of non-tact generic learning
objectives were targeted, and (2) ITP intervention, during which 5 sets of tacts were targeted. This resulted
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in 13 sets of probe data per participant, including 3 before baseline, 5 during baseline, and 5 during
intervention.
The specific sequence of procedures occurred as follows: (1) Pre-intervention probes were
conducted by documenting the pure mands, pure tacts, and intraverbals emitted by each participant in NIS
on 3 consecutive days prior to the initiation of baseline. (2) For each participant, the mean number of
daily learn units and the mean number of learn-units-to-criterion were calculated for the month prior to
the initiation of baseline. (3) During baseline, the number of learn units per participant was determined by
adding 100 to the mean number of daily learn units the participant had received in the previous month.
The extra 100 learn units were allocated equally to target 5 sets of pre-selected non-tact generic learning
objectives. (4) Whenever a participant met criterion on a set of non-tact generic learning objectives,
another probe was done in the NIS to assess pure mands, pure tacts, and intraverbals. This resulted in 5
sets of probe data during baseline. (5) After a participant achieved criterion on all 5 sets of non-tact
learning objectives, the ITP was initiated. The 100 additional daily learn units that had been used during
baseline to target 5 sets of non-tact generic learning objectives were replaced with 100 daily learn units of
ITI to target 5 sets of tacts. (6) Whenever a participant met criterion on a set of tacts during ITI, another
probe was done in the NIS to assess pure mands, pure tacts, and intraverbals. This resulted in 5 sets of
probe data during the ITP.
Probe Sessions. During all probe sessions, pure mands, pure tacts, and intraverbals emitted by the
participants were transcribed word for word and then documented by counting the occurrences of each
type of operant within the 5 minute interval. During the transitioning from the school bus to the
classroom, the instructor started the timer when the participant stepped off the school bus and stopped the
timer after 5-minutes. During the lunchtime probes, the instructor started the timer after the participant
finished eating and concluded after 5-minutes. During the toy area probes, the instructor started the timer
when the participant was playing with toys in the toy area of the classroom and concluded after 5 minutes.
A pen and a data collection form were used to record the data, and a timer was used to determine
elapsed time. A circled capital T next to a transcribed verbal operant classified the operant as a pure tact,
a circled capital M indicated a pure mand, and a circled capital I indicated an intraverbal. At the end of
each day, the numbers of pure tacts, pure mands and intraverbals collected in the three 5-minute segments
were combined into a single session and totaled.
Baseline Sessions. During baseline, the participants were presented with learn units for 5 sets of
non-tact, generic learning objectives. As indicated above, the numbers of daily learn units were increased
for each participant by 100 over the mean number of daily learn units received in the prior month. This
was done to control for intensity of instruction across baseline and intervention phases. Since each
instructional program consisted of 20-learn units, the addition of 100 learn units was accomplished by
presenting one more session in each of the 5 non-tact programs that were selected from the three
participants’ daily curricular instructions.
Table 2 summarizes each participant’s 5 non-tact programs. Five short-term-objectives (STOs) were
chosen for each of these five programs and they were grouped into different sets in sequence. For
example, Participant A had to master each of the first STOs in his five selected programs (Edmark
Reading objectives, textually responding to targeted sight words, math objectives, prepositions as
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autoclitics, and writing picture descriptions) before he progressed to the next objectives. A plus sign (+)
was recorded when the participant emitted a correct response, and a minus sign (-) was recorded if he
emitted an incorrect response or no response. Mastery of a short-term-objective (STO) was defined as
90% accuracy across 2 consecutive sessions or 100% accuracy for 1 session.
When the participant attained mastery in one or more programs in one set, the 100 learn units
were devoted to the rest of the programs that were not met, which were rotated until the participant
received 100 learn units in those five non-tact programs. The participant was not presented with a novel
set of 5 categories until he met criterion on all 5 programs in the prior set. A day of post probe was
conducted after the participant met criterion on the prior set.
Table 2. Five non-tact programs selected for the three participants for instruction in baseline
Programs
Participant A
Participant B
Participant C
Program 1
Edmark Reading objectives
Calendar
Action discrimination
Program 2
Textually Responding to
targeted Sight Words
Letters
Dolch Words
Program 3
Math objectives
Body parts identification
Body parts identification
Program 4
Prepositions as autoclitics
Number identification
Number identification
Program 5
Writing Picture Descriptions
Follow vocal directions
2-step motor imitation
Intensive Tact Instruction (ITI). During ITI, data were recorded on the number of correct responses to
the target stimuli. A plus sign (+) was recorded when the participant emitted a correct response, and a
minus sign (-) was recorded if he emitted an incorrect response or no response. Mastery of a set
(category) of tact stimuli was defined as 90% accuracy across 2 consecutive sessions or 100% accuracy
for 1 session (equivalent to mastery of an STO in the generic instruction phase). After achieving criterion
on one of the training sets, a new set (category) of tacts was introduced. Thus the procedures were the
same for the ITI as for the non-tact generic instruction in the baseline.
As indicated earlier, participants received intensive tact training on 5 sets of stimuli, one set at a
time. Each set represented one of 5 categories: community helpers, animals, food, instruments and
transportation. Each category included 4 stimuli. For example the category of ‘instruments’ included
piano, cello, triangle, and organ, and each stimulus item was represented by 5 different pictures (e.g., 5
different pictures of a piano, 5 different pictures of a cello, etc.). This resulted in a total of 20 pictures per
set. For each set, the 20 pictures were rotated systematically so that a participant received 20 learn units
with equal numbers of response opportunities for each stimulus item within the set.
Interobserver Agreement (IOA)
IOA on verbal operants during probe sessions. IOA was conducted by measuring percent
agreement between the data collected during NIS by the primary instructor and the data collected
simultaneously and independently by the classroom teacher or a teaching assistant. All observers used
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event recording. The classroom teacher and teaching assistants were trained through observations by the
supervisor and one of the experimenters. Some of the probe sessions were also videotaped so that another
independent observer could view the video and record the data at a later time. IOA for pure tacts, pure
mands and intraverbals across all observations of Participants A and B was 100%. The mean IOA for the
same operants produced by Participant C across all observations was 90% (range = 80% -100%).
IOA during baseline (while targeting non-tact generic learning objectives). IOA during baseline
was also measured by percent agreement. It was assessed by two independent observers throughout 17%
of sessions for Participant A, 67% of sessions for Participant B, and 21% of sessions for Participant C.
Each observer used the Teacher Performance Rate Accuracy Protocol (TPRA) (Ingham & Greer, 1992)
which assesses both the accuracy of the measurement of the students’ responses and the fidelity of
implementation of learn units. The results for Participants A, B, and C resulted in mean IOA values of
93% (range = 85% - 100%), 98%, (range = 95% -100%), and 93% (range = 85% - 100%), respectively.
IOA during the ITP (when using ITI to target 5 categories of tacts). IOA during ITP was measured
via percent agreement by two independent observers throughout 19% (43/227) of sessions for Participant
A, 30% (56/187) of sessions for Participant B, and 24% (32/131) of sessions for Participant C. These
observers also used the TPRA (Ingham & Greer, 1992) to assesses the accuracy of the measurement of
the students’ responses and the fidelity of implementation of learn units. The mean IOA for learn unit
accuracy during ITP for Participants A, B, C was 98% (range =95% - 100%), 100%, and 90% (range =
90% - 100%), respectively, across all sessions.
Results
Table 3 shows the number of tacts, mands, and intraverbals produced by each participant during
the pre-baseline probes. Figure 1 shows the number of pure tacts, pure mands, and intraverbals produced
by each participant during the 15-minute probes in NIS following mastery of sets targeted during non-tact
instruction (NTI) and following mastery of sets targeted during ITI. The response patterns demonstrated
by each individual participant are summarized below.
For participant A, Table 3 shows a total of 0 tacts, 13 mands (i.e., 4, 5, & 4 respectively), and 0
intraverbals during the pre-baseline probe sessions. Figure 1 shows the following progression for verbal
operants emitted in NIS following mastery of each NTI set: 0 tacts, 8 mands, and 1 intraverbal following
Set 1; 0 tacts, 19 mands, and 1 intraverbal following Set 2; 0 tacts, 7 mands, and 1 intraverbal following
Set 3; 0 tacts, 7 mands, and 2 intraverbals following set 4; and 0 tacts, 8 mands, and 2 intraverbals
following Set 5. In contrast, Participant A emitted the following pattern of verbal operants in NIS
following mastery of each ITI set: 3 tacts, 6 mands, and 2 intraverbals following Set 1; 4 tacts, 6 mands,
and 2 intraverbals following Set 2; 6 tacts, 8 mands, and 2 intraverbals following Set 3; 17 tacts, 9 mands,
and 1 intraverbal following Set 4; and 15 tacts, 7 mands, and 2 intraverbals following Set 5.
For Participant B, Table 3 shows a total of 0 tacts, 1 mand and 3 intraverbals across 3 pre-baseline
probe sessions. Figure 1 shows the following progression for verbal operants emitted in NIS during
probes following the mastery of each NTI set: 2 tacts, 5 mands, and 0 intraverbal following Set 1; 0 tacts,
2 mands, and 0 intraverbal following Set 2; 2 tacts, 4 mands, and 0 intraverbal following Set 3; 3 tacts, 0
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mands, and 0 intraverbals following set 4; and 0 tacts, 2 mands, and 0 intraverbals following Set 5. In
contrast, Participant B emitted the following pattern of verbal operants in probes following mastery of
each ITI set: 4 tacts, 7 mands, and 1 intraverbals following Set 1; 4 tacts, 9 mands, and 3 intraverbals
following Set 2; 16 tacts, 4 mands, and 2 intraverbals following Set 3; 10 tacts, 7 mands, and 2 intraverbal
following Set 4; and 15 tacts, 6 mands, and 2 intraverbals following Set 5.
For Participant C, Table 3 shows a total of 9 tacts (i.e., 4, 2, & 3 respectively), 2 mands , and 0
intraverbals across 3 pre-baseline probe sessions. Figure 1 shows the following progression for verbal
operants emitted in NIS during probes following the mastery of each baseline NTI set: 4 tacts, 5 mands,
and 2 intraverbal following Set 1; 3 tacts, 5 mands, and 4 intraverbal following Set 2; 6 tacts, 3 mands,
and 1 intraverbal following Set 3; 4 tacts, 8 mands, and 1 intraverbals following set 4; and 5 tacts, 18
mands, and 1 intraverbals following Set 5. In contrast, Participant C emitted the following pattern of
verbal operants in NIS during probes following mastery of each ITI set: 10 tacts, 2 mands, and 2
intraverbals following Set 1; 14 tacts, 3 mands, and 3 intraverbals following Set 2; 18 tacts, 6 mands, and
1 intraverbals following Set 3; 12 tacts, 3 mands, and 1 intraverbal following Set 4; and 10 tacts, 4 mands,
and 1 intraverbals following Set 5.
Table 3. Three participants’ number of verbal operants during pre baseline probes
Pre-Probes Verbal Operants
Tacts
1
2
3
4
Participant A
0
Participant B
0
Participant C
4
Mands
4
0
0
Intraverbals
0
0
0
Tacts
0
0
2
Mands
5
0
1
Intraverbals
0
0
0
Tacts
0
0
3
Mands
4
0
1
Intraverbals
0
1
0
Tacts
0
Mands
Intraverbals
1
2
Table 4 summarizes the number of each participant’s learn units to criterion for sets 1, 2, 3, 4, and
5 during Baseline (NTI) and for sets 1, 2, 3, 4, and 5 during the intensive tact procedure (using ITI).
These data show that Participant A’s learn units to criteria for programs 1 through 5 were 80, 64, 96, 84,
and 84 , respectively. Participant B’s learn units were 72, 92, 92, 80, and 76 respectively; and Participant
C’s learn units were 100, 80, 80, 124, and 100, respectively. During the 5 ITI sets, we see that Participant
A’s learn units to criteria were 200, 136, 236, 216, and 124, respectively. Participant B’s learn units to
criterion were 124, 264, 144, 128, and 88, respectively, and Participant C’s learn units to criterion were
96, 128, 88,104, and 112, respectively.
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For Participants A and B, mastery of sets during ITI required significantly more learn units than
did mastery of sets during NTI. Participant A required 408 learn units (mean = 81.6) to master NTI sets
compared with 912 (mean = 182.4) to master ITI sets. Participant B required 412 learn units (mean =
82.4) to master NTI sets compared with 748 (mean = 149.8) to master ITI sets, and Participant C required
484 learn units (mean = 96.8) to master NTI sets and 528 learn units (mean = 149.8) to master ITI sets.
Figure 1.Verbal operants emitted by three participants during 15-minute probes in non-instructional
settings following the mastery of 5 sets targeting non-tact objectives 5 sets of intensive tact
instruction
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Table 4. Three participants’ number of learn units to criterion for each set mastered.
Treatment 2 (ITP)
Baseline 1 (NTI)
Conditions
Set 1
Set 2
Set 3
Set 4
Set 5
1
2
TOTAL
Set 1
Set 2
Set 3
Set 4
Set 5
TOTAL
Participant A
80
64
96
84
84
Participant B
72
92
92
80
76
Participant C
100
80
80
124
100
408
412
484
200
136
236
216
124
124
264
144
128
88
96
128
88
104
112
912
748
528
NTI = Non-Tact Instruction
ITP = Intensive Tact Procedure using Intensive Tact Training (ITI)
Figures 2, 3, and 4, show the responses of Participants A, B, C to their intensive tact instruction.
Figure 2 shows responses for Participant A, Figure 3 for Participant B, and Figure 4 for Participant C.
These data show the mastery of each set for each participant.
Discussion
The results of this study demonstrated a functional relationship between intensive tact instruction
and the emission of pure mands, pure tacts and intraverbals by three participants in non-instructional
contexts. These findings are consistent with the results of Pistoljevic & Greer (2006), Schauffler & Greer
(2006), Pereira-Delgado, & Oblak (2007), and Pistoljevic (2008) in that that the intensive tact instruction
facilitated the acquisition of tacts and mands.
The current study also addressed the question raised by Pistoljevic and Greer (2006) of whether the
increased emission of verbal operants following intensive tact instruction was simply due to an increase in
the number of learn units provided to participants or to the specific features of intensive tact instruction.
The results of this study show that the emission of tacts in non-instructional settings was due to the
intensive tact instruction and not simply to the addition of learn units. Increasing the numbers of learn
units for the non-tact programs increased the number of pure mands, but not the number of pure tacts
emitted by the participants in non-instructional settings.
The increase in the number of pure tacts emitted in non-instructional settings may be explained in
that tacts link to the recruitment of generalized reinforcement from adults. It is also possible that intensive
tact instruction enhanced the reinforcement effect of social attention, which prior research has shown to
be the critical control for the emission of tacts (Tsiouri & Greer, 2003; Pistoljevic, 2008).
Like prior studies of the intensive tact procedure, the specific tacts emitted by children in noninstructional settings were seldom the same tacts that were directly trained during intensive tact
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instruction. Greer and Speckman (2009) argue that acquiring conditioned reinforcement for attention is
Figure 2. Participant A’s instructional sessions for each category of each set of tacts
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Figure 3. Participant B’s instructional sessions for each category of each set of tacts
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Figure 4. Participant C’s instructional sessions for each category of each set of tacts
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the strongest predictor of children’s emission of tacts. The acquisition of conditioned reinforcement for
attention is basic to the development of more advanced verbal development especially the emission of
conversational units and the acquisition of Naming.
Why did the mands increase in the baseline during generic educational instruction? We think that
with the increased daily number of learn units in generic non-tact instruction, the participants were
presented with more opportunities to be reinforced and more opportunities for emitting mands for their
tokens and other reinforcers, and these experiences may have resulted in generalization to noninstructional settings. However, the increased intraverbals following intensive tact instruction also
showed that the participants engaged in more speaker-listener exchanges with others after the intensive
tact instruction, again suggesting the enhanced reinforcement of social attention. Greer and Speckman
(2009) and Greer and Ross (2008) argue that the emission of mands is much easier to obtain because of
the nature of reinforcement for mands, since they specify their reinforcer. In contrast, the emission of
tacts is controlled by social contingencies of reinforcement. The latter is critical to becoming truly verbal
(Greer & Speckman; Barnes-Holmes, et al., 2000; Horne & Lowe, 1996) in the joining of the listener and
speaker.
The intensive tact procedure is an effective means to compensate for the missing language
opportunities associated with children like those described in studies by Pistoljevic and Greer (2006) and
Pereira-Delgado & Oblak (2007). The protocol simply ensured that the participants received frequent tact
instruction. The findings in the current study were consistent with Pistoljevic and Greer (2006) , PereiraDelgado, & Oblak (2007), and Pistoljevic (2008) in that the participants used both the tacts that they had
in repertoire and those that were taught, while most of the tacts that the students emitted in noninstructional settings were not the tacts that they were taught during intensive tact instruction. The
intensive tact procedure may have increased the reinforcement value of generalized reinforcement for
tacts. This interpretation is supported by the fact that the participants emitted tacts that were not targeted
during intensive tact instruction for the most part. Thus the participants may have learned to emit the tacts
as a means to recruit generalized reinforcers in the form of attention from the teachers made possible by
the enhanced effects of attention as a generalized reinforcer.
Several limitations of the current study should be noted. First, there are only three participants.
More participants functioning at similar and different verbal behavior levels are needed to assess the
generality of these findings. Second, the instruction for the intensive tact procedure was delivered in some
of the same contexts (e.g., play area) where probe data were collected to assess verbal operants in noninstructional settings. This enhanced the generality of responding and differed from some prior studies
where the intensive tact instruction occurred at the children’s desks. Third, responses made by some of
the participants were not consistently progressive. There was an especially noticeable decrease in
Participant C’s emission of pure tacts during probe 4 in comparison to probe 3 of intensive tact
instruction. This might have been due to a significant change in this Participant’s environment. His school
had rearranged all of the students and staff at the time he was learning Set 4 of intensive tact instruction.
Moreover, based on the significant progress he had made across the semester, he had been switched to a
new classroom with peers who demonstrated relatively higher verbal behavior levels. Therefore, the
probes conducted after Set 4 took place in the new classroom with new peers and teachers. Together with
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Participant C’s new placement, the books and toys he usually read and played with were different. What’s
more important, the peers that he interacted with and emitted tacts with had changed as well. The children
in the new classroom were more verbally sophisticated and had more verbal capabilities. In this new
class, Participant C’s verbal behavior levels became relatively lower compared to his new friends. His
decrease in the numbers of pure tacts following the final set may be a reflection of this change. According
to Kantor (1958), the founder of Interbehaviorism, any interaction of events occurs in a context rather
than in isolation. Perhaps, the social control for tacts is contextually related to one’s acquaintances. This
needs to be assessed empirically.
Despite its limitations, the results of this study replicated those of prior studies regarding the
effects of the ITP on “spontaneous speech”. Moreover, they suggest that it is the tact training and not an
increase in instruction that was the source of the increase in spontaneous vocal verbal behavior. The fact
that the tacts emitted in the non-instructional settings were not those taught is also consistent with prior
findings. We speculate that either the procedure acts as an establishing operation for tact operants or that
the attention of other individuals is conditioned as a reinforcer for the emission of tacts. The current
findings, together with prior studies on the intensive tact instruction, suggest that the effect of the
procedure is relatively robust. Children like these and children like those in the prior studies are likely to
increase their emission of “spontaneous” verbal operants in non-instructional settings. At the very least
they acquire more tacts, and until they acquire Naming this is their only way to expand their verbal
repertoire.
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Selinski, J., Greer, R. D., & Lodhi, S. (1991). A functional analysis of the comprehensive application of behavior
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Skinner, B.F. (1957). Verbal Behavior. Acton, MA: Copley Publishing Group.
Sundberg, M. L., Michael, J., Partington, J. W., & Sundberg, C. A. (1996). The role of automatic reinforcement in
early language acquisition. The Analysis of Verbal Behavior, 13, 21-37.
Tsiouri, I. & Greer, R. D. (2003). Inducing vocal verbal behavior through rapid motor imitation training in young
children with language delays. Journal of Behavioral Education, 12, 185-206.
Williams, G., & Greer, R. D. (1993). A comparison of verbal-behavior and linguistic communication curricula for
training developmentally delayed adolescents to acquire and maintain vocal speech. Behaviorology, 1, 3146.
Zimmerman, I. L., Steiner, V. G., & Pond, R. E. (2002). Preschool language scale (4th ed.). San Antonio, TX:
Psychological.
Authors Note
This experiment was conducted as part of the second author’s doctoral coursework under the supervision of the first
author. We appreciate the contributions and cooperation of the children during the conduct of this research.
Author contact information
R. Douglas Greer
e-mail: [email protected]
Box 76 Teachers College
Columbia University
New York, NY 10027
Lin Du
Department of Health and Behavior
Teachers College
Columbia University
New York, NY 10027
Email: [email protected]
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Volume 5, Issue No. 1
Effects of Multiple Exemplar Instruction on
Transformation of Stimulus Function
Across Written and Vocal Spelling Responses
by Students with Autism
Carly M. Eby, R. Douglas Greer, Lisa D. Tullo, Katherine A. Baker, and Rebecca Pauly
Abstract
Transfer of stimulus function (TSF) involves the acquisition of an untaught response to a stimulus
which previously evoked only a single taught response. We tested the effects of multiple exemplar
instruction on the TSF across vocal and written spelling responses of 3 elementary students with autism.
Participants were taught to spell 4 words (Set 1) either vocally or graphically. Untaught responses were
probed. Then, participants were taught to spell 4 different words (Set 2) in the opposite topography.
Following mastery, untaught responses to Set 1 were again probed. Finally, 4 novel words (Set 3) were
taught in a single-response-topography (saying or writing) and the untaught topography was probed.
Results showed correct untaught responses to Set 1 words and eme rgence of set 4.
Keywords : spelling, multiple exemplar instruction, independence of verbal operants, transformation of
function
Introduction
According to Skinner (1957), speaking and writing are different kinds of verbal operants that
initially must be “separately conditioned” (p. 191). Skinner (1957) proposed that words that occur in
written form are functionally independent of the vocal form of the same word. He refers to this as the
“same response in different media” (p.191). On this topic, Skinner wrote:
But speaking and writing are obviously different kinds of behavior, which utilize
different parts of the body in different ways. Where we could paraphrase “the
same word used in different ways” as “the same response in different types of
operant,” here we must attempt to bridge the gap between spoken and written
behavior either by pointing to something common to the occasions upon which
the behaviors occur or among the effects which they have upon the listener and
reader. But common controlling variables, action either prior to the behavior in
the stimulation occasion or after the behavior as part of the event called
reinforcement, will not permit us to get from one form of the response to the
other. The two forms of behavior must be separately conditioned. (p. 191)
Consistent with Skinner’s theory, several types of verbal operants are initially independent
including: mands and tacts (e.g., Lamarre & Holland, 1985; Hall & Sundberg, 1987; Twyman, 1996;
Williams & Greer, 1993), listener and speaker responses (Horne & Lowe, 1996), and written and spoken
responses (Greer, Yuan, & Gautreaux, 2005). Recent research reported the effectiveness of multiple
exemplar instructional methods in joining separate verbal operants to a single controlling stimulus, such
as with listener and speaker responses (Horne & Lowe, 1996; Fiorile & Greer, 2007; Greer, Stolfi,
Chavez-Brown, & Rivera-Valdez, 2005; Pistoljevic, 2008), and with written and spoken responses
(Greer, Yuan, et al., 2005). Similarly, Nirgudkar (2005) and Nuzzolo-Gomez & Greer (2005) joined
single responses to the control of different establishing operations for mand and tact operants as a
function of multiple exemplar instruction (MEI) across establishing operations.
According to Greer & Ross (2008) MEI) (also known as multiple exemplar training or MET) has
been described in the literature in two ways. In one use of the term (also called general case teaching),
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MEI refers to a tactic in which different examples of the same stimulus are presented when teaching
generalization or abstraction (e.g., Hughes & Rusch, 1989; Sprague & Horner, 1984). For example,
teaching textual responses to phonemes across multiple exemplars results in the emission of accurate
textual responses to novel words (Engelmann & Carnine, 1982). In another usage, MEI refers to a tactic
used to bring independent operants (e.g., writing, spelling aloud, and textually responding) under joint
stimulus control for novel stimuli by rotating different responses to a single stimulus in instructional sets
(Greer, Yuan, et al., 2005; Fiorile & Greer, 2007; Greer, Stolfi, et al., 2005). That is, “the manipulation of
initially independent response topographies with the same stimulus may generate the joint stimulus
control such that a single stimulus can evoke both responses” (Greer, Yuan, et al. p. 100). In the study
described herein, the latter description of MEI applies.
Greer, Yuan, et al. (2005) tested the effect of MEI across written and spoken responses in
instructional sets on the acquisition of untaught spelling responses in the vocal or written form, for four
young children, using a delayed multiple probe design. After an initial test showed that the participants
could not spell three sets of five words, the participants were taught to spell Set 1 words in one response
form (either vocal or written), and after achieving mastery in the taught form, probes were conducted on
the untaught form. The probes showed that the participants could not emit the untaught responses.
Participants were then taught to spell an instructional set of words (Set 2) to mastery, rotating the
responses across writing and saying letters. Following the MEI intervention (with Set 2 only) probes were
again conducted on the untaught response forms in Set 1 and the results showed that the untaught forms
emerged. Lastly, participants were taught to spell Set 3 words using single response training, and then
probes were conducted on the untaught form. Correct responses to the untaught forms emerged.
The results of the Greer, Yuan et al. (2005) study showed that correct responding of the untaught
form for Set 1 was low for all four participants prior to the MEI intervention. Following MEI, all four
participants demonstrated correct responses in the untaught form in 80% to 100% of probe trials. In
addition, when Set 3 was introduced, all four participants demonstrated correct responses in the untaught
form in 80% to 100% of probe trials. These results were replicated with a second group of Kindergarten
students diagnosed with autism spectrum disorders (ASD) who performed academically at or above grade
level. The participants in the Greer et al. study were kindergarteners who were either described as having
language delays (Experiment 1) or as performing at or above grade level (Experiment 2). These
procedures have not yet been tested with participants with more limited levels of verbal behavior.
Therefore, we tested the effects of multiple exemplar instruction across saying and writing on the
acquisition of untaught spelling responses with elementary-aged children who were diagnosed with ASD
and who had more limited verbal repertoires.
Method
Participants
Three 7-year old males were selected for this study because, based on baseline probes, they did
not demonstrate joint stimulus control of spelling across written and spoken functions and they could not
spell any of the words used in the experiment in either topography. All of the participants had a diagnosis
of ASD. The participants’ verbal capabilities were assessed using the International Curriculum and
Inventory of Repertoires for Children from Pre-school through Kindergarten (AIL/PIRK) (Greer &
McCorkle, 2008), a curriculum-based assessment that includes assessments of children’s verbal
developmental cusps and capabilities as identified in Greer and Ross (2008) and Greer and Speckman
(2009). See Waddington and Reed (2009) for a description and evaluation of the PIRK.
Table 1 includes a more detailed description of the participants. Participant 1 was a 7.9-year old
male. His verbal capabilities and cusps included: basic listener literacy, the teacher’s presence results in
instructional control, following of two-step directions, generalized match-to-sample responding, and the
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presence of mands and tacts with autoclitic s (Greer & Ross, 2008). In addition, Participant 1 read at a
first grade level.
Participant 2 was a 7.8- year old male. His verbal capabilities and cusps included: basic listener
literacy, basic mand and tact operants, following of multi-step directions, and generalized match-to
sample responding. He read at a Kindergarten level. Participant 2 had a speech disorder that affected his
articulation of consonant sounds. For example, when reading the word, “Cat,” he often omitted both the
“c” and “t” sounds, thus reading the word as “ah” or “gah.” The participant had an echoic repertoire at
the time of the study and targeted echoic responses were shown to improve with the application of learn
units as a method of instruction.
Participant 3 was a 7.0-year-old male. He followed one-step instructions and emitted some
mands and tacts in the context of instruction. He performed at a Kindergarten level for math and a first
grade level for reading. His verbal cusps and capabilities included generalized motor imitation, match-tosample responding across the senses, echoic -to-mand, echoic -to-tact, and transformation of establishing
operations across mands and tacts. Participant 3 did not have the topography of handwriting in his
repertoire at the time of the study, however he could use a computer keyboard to type words, therefore
during the study all writing responses for this participant were typed.
Table 1. Description of Participants
Part
Age
Diagnosis & Level of
Verbal Ability
Standardized Test Scores
PIRK Verbal Behavior
Developmental Cusps and
Capabilities
1
- 7.9
- male
-ASD
- Listener/Speaker
- Writer/Reader
- 1st grade reading level
- Preschool Language Scale-4:
Auditory Comprehension:
SS=53, 3%; Expressive
Communication: SS=50; Total
Language: SS=50
- Receptive One-Word Picture
Vocabulary Test: SS=84, 14%
-Mands/Tacts with autoclitic
frames
-Following vocal verbal
directions
-Conversational units emitted
-Matching and
pointing/Listener repertoires
2
-7.8
- Male
-ASD
-Listener/Speaker
-Emergent Reader/Writer
-Vineland-II Adaptive
Behavior Scales: Adaptive
Behavior Composite: 61
- Receptive One-Word Picture
Vocabulary Test: SS:62:1%
- Expressive One-Word Picture
Vocabulary Test: SS:<55;<1%
-Test for Auditory
Comprehension of Language3: 53; <1%
-Mands with autoclitic frames
-Tacts
-Following vocal verbal
directions
-Matching and
Pointing/Listener repertoires
- ASD
- Listener/Speaker
- Emergent Reader/Pre Writer
- Reads on Kindergarten
level
- Receptive One-Word Picture
Vocabulary Test: Total A.E.
5.3
- Expressive One-Word Picture
Vocabulary Test: A.E. 5.2
-Beery-Visual Motor
Integration-V: SS=76, 5%
- Mands/Tacts
- Following vocal verbal
directions Transformation of
establishing operations for
mands and tacts
3
- 7.0
- male
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Setting
The participants were selected from a self-contained classroom within a public school located in a
suburb outside of a large metropolitan area. The classroom was characterized by its comprehensive
application of applied behavior analysis strategies and tactics to teach the range of curricula. All
participants had a history of instruction that consisted of learn units (Greer & McDonough, 1999; Albers
& Greer, 1991) that made up all of their daily academic, verbal behavior, self-management, and problem
solving instruction. A learn unit consists of a series of interlocking operants for a student and teacher, in
which there is one potential three-term contingency for the student and two or more for the teacher. The
learn unit begins with the student emitting an attending response, which is the first antecedent for the
teacher. The teacher presents an antecedent stimulus to the student (functioning as both teacher behavior
and student antecedent). The student responds to the teacher antecedent (functioning as both student
behavior and teacher consequence). Following the student’s correct or incorrect response the teacher
immediately delivers a consequence (reinforcement for a correct response or correction for an incorrect
response) and records the student response (functioning as both student consequence and teacher
behavior). The student attends to the correction or reinforcement and actively responds to any corrections
(functioning as teacher consequence and completing the learn unit).
Instructional sessions took place in the participants’ classroom. During all sessions, other
students in the class received instruction from other professionals at the same time. Both the student and
the teacher sat at either a horseshoe shaped table or a desk, in child-sized chairs, facing one another.
Materials included data sheets, black pens, and prosthetic reinforcers. Student materials included pencils
and lined paper used for elementary school-age children’s writing instruction. Participant 3 used a Dell™
Computer keyboard for his written responses.
Dependent Variable
The dependent variable was correct responses to no feedback probe trials for untaught response
topographies, either written or spoken. Prior to the baseline probe for Set 1, the participants were taught to
mastery either the written or spoken response form for Set 1 using learn units. During instruction, the
teacher said, “Spell ___” (for Participant 1) or “Write ___” (for Participant 2) and reinforcement and
corrections were provided, as described in the Independent Variable section. The instruction “Spell” was
used to evoke a spoken response for the letters of the words and the instruction “Write” was used to evoke
a written response.
Response Definitions
The target behaviors were written and spoken responses to vocal dictation by the teacher. The
definition of a correct spoken spelling response was, given the antecedent, “Spell ____,” the student
would say the letters of the word in the correct order so that there was point-to-point correspondence to
the conventional spelling of the word. For example, in response to the teacher-delivered antecedent,
“Spell boat,” the student would say “b-o-a-t.” Examples of an incorrect spoken spelling response
included, saying the letters in the wrong order, omitting or adding incorrect letters, spelling a different
word, or no response.
The definition of a correct written spelling response was, given the instruction, “Write ____,” the
student would write the letters of the word in the correct order according to the conventional spelling of
the word. For example, given the teacher instructional antecedent, “Write jump,” the student would write
jump. Examples of an incorrect written spelling response included, writing the letters in the wrong order,
writing a word other than the target, omitting or adding incorrect letters, writing illegibly, or no response.
Each of the participants was assigned three sets of four words. The three sets of words for each
participant are shown in Table 2. The words were two-, three-, four-, and five-letter words from a list of
high-frequency words (Eldredge, 1995).
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Table 2. Word Sets for Participants 1, 2, and 3
Participant
1
2
3
Set 1 Words
where, away, three, I
Vocal Instruction
Written Probe
help, jump, not, here
Written Instruction
Vocal Probe
seven, carry, try, gave
Written Instruction
Vocal Probe
Set 2 Words
help, jump, not, here
MEI: Vocal and Written
Instruction
where, away, three, I
MEI: Vocal and Written
Instruction
why, upon, myself, your
MEI: Vocal and Written
Instruction
Set 3 Words
Little, find, make, fear
Written Instruction
Vocal Probe
every, warm, live, take
Vocal Instruction
Written Probe
buy, does, the, mad
Vocal Instruction
Written Probe
Data Collection.
An experimenter collected data after each response using pencil and paper. Some sessions were
video recorded using a digital video camera with an audio recorder. This was used for interobserver
agreement purposes. Data were collected on untaught written and spoken spelling responses that served
as the dependent varia ble (Set 1 and Set 3 words). Data were also collected on the responses to learn unit
instruction used in the MEI intervention for both written and spoken topographies for Set 2 words, as well
as the taught topographies for Set 1 and Set 3 words. Correct responses were recorded by marking a plus
(+) on the data form and incorrect responses were recorded by marking a minus (-) on the data form.
During the intervention phase, if one response type was mastered before the other, we continued to
present it in the rotation as an antecedent, however they were no longer recorded or graphed. That is, if a
participant met criterion for vocally spelling the words in his training set, but did not yet meet criterion in
the written topography for those same words, both topographies continued to be presented and reinforced
on a continuous schedule until criterion was met in both response topographies.
Interobserver and Interscorer Agreement
Independent observers recorded correct and incorrect responses in 42% of probe sessions either
during the sessions or after viewing the video recordings. The percentage of agreement for correct and
incorrect responses was 100% across all sessions in which there was an independent observer. We
determined the percentage of agreement by dividing the total numbers of point-by-point observer
agreements by the total numbers of agreements plus disagreements, and then multiplying by 100.
Procedure
Design. The design was a multiple probe design across participants. Sessions were time lagged to
control for maturation and history. The order of response type, written or spoken, was counterbalanced
across participants, such that Participant 1 received vocal response instruction on Set 1 words and
Participants 2 and 3 received written response instruction on Set 1 words. The conditions were presented
in the following sequence: (a) Pre-experimental probes of written and spoken responses to all three sets of
words, demonstrating that the students could not spell the words in either topography; (b) single response
instruction in either spoken or written responses to Set 1 words, (c) probes for untaught responses to Set 1
words, (d) multiple exemplar instruction across vocal and written responses for an instructional set of
words, (e) probes for untaught responses to Set 1 words, (f) single response instruction in either spoken or
written responses to a new set of words (Set 3), (g) probes for untaught responses to Set 3 words
General Procedure. The participant and experimenter were seated at a table with limited
distractions. The experimenter gained the participant’s attention before delivering each antecedent by
saying his name and/or waiting for the participant to make eye contact or emit a ready response, such as
the participant saying, “I’m ready.” Depending on the condition, the experimenter would deliver one of
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two antecedents. In the written condition, it was “Write the word ____.” In the vocal condition, it was
“Spell the word ___.” Instructional sessions consisted of 20 learn units. Probe sessions consisted of 20
trials with no feedback (no reinforcement or corrections).
Pre-Experimental Probe Conditions (Phase 1). A pre-test was conducted in which each of the
three sets of words was presented under probe trial conditions prior to the baseline. This consisted of five
presentations of each of the four words (i.e., 20 trials) for each of the three sets of words (Sets 1, 2, and
3), and for each of the response topographies (i.e., vocal and written). In the written condition, it was
“Write the word ____.” In the vocal condition, it was “Spell the word ___.” No programmed
reinforcement or corrections occurred. The experimenter delivered the relevant antecedent, waited 5 sec
for a response, and then presented the next trial. There were 20 massed trials for vocal responses
followed by 20 massed trials for written responses. None of the students emitted any correct responses in
either the written or spoken response forms to any of the three word sets.
Single Response Instruction – Set 1 (Phase 2). Learn units were implemented to teach a set of
spelling words in either the written or vocal topography. Table 2 shows the words that were selected for
each participant and the topographies that were taught and/or probed during each phase. Participant 1
received instruction on the vocal topography only for the words where, away, three, and in. Participant 2
received instruction on the written topography only for the words help, jump, not, and here. Participant 3
received instruction on the written topography only for the words seven, carry, try, and gave. Sessions
consisted of 20 learn units, such that every word was presented five times per session. The order of word
presentation was pre-determined so that the words were not presented in the same order each time. The
experimenter gained the participant’s attention and delivered an antecedent. For Participant 1 the
antecedent was, “Spell the word ___.” For Participants 2 and 3 it was, “Write the word ___.” Correct
responses were followed by the delivery of reinforcement in the form of verbal approval (e.g., “that’s
right”), tokens, and for Participant 2 and 3, small pieces of preferred foods. The difference in
reinforcement operations was based on the participant’s prior instructional history. If the participant
emitted an incorrect response or did not begin to respond within 5 sec of the antecedent, a correction
procedure followed. A correction procedure consisted of the experimenter re-stating the antecedent,
providing a model response, and having the participant emit the correct response. Corrections were not
reinforced according to learn unit protocol. Criterion for mastery was 90% correct across two consecutive
sessions or 100% in one session. Following mastery of Set 1 spelling words, a probe was conducted on
the topography that was not taught.
Post Single Response Instruction Probe (Phase 3). The same set of words from Phase 2 was
presented, except the antecedent changed in order to evoke the untaught response topography. Thus,
Participant 1 was asked to “Write the word ___.” Participants 2 and 3 were asked to “Spell the word
___.” No programmed reinforcement or corrections occurred. The experimenter delivered the antecedent,
waited 5 sec for a response, and then presented the next tria l. Sessions consisted of 20 trials.
Multiple Exemplar Instruction – Set 2 (Phase 4). We implemented multiple exemplar instruction
across vocal and written topographies of spelling as an instructional tactic to teach Set 2 words in both
topographies. Table 2 shows the words that were selected for each participant. Participant 1’s words were
help, jump, not, and here. Participant 2’s words were where, away, three, and in. Participant 3’s words
were why, upon, myself, and your. Instruction consisted of learn units. The experimenter presented an
antecedent to the attending student, depending on the condition. In the spelling condition, the antecedent
was “Spell the word ___”. In the writing condition, the antecedent was “Write the word ___”. The order
of presentation of words was counterbalanced across response topographies and words so that the same
word was never presented in two consecutive learn units. An example of an instructional sequence was:
“Write help,” “Spell jump,” “Write not,” “Spell here”. Participants were given 5 sec to respond. Correct
responses were followed by the delivery of reinforcement in the form of verbal approval (e.g., “that’s
right”), tokens, and for Participant 2 and 3, small pieces of preferred foods. Incorrect responses or no
response within 5 sec were followed by a correction operation in which the teacher re-stated the
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antecedent, modeled the correct response, and the student repeated vocally or wrote the correct response,
depending on the condition. Corrected responses were not reinforced. Sessions consisted of 20 vocal
learn units and 20 written learn units presented in an alternating fashion, thus a total of 40 learn units per
session. Mastery criterion during instruction was 90% across two consecutive sessions or 100% in one
session for both response types.
Post Multiple Exemplar Instruction Probe (Phase 5). The procedures in this condition were
identical to those described in Phase 3.
Post MEI Single Response Instruction – Set 3 (Phase 6). The procedures in this condition were
similar to those described in Phase 2, however a new set of words was introduced and the response
topography that was not taught (i.e., the probe topography) in the first single response instruction phase
was taught in this phase. Thus, Participant 1 received instruction in the written topography only for the
words little, find, make, and fear. Participant 2 received instruction in the vocal topography only for the
words every, warm, live, and take. Participant 3 received instruction in the vocal topography only for the
words buy, does, the, and mad.
Post Single Response Instruction Probe (Phase 7). The same words from Phase 6 were presented,
except the antecedent changed in order to evoke the untaught response topography. Thus, Participant 1
was asked to “Spell the word ___.” Participants 2 and 3 were asked to “Write the word ___.” No
programmed reinforcement or corrections occurred. The experimenter delivered the antecedent, waited 5
sec for a response, and then presented the next tria l. Sessions consisted of 20 trials.
Fidelity of Treatment. Fidelity of treatment was measured using the Teacher Performance Rate
and Accuracy scale (Ingham & Greer, 1992) that simultaneously assessed both the accuracy of the
measurement of the students’ responses and fidelity of treatment. Fidelity of treatment observations were
conducted during 19% of the instructional sessions and the mean percentage of agreement was 92%
(range, 84% to 100%).
Results
The results for the acquisition of spelling responses for Participants 1, 2, and 3 are displayed in
Figure 1. The results for the pre- and post-instructional probes for Participants 1, 2, and 3 are displayed in
Figure 2. In the pre-experimental probes, none of the participants emitted any correct responses to the
three word sets, in either the vocal or written response form. Following single response instruction on Set
1 words, Participants 1, 2, and 3 emitted 70%, 55%, and 0% correct untaught responses to Set 1 words,
respectively. Following MEI with Set 2 words, correct untaught responses to Set 1 increased to 95%,
90%, and 90% for Participants 1, 2, and 3, respectively. Following instruction on a single topography for
Set 3 (a novel set of words), correct untaught responses to Set 3 were 95%, 100%, and 100% for
Participants 1, 2, and 3, respectively.
Participant 1 achieved criterion for vocal responses to Set 1 words after two sessions (i.e., 40
learn units). He achieved criterion for vocal and written responses during the MEI training condition with
Set 2 words after two sessions (i.e., 80 learn units). Finally, he achieved criterion for written responses to
Set 3 words after three sessions (i.e., 60 learn units).
Participant 2 achieved criterion for vocal responses to Set 1 words after six sessions (i.e., 120
learn units). He achieved criterion for vocal and written responses during MEI with Set 2 words after six
sessions (i.e., 240 learn units). Finally, he achieved criterion for written responses to Set 3 words after
four sessions (i.e., 80 learn units).
Participant 3 achieved criterion for vocal responses to Set 1 words after three sessions (i.e., 60
learn units). He achieved criterion for vocal and written responses during MEI with Set 2 words after
four sessions (i.e., 140 learn units). Finally, he achieved criterion for written responses to Set 3 words
after three sessions (i.e., 60 learn units).
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Figure 1. Correct vocal and written responses to learn unit presentations during: (a) baseline instruction in
single response forms, (b) multip le exemplar instruction across written and vocal topographies, (c) single
response form instruction for Participants 1, 2, and 3.
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Figure 2. Correct untaught spelling responses by Participants 1, 2, and 3 following: (a) baseline
instruction in single response forms, (b) multiple exemplar instruction across written and vocal
topographies, (c) single response form instruction for Participants 1, 2, and 3.
Discussion
The results of this study replicated previous findings of Greer, Yuan, et al. (2005). Prior to the
study, none of the participants could spell any of the words that were presented, either in written or vocal
forms. The number of correct untaught spelling responses increased as a function of the MEI tactic for all
three participants. Thus, MEI across saying and writing was an effective intervention for all three
participants that resulted in the transformation of stimulus function across written and vocal spelling
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responses for the initial untaught response sets. Moreover, when a novel set of words was introduced and
taught in one response topography, the untaught topography emerged for all three participants. This
transformation of function was not present for any of the participants prior to the intervention, but was
present following the intervention.
Greer, Yuan, et al. (2005) first characterized this phenomenon as the acquisition of joint stimulus
function. They proposed that the multiple exemplar training, in which participants were taught vocal and
written responses to a subset of words in an alternating fashion, “produced joint stimulus function for
both responses to novel words taught as a single response” (p. 111). According to Greer et al. (2005), this
could be characterized as a higher order class of behavior, as described by Catania (1998), or as a
relational frame as described by Barnes-Holmes, Hayes, Barnes-Holmes, & Roche (2001).
According to Catania (1998), a higher-order class of behavior is “an operant class that includes
within it other classes that can themselves function as operants, as when generalized imitation includes all
the component imitations that could be separately reinforced. Higher-order classes may be a source of
novel behavior” (p. 392). Greer, Yuan, et al. (2005) suggested that the transformation of stimulus
function observed in their study could perhaps be explained in terms of a derived relation (BarnesHolmes, Barnes-Holmes, and Cullinan, 2000; Barnes-Holmes, et al., 2001) between saying the letters and
writing them, such that “once individuals have derived relations between saying the letter and writing the
letter, rotated experiences for a subset of exemplars can result in the emission of untaught response
forms” (Greer et al., 2005, p. 112). Although the presence of the derived relation was not tested, Greer et
al. suggested that it was probable that their participants had certain prerequisites that allowed the
fundamental derived relations to be present.
The strongest results in the current study were shown by Participant 3, who emitted zero correct
untaught responses prior to the intervention and following the intervention increased by 90% on Set 1,
then emitted 100% correct untaught responses to the novel Set of words. Both Participants 1 and 2 did
demonstrate some joint speaker-writer behavior prior to the intervention, however neither responded at
criterion level (90%). Participant 1 responded correctly in 70% of probe trials prior to the intervention,
and Participant 2 responded correctly in 55% of probe trials prior to the intervention. Although these preexperimental levels of responding indicated that the joining of speaker and writer responses was not fully
present for these participants, we recognize that they may have had degrees of this “cusp” prior to
receiving the intervention. However, the multiple exemplar instructional experience that they received in
this study functioned to strengthen or perhaps induce the joining of saying and writing for Participants 1
and 2. For Participant 3, the results showed that the capability of jo ining saying with writing was not
present prior to the intervention and emerged as a result of the intervention.
It is likely that the acquisition of phonemic control for letter sounds and the joining of the sounds
of letters with saying the letter names and the writing of the letters is the source of the derived relation
between saying and writing. While direct phonemic instruction can assist this development, in many cases
exemplar experiences appear to lead to the abstraction of phonemic control without direct instruction as
when children who are taught to read with the whole word approach derive phonemic control. Thus, the
participants in this experiment will likely require more exemplary experiences or direct instruction in
phonemes and exceptions for saying and writing letters in order to have complete transformation of
stimulus function, however the basic instantiation of the transformation of stimulus function has been
established. This and the prior experiments reported by Greer, Yuan et al. (2005) increases the probability
that multiple exemplar experiences or instruction leads to the joining of saying and writing. If other
laboratories can replicate these procedures it would appear that what Skinner (1957) identified as the
missing controlling variables for the joining of saying and writing have been identified
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References
Albers, A. E., & Greer, R. D. (1991). Is the three-term contingency trial a predictor of effective instruction?
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Barnes-Holmes, Y., Hayes, S. C., Barnes-Holmes, D., & Roche, B. (2001). Relational frame theory: a postSkinnerian account of human language and cognition. Advances in Child Development and Behavior, 28,
101-138.
Catania, A. C. (1998). Learning (4th edition). New Jersey: Prentice Hall.
Eldredge, J.L. (1995). Teaching decoding in holistic classrooms. Englewood Cliffs, NJ: Prentice
Hall.
Engelmann, S., & Carnine, D. (1982). Theory of instruction: Principles and applications. New York: Irvington.
Fiorile C.A, & Greer, R.D. (2007). The induction of naming in children with no echoic-to-tact responses as a
function of multiple exemplar instruction. The Analysis of Verbal Behavior, 23, 71-88.
Greer, R.D. & McCorkle, N.P. (2008). CABAS® international curriculum and inventory of repertoires for children
from pre-school through kindergarten (AIL/PIRK), 3rd edition. Yonkers, NY: CABAS®/Fred S. Keller
School.
Greer, R. D. & McDonough, S. H. (1999). Is the learn unit a fundamental measure of pedagogy? The Behavior
Analyst, 22, 5-16.
Greer, R. D. & Speckman, J. (2009). The integration of speaker and listener responses: A theory of verbal
development. The Psychological Record, 59, 449-488.
Greer, R. D., Stolfi, L., Chavez-Brown, M., & Rivera -Va ldez, C. (2005). The emergence of the listener to speaker
component of naming in children as a function of multiple exemplar instruction. The Analysis of Verbal
Behavior, 21, 123-134.
Greer, R. D., Yuan, L., & Gautreaux, G. (2004). Novel dictation and intraverbal responses as a function of multiple
exemplar instructional history. The Analysis of Verbal Behavior, 21, 99-116.
Greer R.D. & Ross D.E. (2008) Verbal behavior analysis: Inducing and expanding complex communication in
children with language delays. Boston: Allyn & Bacon.
Hall, G.A., & Sundberg, M.L. (1987). Teaching mands by manipulating conditioned establishing operations. The
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Horne, P. J. & Lowe, C. F., (1996). On the origins of naming and other symbolic behavior. Journal of the
Experimental Analysis of Behavior, 65(1), 185-241.
Hughes, C., & Rusch, F. R. (1989). Teaching supported emp loyees with severe mental retardation to solve
problems. Journal of Applied Behavior Analysis, 22, 365-372.
Ingham, P. I. & Greer, D. R. (1992). Changes in student and teacher responses in observed and generalized settings
as a function of supervisor observations. Journal of Applied Behavior Analysis, 25(1), 153-164.
Lamarre, J., Holland, J.G. (1985). The functional independence of mands and tacts. Journal of the Experimental
Analysis of Behavior, 43, 5-19.
Nirgudkar, A.S. (2005). The relative effects of the acquisition of naming and the multiple exemplar establishing
operation experience on the acquisition of the transformation of establishing operations across mands and
tacts. (Doctoral dissertation, Columbia University, 2005). Abstract from UMI Proquest Digital
Dissertations [on-line]. Dissertations Abstract Item: AAT 3159751.
Nuzzolo-Gomez, R., & Greer, R. D. (2004). Emergence of untaught mands or tacts with novel adjective-object pairs
as a function of instructional history. The Analysis of Verbal Behavior, 24, 30-47.
Pistoljevic, N. (2008). The Effects of Multiple Exemplar and Intensive Tact Instruction on the Acquisition of Naming
in Preschoolers Diagnosed with Autism and Other Language Delays. Unpublished doctoral dissertation,
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Columbia University Teachers College. Abstract from UMI Proquest Digital Dissertations [on-line].
Dissertations Abstracts Item: AAT 3317598.
Skinner, B.F. (1957). Verbal Behavior. Engelwood Cliffs, NJ; Prentice Hall.
Sprague, J. R., & Horner, R. H. (1984). The effects of single instance, multiple instance, and general case training on
generalized vending machine use by moderately and severely handicapped students. Journal of Applied
Behavior Analysis, 17(2), 273-278.
Twyman, J. (1996). The functional independence of impure mands and tacts of abstract stimulus properties. The
Analysis of Verbal Behavior, 13, 1-19.
Waddington, E. M, & Reed, P. (2009). The impact of using the “Preschool Inventory of Repertoires for
Kindergarten” (PIRK®) on school outcomes of children with Autism Spectrum Disorders. Research in
Autism Spectrum Disorders, 3, 809-827.
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Authors’ contact information:
Carly M. Eby
Box 76, Teachers College, Columbia University
525 West 120th St.
New York, NY 10027
(212) 678-3880, [email protected]
R. Douglas Greer
Box 76, Teachers College, Columbia University,
525 West 120th St.
New York, NY 10027
(212) 678-3880, [email protected]
Lisa D. Tullo
Box 76, Teachers College, Columbia University
525 West 120th St.
New York, NY 10027
Katherine A. Baker
Box 76, Teachers College, Columbia University,
525 West 120th St.
New York, NY 10027
(212) 678-3880
[email protected]
Rebecca Pauly
Box 76, Teachers College, Columbia University
525 West 120th St.
New York, NY 10027
(212) 678-3880.
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AAC Interventions: Case study of In-utero Stroke
Cindy Geise Arroyo, Robert Goldfarb, Danielle Cahill, & Janet Schoepflin
Abstract
A case study design was used to examine the progression of Alternative Augmentative
Communication (AAC) interventions including Picture Exchange Communication System (PECS) and the
Speech Generating Devices (SGDs) 7-Level Communication Builder and Dynamo . The participant was a
preschooler (CA=4:5) who presented with a history of hearing loss and, based on MRI/CT examination, a
possible in-utero hypoxic-ischemic event. The goals of reducing maladaptive behaviors, improving
receptive language skills , and using an AAC system to request, comment, and respond were achieved. The
participant transitioned from using PECS, to using a fixed display and ultimately to using dynamic-display
speech generating devices (SGDs). Naturalistic teaching strategies including graduated prompting, mandmodel, and fading were used. Long term follow-up revealed the participant’s present ability to
communicate effectively without the support of AAC.
Keywords : Augmentative and Alternative Communication (AAC), Speech Generating Device (SGD), inutero-stroke, fixed display, dynamic display, naturalistic teaching.
Introduction
Fetal stroke may follow an ischemic (thromboembolic) or hemorrhagic event which occurs
between 14 weeks of gestation and the onset of labor resulting in delivery (Ozduman, et al., 2004). In
ischemic strokes, cerebral blood flow falls below a level necessary to maintain nerve cell integrity and
neurological function. Hemorrhagic strokes occur secondary to intra-cranial bleeding. A perinatal stroke
is similar to an ischemic stroke, but it occurs between 28 weeks of gestation and 7 days of age. Poor
understanding of etiologies of fetal and perinatal strokes have led to an estimate of 1 in 4,000 live births,
with the true incidence probably being higher. Diagnosis usually includes ultrasound measurement of the
fetal cranium and, more recently, fetal magnetic resonance imaging (MRI) and computed tomography
(CT), which provide better definition of the injury to the fetal cerebrum. Patients often remain
undiagnosed, as clinical outcomes of surviving infants may not be present until later in the first year of
life (Ozduman, et al., 2004).
Reports of in-utero strokes began some 30 years ago, based on autopsy data, and continue to
follow a case report format, viewing living brains. An early review of nearly 600 infants examined at
autopsy (Barmada, Moossy & Shuman, 1979) indicated the presence of cerebral infarcts (necrosis in an
area of brain tissue, caused by an obstruction, usually a thrombosis or an embolism) in about one in
twenty (5.4%) instances. Neonates delivered at term were more likely to be brain-damaged than
premature infants, where multiple smaller infarcts had occurred. Surprisingly, for the infants who
survived, disorders associated with focal neurological deficits were not predominant. Rather, the clinical
features tended to include such autonomic disturbances as prolonged apnea and episodic seizures, and, in
those infants with less severe complications, hemiplegia, mental and motor retardation, and recurrent
seizures. As recently as 25 years ago, few infants surviving stroke were reported in the literature (Ment,
Duncan & Ehrenkranz, 1984). Among infants who died during the first months of life, necrotic foci
(areas of cell death) were generally located in border zones between vascular territories (Lou, 1983). This
suggests that the in-utero brain is fragile, offering the brain poor protection against perfusion pressure,
with normal birth causing a decrease in oxygen or mild hypotension sufficient to abolish autoregulation
(the process by which organs maintain their own blood supply). Inadequate pressure, caused by reduced
blood flow to the brain, can cause ischemia. Neonatal ischemia in surviving infants was seen as decisive
in development of atrophic encephalopathy, where brain cells decrease in size, with the resultant clinical
picture of motor and cognitive dysfunction.
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Etiologies of fetal and neonatal strokes are reported both as ischemic (thromboembolic) in “a
significant number of these events” (Chalmers, 2005, p. 333) and hemorrhagic, with intracranial
hemorrhage occurring in “approximately 40% of infants of less than 32 weeks’ gestation” (Huang, Chen,
Tseng, Ho, & Chou, 2006, p. 135). One cause of the discrepancy may be the use of ultrasonography (US)
for prenatal detection of fetal strokes. The use of MRI to supplement US findings may contribute to
diagnostic accuracy and improve prediction of postnatal neurodevelopmental prognosis (Elchalal, et al.,
2005). Confirmation of diagnosis by MRI or CT scan has implicated the brain’s ventricles, which
produce the cerebrospinal fluid (CSF) needed to surround and protect the brain. Periventricular venous
infarction may result in a focally enlarged lateral ventricle (Takanashi, Barkovich, Ferriero, Suzuki, &
Kohno, 2003; Takanashi, Tada, Barkovich, & Kohno, 2005), or in hydrocephalus following hemorrhage
in the choroids plexuses, which manufacture CSF in the ventricles (Huang, et al., 2006). Motor
outcomes, after follow-up of more than five years, included leg hemiparesis and spasticity, if the basal
ganglia were involved; non-motor disorders associated with cortical involvement included cognitivebehavioral impairments, visual deficits, and epilepsy (Kirton, Deveber, Pontigon, Macgregor, & Shroff,
2008).
Another avenue of investigation in neonatal stroke is mutation in the factor V gene (factor V
Leiden mutation), which is the most common cause of familial thrombosis, an inherited deficiency of
antithrombin III (Thorarensen, Ryan, Hunter, & Younkin , 1997). Although not a risk factor for ischemic
stroke in adults, the factor V Leiden mutation may be associated with in-utero cerbrovascular disease and
hemiplegic cerebral palsy. Anticoagulants taken by the mother may be a factor in a fetal hemorrhagic
stroke. Although heparin , which inhibits the activity of thrombin in coagulation of the blood, does not
cross the placenta and cannot cause a fetal stroke, anti-epileptic medications may be associated with a
decrease in vitamin K-dependent coagulation factors (Ozduman, et al., 2004).
Varied outcomes and uncertainties regarding long-term prognosis following fetal strokes have
been reported in the literature. Ozudman, et al., (2004) reported that 55% of the 22 children with a
history of fetal stroke in their study were handicapped at follow-up ages of 3 months to 6 years. Sreenan,
Bhargava, & Robertson (2000) reported that two-thirds of children in their study suffered from mental
retardation, visual impairment, motor disabilities, or seizure disorders. Children with a history of fetal
stroke may have good short-term outcomes but also the possibility of later onset of seizures, cognitive
deficits, and sensory impairments (Roach et al., 2008; Sran & Baumann, 1988). Although motor deficits
such as hemiplegia and asymmetries often are associated with neonatal infarction, signs of neuromotor
impairment affecting speech, cognition, and behavior may also be evident at early school age. Neonatal or
postnatal clinical evaluations have not always been predictive of outcomes; rather the extent of the
damage as evidenced on the MRI is usually a better predictor (Mercuri, et al., 2004). Improvements in the
diagnosis and understanding of the neuropathology underlying strokes in children have resulted in
increased attention to implementing appropriate therapeutic interventions (Hartman, Lunney, & Serena, in
press).
Alternative and Augmentative Communication
Management of the speech, language, and communication disorders which affect survivors of inutero stroke can require augmentative and alternative communication (AAC) strategies, particularly when
the clinical picture includes cerebral palsy. Augmentative communication is operationally defined here as
a system which supports or enhances currently existing language and communication abilities.
Alternative communication refers to a system which replaces the communication of non-vocal individuals
(Nicolosi, Harryman & Kresheck, 2005).
According to the American Speech-Language-Hearing Association (ASHA, 2005, p. 1):
AAC refers to an area of research, clinical, and educational practice. AAC
involves attempts to study and when necessary, compensate for temporary
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or permanent impairments, activity limitations, and participation
restrictions of individuals with severe disorders of speech-language
production and/or comprehension.
Modes of AAC
Unaided AAC: Unaided AAC methods, such as sign language or gestural cueing systems, require
no external device. American Sign Language (ASL) is a complex visual-spatial language that is used by
the Deaf community in the United States and the English-speaking parts of Canada (Humphries &
Padden, 2004). It is a linguistically complete and natural language. ASL encompasses hand gestures,
facial expression, and the use of the space surrounding the signer to aid in the description of places and
persons. Many signs represent ideas and are therefore iconic, us ing a visual image to represent a specific
idea (Riekehof, 1987). A number of manual sign systems, including ASL, also have been used by
individuals with severe communication disorders, but no hearing impairment (Beukelman & Mirenda,
2005). Unaided AAC requires a certain level of motor control to produce signs or gestures. This method
of AAC has the advantage of speed, portability, and access to a wide number of messages, but it also has
limitations. Signs require a certain level of fine motor dexterity, and there is a restricted set of potential
listeners, as not everyone understands sign language (Wilkinson & Hennig, 2007).
Aided AAC - Light Technology: Aided AAC involves an external component to communicate,
using symbols or voice output. Light technology involves little to no technology (e. g., electronic output),
but requires external aids of some sort. These may include alphabet boards, communication/ picture
books/boards and communication programs such as the Picture Exchange Communication System
(PECS). PECS was developed by Frost and Bondy (1998; 2002) as an augmentative and alternative
communication method using operant-based procedures. Designed for children with autism and related
developmental disabilities, it is a self-initiating and functional communication system that is rapidly
acquired. PECS begins with the exchange of simple icons and builds sentence-like structures. It
emphasizes a request function before the child responds to or comments about simple questions. An
independent validation of PECS (Charlop-Christy, Carpenter, Le, LeBlanc, & Kellet, 2002) used a
multiple-baseline design with three children with autism. All three children met the learning criterion for
PECS, with concomitant increases in verbal language, as well as ancillary increases in socialcommunicative behaviors and decreases in problem behaviors.
Light technology does not provide voice output, and therefore requires a communication partner to
interpret the messages that the AAC user selects.
Aided AAC- High Technology: Communication devices classified in the category of high
technology may consist of a standalone device with voice output or a computer operating with
communication software. A device designed specifically for communication is called a dedicated
communication device, although it may be able to interface with a computer and perform environmental
control functions. Computer communication devices are typically not considered to be dedicated devices,
because communication is just one of the many software functions that can be accessed. The voice output
provided by high technology has advantages over light technology, especially when the user is
communicating in situations such as a classroom. Changes in technology continue to occur at a rapid
pace with progressive changes in memory capacity, processing speeds, and battery life in high technology
devices. The ability to integrate new technology such as digital cameras, a variety of software programs,
scanners, and the ability to interface with the internet have resulted in a wider application of use and
functions for individuals with severe communication impairments.
Types of displays: There are two primary methods of displaying symbols for communication on
AAC devices: fixed (or static) and dynamic displays. In fixed displays, pages or overlays containing
symbols are set up on a board or on a simple voice output communication aid. Fixed displays usually
require another person to change the pages/overlays if the AAC user cannot do so independently. These
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simple voice output devices generally operate via recorded voice. The content of the message can be
recorded by a parent, professional, or another child , and can be easily re-recorded. Overlays can be
designed around a specific topic or activity, offering opportunities for commenting and requesting using
that vocabulary (e.g., house overlay, art activity). The advantages of these more simple fixed-display
AAC devices include the ability to record a variety of voices, music, etc.; ease of recording; and relatively
inexpensive cost. Disadvantages include the fact that the user is dependent on others to create and change
the symbol overlays; only a limited number of symbols are available at one time, and this limits the
number of possible messages and communicative interactions (Wilkinson & Hennig, 2007).
Dynamic displays operate via communication software running on an electronic (aided) device,
often a modified computer. Symbols can speak words/phrases/sentences via digitized voice. There can be
links to different pages of symbols, activated via a navigation button on the device. The AAC user is not
reliant on someone else to change an overlay to access additional vocabulary or messages (Wilkinson &
Hennig, 2007).
In either type of display, symbols should be organized in ways that promote efficient and
effective communication (Beukelman & Mirenda, 2005). One of the more frequently used strategies
involves organizing vocabulary according to event schemes, routines, or activities (Drager, Light, Speltz,
Fallon, & Jeffries, 2003). Each display includes symbols for the vocabulary items that are relevant to the
activity or routine (e.g., vocabulary for participation in morning circle). In this configuration, the use of
single-meaning symbols can also support more complex linguistic functioning through symbol
combinations and the use of sight words paired with the symbols (Wilkinson, Romski, & Sevcik, 1994).
In addition to enhancing participation, schematic and activity displays can promote the use of multiword
linguistic structures and facilitate receptive language growth and the development of syntactic skills
(Beukelman & Mirenda, 2005).
Roles of AAC as a Communication Mode: The primary role of AAC is to enhance or augment
the expressive language skills of individuals who have severe communication impairments. There are no
particular prerequisite cognitive skills or receptive language levels that need to be met before introducing
AAC. The range of AAC options that are available makes it possible to address a variety of language
impairments.
Another role of AAC is to enable the user to express a range of communication functions across
different environments and with a variety of communication partners. AAC may also serve to reduce
challenging behaviors such as aggression, self-injurious behaviors, or behaviors resulting from frustration.
PECS training with the population of individuals with autism has often resulted in a decrease in problem
behaviors and an increase in verbal speech (Charlop-Christy, et al., 2002). Students with severe
communication deficits have been taught to use assistive devices in everyday environments, resulting in
decreased levels of problem behavior (Durand, 1999). AAC may provide a bridge to later linguistic
development through the use of orthographic or other generative symbols (Wilk inson & Hennig, 2007).
It is a common misconception that AAC may replace the possibility of speech as a mode of
communication. The use of AAC may enhance existing speech skills among children with developmental
and intellectual disabilities (Millar, Light, & Schlosser, 2006; Romski & Sevcik, 1996). The
predominance of evidence supporting the mutual benefits of AAC to enhance speech development, as
well as the acknowledged value of multimodal communication, result in reduced use of cognitive
prerequisites as inclusion or exclusion criteria for services, particularly in younger populations
(Wilkinson & Hennig, 2007).
The behavioral paradigm of contingent reinforcement applies to AAC intervention for children
with expressive speech and language delays. If the antecedent event is a symbol presented with the
spoken word, as in high-technology AAC, and the consequent event is receipt of the labeled item, both
the AAC mode and speech production should increase in frequency. A meta -analysis supported using
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AAC to facilitate production of natural speech as well as the development of communicative competence
and language skills (Millar, et al., 2006).
A number of teaching strategies have been associated with AAC interventions. In graduated
prompting, the goal is to use a least-to-most cuing hierarchy (natural cue, expectant pause, general point
& pause, and model), fading cues as soon as possible (Beukelman & Mirenda, 2005). In naturalistic, or
milieu teaching, the emphasis is on teaching functional language skills in the context of common
activities or routines. In this method, the facilitator initially provides verbal, gestural cues, modeling, or
physical prompts to assist the individual to make requests. Requests are then followed by consequences
that are functionally related (e.g., obtaining requested object/action) (Goodman & Remington, 1993;
Kaiser, Yoder, & Keetz, 1992). The mand-model procedure has been effective in enhancing
communication skills by obtaining the child’s focus, then delivering a mand (non-yes/no request or
command), providing an interval for a response, and providing a model of the desired response, if needed
(Venn, Wolery, Fleming, DeCesare, Morris, & Cuffs, 1993).
Case Study
In the present paper we use a case study design to examine in depth a specific individual in
specific situations in order to illustrate important principles that might be overlooked in examining group
data. Case study research also permits evaluation of phenomena that occur rarely and that may provide
exceptions to generally accepted rules. Among weaknesses of case study research are the limitations of
generalization and the increased likelihood of subjective biases on the part of the investigators. However,
the factors that threaten internal validity in experimental research, especially history (events occurring
between the first and second measurements in addition to the experimental variable) and maturation
(changes in the subjects themselves that cannot be controlled by the experimenter and whose effects are
attributed, incorrectly, to the experimental treatment), may be the substance of the case study approach
(Schiavetti & Metz, 2006).
This case study focused on the progression of AAC interventions for a young non-verbal child
with a history of possible in-utero stroke and maladaptive behaviors. Often when young children have no
consistent means of communication, they may express their wants and needs in socially unacceptable
ways. AAC systems can help replace these maladaptive behaviors and often foster the development of
natural speech (Cress & Marvin, 2003; Goldstein, 2002; Mirenda, 2003; Romski & Sevcik, 2005).
Through this case research, we hope to support the evidence for the importance of individualized
modality selection when making intervention recommendations. There has been an increase in the
theoretical arguments for the use of AAC with young children but little research to inform clinical
practice in this area (Mirenda, 2003). Decisions concerning appropriate AAC interventions must be made
with considerations for the individual learners, in specific contexts to meet individual needs (Beukelman
& Mirenda, 2005).
Method
Participant
The child at the core of this case study, CM, a white, middle -class female, was age 4;5 (years;
months) at the initiation of treatment discussed in this article. CM presented with a history of profound
hearing loss in her right ear and a high frequency hearing loss in her left ear, as well as significant delay
in speech skills, language skills, pragmatic skills, motor skills , and attention skills, which inhibited her
participation in age-appropriate activities. According to parental report, CM had been receiving speechlanguage therapy focusing on American Sign Language (ASL) training. She also received physical
therapy, occupational therapy, and parent training through the Committee on Pre-school Education.
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According to parental report, CM was using a Phonic Ear Solaris binaural FM hearing system with
headset receivers in her school setting. FM hearing systems are personal wireless systems that utilize
transmitters and receivers that are small enough to be worn on a person’s body. Generally, they are used
to compensate for a hearing loss. This Phonic Ear FM system features a receiver that is approximately
the size of a deck of cards and can be connected to a hearing aid or used with a head set, ear buds, or other
accessories.
Audiological Findings: CM was first seen for audiological testing at Adelphi University’s Hy
Weinberg Center for Communic ation Disorders on May 10, 2005 (CA= 5:7). The evaluation continued
for a total of eight sessions, over a period of two months. Multiple sessions were needed because of her
tantrums and refusal to comply with assessment procedures. CM was accompanied to each test session
by her mother, who served as informant.
Otologic history indicated that CM passed her neonatal hearing screening, bilaterally. At about 3 ½
years of age, CM reportedly contracted scarlet fever. In August of 2003 (CA=3:10), sound field test
results from another facility revealed a mild hearing loss in at least one ear. Type A tympanograms were
obtained, bilaterally, consistent with normal middle ear function in each ear. Subsequent auditory
brainstem response (ABR) testing (CA=4:0) yielded results consistent with a mild hearing loss at 2000 Hz
in the left ear and a profound hearing loss in the right ear. Type A tympanograms were again obtained,
bilaterally. An FM unit was recommended in November of 2003 for use during group language-based
activities in the classroom and for individual speech sessions.
On the initial test date at the Adelphi University facility, spondee recognition threshold (SRT) testing
and tympanometry were completed. An SRT of 10 dB HL was obtained in the left ear; no response was
obtained when testing the right ear. Type C tympanograms were obtained, bilaterally, indicating
significant negative pressure in each ear. On subsequent test dates (4 sessions), sound field warble tone
thresholds were obtained at levels between 10 dB HL and 25 dB HL for octave frequencies 500 Hz
through 4000 Hz, suggesting adequate hearing through the speech frequencies in the better ear.
Tympanometric testing reflected normal middle ear function on the last test date. Bone conduction testing
was attempted in two subsequent sessions, but was abandoned, due to CM’s rejection of the
instrumentation. In her final testing session, an SRT of 15 dB HL was obtained in the left ear and an SRT
of 25 dB HL was obtained in the right ear via bone conduction. Type A tympanograms were obtained,
bilaterally.
At age 5:9, CM participated in transient evoked otoacoustic emission (TEOAE) testing. Left ear
responses were obtained at frequencies from 1000 to 4000 Hz. Right ear responses were obtained at 2800
Hz and 4000 Hz. EOAEs reflect active cochlear processes and the presence of TEOAEs suggest hearing
levels to be no poorer than 30 dB HL. The right ear responses were clearly unexpected, given the
previously reported profound hearing loss. It is quite possible that these responses were artifacts, resulting
from the equipment or poor probe placement. However, it is also possible that there are some surviving
outer hair cells in the 2800 Hz to 4000 Hz cochlear region. A similar case was reported by Prieve, Gorga ,
and Neely (1991), in which an adult with a bilateral severe-to-profound hearing loss was found to have
EOAEs in a restricted frequency in one ear. Unfortunately, CM did not return to this Center following this
last test date, and the finding in this case could not be confirmed with a different measurement system (as
was done in the Prieve, et al. study).
An alternative conclusion, based on neurologic and audiometric findings, is that part of the behavior
that had been attributed to a profound hearing loss may have resulted from an auditory processing deficit
secondary to in-utero CVA.
MRI Results: Following oral sedation with chloral hydrate, an MRI study of the brain was
conducted when CM was age 1:11. T1, T2, and FLuid-Attenuated Inversion-Recovery (FLAIR) imaging
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were incorporated, encompassing all three imaging planes. The second author (RG) added ultraviolet
digital enhancement to the image in Figure 1.
The MRI study demonstrated scattered abnormalities within the white matter of both
hemispheres, as seen on a CT examination. There were hyper-intense signals on the FLAIR and T2
images within the periventricular white matter, most notable within the peri-trigonal white matter. In
addition, there were multi-focal, more discrete areas of abnormal signal throughout the frontal, parietal,
and temporal lobes, bilaterally. These were scattered within the centrum semiovale. When evaluating the
white matter, there was an age -appropriate pattern of myelination, landmarks achieved. There was mild
relative prominence of the lateral ventricles, without evidence for acute hydrocephalus. The major
vessels were grossly patent, with no gross malformation. The skull base appeared intact.
While there is normal immature periventricular white matter seen on T2 imaging in children, the abovementioned findings are more pronounced. The hyper-intense signals on the FLAIR and T2 images within
the periventricular white matter support a consideration of an in-utero stroke, where periventricular
venous infarction may result in a focally enlarged lateral ventricle . Compared to the CT examination, the
abnormality revealed in the MRI is more generalized but less pronounced.
Figure 1. MRI of CM’s brain.
Settings
PECS training and other AAC interventions were conducted at a university speech and hearing
center in a suburb of New York City for 10 weeks, 2 times per week for 30-minute durations. The therapy
room contained a small table and two chairs positioned facing each other. Sessions were able to be
viewed via a camera system with the capability of video-taping. The room was free of visual distractions
and external auditory distractions were minimal. A graduate student in Speech-Language Pathology was
the primary interventionist, implementing the six phases of PECS as recommended by Frost & Bondy
(2002) and later introducing Boardmaker communication boards, the 7-Level Communication Builder,
and the Dynamo. A clinically certified speech-language pathologist/university professor supervised 100%
of the therapy sessions and a certified speech-language pathologist with extensive AAC experience
provided recommendations for the introduction of AAC materials.
CM was not receiving any concurrent speech-language intervention in another setting during the
time she was seen at the university clinic.
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Materials
PECS Materials : Individual cards using colored symbols from The Picture Communication
Symbols Combination Book (Mayer-Johnson Company, 1994) were used as recommended by Frost and
Bondy (1994) during Phases I and II of PECS training. These pictures were compiled into a PECS
communication book during Phases II, III and IV. In Phase IV a sentence strip was added using a Velcro
strip at the bottom of the binder with the carrier phrase “I want.”
Boardmaker: Boardmaker is a graphic database that contains upward of 3,000 picture
communication symbols. Each symbol may be translated into various languages and may be printed with
or without text on the symbol. Boardmaker symbols were used to construct supplemental communication
boards with a schematic or topic orientatio n and they were also used as overlays for the 7-Level
Communication Builder.
7 – Level Communication Builder (manufacturer: Enabling Devices): This is a self-contained
speech generating device (SGD) using recorded speech and requiring paper overlays that need to be
changed to correspond with each of the 7 levels. It allows the user to use 1, 2, 4, 8, or 16 different
messages per level, giving a possible 112 messages (in the 16 window setting).
Dynamo (manufacturer: DynaVox): The Dynamo is a small, portable SGD using digitized
speech. It has a dynamic black and white screen display and allows access to several levels.
Clinical Intervention
Baseline behaviors including sitting with trunk alignment, eye contact, and ability to transition
across activities without tantrums were identified to be targeted as goals, and were calculated across the
10-week period.
Individual picture cards using colored symbols from The Picture Communication Symbols
Combination Book were introduced and PECS (Frost & Bondy, 2002) training was initiated. CM learned
PECS in the six phases recommended by the authors.
Phase I, How to Communicate, had the goal of training the motor response after initiation.
Accordingly, CM was taught to pick up, reach, and release the stimulus picture. For the two-person
prompt procedure, one clinician, who stood in front of the child, served as her communication partner,
while a second clinician acted as a physical prompter behind the child, aiding in the motor response. The
clinician in front used an empty hand to provide information about where to place the picture, and opened
once CM reached for the picture or initiated an action. The empty hand was not used as a prompt. A
consequent event (secondary reinforcement) was delivered within 0.5 sec of CM’s response, and
generally took the form of social praise.
Phase II, Distance and Persistence, had the goal of persistence across obstacles. CM was trained
to increase the distance she traveled for the picture, or to deliver the picture to her communication partner
or to her PECS book. CM was also trained to gain the attention of the clinician whose back was turned,
to carry her PECS book, and to request action during activities.
Phase III, Discrimination, had the goal of demonstrating ability to select from all pictures in the
PECS book. In a two-way discrimination task, CM had to select one of two choices, only one of which
resulted in reinforcement. When provided with multiple choices of preferred items, CM’s actions had to
match her request, and she learned to demonstrate correspondence between picture and item.
Phase IV, Sentence Structure, had the goal of building toward commenting. The carrier phrase,
“I want” was combined with a symbol of a desired item on the sentence strip of CM’s PECS
communication book. After combining the symbols on the sentence strip, CM was expected to give it to
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her communication partner (clinician) and the clinician then read the strip. The clinician added attributes,
such as colors, to lengthen the sentence strip.
Phase V, Responsive Requesting, had the goal of responding to the question, “What do you
want?” In the first step, the clinician simultaneously asked a question (which served as a cue), and pointed
to the sentence starter or carrier phrase (which served as a prompt). The clinician gradually increased the
interval between cue and prompt until CM was able to “beat” the prompt.
Phase VI, Commenting, had the goal of spontaneous commenting on the environment. CM was
prompted to respond to the question, “What do you see?” and then to comment by combining the symbol
for “I see” with an object symbol on her sentence strip.
Successful completion of each phase was attained using a criterion of 80% unprompted successful
trials over two successive sessions.
Communication boards using symbols from Boardmaker software were introduced concurrent
with the last phases of PECS training to motivate communication during preferred activities. Words were
always included with picture symbols to enhance pre-literacy skills (see Fig. 2). A schematic or topic
orientation was used, for example, a board with symbols for materials needed for an art activity. Topic
strategies allow beginning communicators to initiate and establish topics of communication using various
types of basic symbols. Initial training on a fixed display is often desirable to achieve symbol recognition
(Beukelman & Mirenda, 2005). These same (fixed) overlays were transferred onto the 7-Level
Communication Builder, an SGD with recorded voice output. Finally, the same overlays were
programmed onto the dynamic display on the SGD Dynamo. Support for a transition to an SGD with a
dynamic display comes from observations that speed and accuracy of use with fixed displays diminishes
after 8-9 practice sessions (Hochstein, McDaniel, & Nettleton, 2004; Reichle, Dettling, Drager, & Leiter,
2000). The natural branching capabilities of the dynamic screens were used to promote phrase and
sentence construction within specific activities. The use of the SGD to support more complex linguistic
functioning through symbol combinations and the use of sight words paired with the symbols was the
primary focus to support pre-literacy skills. The same criterion of 80% unprompted successful trials over
two successive sessions was used to achieve esta blished goals. During training with these AAC modes,
the mand-model procedure (Venn, et al., 1993) was initially used. CM’s attention was obtained via
verbal/visual prompting, a mand was delivered (non-yes/no request or command), an interval for response
was given, and a model was provided, if necessary. Intervention then incorporated more of a graduated
prompting strategy utilizing natural cues in context, expectant pauses, and modeled pointing to symbols ,
if necessary, fading cues as soon as possible.
Long-term follow-up was conducted by interviewing the parent four years after the presented
therapy protocol was completed.
Results
Receptive Language : By the conclusion of the 10-week period, CM reached established criterion
levels (80%) for following two-step directives and receptively identifying colors, nouns, verbs, adjectives
and prepositions by pointing to the symbol representing the words on fixed and dynamic displays. The
ability to point to letters of the alphabet when named and some sight words was emerging.
Acquisition of PECS: CM advanced through the PECS phases rapidly and met criterion (80%
correct) for each phase.
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Figure 2. PECS stimuli.
Expressive Communication: At the initiation of therapy, CM exhibited significantly delayed
expressive language skills, using some signs/gestures and sound combinations to communicate. Her
limited communication skills may have been contributing to her problem behaviors (e.g. tantrums).
During the course of therapy, the following variables were calculated: number of responses using
AAC modes; number of requests using AAC modes; number of word approximations/words used per
session.
CM increased her responses (e.g. to a mand-model) using AAC modes from 3 out of 15 to 14 out of
15 trials over the 10-week period. Her requests increased from 1 out of 6 trials to 19 out of 20 trials (see
Fig. 3). CM’s use of word approximations/words increased from 2 in the initial session to more than 20 in
the final session (see Fig. 4). Using PECS and Boardmaker boards, CM was able to label transitive verbs,
independently initiate a conversational exchange, and request action.
By the last therapy session, CM had attempted the following words and/or word approximations:
go, happy, house, radio, kitchen, cake, table, fruit, bath, computer, pizza, Dad, banana, TV, apple, pool,
crab, ice, one, three, and five and the phrases ‘I go’ and ‘I want.’
Behaviors : Appropriate sitting behavior, defined by postural (trunk) alignment, remaining in the
chair and eye contact with the clinician increased over the 10-week period from 0% to 75% of observed
intervals. CM’s ability to achieve and maintain seating posture and eye contact became more
spontaneous, requiring fewer verbal/physical cues from the clinician. Tantrums, secondary to CM’s
difficulties with transitioning across activities were observed in 90% of trials at baseline, reducing to 30%
at the conclusion of PECS training and to 0% after the AAC devices (SGDs) were introduced (see Fig. 5).
Long-term follow-up was conducted via interview with the parent when CM entered the 4th grade
in a public school setting. According to parental report, CM is no longer using her SGD or any other form
of AAC. Her vocal speech has flourished, and CM is clearly understood by most listeners. She is
receiving speech-language therapy five times a week in her school setting and once a week privately. CM
is awaiting the repair of her FM system, which she continues to use in her classroom settings. According
to the results of her New York State 3rd grade assessment tests, she scored above average in the English
portion and met the learning standard in the mathematics portion. She is also adjusting well to pushing
into mainstream 4th grade settings.
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30
Responses/Requests
25
20
15
10
5
0
1
2
3
4
5
6
7
8
9
10
Sessions
Fig. 3. Responses/Requests Using AAC
Weeks 2-5: PECS/Communication Boards
Weeks 6-7: 7 Level Communication Builder
Weeks 8-10: Dynamo
Word Approximations/Words
25
20
15
10
5
0
1
2
3
4
5
6
7
8
9
10
Sessions
Fig. 4. Number of word approximations
used spontaneously.
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Volume 5, Issue No. 1
100
90
80
Tantrums
70
60
50
40
30
20
10
0
1
2
3
4
5
6
7
8
9
10
Sessions
Fig. 5. Percentage of tantrums observed during transitions across activities.
Discussion
The child in this case study (CM) had previously been diagnosed with a profound hearing loss.
Subsequent audiological assessments using TEOAE testing reflected active cochlear processes. These
surprising results may suggest the possibility of some surviving outer hair cells in the cochlear region.
Alternatively, since CM’s MRI results reflect the possibility of an in-utero stroke, auditory processing
deficits may account for the inconsistencies in performance. The importance of thorough diagnostic and
medical evaluations, especially for the young, non-verbal child is apparent. Bax, Tydeman, and Flodmark
(2006) found white-matter damage of immaturity, including periventricular leukomalacia (PVL) to be the
most common finding in brain MRI scans of children with diagnoses of cerebral palsy. The authors
recommended that all children with cerebral palsy should have an MRI scan to determine the extent of the
damage, with the assurance that cranial MRI is a procedure that is safe to use with the pediatric
population. Strokes occurring between 28 weeks gestation and four weeks postnatally are seen in at least
1 in 4,000 live births per year. These children may be at risk for long-term learning, language and
behavior diffic ulties (McBride, 2003). The destruction of cerebral white matter or extrapyramidial tracts
may play a prominent role in disturbances of motor control, including speech (Paneth, Korzeniewski, &
Hong, 2005).
Over the course of therapy, AAC interventions were introduced to CM to increase her
communication skills. Steadily, improvements in sitting behaviors and eye contact were observed. At the
same time, CM’s problematic behaviors (e.g., tantrums) decreased significantly and she was able to
transition across activities with more ease. Brady (2000) reported successful use of an SGD to request by
a five-year-old child with autism, resulting in increased comprehension of object names. The ability to
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use SGDs to communicate has been associated with a concurrent reduction in the frequency of problem
behaviors such as tantrums (Durand, 1999).
Parents and professionals may be reluctant to initiate AAC interventions , because of the
misconception that AAC may inhibit the emergence of natural speech production (Beukelman, 1987;
Silverman, 1995). Individuals with developmental disabilities are often perceived to have the tendency to
rely on methods other than speech, such as manual signs or picture communication boards (Glennen &
DeCoste, 1997). However, natural speech is certainly the most efficient and expedient means of
communication. Children typically chose the easiest, most efficient mode of communication, if it is
within their capabilities (Millar, et al., 2006). Support also comes from the belief that AAC provides an
immediate and consistent model, along with reinforcement for individuals with developmental
disabilities, especially when there are visual stimuli and voice output (Blischak, 2003; Romski & Sevcik,
1996). It has also been proposed that AAC interventions serve as a mechanism for individuals with severe
speech impairments, to bypass the cognitive and motor demands of speech production (Romski & Sevcik,
1996).
The increases in CM’s communication skills, including requesting, responding, and production of
words/word approximations concurrent with the use of AAC strategies, support the conclusion that AAC
can enhance communicative competence and language skills. Millar, et al. (2006) found that 94% of the
participants in their meta-analysis review demonstrated an increase in speech production during or
following at least one in a range of AAC interventions. They concluded that the gains in speech
production were observed shortly after the introduction of AAC interventions, supporting the theory of
automatic reinforcement.
Too often, AAC is viewed as a last resort for individuals with developmental disabilities.
Evidence supports the early introduction of AAC to facilitate communicative competence and language
skills , and the development of natural speech (Millar, Light, & Schlosser, 1999). The implementation of
AAC can set the stage for further language and communication development during the preschool and
early school years (Romski & Sevcik, 2005).
Clinical Implications
The results of this case research support the importance of individualized modality selection when
implementing AAC strategies. Implementation of PECS and SGDs using mand-model procedures and
graduated prompting resulted in a reduction in problematic behaviors and a subsequent improvement in
receptive language and expressive communication. Delaying the introduction of AAC strategies when
behaviors and verbal performance suggest high risk for speech/language impairment can be detrimental to
a child’s long-term speech and language development (Cress & Marvin, 2003). AAC should not be
viewed as a last resort but rather as an early course of intervention that can provide a foundation for the
development of verbal language and communicative competence.
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Author Information
Cindy G. Arroyo D.A., Assistant Professor
Communication Sciences & Disorders
Adelphi University
401 Franklin Avenue Room 2442
Garden City, New York 11530
Phone: (516) 877 - 4768
e-mail: [email protected]
Robert M. Goldfarb Ph.D., Professor and Program Director
Communication Sciences & Disorders
Adelphi University
401 Franklin Avenue Room 2442
Garden City, New York 11530
Phone: (516) 877-4785
e-mail: [email protected]
Janet Schoepflin Ph.D., Associate Professor and Program Chair
Communication Sciences & Disorders
Adelphi University
401 Franklin Avenue Room 2442
Garden City, New York 11530
Phone: (516) 877-3343
e-mail: [email protected]
Danielle Cahill M.S.
Adelphi University
401 Franklin Avenue Room 2442
Garden City, New York 11530
Phone: (516) 877 - 4770
e-mail: [email protected]
47
Implications of Skinner’s Verbal Behavior for Studying Dementia\\
Jeffrey A. Buchanan, Daniel Houlihan, & Peter J.N. Linnerooth
Abstract
Persons with dementia experience continual declines in a number of abilities. Language abilities
are particularly hard hit and become increasingly impaired as the underlying disease progresses. These
language impairments make verbal communication very challenging for family and professional
caregivers. As a result, caregivers may inadvertently punish verbal behavior, thereby exacerbating the
deterioration of verbal repertoires. Although the topography of language impairments associated with
dementia have been well described, less empirical work has been conducted concerning how to minimize
these impairments and their deleterious effects. In 1957 B.F. Skinner outlined his conceptualization of
language and cognition in his book Verbal Behavior. This paper will explore the implications of
Skinner’s Verbal Behavior for studying communication impairments associated with dementia.
Keywords : elderly; dementia; verbal behavior; communication
Overview of Dementia
“Dementia” is a generic term that describes the progressive decline in a number of cognitive
abilities such as attention, memory, language, perception, and reasoning that interferes with daily
functioning (APA, 2000). Dementia can also result in behavioral changes such as wandering or
aggression, declines in self-care skills, and mood disturbances such as depression or anxiety. Dementia
can be caused by a number of different, irreversible causes (e.g., Alzheimer’s disease, vascular disease,
Pick’s disease) as well as reversible causes (e.g., vitamin B12 deficiency, medication overdose).
Dementia is a serious public health concern in the United States. If one considers all causes of dementia,
approximately 6-10% of individuals over the age of 65 suffer from dementia, with Alzheimer’s Disease
(AD) accounting for approximately 65% of all cases (Hendrie, 1997). Age is the number one risk factor
for developing dementia, which is particularly concerning given the rapidly aging population of the
United States. It is projected that 13 to 15 million Americans could suffer from AD alone by the year
2050 if no cure is found (Hebert, Scherr, Bienias, Bennet, & Evans, 2003).
Language deficits associated with dementia. Language deficits (i.e., aphasia) associated with
dementia can take on various forms/topographies, including receptive and expressive language deficits.
Language deficits in the early stages of dementia are characterized by pronounced difficulties with speech
production as opposed to comprehension (Levine, 2006). Common early stage deficits include word
finding deficits (i.e., anomia), poor spontaneous writing, indefinite references (“it”, “those”, or “thing”),
repetition of words or ideas, and difficulty understanding complex language such as metaphors or
analogies (APA, 2000; Kempler, 1991; Orange, 2001). As the disease progresses deficits such as empty
content, inappropriate word substitutions, difficulties following multi-step commands, poor topic
maintenance and inappropriate topic shifts, reduced reading comprehension, frequent digression from
conversational topics, reduced verbal fluency, difficulties with turn-taking and producing fewer utterances
per conversational turn (APA, 2000; Kempler, 1991; Orange, 2001; Levine, 2006) become apparent. In
the final stages of the disease, the patient may engage in echolalia, produce continuous streams of
nonsensical language, or become mute (Orange, 2001). These language deficits have important everyday
implications for patients, and caregivers, who have described communication deficits as one aspect of
dementia with which it is particularly challenging to cope (Orange, 1991). The many implications of
language deficits associated with dementia will be further described in the sections below.
48
Skinner’s Conceptualization of Verbal Behavior and Its Implications for Dementia
Skinner (1957) distinguished and functionally defined 6 types of verbal behavior including the
tact, mand, echoic, textual, intraverbal and autoclitic. To say that these are defined functionally means the
categories are delineated according to the reinforcement relations that shaped and/or maintain them as
operant responses, not according to any topographical property of the word(s). For example, the word
“water” could be an example of any of the categories, depending upon the conditions that evoke the
response. Shouting “Water!” whenever a river or lake is visible is a tact whereas the same, “Water!”
emitted after an hour in warm sun, even if perfectly similar in tone, inflection, or all formal properties, is
a mand, for it is controlled very differently, and has a much different ultimate function.
With this critically important difference between the Skinnerian versus traditional analyses (that
of grammarians, for example) in mind, the 6 categories are defined in the following sections along with a
discussion of a seventh variable – the audience. The sections below will cover the following information:
1) a short overvie w and definition of each verbal operant. 2) Examples that illustrate how each verbal
operant may be relevant in the context of dementia, with a particular emphasis on the potential negative
implications of a breakdown in verbal functioning. Examples involving both higher and lower functioning
patients will be provided to emphasize that individuals with dementia vary in their degree of functional
impairment and challenges experienced by patients and caregivers differ at different points in the disease
process. 3) When available, examples of empirical literature relevant to the particular verbal operant will
be presented. The discussion of empirical literature is not meant to be exhaustive, but illustrative of the
work that has been done examining verbal behavior in persons with dementia.
Tact
Tacts (verbal behavior that contacts the environment) occur under the control of a (usually
nonverbal) antecedent stimulus. The discriminative stimulus that controls a given tact might be an event
(“It is lunchtime”), an object (“Hamburgers are on the menu”), or a property of either (“My hamburger is
too rare”). Tacting is frequently likened to the conventional term “informing,” (Baum, 2005) but Skinner
(1957) is careful to point out 2 things: First, a given tact is simply a bit of verbal behavior made more
likely by the presence of a certain stimulus (1957, p. 82). In other words, the antecedents controlling it
must drive our analysis, not any idea about the “meaning” of what is said. Second, as a functional class of
verbal behavior, tacting encompasses a diversity of forms, including announcing, proclaiming, stating and
naming (1957, p. 186). The control of tacting by prior stimuli is the essential property to grasp. For
example, the third author is always amused when his elderly grandparents visit him in a new city. They
spend their entire time on any car ride emitting tacts evoked by commonplace stimuli (e.g. “There’s a
hamburger restaurant just down the street!”). Presumably, the novel setting for the “golden arches”
evokes the tact. No such effect would be seen in a longtime resident, and a person familiar with the
community even ends up hard-pressed to reinforce such tacts.
Dementia clearly impairs tacting throughout the disease process. For example, in the early stages
of dementia, even familiar objects (e.g., family members, friends, utensils, animals) inadequately control
tacting. This is often referred to as “anomia”, or the inability to name objects or people accurately. As the
disease progresses, the individual has particular difficulty tacting private stimuli such as the urge to use
the restroom, thirst, pain, or aversive emotional states such as fear or anger. The negative effects of
impaired tacting are evident. For example, forgetting a grandchild’s name can be very upsetting for the
child as well as the patient. Another common example in long-term care facilities involves the inability to
tact physical pain. Patients may engage in “disruptive behaviors” such as loud moaning or physical
aggression when they cannot say “I’m in pain” or “that hurts.” Prolonged suffering, loss of dignity, and
inadequate care are but a few consequences of this breakdown in the ability to tact.
49
Few empirical studies have attempted to improve tacting in dementia patients, but some
intriguing findings exist. For example, Cameron Camp and his colleagues have investigated the
effectiveness of a procedure called spaced retrieval (SR) to improve tacting in persons with dementia. SR
is a shaping paradigm that involves giving a person practice at successfully recalling information over
successively longer time periods (Camp, 1998). SR has been found to assist dementia patients in learning
the names of people (Camp & Schaller, 1989) and objects (Abrahams & Camp, 1993). SR appears to
represent a simple, portable, and teachable intervention that can reestablish the ability to name specific
objects or people over relatively long periods of time (e.g., a week or more) in persons with mild to
moderate dementia.
Another line of empirical work designed to improve tacting involves the use of memory books
that consist of a series of bound pages with a picture, and sometimes a description, of a person, place, or
symbol that is meaningful to the patient. Bourgeois and her colleagues (1992, 1993; Hoerster, Hickey, &
Bourgeois, 2001) investigated the effects of an external communication aid called personalized memory
books for improving communication between dementia patients and caregivers. These studies have
demonstrated positive outcomes in terms of tacting including more novel, detailed, and factual statements
during conversations and more on-topic verbalizations. Additional benefits include better turn-taking;
reductions in negative caregiver interactions; caregivers asking fewer questions; and conversation that is
more focused on the patient (Hoerster, et al.).
Mand
Mands (as in “demand” or “command”) are verbal operants whose likelihood of occurrence and
form are controlled by: 1) a given state of deprivation or aversive stimulation and; 2) a specific type of
reinforcement (Pear, 2001; Skinner, 1957). Unlike tacting, manding has no particular relation to an
antecedent stimulus. Mands such as “Please turn on the light,” typically produce a reinforcer (the listener
turns on a light) appropriate to the state of deprivation or aversive stimulation (e.g., perhaps the speaker
cannot see to read). Most mands specify the appropriate reinforcer (Baum, 2005) and many specify the
behavior of the listener as in the preceding example. The speaker then often provides generalized
conditioned reinforcement of the listener’s behavior, such as praise, or a “thank you.”
Like tacting, manding occurs in a diversity of forms such as requests for assistance, gesturing or
advice given to others. For example, a nursing home resident who cannot hear the dayroom T.V. might
mand “Could you please turn up the volume?” a behavior reinforced by the health care aide (the listener)
adjusting the sound. As the ability to mand in a precise manner deteriorates as the disease progresses,
difficulties between caretakers and patients commonly occur. For instance, the first author witnessed a
situation where a patient rolled his wheelchair to the nurse’s station and began moaning and pointing to
his foot. The nursing assistant, confused by the patient’s behavior, sternly asked him to quiet down. The
patient subsequently began moaning and yelling louder while continuing to point at his foot. As the
situation escalated, a more experienced nursing assistant came by, moved the patient’s foot onto the
footrest of his wheelchair, and the patient consequently stopped moaning.
This incident represents a larger issue commonly encountered in long-term care facilities, namely
that severely impaired patients may engage in “socially inappropriate” behavior (e.g., loud moaning) or
vague gestures or verbalizations (e.g., pointing to one’s foot, one-word utterances such as “foot” or
“there”) that function as imprecise mands. Staff that has little shared history with the patient consequently
respond ineffectively (e.g., reprimand, speak louder, ask for clarification), which results in aversive
interactions with staff as in the example above. For those patients with more severe language
impairments, external aids such as picture books may help supplement mands in that individuals can also
point to pictures of desired objects, activities, or people. In the example above, a simple picture of a foot
sitting on a footrest (along with other pictures of commonly desired objects) was attached to the patient’s
wheelchair and resulted in reduced staff-patient conflicts.
50
Echoic
Echoic responses are controlled by specific auditory stimuli, and feature a“point-to-point physical
similarity” with that stimulus (Pear, 2001, p. 377). Echoics are likely the earliest verbal response to be
learned (e.g. an infant’s “Mama!” is shaped from diffuse babbling to a perfect similarity to his or her
mother’s usage). Like tacts, echoics are shaped primarily through generalized conditioned reinforcement.
For example, a new nursing home resident might emit the echoic “319,” when told “Your room number is
319” and be reinforced with “That’s correct!”
Two points regarding echoics that are possibly important for the subject of this paper. First,
echoics are useful in building tacts and mands (Pear, 2001), although it is unclear if this is possible in
individuals with dementia. Henry and Horne (2000) have demonstrated that contingent reinforcement can
strengthen echoic behavior in persons with severe dementia. Future research will be needed, however, to
determine if rehabilitation efforts that involve strengthening echoic behavior in persons with dementia
will provide the substrate for rebuilding more complex manding and tacting repertoires.
Second, echoics may be mistaken for tacts (that is, mistaken for “understanding” or
misinterpreted as indicating high likelihood of compliance). For example, a family member might be
preparing to leave her (early Alzheimer’s) mother’s home just as mom is finishing a cooking task. The
daughter in this situation might mand “Mom, when you are done, remember to turn off the stove!” to
which Mom replies “Turn off the stove, right!” The daughter discovers the stovetop still hot the next
morning. What has occurred here? We might hypothesize that “Mom’s” response was not a tact. In such a
situation, a verbally intact individual would likely respond to the daughter’s mand with a chain of pr ivate
tacts (“The stove is on,” “This sauce will be done after 2 more minutes of stirring,” and “I need to turn off
the stove at that time.”) and essentially reinforce the mand with an autoclitic describing the likely strength
of the appropriate response (see Skinner, 1957, p. 315) indicating “Yes, I will definitely turn off the
stove.” The mother in this example seemed to respond appropriately, but in reality simply responded with
an echoic (“turn off the stove”) and, almost reflexively, added a socially appropriate intraverbal
(discussed below), the “right!” that ended her sentence. Thus, what the daughter believes to be mom’s
“strong intention” to safely extinguish the stove is nothing more than the confluence of two well-trained
verbal operants (repeating what we are told, and doing so politely) divorced from any connection to what
should be easily tacted as the dangerous stimulus in the environment. The example above shows how the
ability to engage in echoic behavior can actually cause communication problems between caregivers and
patients, particularly with professional caregivers who have little to no shared history with the patient.
These communication problems are at best frustrating and at worst dangerous. Unfortunately, confusing
echoics with other verbal operants is particularly likely given that the ability to engage in echoic
responses is intact late into the dementing process.
In the case described above, Skinner’s analysis might be useful for enhancing the safety and
independence of the patient. It would suggest, for example that the daughter could gain greater control
over her mother’s behavior by amplifying her vocal mand. She could, for example, post on the stove a
written mand: “MOM, TURN OFF THE STOVE,” perhaps even including a photo of herself looking
concerned and pointing toward the relevant control. Or she could devise some way that a heated burner
might more effectively control the mother’s tact (“Oh, my, the stove is on”) and/or nonverbal behavior
(actually turning it off). Stoves often provide only a weak SD to occasion turning off a burner, thus the
impaired user might be assisted by using a larger light or an alarm sound.
Intraverbal
51
Intraverbal responses are evoked by prior verbal stimuli, much as tacts are evoked by
environmental antecedents (Pear, 2001). Unlike echoic responses, intraverbals have no formal
correspondence with the evoking stimulus. But like both echoics and textuals, intraverbals are maintained
via generalized conditioned reinforcement. Thus, the stimulus and response may be either vocal or
written, or any combination and the analysis remains the same. A simple example of what Skinner (1957,
pp. 71-72) refers to as “trivial” intraverbals, are the “answers” evoked by common social “questions”
such as the intraverbal response “I am fine,” in response to the vocal verbal stimulus “How are you
today?” Persons with dementia typically maintain the ability to respond appropriately to these common
social questions (it is often said that patients maintain “social graces”) in the early stages of the disease,
making early detection a difficult task, even for those who know the patient well.
However, intraverbal is not necessarily to be equated with trivial, and Skinner goes on to note
many situations in which complex conversations or answers (e.g. “the facts of science” p. 72) are mainly
intraverbally controlled. Lack of such control can even have diagnostic importance, such as when we ask
a mental status exam question such as “Complete this sentence, ‘Right as _____’.” We might assess
further if we receive the wrong answer from a patient whose response (“rain”) should have been well
established intraverbally through years of training within our particular verbal community.
Textual
Textual (as in reading a text) responses are vocal responses controlled by non-auditory stimuli.
These SDs may be visual or tactile (i.e. Braille) stimuli and may have a diversity of forms (e.g. words,
pictures, symbols). But all simply set the occasion for a vocal response. Like echoic behavior, much of a
texting repertoire is explicitly evoked and reinforced, with generalized conditioned reinforcers, in
“educational” settings (school) or relationships (parent-child). Here the listener reinforces the speaker’s
vocal responses if they have the correct relationship to the textual stimulus.
Fortunately the ability to engage in textual responses remains intact early in the dementing
process (Orange, 2001), thus behavior may be controlled by more complex stimuli such as lists,
calendars, or notes produced by others or themselves. Therefore, analyzing textual control, and making
practical use of textual stimuli in populations such as patients with dementia is relevant and useful. This is
illustrated above with our “turn off the stove” example. Bourgeois and colleagues (1997) demonstrated
that repetitive questions could be reduced in community-dwelling persons with dementia by having
family members prompt patients to read cards that contained the answers to frequently asked questions.
Even as the underlying disease progresses into the moderate stages, patients can respond
effectively to simple, frequently-occurring words (Cummings, Houlihan, & Hill 1986) or pictures
depicting objects or actions. The first author worked with a family in which the father with dementia left
his dirty clothes on the bathroom floor. A large sign on the top of the hamper reading, “PUT CLOTHES
HERE” resulted in near elimination of this behavior. Hussian (1988) showed how stimulus enhancement
techniques such as making words or pictures larger, more colorful, or in prominent, noticeable places may
be particularly helpful in reducing challenging behavior in persons with dementia that is due to
insufficient stimulus control such as attempting to leave protective environments or inappropriate voiding.
Whether textual (written by others) or self-textual (e.g. a reminder note to one’s self) the influence of
written or pictorial SD s may long outlast similar echoic stimuli, and thus control behavior more
effectively. And, as Skinner further notes, the massive reinforcement history for responses such as
reading makes it likely that textual stimuli will attract attention.
Autoclitic
Autoclitic are verbal responses controlled by the speaker’s own previous verbal behavior. They
allow the speaker to create longer pieces of verbal behavior that are “intelligible,” that is, that function to
allow the listener to take “effective action” (Skinner, 1957, p. 314). Pear (2001) interestingly describes
52
autoclitics in a manner useful for the topic of the current paper. He casts them as verbal escape or
avoidance responses that are reinforced by modifications in the listener’s response. An extension of
Pear’s (2001, p. 377) pediatric example may illustrate. A geriatric patient might mand “Please give me
my medication,” but then quickly add the autoclitic “the blue tablets,” to ensure that the listener does not
dose him with the white tablets and blue capsules he has recently taken. The autoclitic phrase is here
controlled by the deficient mand, and will be negative ly reinforced by avoidance of the overdose that the
listener might otherwise have supplied.
The Audience Relation and the Negative Audience
As language deficits become evident, there will be at first an insidious effort to alter how one
interacts with that person. Although some small adjustments might be helpful in facilitating
communication (i.e., slowing down, using fewer words to communicate), many other adjustments (e.g.,
corrections and criticisms, or ignoring the individual) may actually serve to punish verbal behavior. These
‘tell-tale’ signs of change in communication patterns coincide with what Skinner termed the “Negative
Audience” which is, “an audience in the presence of which verbal behavior is punished” (Skinner, 1957 p.
178).
Changes in interactions with the verbal community alter patterns of reinforcement with very
established histories. The impact of these contingencies on communication and their relative strength is
established over a lifetime, and do not simply emerge as relevant when dementia begins to erode these
established communication patterns. We start out our lives with our parents celebrating every word we
utter. Later on, adolescence presents a rich tapestry of communication opportunities with the adolescent
needing to effectively communicate with everyone from the very young (e.g., nieces and nephews) to the
very old (e.g., grandparents) (Williams & Garrett, 2002).
With age comes a narrowing of the channels of communication with a cohort that grows
progressively smaller over time through attrition. Unfortunately, with the dwindling of an audience there
also comes the potential for a concurrent decline in verbal behavior. Also, fewer opportunities for
meaningful communication concomitantly increase the meaning of social opportunities and the
reinforcement they provide (see Houlihan, Rodriguez, Levine, & Kloeckl, 1990). In fact, results of the
Geriatric Reinforcer Survey (Houlihan et al.) show that what elderly residents of nursing homes find most
rewarding is social contact and conversation with family and friends.
Despite this need for socialization, many changes in the verbal community actually produce
reductions in social interaction. Initially, the remaining audience is one often made up of family and
friends that are most familiar to the dementia sufferer. These individuals may no longer reinforce
verbalizations with smiles and head nods, but instead replace them with looks of concern, frustration or
disinterest (Skinner, 1957). These audiences may effectively punish verbal behaviors in the sense of
socially conveying a visible preference for silence. Because recognition is a memory system that relies on
information already established in memory to match or compare, it generally outlasts recall which
involves a search of memory for something that is often more recently established. This is to say that
people are generally better with faces than names. Izard has shown convincingly that facial expressions
are our earliest and most established forms of expression and communication (Izard & Ackerman, 1997).
Smiles, nods, and continuation of conversations serve as setting events for positive social behaviors.
Looks of disinterest or statements like “I told you that already,” or “I know you’re not that stupid,” serve
to punish prosocial behaviors and negatively reinforce social withdrawal or dependence. The meaning of
those expressions is amongst some of the last things lost to memory. People are sometimes even more
callous or blunt with individuals with memory problems because they figure that they will just forget the
negative statements anyway.
Although those familiar with the patient may initially serve as a negative audience in the manner
described above, the situation often continues as impairment worsens and the patient requires placement
53
in long-term care facilities (e.g., nursing homes, assisted living facilities). In long-term care, the patient is
being cared for by individuals who share no history with the patient and who are paid little, have little
training, and have many patients to care for in a short amount of time. This combination of factors can
understandably lead to poor staff-patient communication. For example, recent studies by Williams and
colleagues (2009; Cunningham & Williams, 2007) have shown quite clearly that a disrupted pattern of
communication known as elderspeak (i.e., infantilizing speech similar to that used with small children)
exists in staff-patient relationships in nursing homes and that elderspeak increases the probability of
resistance to care (e.g., hitting, saying no, crying) by dementia patients.
Kitwood (1990a) refers to these negative changes in patterns of communication as the “malignant
social psychology.” The result can be social withdrawal, which is understandable in that many of these
patients have lengthy histories of being immersed in an environment that generally provided rich
schedules of reinforcement (both positive and negative) for their spoken language. As Skinner (1957) has
noted, a rich schedule of reinforcement is also a schedule that is most easily extinguished (Neisworth,
1985). Over time, the graduated banishment, first psychologically and eventually physically, of the
dementia sufferer from the verbal community may occur and the end can be marked by a nearly total
deprivation of sustaining human contact.
Overall, it appears that at a point in your life when you most crave and value human social
contact, sources of social contact begin to diminish and the type and quality of communication changes.
Even those fortunate enough to maintain their cognitive abilities into old age might find themselves on a
schedule of extinction with few opportunities for discussion with others and their ideas often being
devalued due to their age. The net result of diminished opportunities for social interaction, instances of
elderspeak such as “let’s go potty,” combined with negative visible or verbal reactions to flawed
statements, is to take our memory impaired loved ones away from us well before the disease does.
Kitwood (1997) suggests that this malignant social psychology (i.e., negative audience) might “…even
serve to accelerate the advance of neurological degeneration” (p. 51).
Some empirical work has focused on interventions targeting specific repertoires of the verbal
community with the goal of improving communication with patients, reducing problematic behavior (e.g.,
resistance to care) and improving mand compliance. These studies demonstrate how important the verbal
community is in contributing to the functioning of dementia patients as well as the importance of
specifying behaviors of the verbal community that either increase or decrease the likelihood of evoking
effective behavior from persons with cognitive impairment. For example, Gentry and Fisher (2007), using
an ABAC design, compared two different types of listener repair responses on the verbal behavior of
three dementia patients. Repairs were either direct (i.e., the listener provided corrective feedback to the
patient when an error is made) or indirect (i.e., the listener restated his/her understanding of what the
patient said). Results indicated that indirect repairs were associated with more words spoken, longer
speech duration, fewer topic changes, and fewer incomplete interactions compared to direct repairs.
Recently studies have begun to investigate the relationship between patient mand compliance and
the type of mands delivered by caregivers during personal care tasks (Buchanan, Christenson, &
Houlihan, 2008). Preliminary results show that alpha commands (i.e., commands that are clear, concise,
and feasible) produce significantly better mand compliance than do beta commands (i.e., commands that
are vague, ambiguous, or do not give the individual an opportunity to comply). In addition, commands
that involved one step, that were stated directly, that were repeated exactly, and that clarified previous
commands were more effective in producing compliance. On the other hand commands in the form of
questions, commands that involved more than one step, and commands using first-person plural pronouns
(“we need to go to the bathroom”) produced greater rates of noncompliance.
Practical Implications
54
An important practical implication of Skinner’s functional analysis is that it provides a
framework for conceptualizing intervention targets (e.g., tacting or manding repertoires) that could
potentially help maintain independence, preserve dignity, and reduce burden on caregivers. The 7 verbal
operants provide valuable a system for categorizing communication problems and, as many of the
examples described throughout this paper illustrate, can even be prescriptive in the sense of suggesting
intervention strategies. As an additional example, consider a familiar scenario that occurs in long-term
care facilities where an individual with dementia is physically or verbally aggressive during activities of
daily living (ADLs) such as bathing. Commonly a patient will begin by protesting to getting wet or
having clothes taken off with either vague statement (saying “no” “why”, or “stop”) or seemingly benign
behaviors (e.g., heavy sighing, tightening muscles, or pulling away from caregivers). These behaviors
often function as mands that essentially communicate something like, “Please back away from me
because I’m scared, in pain, cold, embarrassed, etc…” For various reasons (e.g., ADLs must be
completed, the patient’s mands may be imprecise or incomplete, the caregiver is attending to another
caregiver and not the patient), these mands are often ignored by caregivers. Patients may respond by
augmenting their mands with cursing, threatening, or hitting caregivers in order to escape or otherwise
change the aversive situation. Caregivers may respond by altering their behavior in a variety of ways
(e.g., provide a brief break, end the task, re-establish eye contact with the patient, talk directly to the
patient as opposed to another caregiver, apologize, change the water temperature) that can serve to
reinforce aggression. Ideally, a caregiver could reflect upon this situation and identify that a mand was
overlooked early in the bathing process and consider other ways to approach bathing next time by, for
example, proceeding more slowly, changing water temperature when asked, talking directly to the patient
about familiar topics, or periodically giving the patient a break contingent upon more appropriate
behavior. This approach is likely to be far more fruitful than simply labeling the patient as “aggressive” or
“violent.” At best these labels result in caregivers becoming resigned to the “fact” that the patie nt is, and
always will be, aggressive and aversive interactions continue. At worst these labels result in placing the
patient on psychotropic medications that often are ineffective and have harmful side effects such as
sedation or confusion.
Future Research Implications
Skinner’s analysis may also provide a useful guide for future research on communication
difficulties in persons with dementia. Although the discussion above points to numerous areas for future
empirical inquiry in our opinion, four particularly important targets for future research with dementia
patients include: 1) Improving tacting. The inability to name objects or people is a prominent deficit early
in the disease process and can be very distressing for patients and their families, particularly when the
names of loved ones cannot be produced. 2) Improving manding. The ability to clearly express needs
verbally is impaired throughout the disease process. Unsuccessful attempts to communicate needs can
produce frustration and social withdrawal in both patients and their caregivers and leave the patient’s
needs unmet. Eventually, behavioral disturbances such as loud, repetitive vocalizations, pacing or
physical aggression may develop as an alternative means for expressing needs. 3) Improving mand
compliance. Although mand compliance is a listener repertoire, and thus not technically verbal behavior,
Henry and Horne (2000) appropriately note that one must learn appropriate listener behavior in order to
function as a member of the verbal community. Also, because individuals with advanced dementia require
assistance to complete personal care such as dressing or bathing, mand compliance is critical for the
successful completion of these tasks. Developing ways to improve mand compliance may result in less
stressful interactions during personal cares and fewer injuries to caregivers and patients. 4) Altering the
behavior of the verbal community to better support the patient’s independence. This may include
behaviors such as improving delivery of mands or altering communication styles so as to encourage
verbal behavior instead of inadvertently punishing it.
Summary
55
Perhaps the most valuable contributions of Skinner’s analysis for studying dementia are its focus
on three major themes. First, Skinner conceptualizes any behavior (not just vocal behavior, but written,
gestural, etc…) that exerts its effect through the actions of another person as being “verbal.” This point is
worth emphasizing because many take “verbal behavior” to be equivalent with “speaking” when in fact
verbal behavior can involve gesturing, unintelligible vocalizations, or writing. Conceptualizing verbal
behavior as more than just speaking can help caregivers interpret a variety of different behaviors as being
verbal in nature and serving a social function.
This emphasis on function versus topography of behavior is the second important theme in
Skinner’s analysis that is beneficial for studying dementia. Skinner’s focus on function and environmental
causation encourages theorists to examine the social context in which verbal behavior occurs and the
transactional influence of the patient’s verbal behavior on the verbal community, and the verbal
community’s response on the patient’s verbal repertoire. In general, those studying dementia have placed
less emphasis on understanding the social context in which verbal behavior occurs, and how the verbal
community can contribute to maintaining existing repertoires or, conversely, exacerbate existing deficits
and cause excess disability. Because conditions like Alzheimer’s disease cause progressive and
irreversible impairment, changing the behavior of the patient’s verbal community may be more realistic
than teaching the patient new repertoires or reestablishing lost ones (Gentry & Fisher, 2007).
Furthermore, as many of the examples described previously illustrate, the focus on function may
also help one better understand that seemingly disruptive behaviors (e.g., loud moaning, calling out, or
repeating questions) can serve important social communicative functions and should not necessarily be
eliminated through the use of psychotropic medications. The situation above concerning physical and
verbal aggression during ADLs provides a good example of this point. Simply eliminating behavior
through the use of medication could be considered unethical in that medications exacerbate the loss of
verbal behavior in individuals who are already losing it as a consequence of their disease. In addition, an
important social need would potentially be left unmet.
Third, Skinner’s analysis insists on fully accounting for the environmental contingencies that
affect verbal behavior versus ascribing such behavior to a ghostly (Baum, 2005) inner agent. This
contrasts with how impairments in verbal behavior related to dementia have been traditionally
conceptualized. Research in the communication disorders literature has thoroughly described specific
topographies of verbal deficits associated with different stages of the disease process (see Kempler, 1991
for an excellent example), but has been less fruitful in terms of understanding their causes and in
designing interventions for deficits in verbal behavior. Furthermore, because Alzheimer’s disease and
other dementias have biological correlates (e.g., brain atrophy, declines in neurotransmitters, toxic
accumulations of twisted proteins such as beta amyloid), language disturbance is often attributed
primarily to biological effects of the disease. Attributing deterioration solely to biological processes has
stifled theoretical and empirical inquiry into environmentally-based causes and interventions, although
some notable exceptions exist (e.g., Kitwood, 1997). Skinner’s formulation could potentially move
theorists away from exclusive reliance on internal causes of behavior. It places the analysis in the
environment, which is currently much more manipulable given that medications for dementia (e.g.,
cholinesterase inhibitors) have only modest benefits (Whitehouse, 2008, pp. 117-119).
Skinner’s Verbal Behavior is replete with ideas that can be applied to the study of dementia and
only a portion of Skinner’s overall analysis was addressed in the current paper. As Giles (1999) notes,
there is an inherent need to better understand through research the injustices put on the elderly as they
struggle to communicate effectively. It is hoped that the examples and empirical work described
throughout this paper will inspire the reader to explore this literature further and lead to the creation of
ideas for empirical work in this under-developed, yet critically important area.
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Author Contact Information
Jeffrey Buchanan, Ph.D.
Minnesota State University, Mankato
23 Armstrong Hall
Mankato, MN 56001
Phone: 507-389-5824
e-mail: [email protected]
Daniel Houlihan, Ph.D.
Minnesota State University, Mankato
23 Armstrong Hall
Mankato, MN 56001
Phone: 507-389-6308
e-mail: [email protected]
Peter Linnerooth, Ph.D.
Minnesota State University, Mankato
23 Armstrong Hall
Mankato, MN 56001
Phone: 507-389-6217
e-mail: [email protected]
58
Using Skinner’s Model of Verbal Behavior Analysis to study
Aggression in Psychiatric Hospitals
Michael Daffernand Matthew Tonkin
Abstract
An adaptation of Skinner’s verbal behaviour model is proposed as a framework for analyzing
the aggressive behaviour of hospitalized psychiatric patients. Few behavio ur analytic studies have
addressed verbal aggression and none draw upon Skinner’s model. These few studies suggest that the
aggression of psychiatric patients is multiply determined and multi-functional. In this context,
aggression occurs primarily to express anger. It is preceded proximally by aversive interpersonal
interactions and often protects status. More recent approaches to the asses sment of function are broader
and more instructive for observers of aggressive behavior than Skinner’s original conceptualisation.
These approaches eliminate those operants (textual, transcriptive) that lack relevance to the study of
psychiatric inpatient aggression and they differentiate the functions of other operants (mands, tacts ) to
reflect the functions of aggression demonstrated by these patients .
Keywords: Verbal behavior, aggression, psychiatry, hospital
Introduction
Skinner’s (1957) conceptualization of verbal behavior has its roots in a series of lectures first
presented at the University of Minnesota in the late 1930s, and subsequently at Harvard University,
and the University of Chicago. In these lectures Skinner proposed a new theory of verbal behavior,
which differed from existing explanations of verbal behaviour that tended to account for language in
terms of its underlying meaning. For Skinner, existing explanations were scientifically inadequate
because they failed to identify measureable and controllable variables that were causally linked to
observable behavior (Skinner, 1957). Skinner, therefore, rejected the traditional formulation of verbal
behavior in favor of a new, behaviorally derived formulation.
Skinner’s new formulation accounted for verbal behavior in terms of operant conditioning. He
suggested that verbal behavior (1957) could be understood (and therefore controlled) by gaining an
appreciation of the antecedents and consequences of specific utterances, which was best done using
functional analysis. So, like other operant behavior , verbal behavior (1957) was conce ptualised as a
function of the speaker's c urrent environment and their behavioral history. It is these factors that
Skinner argued were central to the scientific investigation and understanding of verbal behavior
(1957).
Skinner’s functional analysis identified four antecedents (stimuli) and two consequences
(reinforcers) that function to control verbal behavior. The four antecedent variables were: (1) some
state of deprivation or aversive stimulation, (2) some aspect of the envir onment, (3) other verbal
behavior, and (4) one’s own verbal behavior. The two consequences of verbal behavior were: (1)
something related to the state of deprivation/aversive stimulation, and (2) social/educational
consequences (Frost & Bondy, 2006). These six variables combine to form six basic functional
(stimulus-response) relationships, which specify the antecedent conditions and subsequent
consequences of verbal behavior. These six basic units or verbal operants are the building blocks of
verbal behavior, and can either stand alone as simple forms of language or can combine to create
more advanced forms of verbal behavior (Sundberg & Michael, 2001).
The first verbal operant explained by Skinner (1957) was that of the mand. The term mand
was used to refer to verbal behaviors that occur in response to a state of deprivation/aversive
stimulation and which tends to produce some beneficial or desired outcome related to that state . In
other words a mand is a verbal operant that specifies its reinforcer. A typical example is a request for
water by one who is thirsty.
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Another verbal operant identified by Skinner (1957) is the tact. Tacts are verbal behavior
evoked by an object/event or some property of an object/event (Skinner, 1957). That is, the presence
of a given object (the stimulus) increases the probability of a given response (the tact), which in turn
is generally reinforced (e.g. praise). For example, presenting a picture of a cat to a child may evoke
the response “cat”, which is reinforced by praise from the parent.
Additional verbal operants are the echoic, intraverbal, textual, and transcriptive. These are
similar to tacts in that they are made as a response to some external stimulus. The difference,
however, is that intraverbal, echoic, textual and transcriptive operants occur in response to a verbal
discriminative stimulus (S D), whereas the tact is made in response to a non-verbal stimulus. Echoic
verbal operants refer to verbal behaviors that are simple imitations of the verbal behavior of others.
Intraverbal operants also occur in response to an S D but are not echoic in nature. Common examples
of intraverbal behaviors are answering a question or filling in a blank, such as when a child says
“farm” after hearing “Old MacDonald had a…” (Frost & Bondy, 2006). Conversational responses are
also common forms of intraverbal operants. Textual verbal behavior is controlled by the written word
(a form of non-auditory verbal stimulus). For example, reading aloud the word “Cat” that is written on
a page. Here the written word is the stimulus, saying the word aloud is the response, and typically the
reinforcement is social approval (Skinner, 1957). Transcription can either be in the form of “taking
dictation,” where the stimulus is auditory and the response written, or it can be in the form of
“copying text” where both the stimulus and the response are in written form. Transcriptive verbal
operants receive ‘many special educational and economic reinforcements’ (Skinner, 1957, p. 71).
More detailed analyses of Skinner’s conceptualisation are presented by Frost and Bondy (2006), and
by Sundberg and Michael (2001)
Existing applications of Skinner’s Verbal behavio r
Although Skinner’s (1957) book, Verbal behavior , was essentially theoretical, in that he did
not present any experimental data, it was practice-oriented. Despite this, it took over 40 years before
Skinner’s terminology and theory were applied in a practical manner (Sundberg & Michael, 2001).
However, several applications were reported prior to this, including Zoellner’s (1969) method for
teaching English composition to College students, Skinner’s (1981) application to professional
writing, and Sloane, Endo, and Della -Piana’s (1980) suggestions for facilitating creativity. More
relevant to the current article, perhaps, was the application of Skinner’s tacts, mands and intraverbal
responses to the study of verbal communication among a group of emotionally-disturbed adolescents
(Salzinger, 1958). This study developed a framework for categorising the verbal behavior used in
letters to friends and relatives. Skinner’s theory was useful in this context because it provided a
structured system for breaking down verbal behavior into its constituent parts, which enabled the
researchers to conduct a more fine -grained analysis and comparison with ‘normal’ individuals than
would otherwise have been possible. Also relevant are Glenn’s (1983) analysis of client maladaptive
behavior in clinical situations (e.g. lying, denial, demanding) and Burns, Heiby, and Tharp’s (1983)
analysis of auditory hallucinations, both of which adopted a verbal behavior perspective.
Although interesting , these applications of Verbal behavior (1957) did not give rise to any
consistent, formal programs that could be applied to the treatment or assessment of clinical problems.
Indeed, it was not until the last decade or so that a body of research by applied behavior analysts (see
below) has enabled Skinner’s theory to be applied to the treatment of individuals with communication
deficits. Much of this research has focused on developing language acquisition programs for children
with autis tic spectrum disorders, such as the aptly named ‘Verbal Behavior’ program (Sundberg,
Michael, Partington & Sundberg, 1995). The most prominent deficit in autistic children tends to be
their use of language to interact effectively with others (Paul & Sutherland, 2005). The Verbal
Behavior program, therefore, adopts two main aims: (1) To improve the maturity of language forms;
and (2) To enable a more effective use of communication. In order to achieve these aims the program
provides a carefully sequenced curriculum for teaching language, which works through a series of
increasingly more complex language goals.
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The five language goals of the program (ordered in terms of complexity) are: Echoes (to
facilitate the use of imitation); Mands (to facilitate the use of verbal behaviors that produce an
immediate effect on the environment, such as having a request reinforced); Tacts (to facilitate the use
of verbal labels); Reception by feature, function and class (RFFC, to improve the use of verbal
behaviors made in response to common verbal stimuli, such as written words); and Intraverbals (to
improve the use of non-echoic verbal responses that occur in response to the verbal behavior of
others, such as conversation).
The program begins by teaching the child echoic and mand verbal behavior. As the child
masters these more elementary forms of communication s/he is taught the more complex forms of
verbal behavior. The program can, therefore, be described as a tiered approach to language
acquisition. However, in addition to the language goals being presented in a tiered manner, within
each language goal the child is taught in a tiered fashion. For example, echoic responses are initially
taught by having the child imitate simple speech sounds (such as “ma” and “da”). Once these have
been mastered the child is taught to imitate entire words, then entire phrases and so on, with the hope
that the child’s programmed behavior will generalize to imitating novel words and phrases. The
Verbal Behavior program has received empirical support, with graduates demonstrating increases in
verbal production (e.g. Partington, Sundberg, Newhouse & Spengler-Schelley, 1994; Sundberg &
Michael, 2001; Sundberg et al., 1995). It has also been adapted to facilitate the acquisition of nonverbal forms of communication (e.g., see Carbone, 2003).
The practical applications of Skinner’s theory have, therefore, been quite limited in scope and
number. This is despite Skinner’s original emphasis on the applied nature of Verbal behavior (1957)
and despite scholars highlighting the significant applied and theoretical potential of the book (see
Sundberg, 1991) (e.g., to the analysis of bizarre verbal behaviors, complex personal and family
problems, and for changing the verbal behavior of juvenile delinquents). Interestingly, many of the
potential applications suggested by Sundberg are relevant to the issues and behaviors that manifest
within psychiatric hospital settings. The current application of Verbal behavior to aggression in
psychiatric units, therefore, seems timely and appropriate. We begin this application by considering
the scope and impact of aggression in psychiatric hospital settings.
Aggression during psychiatric hospitalization
Aggression during psychiatric hospitalization has long been recognized as a commonly
occurring and significant problem (Fottrell, 1980; James, Fineberg, Shah, & Priest, 1990; Yesavage,
1983). That aggression is widespread in many psychiatric hospitals is unsurprising. Necessary criteria
for admission in a mental health service as an involuntary patient is to prevent injury to both the
public and the admitted person. Aggression has a significant impact on patients and staff, ward
routine , and mental health services in general (Daffern & Howells, 2002). Aggression may affect
patients’ treatment and access to rehabilitation programs. It can also influence the level of supervision
and may result in the patient’s isolation from others or prolong hospitalization. Injury to patients
engaging in aggression, and injury to co-patients and staff who are the victims of aggression, are also
common consequences of inpatient aggression. Aggression can significantly compromise ward
atmosphere, morale, and functioning (Monroe, Van Rybroek, & Maier, 1988). Organizational
problems related to aggression include time lost from sick leave taken by staff in response to
aggression, problems with staff recruitment and retention to hospitals where aggression is common,
financial costs associated with compensation for injury, as well as official inquiries and litigation
(Hillbrand, Foster, & Spitz, 1996).
Of the considerable body of research examining aggressive behaviors in psychiatric hospitals,
most studies have drawn upon structural rather than functional assessment approaches. Structural
assessment approaches emphasize the correct classification of the form of a particular behavior,
whereas functional assessment approaches emphasize the purpose of the behavior (Owens &
Ashcroft, 1982). Furthermore, studies of aggressive behavior have typically focussed on the
demographic and clinical characteristics of aggressive patients. Symptoms of psychosis, in particular
delusions and hallucinations, have been a primary focus. Less emphasis has been placed on the
61
interpersonal context (i.e. the interaction between individuals on the unit) and environment in which
aggression occurs (for exception see Gadon, Cooke & Johnstone, 2006,) though recently the
interactional nature of aggression has been emphasized (Daffern, Duggan, Huband & Thomas, 2008;
Whittington & Richter, 2005).
Results of various studies suggest a complex array of interrelated factors contributes to
aggression. Certain symptoms of mental disorder, specifically active symptoms of psychotic illness
such as command auditory hallucinations and persecutory delusions , increase the likelihood of
aggression during hospitalization for some patients. Disorder of thought, increased physiological
arousal, disorganized behavior, and substance use may all contribute, although to a somewhat lesser
extent (Daffern & Howells, 2002). Personality factors, including disorders such as psychopathy
(Heilbrun et al., 1998) and interpersonal style (Daffern et al., 2008) also relate to aggression during
hospitalization. The physical characteristics of the hospital, the rules and regulations by which it
operates, and the behavior of ward staff and other patients are also important (Daffern & Howells,
2002).
The functionality of behavior emitted by patients of psychiatric hospitals
Published examples of behavior analytic assessment of aggression within psychiatric
hospitals are scarce. This may be because traditionally, the behavior of mentally ill patients,
particularly those in the acute phase of psychotic illness, was considered purposeless or driven
exclusively by symptoms of psychiatric illness. Thus, they were viewed as unrelated to
environmental contingencies. Furthermore, aggression generally is considered pathological because it
breeches social mores and may have profoundly negative consequences for the perpetrator (Layng &
Andronis, 1984). It is however, like other bizarre behavior, still generally adaptive when considered
within the context of the aggressive patient’s limitations, tendencies, skills, or pre-existing
vulnerabilities (Goldiamond, 1975a & b) and environmental contingencies (Daffern, Howells, &
Ogloff, 2006).
Layng and Andronis (1984) assumed that behavior, in their case delusional speech and
hallucinatory behavior, is operant, in that its frequency is a function of contingent consequences. As
an example, they report on the case of a psychiatric patient behavin g erratically and speaking in a
delusional manner. The woman complained about how hard it was for her to go to the nurse’s station
to talk to staff and that when she did her requests for help often incurred hostile responses. “Her
delusion was an immediately less onerous, but ultimately very costly, alternative to the more difficult
task of going to the nurse’s station to seek out unit staff. Both patterns, it was noted, appeared to
produce the same maintaining consequences, i.e., conversations with staff” (p. 142). According to
Layng and Andronis (1984), when the consequential alternatives that were available to the woman
were considered, her so-called delusional behavior was comprehensible. In Skinner’s terminology ,
this patient’s delusional speech may be considered a dysfunctional mand in that the dysfunctional
speech occurred in response to a state of deprivation/aversive stimulation (perhaps loneliness) and
resulted in the desired outcome (i.e., talking with staff). Further demonstrations of the role of social
and environmental contingencies on psychiatric symptoms are evident in Alford and Turner’s (1976)
introduction of social reinforcement, and Belcher’s (1988) use of aversive contingencies to reduce
hallucinatory behavior.
In one of few function analytic studies of aggression within psychiatric hospitals, Shepherd
and Lavender (1999) studied the antecedents and aggression management strategies of 130 incidents
of aggression: dividing antecedents into external and internal factors. In this study the majority of
incidents (60%) were preceded by external factors such as staff refusal of a patient’s request or staff
demand for activity, hospital related matters such as ward restrictions and transfers between wards, or
patient-on-patient conflict. Forty percent of all incidents were attributed to internal factors such as the
patient’s mental state or substance use. The function of these incidents was not recorded by Shepherd
and Lavender (1994). However, they noted that aggression frequently occurred consequent to social
distance (indicating attention seeking was a primary function) or as a consequence to aversive
stimulation, which may suggest aggression was reactive or anger-mediated rather than predatory.
62
Daffern et al. (2006) have developed a system for classifying and recording the functions of
psychiatric inpatient aggression. This method, the Assessment and Classification of Function (ACF),
was informed by the cognitive model of anger developed by Raymond Novaco (Novaco, 1976; 1994),
the instigating mechanisms outlined by Albert Bandura in his social learning theory of aggression
(Bandura, 1973), and the interactions antecedent to aggression identified in previous research on
aggression in psychiatric inpatient wards (Shepherd & Lavender, 1999). The following functions are
included in the ACF:
1. Demand avoidance: Demands by co-patients or staff to cease an activity or to complete a
task (e.g. to adhere to hospital routine, to cease a behavior, or to attend to an activity such as taking a
shower) often precede aggression. This function is evident when the patient does not wish to attend to
the demand and acts aggressively to avoid or escape from it.
2. To force compliance: Aggression frequently occurs following the denial of a request (e.g.,
to make a telephone call, attend a program, leave the unit, obtain medication, or receive information
about their treatment). This function is evident when the patient is refused a request and then behaves
aggressively in a demand for compliance.
3. To express anger: Aggressive behavior usually follows an event that the patient perceives
as provocative. Types of provocation include perceptions of disrespectful treatment;
unfairness/injustice; frustration/interruption; annoying traits, and irritations. Provocation may also
include physical assault or threat by others. This function is evident when the patient is obviously
angry and their aggression appears to be an expression of their anger.
4. To reduce tension (catharsis): Aggression tends to reduce general physical arousal. Some
people may deliberately behave aggressively to reduce tension. For others, aggression may reduce
tension even if this was not their intention. This function is evident when the patient’s aggression
reduces tension.
5. To obtain tangibles: Aggression may be used to obtain tangible items such as cigarettes or
money. This function is evident when the patient seeks to or obtains tangible items as a result of their
aggression.
6. Social distance reduction (attention seeking): Aggressive patients tend to seek high levels
of supervision and/or compete more frequently for staff attention. Some patients behave aggressively
to reduce social distance, a function that may colloquially be referred to as attention seeking. This
function is evident when the patient’s drive for behaving aggressively is to obtain additional attention.
7. To enhance status or social approval: Humiliating affronts and threats to reputation often
precipitate aggression, particularly in settings where dominance and privilege is afforded to those who
use aggression. This function is evident when the patient uses aggression to enhance status or prevent
deterioration in status.
8. Compliance with instruction : Aggression may occur following a command auditory
hallucination or following instruction by another person. Compliance may alleviate distress or create
alliances with others. This function is evident when the patient responds to a command/instruction to
behave aggressively.
9. To observe suffering: Some patients may be motivated to act aggressively by the
observation of suffering in their victim. This function is evident when the patient appears to find their
aggressive behavior satisfying and where there is no obvious provocation.
Most of the aforementioned purposes suggest verbal aggression is a consequence of
inappropriate mands. As an example, for demand avoidance , the antecedent is a state of aversive
stimulation (a demand made of the patient for activity such as taking medication), t he consequence is
a reduction in the state of aversive stimulation (i.e. the demand goes away). At the same time, the
aversive state may dissipate (To reduce tension) and other patients may praise the patient (To
enhance status or social approval). Acts of aggression are therefore likely to be multifunctional.
Verbal aggression may, therefore, arise because the patient has an inappropriate repertoire of mands ;
their repertoire of mands is predominantly aggressive and antisocial rather than prosocial and calm,
63
but nevertheless functional for the individual . This problematic behavioral repertoire exists because
the patient’s learning history has supported the acquisition and maintenance of these problematic
mands which discouraged the development and expression of prosocial mands . Similarly, the ward
environment may support aggressive mands, with such verbal behavior affording the speaker
enhanced status and social approval.
Another verbal operant, the tact, is evident in some of the functions that relate to aversive
stimulation aroused by aspects of routine/hospitalization. For example, being forced to congregate
with other patients during mealtimes or being forbidden to leave the unit may lead to a state of
irritation. Regarding the other verbal operants, it is possible to argue that in an environment where
verbal aggression is common, that such behavior is simply echoic. However, it is rare that aggression
within psychiatric units is a simple imitation isolated from other aversive antecedent states. As such
verbally aggressive behavior may be better construed as mands. Similarly, although some aggression
may occur in response to a question or demand (e.g., a demand from a staff to return to their room)
and could be considered as a dysfunctional intraverbal behavior, the aversive stimulation and
anticipated and real consequences of aggression suggest it is better to regard these types of aggressive
responses as mands.
Glenn (1983) notes how rumination may be considered a form of intraverbal behavior.
Originally, Skinner used the term intraverbal to refer to verbal behavior between two individuals.
According to Glenn (1983), intraverbal behavior can also refer to inner speech (one’s own
monologue), which may lead to the rehearsal of aggressive scripts, which often precede aggressive
behavior (Bushman & Anderson, 2001). There is little similarity in the functions of aggressive
behavior incorporated in the ACF with textual verbal behavior or transcription.
Using the ACF, Daffern, Howells and Ogloff (2006) studied the functions of 502 acts of
aggression perpetrated by patients of a secure psychiatric hospital in Melbourne, Australia. Their
findings showed that most acts of aggression were functional, precipitated by identifiable events, and
not simply the result of a spontaneous manifestation of underlying psychopathology. A number of
dynamic interpersonal and contextual factors that contribute to aggression were identified. These
included staff–patient interactions associated with treatment or maintenance of ward regime (Demand
avoidance and To force compliance) that were considered frustrating and/or provocative (To
express anger), or that threatened the status of the patient (To enhance status or social approval).
Subsequent research has shown that the functions for aggression within hospitals may differ from the
functions of aggression in the community and that the functions for aggression in personality
disordered patients may be somewhat different from the functions of aggression for patients with
mental illness (Daffern & Howells, in press). The extent to which this is true means that distinctly
different functional relationships may guide the production of aggressive behavior (verbal or
otherwise) in patients with personality disorder versus mental illness.
Verbal aggression in psychiatric hospitals
Like delusional speech and hallucinatory behavior, verbal aggression may result in
considerable benefits (e.g., avoiding a demand) and/or costs (e.g., seclusion, restraint, restriction in
privileges, physical injury, isolation and rejection) to the individual. Layng and Andronis (1984)
suggest a cost/benefit type analysis can be extended to patterns of behavior not only considered
irrational, but also to those behaviors whose costs are dramatic and immediate (like aggression), and
that may obscure a clinician’s view of any possible benefits. Such an approach seems warranted for
patients whose speech may be incomprehensible or for patients with limited vocabulary who may use
topographically similar verbal behaviors (i.e., they may utter the same expletives) for dissimilar
reasons.
Personal histories of reinforcement and punishment in an environment likely influence the
form of observed aggressive behavior.For instance, in hospitals where there is a history of particular
aggressive acts (e.g. sexual assaults or assaults with particular weapons) then threats to sexually
assault or attack staff with these weapons may predominate because they are effective, generating
more fear and distress in victims than random utterances which may have no history within the
64
institution. Where verbal aggression occurs, the task for staff is to identify the determinants of the
aggressive behavior and to attempt to modify these. According to Skinner (1993) “h ow a person
speaks depends on the practices of the verbal community of which he is a member” (p. 99). Analysis
of verbally aggressive behavior therefore demands investigation into (1) the characteristics of the
environment that are conducive to aggression , and (2) the limitations existing within the individual
that resulted in their needs being expressed in a problematic manner. For instance, an individual who
needs analysis of low severity sexual aggression (e.g. threats to sexually aggress and lewd
suggestions) may indicate that (1) sexual needs exist which are unable to be satisfied in more adaptive
and prosocial ways, (2) that the individual has a sexual preference for aggression, or (3) that the
aggression is more to do with expression of anger, and that this particular threat satisfies the drive for
aggression without exposing the individual to aversive consequences (Daffern et al., 2008). At the
contextual level, frequent sexual aggression, expressed verbally, may suggest consequences to such
acts are negligible, or that other controlling factors are absent (e.g., male staff). Similarly,
interpersonal consequences may be positive; lewd comments may be reinforced by co-patients,
particularly when patients have an antagonistic relationship with staff.
In one of few studies of the functions of verbally aggressive behavior in psychiatric hospitals,
Daffern (2004) revealed the multifunctional nature of verbal aggression. The most common functions
of verbal aggression in this study were to express anger (79.5%), reduce tension (61.1%), force
compliance (44.4%), avoid a demand (36.8%), enhance status or social approval (33.3%), obtain
tangibles (14.6%), narrow social distanc e (attract attention) (8.1%), cause suffering (2.4%), and to
comply with instruction (1.7%). In Skinner’s terminology, then, the most common antecedent of
verbal aggression is a state of aversion/deprivation (to express anger, reduce tension, force
compliance, and avoid a demand). The functions of verbal aggression identified by Daffern were
similar to those of physical aggression (Daffern et al., 2006). However, when compared to physical
aggression, verbal aggression was more common when the purpose was to avoid a demand or to force
compliance following the denial of a request. When the purpose of aggression was to reduce tension
verbal aggression was also more likely. When patients were complying with instruction the
aggression was more likely to be physical. Results also showed that patients were more likely to be
verbally aggressive towards staff and physically aggressive towards other patients. It is likely that
staff are protected from more severe physical aggression because of (1) anticipated consequences to
assaulting staff (e.g., restraint, seclusion, reduced privilege s, prolonged hospitalization), which
patients believe are less certain tha n when they assault patients, or (2) because patients accept that the
demands and limits imposed by staff are routine aspects of care. The provocation although frustrating
may not generate fear and excessive anger; physical aggression may not be justified.
Verbal aggression as a warning
One question often asked is whether verbal aggression, particularly threats, is a prelude to
physical aggression, or whether the threat is adequate or satisfactory to obtain the desired outcome.
Recent research (Ogloff & Daffern, 2006) on the prediction of imminent aggression suggests verbal
aggression is a common antecedent to physical aggression. Two instruments used to assist psychiatric
nurses to appraise risk for imminent physical aggression , the Broset Violence Checklist (BVC)
(Almvik, Woods & Rasmussen, 2000) and the Dynamic Appraisal of Situational Aggression (DASA )
(Ogloff & Daffern, 2006); both incorporate a measure of verbal aggression. It is less clear whether
verbal aggression directed towards a particular individual is a prelude to an attack against that person,
or whether it is indicative of a generalized increase in risk to others.
Threats, specifically threats to kill, are a particular form of aggressive behavior, which in
many jurisdictions such as Victoria, Australia, constitutes criminal behavior carrying a prison
sentence. Some (e.g. Calhoun, 1998) have suggested threateners may be differentiated into those who
‘howl’ and those who ‘hunt.’ In this typology, some individuals who threaten presumably intend
violence (the hunters) and do not find the harm caused by the actual threat to be satisfactory, while
others merely want to threaten to draw attention to themselves (howlers) and find this verbal
aggression satisfactory. Those who ‘howl’ may well simply be verbally aggressive to avoid an
aversive state (such as anger), they are just ‘sounding off,” whereas those who go on to physically
65
aggress (‘hunters’) might be using their verbal aggression to communicate some sort of request
(mand). When this request is not understood or not met, they may then become physically aggressive.
Glenn (1983) makes the point that inappropriate tacting in clients can often lead to feelings, needs etc.
not being communicated effectively. The same point applies to aggression; an inability to label the
behaviors of oneself and others (inappropriate tacting) makes it very difficult for someone to
communicate in a clear way. So if patients can’t communicate their problems and desires clearly they
are likely to feel frustrated and may then escalate from verbal to physical aggression.
According to Warren, Mullen, Thomas, Ogloff, and Burgess (2007) the evidence that may be
drawn upon to assist discrimination of those who eventually act from those whose who do not, is
limited. In a data linkage study Warren et al. (2007) examined subsequent criminal convictions in 613
individuals convicted of threats to kill. Within 10 years, 44% of their cohort had been convicted of
further violent offending. The original threat victim was subsequently a victim in 85 (13.9%)
instances. Five of the original victims were eventually killed by the threatener, and for three others the
threatener was later convicted of attempting to murder them. Subjects also reoffended against the
threat victim by assaults (n=50), rapes (n=3), stalking (n=11), and further death threats (n=10).
Conclusion
Verbal aggression by psychiatric patients is multiply determined and multifunctional. Most
commonly, verbal aggression , particularly towards staff, occurs consequent to demands for activity,
or when requests are denied. As patients are typically angry when verbally aggressive, it is likely that
these acts are not predatory. Psychiatric illness impairs the ability of many patients to manage the
anger that is aroused by the demands and expectations of involuntary treatment. Forums allowing
prosocial expression of discontent, access to staff who can support and encourage appropriate conflict
resolution, and adoption of limit setting styles by staff that do not activate anger (Lancee, Gallop, &
McCaye-Toner, 1995) are critical. Effective treatments of characteristics within patients that
contribute to their inability to manage the demands of the psychiatric hospital without recourse to
aggression are also required. This includes attempts to modify established contingencies assoc iated
with interpersonal aggression. Psychiatric hospitals should carefully monitor aggressive behavior and
compare their experiences with other hospitals. Only when patterns of aggression are compared can
the determinants of aggression be elucidated and effective controlling variables introduced.
Finally, although several verbal operants identified by Skinner (1957) seem relevant to verbal
aggression in psychiatric hospitals there are several operants that are not immediately relevant.
Further, the most relevant operants, mands and tacts, may be inadequately sensitive to the functions of
aggression, when compared with more novel classifications systems such as that developed by
Daffern and colleagues (2006). However Skinner’s work on verbal behavior (1957) may have
implications for other components of patient behavior and response to treatment within psychiatric
hospitals, for example, the treatment of aggressive behavior. Verbal ability is an important component
of treatment readiness. Without the ability to make requests (mands) or engage in coherent
conversation individuals are unlikely to develop prosocial assertiveness skills. Instead, they may rely
on violent and coercive acts to meet their needs. Similarly, a key part of therapy is disclosing feelings
and emotion. Without the ability to label these emotions, thoughts and feelings (tacts), therapy will
necessarily become very difficult. It may be that verbal assessment guided by Skinner’s terminology
could function to effectively identify behavioral readiness for treatment (i.e. patients with a sufficient
grasp of mands, tacts and intraverbals). This would work in much the same way that children and
adults with communication difficulties are assessed using this methodology.
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Author Information
Michael Daffern
Centre for Forensic Behavioral Science
c/o Thomas Embling Hospital,
Locked Bag 10, Fairfield, Victoria 3078
Australia
Tel +61 394959160
Fax +61 394959195
Email [email protected]
Affiliations
Centre for Forensic Behavioral Science
School of Psychology, Psychiatry and Psychological Medicine
Monash University Clayton
Melbourne, 3800, Australia,
Victorian Institute of Forens ic Mental Health (Forensicare),
Locked Bag 10,
Fairfield, Victoria, 3078
Australia
Peaks Academic and Research Unit
Rampton Hospital,
Retford, Nottinghamshire, DN220PD
United Kingdom
Division of Psychiatry,
Forensic Mental Health Section
Nottingham University, Nottingham, NG3 6AA
United Kingdom
Matthew Tonkin
Peaks Academic and Research Unit
Rampton Hospital
Retford, Nottinghamshire, DN220PD
United Kingdom,
69
Evaluation of Two Communicative Response Modalities
for a Child with Autism and Self-Injury
Stacy E. Danov, Ellie Hartman, Jennifer J. McComas, and Frank J. Symons
Abstract
There is little empirically replicated guidance from the research literature on selecting a
communicative response modality when implementing functional communication training (FCT). In this
study, two forms of communicative responding (verbal speech and picture cards) were evaluated during
functional communication training (FCT) treatment of self-injury for a three-year-old boy with autism. The
functional analysis indicated the self-injury was maintained by positive reinforcement in the form of access
to preferred items. Findings indicated (a) SIB was eliminated during FCT sessions, and (b) independent
picture cards (but not verbal speech) were used in all evaluation sessions. Results are discussed in relation
to the clinical issue of choosing among different possible communication response modalities to effectively
compete with severe problem behavior.
Keywords: Communication response, Self-Injurious Behavior, Functional communication training, mand
selection
Introduction
Severe problem behavior among children with pervasive developmental disorders including
autism is relatively prevalent (Horner, Carr, Strain, Todd & Reed, 2002) and costly both to the individual
and society (Schroeder, Rojahn, & Oldenquist, 1989). Severe forms of behavior problems such as selfinjurious behavior (SIB) or aggression can hinder communicative development and limit verbal and
nonverbal communication capacity (National Research Council, 2001).
Behavioral interventions based on the function of the problem behavior have been successfully
applied to children with pervasive developmental disorders for a range of problem behaviors including
SIB (Carr & Durand, 1985) and aggression (Richman, Wacker, & Winborn, 2001). Identifying a
functional relation through analyses designed to expose reinforcement contingencies before treatment
increases the likelihood of developing a targeted function-matched intervention to decrease problem
behavior and increase adaptive behavior. It is important to identify a behavioral function prior to
treatment selection for severe behavioral problems because interventions based on behavioral function are
more likely to be effective than arbitrarily chosen interventions (Carr & Durand, 1985; Repp, Felce, &
Barton, 1988; Wacker et al., 1998; Wacker et al., 2005).
Among behavioral interventions, functional communication train ing (FCT) consists of teaching
communicative responses such as words, gestures, or signs that are used to effectively compete with
problem behavior by producing the same functional reinforcer (Carr, 1988; Wacker et al., 1996). Carr and
Durand (1985) demonstrated the power of such an approach with children (N = 4) diagnosed with autism
by developing a functional assessment tool to identify environmental conditions in which problem
behaviors such as aggression, self-injury, and tantrums occurred. The results of the functional assessment
were used to define and teach an appropriate replacement behavior with corresponding reductions
reported in problem behavior. Wacker et al. have demonstrated consistently (e.g., 1998, 2005) that FCT is
highly effective in reducing problem behavior displayed by individuals with developmental disabilities
including autism.
Less clear, however, is empirical guidance on selecting the type or form of communicative
response to be used during FCT when more than one form (e.g., verbal, gestural) concurrently exists in
70
the child’s repertoire. Recently, Ringdahl et al. (2008) compared two mand topographies (high and low
proficiency) during FCT and concluded that FCT was more effective when the high proficiency mand
was incorporated into FCT. There are only a limited number of studies, however, explicitly examining
the effects of alternative modes of communication on verbal communication in autism and related
pervasive developmental disorders. Bondy and Frost (1998) reported that alternative modes of
communication do not prohibit the acquisition of verbal behavior, but may actually promote it. They
demonstrated that a boy who began training with picture cards began speaking after using the system for
11 months. Eighteen months later his speech replaced the cards as his mode of communication. More
recently, Charlop-Christy, Carpenter, Le, LeBlanc, and Kellet (2002) reported an increase in spontaneous
and imitative speech following the implementation of picture cards. Further, Ganz and Simpson (2004)
found that picture card use was mastered rapidly and word utterances increased in number of words and
complexity.
The use of an alternative mode of communication in the form of a mand or request for a
functional reinforcer, can also lead to a decrease in problem behavior. Frea, Arnold, and Vittimberga
(2001) reported that the problem behavior of a four-year-old boy with autism decreased when he started
using the Picture Exchange Communication System. Winborn et al. (2002) showed for two subjects that
both existing and novel requests were effective replacements for problem behavior using a concurrentschedules design, without a reversal or extinction phase. Horner and Day (1991) and Richman, Wacker,
and Winborn (2001) demonstrated that when replacing a problem behavior with a request during FCT,
response efficiency is important. Problem behavior and requests can be viewed as concurrently available
response options, with the goal being to promote the use of the request rather than problem behavior to
access reinforcement.
In this single -case study, two communicative response forms (speech, picture cards) were
compared during ongoing FCT in which a child with autism was being taught to appropriately request
toys and related materials to compete with SIB. Reinforcers and response forms were selected following a
functional analysis. Comparisons of the occurrence of SIB and requests were made across both
communicative forms using a within-subject ABAB design.
Method
Participant
John was a 3 year 2 day old boy diagnosed with autism. John was previously diagnosed with
autism by a licensed psychologist based in the DSM-IV-TR. He received home-based services consisting
of Applied Behavior Analysis (ABA) therapy to develop communicative, social, educational, and
behavioral skills. Reportedly, these services included using a discrete trial method based on individual
treatment goals focusing on spoken communication. He participated in approximately 20-30 hours per
week consisting of both individual and family skill sessions. The program selection and target goals were
determined by parents and trained behavioral professionals. He also attended a pre-school program three
days a week. The pre-school or school based program consisted of functional skills and speech and
language goals. The frequency (daily/weekly) and intensity of John’s self-injury lead to tissue damage
and bruising. Forms of self-injury specifically included hitting the front and back of his head to the floor,
biting and scratching his forearm, and hitting his forearm to an object. John had limited communication
skills. Expressively, he could verbalize single words when prompted, but his articulation was poor and his
speech was often difficult to understand. Receptively, he could follow short, one-step directions. At the
time of the investigation, he was being introduced to a picture exchange system as part of his school
communication program, which was introduced by the teacher and speech practitioner and verbal
communication was introduced as part of his home-based behavior therapy program by the behavior
therapist.
71
Procedures
Phase 1: Functional Analysis
General procedure. First, a functional analysis interview (adapted from O’Neil et al., 1997) was
conducted with John’s mother and home-based therapist by a graduate research assistant to collect
information about the environmental and social events influencing problem behavior. Next, direct
observation of the target problem behavior was conducted to clarify and validate the interview findin gs
and gather further information regarding the target problem behavior and the social context in which it
occurred. Finally, an experimental (i.e., functional) analysis was conducted at home in John’s therapy
room. His mother was coached by a trained graduate research assistant to conduct the functional analysis
sessions. Materials used during the functional analysis included puzzles, books, animal toys, a ball, and
cards with graphic symbols (cards were used in tasks involving matching 2-D pictures to 3-D items).
The functional analysis used a brief multi-element design to evaluate the influence of social
reinforcement contingencies on John’s SIB (Northup et al., 1991). Based on the outcome of the
descriptive assessment, two behavioral mechanisms (positive and negative social reinforcement) were
tested through three conditions including contingent attention, contingent access to tangibles, and
contingent escape from task demand. A control condition in the form of free play was also conducted.
During the attention condition, John’s mother sat on the sofa and read a book while John played alone.
Approximately 10 s of attention in the form of touching his arm and saying, “Keep your hands down,”
was delivered contingent on each occurrence of SIB. During the tangible condition, John had continuous
access to his mother’s attention, but access to prefer play items/toys was restricted. Contingent on each
occurrence of SIB, John’s mother provided him with 10 s access to the preferred toys. During the escape
condition, John’s mother directed him to complete tasks consistent with his ABA therapy program, such
as matching items, receptive labeling, puzzles and imitation. Contingent on each occurrence of SIB, the
task was removed for 10 s. After 10 s, the task demand was re-presented. During the free play condition
John had access to preferred toys and his mother’s attention, and no task demands were delivered. All
sessions were 5 min in length and were videotaped.
Dependent measure. Self-injury directed to John’s head was selected as the primary dependent
variable based on physician and family concerns. Any instance of hitting the front and back of his head to
the floor or wall was recorded (event-count) during the 5-minute session.
Inter-Observer agreement. Twenty-seven percent of the sessions were coded by an independent
second observer. Inter-observer agreement (IOA) was calculated by comparing the frequency of the
recorded behavior by one observer with that of the second independent observer for the 5-minute session.
Percent total agreement was determined by taking the smaller rating and dividing it by the larger rating
and the results are multiplying by 100 (Primavera, Allison, & Alfonso, 1997). The mean IOA for SIB was
100%.
Phase 2: Preference Assessment
Procedure. Following the functional analysis, a variation of a multiple stimulus preference
assessment with replacement was conducted by a graduate research assistant (Windser et al., 1994) to
identify highly preferred play items for use during functional communication training and to verify the
items were items he elected to play with. Items he liked to play with were drawn from the same pool of
items used in the functional analysis. Items were placed in groups on the table, bookshelves, and on the
floor in the room. John was allowed to wander about the room and pick up item. After he selected a toy
he was allowed to play with it for as long as he wanted to. At the point in which John was done playing
with the toy and he dropped the toy from his hands, the toy was removed, placed back into the items on
72
the table, bookshelf or floor and the procedure began again. Three sessions were conducted, each lasted
approximately 10 min.
Dependent measure. The dependent measure for the multiple stimulus preference assessment with
replacement was the duration (seconds) of engagement for each toy for John.
Phase 3: Functional Communication Treatment (FCT)
General procedure. Based on the results of the functional analysis (see below) that suggested
John’s SIB was reinforced by access to preferred toys, FCT was implemented to teach a communication
response as an alternative to SIB (Carr & Durand, 1985). A graduate research assistant taught John to
request, both verbally and with picture cards, for preferred toys and items. An ABAB reversal design was
used to show the effects of FCT between the two communicative response forms. Session length ranged
from 10 to 20 min. At the end of each session, John received a 5-min break with no access to the items
used during the request training. The treatment sessions were conducted in John’s therapy room at a small
picnic table. Items identified in the preference assessment as being highly preferred (i.e., the most number
of seconds engaged with) were used in the treatment sessions to increase the likelihood that John would
request the items.
Verbal request sessions. The request procedures from Hartman and Klatt (2005) were used. The
experimenter sat across the table from John and presented a single item in a counterbalanced order in
front of John. The experiment asked, “What do you want?” A 3 s prompt delay procedure was used to
transfer stimulus control from the experimenter’s prompt to the presence of the item. In the first trial the
experimenter provided an immediate prompt, “(name of item).” After the first trial the verbal prompt was
delayed 3 s followed by a prompt “(name of item).” If John gave a correct response (with or without a
prompt) John received both verbal praise (e.g., “Good job, you want the (name of the item”) and access to
the item for 10 s. If John made an error during a trial or did not respond before the prompt for two
consecutive trials, that item was terminated for that trial. In the next trial the experimenter again waited 3
s before giving a prompt. If John responded before or after the question, the response was recorded as an
independent correct request. Five consecutive trials for each item were presented in each session. If John
turned away from the toy or asked for a different item after the experimenter asked, “What do you want?”
the experimenter stopped the trial. If two consecutive trials were stopped, the trials for that item were
ended for that session.
Dependent measure. The dependent variable in verbal requesting training was the frequency of
independent verbal requests. An independent verbal request was defined as John verbally requesting the
item presented by the experimenter (without prompts).
Picture card request sessions. The research assistant sat across the table from John and presented
him a picture card board. First, only one picture was presented on the picture board, so that the verbal and
picture card procedure would be the same. John requested independently almost immediately, so another
card was added to the board. He demonstrated that he could discriminate between the cards, so more
cards were added until the picture board was full. The board consisted of pictures of items identified as
highly preferred from the preference assessment and other items requested by his mom (e.g., milk).
Graphic symbols/icons from Microsoft Clipart of the preferred items were placed on 2 inch by 2 inch note
cards that were attached with Velcro onto an 8 by 11 inch pieces cardboard. The cardboard held a total of
12 picture cards. The experimenter asked John, “What do you want?” and placed her hand out for John to
place a card into. A 3 s prompt delay procedure was used. In the first trial the experimenter provided an
immediate prompt and used hand over hand prompting to have John choose a picture card and place it in
the experimenter’s hand. After the first trial the physical prompt was delayed 3 s and a verbal prompt was
given, (“What do you want?”). If John gave the correct response (with or without a prompt) he received
both verbal praise (“Oh you want the (name of the item), good job!”) and access to the item for 10 s. John
73
was able to request any item he asked for, even if it was the same item for the entire time of the session.
If SIB occurred during FCT, it was not reinforced. If John verbally requested an item, he was prompted to
use the card and then reinforce his behavior, but John did not have any verbal requests during the picture
card request sessions.
Dependent measure. The dependent variable for the FCT picture card intervention was the
frequency of independent correct picture card requests. An independent correct request was defined as
John pulling a picture off of the picture communication board and handing it to someone else without
prompts (event-count).
Extinction of pictu re card. The procedures for this condition were the same as the FCT picture
card intervention with a key exception. If John requested with the picture card, he was praised (e.g., “That
was a nice way to ask.”) but was not given access to the item (i.e., their use did not produce access to a
requested item). John could only receive access to the preferred item if he verbally requested (e.g. said,
“Milk”).
Inter-Observer agreement for FCT. Twenty-two percent of the sessions were coded by a second
independent observer. IOA was calculated by comparing the frequency of the recorded behavior by one
observer with that of the second independent observer for the 5-minute session. Percent total agreement
was determined by taking the smaller rating and dividing it by the larger rating and the results are
multiplying by 100. The mean IOA for SIB was 100%. The mean IOA for independent requests was
91.5% (Range = 83% -100%).
Treatment integrity. Treatment integrity was calculated for 28% of the treatment sessions
randomly selected across all conditions. Treatment integrity was calculated for as a percentage of requests
that were followed by access to the tangibles requested. Treatment integrity was 100%.
Results
Phase 1: Brief Functional Analysis
The results of the functional analysis can be seen in Figure 1. The data indicate a differential
pattern of SIB responding with elevation during conditions associated with positive reinforcement in the
form of contingent access to tangibles (i.e., toys). SIB occurred 10 times during both tangible conditions.
SIB either did not occur or occurred at very low frequencies in the other conditions (attention, demand,
and control).
Phase 2: Preference Assessment
Results of the preference assessment showed that the duration of engagement with the toys
ranged widely and included in descending order: toy sheep (543 s), toy horse (262 s), toy car (159 s),
beads (63 s), blocks (60 s), toy chicken (38 s), and toy bus (5 s). Following maternal request, milk was
also included as a preferred item accessible during FCT.
Phase 3: Functional Communication Treatment
Results of treatment are shown in Figure 2. When picture cards were available (condition 2,
sessions 3-6; condition 4, sessions 9-11; condition 6, sessions 14-15; condition 8, session 18), John
independently requested using pictures (approximately 1.5 times per minute). During verbal conditions, a
single independent verbal response was made in session 7 and not again in verbal conditions. Following
the initial ABABAB evaluation, pictures were put on extinction in sessions 16 and 17. In the picture
extinction condition use of pictures did not produce access to a requested item. No corresponding
74
‘crossover’ to verbal requesting was observed. During FCT, SIB was observed only during the first verbal
FCT condition.
Figure 1. Frequency of self-injurious behavior (SIB) during functional analysis conditions.
Discussion
Severe problem behavior among children with developmental disorders including autism can
interfere with communicative development. Identifying the function of the problem behavior can lead to
appropriate function-matched targeted interventions that are often communication based. When the child
has two or more possible communicative response modalities already in his or her repertoire, no clear
guidelines exist for practitioners or parents to choose among them. In this single -case demonstration, two
existing communication modalities were directly compared following a functional analysis of self-injury.
Overall, the results showed clearly the effectiveness of a picture versus a vocal (i.e., verbal) response
modality for this child to request preferred items that competed with and functionally replaced self-injury.
Although SIB did not occur after the initial verbal condition, verbal sessions were not associated with any
independent requests.
75
£ = independent requests
¢ = SIB (self-injurious behavior)
Note: All independent requests were picture requests; none were verbal.
During sessions 16 and 17, picture cards were placed on extinction but
responding continued to occur exclusively in the form of picture
requesting.
Figure 2. Frequency per minute of independent requests and SIB during FCT intervention
(verbal and picture requesting training) and extinction trials of picture card.
Because the participant was a clinical referral not selected randomly the results are necessarily
limited and are not generalizable to other children his age with autism and SIB or communication
difficulties. Because SIB was only observed during the first session, it is impossible to infer that one
modality was superior to his SIB. If access to picture cards was removed for longer periods of time, SIB
may have reoccurred. It would be predicted that problem behavior would be more likely to occur if a
child is required to use a mode of communication that he/she cannot use independently, consistent with
Ringdahl et al.’s (2008) recent demonstration. Anecdotally, John appeared more engaged and attentive
during picture sessions when compared to verbal sessions. The overall time scale (and therefore the
intensity) of the intervention was limited. Past research has reported that over longer intervention periods
the acquisition of verbal language may appear during picture card training (Bondy & Frost, 1998;
Charlop-Christy et al., 2002).
In addition to response efficiency and reinforcement, another possible reason for the clear
differentiation between the picture and verbal communication response options could be related to the
structural differences between the instruction sessions themselves that made them nonequivalent. Because
the picture board contained many pictures and John could discriminate between the pictures, he was able
to select from the full array of cards associated with any toy he may have wanted at the moment.
Although, in principle, he could verbally ask for any toy during the verbal request training session, he
never made an independent verbal request. Because of this, we ‘rotated’ through possible preferred toys
during verbal instruction sessions , but it remains possible that we were prompting him to request toys that
he did not want at the moment. For this reason, we created an extinction condition. Sessions during the
76
extinction condition allowed John to choose the toy he wanted from the full pic ture array in which he
could see the pictures but was required to use a verbal request for a toy. However, no independent verbal
requests occurred during the extinction condition sessions either.
In related areas of clinical research, studies examining picture communication found the picture
exchange communication system (PECS) to be effective for teaching functional communication to
children with limited speech (Bondy and Frost, 2001; Charlop-Christy, Carpenter, Le, LeBlanc, and
Kellet, 2002; Ganz and Simpson, 2004), while studies examining manual signs or total communication
found faster receptive and/or expressive vocabulary acquisition than speech alone (Brady & Smouse,
1978; Barrera, Lobato-Barrera, & Sulzer-Azaroff, 1980). Durand (1999) found assistive devices to be
effective for communication in recruiting natural communities of reinforcement. Although the present
study was not designed to demonstrate the acquisition of different communication modalities per se, the
results suggest that picture based requests were more likely to occur and produce a functional reinforcer
than verbally based requests at this time for this young boy with autism. Similar to the results reported
here, Frea, Arnold and Vittimberga (2001) found that problem behavior was decreased when picture were
introduced as a mode of communication for a four year old boy with autism. Winborn et al. (2002)
showed that training both novel requests and existing requests can be effective for replacing problem
behavior. Additionally, Horner and Day (1991) and Richmand, Wacker, and Winborn (2001)
demonstrated that response efficiency is important when replacing a problem behavior with a request
during FCT. In this study, it may be that picture cards were a more efficient alternative thereby reducing
problem behavior.
The applied behavioral literature on FCT and behavioral problems shows clearly the importance
of teaching a replacement behavior (Carr & Durrand, 1985; Wacker et al., 1998). One of the most
effective routes for determining what function the replacement behavior should serve is based on
conducting a functional analysis prior to beginning intervention (Durand, 1999; Horner et al., 2002). But,
determining what form the replacement behavior might take in relation to gains in adaptive behavior and
reductions in problem behavior remains a relatively unexplored clinical area in need of further research.
References
Barrera, R., Lobato-Barrera, D., & Sulzer-Azaroff, B. (1980). A simultaneous treatment comparison of
three expressive language training programs with a mute autistic child. Journal of Autism and
Developmental Disorders, 10, 21-37.
Bondy, A., & Frost, L. (1998). The Picture Exchange Communication System. Seminars in Speech and
Language, 19, 373-389.
Bondy, A., & Frost, L. (2001). The Picture Exchange Communication System. Behavior Modification,
25, 725-744.
Brady, D. O., & Smouse., A.D. (1978). A simultaneous comparison of three methods for language
training with an autistic child: an experimental single case analysis. Journal ofAutism and
Childhood Schizophrenia, 8, 271-279.
Carr, E. G., & Durand, V. M. (1985). Reducing behavior problems through functional communication
training. Journal of Applied Behavior Analysis, 18, 111-126.
Charlop-Christy, M. H., Carpenter, M., Le, L., LeBlanc, & Kellet, K. (2002). Using the Picture Exchange
Communication System (PECS) with children with autism: Assessment of PECS acquisition,
speech, social-communicative behavior, and problem behavior. Journal of Applied Behavior
Analysis, 35, 213-231.
77
Durand, V. M. (1999). Functional communication training using assistive devices: recruiting natural
communities of reinforcement. Journal of Applied Behavior Analysis, 32, 247-267.
Frea, W. D., Arnold, C. L., & Vittimberga, G. L. (2001) A demonstration of the effects of augmentative
communication on the extreme aggressive behavior of a child with autism within an integrated
preschool setting. Journal of Positive Behavioral Interventions, 3, 194-198.
Ganz J. B., & Simpson, R. L. (2004). Effects on communicative requesting and speech development of
the picture exchange communication system in children with characteristics of autism. Journal of
Autism and Developmental Disorders, 34, 395-409.
Hartman, E. C. & Klatt, K. P. (2005). The effects of deprivation, precession exposure, and preferences on
teaching manding to children with autism. The Analysis of Verbal Behavior, 21, 135-144.
Horner, R. H., Carr, E. G., Strain, P. S., Todd, A. W., & Reed, H. K. (2002). Problem behavior
interventions for young children with autism: A research synthesis. Journal of Autism and
Developmental Disorders, 32, 423-446.
Horner, R. H., & Day, H. M. (1991). The effects of response efficiency on functionally
competing behaviors. Journal of Applied Behavior Analysis, 24, 719- 732.
equivalent
Iwata, B. A., Dorsey, M. F., Slifer, K. J., Bauman, K. E., & Richman, C. S. (1994).
Toward a functional analysis of self-injury. Journal of Applied Behavior Analysis, 27, 197-209.
(Reprinted from Analysis and Intervention in Developmental Disabilities, 2, 3-20).
National Research Council. (2001). Educating Children with Autism. Washington, DC: National
Academy Press.
Northup, J., Wacker, D., Sasso, G., Steege, M,, Cigrand, K., Cook, J., & DeRaad ,A. (1991). A brief
functional analysis of aggressive and alternative behavior in an outclinic setting. Journal of
Applied Behavior Analysis, 24, 509-522.
O’Neil, R.E., Horner, R.H., Albin, R.W., Sprague, J.R., Storey, K., & Newton, J.S. (1997). Functional
assessment and program development for problems behavior: A practical handbook. Pacific
Grove, CA: Brooks/Cole Publishing Company.
Primavera, L. H., Allison, D. B., & Alfonso, V. C. (1997). Measurement of dependent variables. In R. D.
Franklin, D. B. Allison, & B. S. Gorman (Eds.), Design and analys is of single-case research (pp.
41- 91). Mahwah, NJ: Erlbaum.
Repp, A., Felce, D., & Barton, L. (1988). Basing the treatment of stereotypic and self-injurious behaviors
on hypotheses of their causes. Journal of Applied Behavior Analysis, 21, 281-289.
Richman, D., Wacker, D., & Windborn, L. (2001). Response efficiency during functional communication
training: effects of effort on response allocation. Journal of Applied Behavior Analysis, 34, 73-76.
Ringdahl, J.E., Falcomata, T.S., Christensen, T.J., Bass-Ringdahl, S.M., Lentz, A., Dutt, A., & SchuhClaus, J. (2008). Evaluation of pre-treatment assessment to select mand topographies for
functional communication training. Research in Developmental Disabilities.
Schroeder, S. R., Rojahn, J., & Oldenquist, A. (1989). Treatment of destructive behaviors among people
with mental retardation and developmental disabilities: overview of the problem. NIH Consensus
Development Conference. Bethesda, Maryland.
Wacker, D. P., Berg, W. K., Harding, J. W., Barretto, A., Rankin, B., & Ganzer, J. (2005).
78
Treatment effectiveness, stimulus generalization, and acceptability to parents of functional
communication training. Educational Psychology, 25, 233-256
Wacker, D. P., Berg, W. K., Harding, J. W., Derby, K .M., Asmus, J. M., & Healy, A. (1998). Evaluation
and long-term treatment of aberrant behavior displayed by young children with disabilities.
Journal of Developmental & Behavioral Pediatrics, 19, 260-266.
Winborn, L., Wacker, D. P., Richmand, D. M., Amus, J., & Geier, D. (2002). Assessment of mand
selection for functional communication training packages. Journal of Applied Behavior Analysis,
35, 295-298.
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methods. Research in Developmental Disabilities, 15, 439–455.
Acknowledgements
This research was supported, in part, by NICHD Grant No. 44763 to the University of Minnesota. The authors
gratefully acknowledge the cooperation of the family and their support in completing this project.
Author Contact Information
Stacy E. Danov
Department of Educational Psychology
Education Science Building
56 River Road
University of Minnesota
Minneapolis, MN 55455
USA
e-mail: [email protected]
Phone: (612) 624-5241
Jennifer McComas
Department of Educational Psychology
Education Science Building
56 River Road
University of Minnesota
Minneapolis, MN 55455
USA
e-mail: [email protected]
Phone : ( 612) 624-5854
Ellie Hartman
U. of Wisconsin-Stout Vocational Rehab. Institute
Pathways to Independence Projects
Wisconsin Department of Health and Family
Services
1 W Wilson St
Madison, WI 53703-3445
USA
e-mail: [email protected]
Phone: (608) 266-2756
Frank J. Symons
Department of Educational Psychology
Education Science Building
56 River Road
University of Minnesota
Minneapolis, MN 55455
USA
e-mail: [email protected]
Phone: (612) 626-8697
79
Using DRO, Behavioral Momentum, and Self-Regulation to
Reduce Scripting by an Adolescent with Autism
Vanessa Ann Silla-Zaleski and Mary J. Vesloski
Abstract
This case study report describes the use of behavioral momentum, differential reinforcement of
other behavior (DRO), and self-regulation to decrease vocal scripting behavior produced by a 12-year-old
male with autism, obsessive compulsive disorder, and attention deficit hyperactivity disorder. The behavior
was documented using partial interval time sampling throughout the day on 67 school days over a 4-month
period. DRO was delivered on a graduated fixed interval schedule. During the self management phase of
the program, a MotivAider® was used by the participant to monitor the beginning and end of each interval.
A dependent paired samples t-test was used to compare initial and final rates of scripting. Results showed a
decrease from an average of 44% to an average of 29%. The implications and limitations of this study are
discussed.
Keywords : autism, self stimulatory behavior, vocal scripting, differential reinforcement, self regulation,
behavioral momentum, MotivAider, fixed interval, DRO
Review of the Literature
Self -Stimulatory Behavior
Considerable impairments in both social and communicative behavior affect most individuals
with autism (Rutter & Schopler, 1978). For example, research indicates that during vocal exchanges and
in social settings, these individuals often produce forms of verbal behavior that significantly differ from
the speech produced by individuals without autism (Fine, Bartolucci, & Szatmari, 1994). This verbal
behavior is often categorized as self-stimulatory or stereotyped behavior, and it consists of recurring
physical movements or vocalizations that serve no obvious function in the external environment (Harris &
Wolchik, 1979). When high rates of delayed echolalia (Fine et al.), also known as scripting, occur in
conjunction with low rates of appropriate conversational skills, the social relational opportunities for
persons with autism may be greatly reduced (Ross, 2002). Additionally, self-stimulation may interfere
with learning or performance (Koegel and Covert, 1972).
Since self-stimulation can be potentially harmful to the student as a learner and to the individual
as a peer, a number of studies have investigated procedures that could decrease this behavior. Laws,
Brown, Epstein, and Hocking (1971) decreased self-stimulatory behavior by directing a teacher to remove
attention when his students self-stimulated and to reinforce suitable behavior when they attended. Azrin,
Kaplan, and Foxx (1973) reduced self-stimulation in nine individuals with mental retardation by
instructing them on the suitable use of vocational and recreational materials. The present study adds to
this literature by demonstrating a decrease in the production of self-stimulatory behavior of vocal
scripting by an adolescent male with autism, obsessive compulsive disorder, and attention deficit
hyperactivity disorder through the use of differential reinforcement, self-regulation and behavioral
momentum.
Differential Reinforcement of Other Behavior (DRO)
All forms of differential reinforcement entail “reinforcing one response class and withholding
reinforcement for another response class” (Cooper, Heron, Heward, 2007, p. 470). One of the most
frequently used types of differential reinforcement is the differential reinforcement of other behavior
(DRO) (Wolery, Bailey, & Sugai, 1988). DRO schedules reverse a contingency by delivering reinforcers
based on the absence of a target behavior (Baer, Peterson, & Sherman, 1967). This type of reinforcement
80
delivery is sometimes referred to as omission training since delivery of the reinforcer is contingent upon
the omission of the target behavior (Weiher & Harman, 1975).
DRO is a useful behavior-reduction procedure for several reasons. First, it highlights the use of
positive reinforcement while avoiding the use of aversive stimuli. As a result, many adverse side effects
may be avoided. Secondly, target behaviors tend to reduce rather quickly under conditions of DRO,
especially if a specific replacement behavior is reinforced (Wolery, Bailey & Sugai, 1998). Lastly, DRO
has been shown to be useful in decreasing or eliminating a variety of behavioral excesses, physical
aggression and tantrums (Allen, Gottselig, & Boylan, 1982).
Behavioral Momentum
Generally speaking behavioral momentum involves the use of a series of high-probability
requests to increase compliance with lower-probability, instructor-issued requests. Over time, in order to
increase generalization and maintenance, fading procedures are implemented such that the interval of time
between high probability requests to low probability requests is increased and the ratio of high probability
requests to low probability requests is decreased (Ray, Skinner & Watson, 1999).
Previous research has demonstrated the benefits of behavioral momentum for increasing
compliance with low-probability requests across commands, demands, or requests (Ray, Skinner &
Watson, 1999). It has been used successfully with children with autism and other developmental delays
to increase compliance in various settings. Mace (1988) used behavioral momentum to increase
compliance with low-probability commands when addressed to adults. Since this experiment, other
researchers have demonstrated that antecedent high-probability commands can be used to increase the
likelihood of gaining student compliance with lower probability commands (Ducharme & Worling, 1994;
Rortvedt & Miltenberger, 1994).
Self -Regulation
Self-regulation develops within the first few months of life, when an infant begins to take interest
in the environment while also regulating his or her arousal and responses to sensory input (DeGangi,
1991). As infants develop, they normally demonstrate a growth in more refined self-regulatory
competencies (Gomez & Baird, 2005). However, self-regulation difficulties have been cited as among
the first indicators of autism (Gomez & Baird, 2005). Gomez and Baird’s (2005) research found that
children with autism were reported by their parents to have exhibited significantly more self-regulatory
deficits at 1 year of age than the comparison group.
Self-regulation is an important concept to teach individuals with autism because it can lead to
empowerment and an enhanced quality of life (Suk-Hyang, Simpson, & Shogren, 2007). Positive
outcomes of teaching self-management procedures to individuals with autism have been reported by
several researchers. Newman, Buffington, and Hemmes (1996) demonstrated the benefits of using a selfmanagement strategy to help three adolescents with autism follow an activity schedule and transition
within their included classrooms. Morrison, Kamps, Garcia, and Parker (2001) used self-monitoring
techniques to teach 44 individuals with autism to monitor their social interaction skills when engaged in
game-play with typical peers. Self-management methods have also been used successfully with
preschoolers with autism to increase sharing behavior (Reinecke, Newman, & Meinberg, 1999).
Methodology
Participant
The participant in this case study, herein known as “Zack”, was a 12-year-old male with autism
spectrum disorder, obsessive compulsive disorder, and attention deficit hyperactivity disorder. These
81
diagnoses were established prior to the beginning of this study by an independent evaluator based on
DSM-IV criteria (American Psychiatric Association, 1994). Zack lived in northern New York and
attended a regular elementary school in a typical 5th grade classroom. He was pulled out of his classroom
twice a day for support services in math and reading comprehension. He also received three, 30-minute
speech therapy sessions and two, 30-minute occupational therapy sessions per week. Zack had an
individualized education program (IEP) which included adaptations and modifications for him to be
included in the regular education environment with typical peers. He was instructed according to the
class-wide curriculum with the support of a one-on-one aide throughout the day, five days per week.
Zack was verbal and could answer questions addressed to him. He was considered by the staff to
be an average functioning individual. However, prior to the start of this program, Zack produced scripting
behavior on frequently throughout the day. It consisted of vocalizing words and/or sentences previous ly
heard in videos, TV shows, commercials or video games. This behavior was disruptive in the classroom,
especially when vocalizations were loud. In fact, it placed his continued enrollment in the general
education classroom at risk. It was also disruptive in one-on-one settings (e.g., speech therapy,
occupational therapy) and in remedial services.
One month prior to the initiation of the intervention described in this paper, an attempt was made
to decrease Zack’s scripting in the general education classroom by using a token system with response
cost. However this procedure did not reduce the scripting behavior because reinforcement could not be
provided at the required level of intensity in that environment.
Also at about one month prior to the initiation of this intervention, Zack began engaging in low
frequency aggressive behaviors such as yelling and hitting. This, in combination with continued
scripting, resulted in a modification of his classroom setting. While he continued to be included in the
general education classroom for one third of the school day, he began to receive instruction in a separate
classroom with a resource teacher and an aide for two-thirds of the day. A functional assessment of
Zack’s aggressive behavior was not conducted due to its low frequency of occurrence prior to the
classroom modification and due to its absence once the modification was implemented.
Target Dependent Variable
As indicated above, scripting was the behavior targeted for reduction in this case study. Scripting
was defined, topographically , as vocalizing words and/or sentences previous ly heard in videos, TV
shows, commercials or video games without any apparent social function.
During the week before implementation of the program described below , a Board Certified
Assistant Behavior Analyst (BCABA) and members of the school staff collected five days of baseline
data. These results of this assessment indicated that Zack engaged in scripting behavior , on average, every
five minutes, and sometimes as frequently as every 30 seconds.
Program Design and Implementation
Functional Assessment: As a basis for designing the intervention program, it was necessary to
conduct a functional assessment of Zack’s scripting behavior. This assessment was organized by the
BCABA. Members of the school staff were provided with an operational definition of scripting and with
forms on which to document antecedent-behavior-consequence (ABC) data. Patterns resulting from the
data collection suggested that scripting served two separate functions: (1) socially mediated negative
reinforcement (i.e., avoiding academic tasks) and (2) automatic positive reinforcement (i.e., selfstimulation). These two functions further suggested that Zack’s academic demands may have been too
challenging or him and may have required too much focus on non-preferred subjects or activities.
82
Selection of Antecedent Strategies: Since the functions of scripting appeared to be avoidance and
self-stimulation due to overly-challenging academic tasks and non-preferred environmental activities, it
was hypothesized that scripting could be reduced in part by two related antecedent strategies: (1)
modifying the academic demands through behavioral momentum and (2) enriching Zack’s educational
environment with preferred objects or activities.
Intervention Agents: The behavioral program described in this paper was implemented by all of
Zack’s instructors. His one-on-one aide was present with him throughout the day. This individual
collected the data and provided access to reinforcement. Prior to program implementation, the entire staff
received training from the BCABA in the concepts of reinforcement, behavioral momentum, and selfregulation. Once the program began to be implemented, the BCABA also conducted biweekly treatment
fidelity checks to ensure that program implementation and data collection were being done properly.
Implementation of Antecedent Strategies: Antecedent strategies were implemented while Zack
was in the resource room with his resource room teacher and his one-to-one aid. Academic demands
were modified by interspersing easy and difficult tasks to create behavioral momentum. Further, the
environment was enriched by the availability (upon Zack’s request) of preferred objects. Some of the
objects were provided by Zack’s parents (e.g., race car, Pokemon magazines, Doritos cool ranch chips,
preferred candy, etc.) and others were provided by the school (e.g., a computer software history package
for which Zack had shown preference).
Differential Reinforcement of Other Behavior (DRO): DRO was implemented across the entire
school environment, including lunch and recess.
As indicated above, Zack engaged in scripting behavior an average of once every 5 minutes
during the five days of baseline data collection. Therefore, a 5-minute fixed interval (FI-5) reinforcement
schedule was used initially to compete with the inappropriate behavior. This schedule was extended
when the data indicated a 10% decrease in the number of intervals during which the target behavior was
observed.
The end of a time interval (and beginning of a new one) was signaled by a vibrator
(MotivAider®) worn initially by Zack’s personal aid and later by Zack himself (see Self-Management,
below). If Zack did not engage in the scripting behavior during the specified time interval, he was allowed
access to reinforcement for a 2-minute period. If he engaged in the behavior during the specified interval,
then the clock was reset.
Reinforcers were identified and updated periodically by asking Zack to name his preferences and
by noting his requests when he named them spontaneously. All reasonable requests were honored.
Examples included history learning activities for the computer, magazines, and snacks.
Self-Management: A self management program was implemented when the targeted behavior
had decreased by 30% and when Zack had learned to refrain from scripting for an 8-minute time interval.
At this point, the reinforcement schedule was increased to FR-10, and Zack began wearing the
MotivAider®. It became his responsibility to inform the teaching assistant of when an interval had ended
and when it was time for reinforcement. Additionally, a token program was implemented in which Zack
earned one token for each 10-minute interval in which the behavior did not occur, and when he received
three tokens, he could “cash them in” for reinforcement.
Non-Target Dependent Variables (Laughing, Hand-Flapping)
Zack periodically engaged in inappropriate laughing. When asked about it he said he was
scripting silently in his head and that “[it’s] not scripting if you don’t say it out loud”. To address this, a
behavioral momentum procedure was used in which effortful academic tasks were interspersed within
sequences of effortless tasks such as crossword puzzles and word searches. Reinforcement then became
contingent upon task completion in addition to the absence of scripting behavior.
83
Data Collection Procedures
Zack was observed throughout the day for 67 days across a 4-month period. On each day, his one-on-one
aid used a partial interval strategy to collect data on the total number of intervals during which Zack
demonstrated any amount of scripting (scripting intervals) and the total number of intervals during which
no evidence of scripting was observed (non-scripting intervals). The percentage of scripting intervals was
then determined per day by dividing the total number of scripting intervals with the total number of
scripting plus non-scripting intervals. On days 19 through 67, data were also collected on the percentage
of intervals during which laughing and hand-flapping were observed.
Results
Figure 1 shows Zack’s rate of scripting from day 1 through day 67 across the 4-month period. As
indicated above, each data point represents the percent of intervals per day during which scripting
behavior occurred at any point within the interval. During the first 22 days, observation intervals were
based on an FI-5 schedule. As the program progressed, the intervals expanded to FI-6, FI-8, and finally to
FI-10 during the self-management phase. The trend line shows that scripting continued to decrease until
the last day.
Figure 1. Percent of Scripting Behavior per Day (Partial Interval Time Sample) (Sessions 1-67)
Figure 2 shows the percent of three self-stimulatory behaviors during days 19 through 67 of the
intervention period. The three behaviors included scripting, laughing, and hand-flapping. To be clear,
scripting was the behavior targeted by the intervention in this study. Laughing was addressed through
behavioral momentum, and a hand-flapping was not addressed at all. The rates of laughing and handflapping were tracked to determine whether non-target self-stimulatory behaviors would increase and
become replacement behaviors when the targeted behavior (scripting) decreased. Figure 2 shows that the
laughing and hand-flapping did not increase. Specifically, laughing decreased and hand-flapping
remained the same.
Figure 2. Percent of Three Self-Stimulatory Behavior per Day (Sessions 19-67)
84
A dependent paired samples t-test was run to compare the rate of scripting during the first 10 days
of intervention with the last 10 days. Results are summarized in Table 1. The alpha level for the t-test
was set at .05 and the significance level (p value) obtained was <.001, indicating a significant difference
between initial and final rates of scripting. The mean rate of scripting for first 10 days was 44.15% and
the mean for the last 10 days was 29.30%.
Table 1. Results from the Paired Samples T-Test
Initial Mean
Final Mean
95% Confidence Interval
of the Difference (Lower)
95% Confidence Interval
of the Difference (Upper)
t Value
Significance (2-tailed)
44.1475
29.2951
9.0453
20.6596
5.116
.001
Note : Means for the Initial and final rates of scripting differ at p<.001
in the Tukey honestly significant difference comparison.
Discussion
In this case study DRO, self-regulation, and behavioral momentum were used to decrease the
amount of scripting behavior produced by a single adolescent male with autism, obsessive compulsive
disorder, and attention deficit hyperactivity disorder. A dependent paired samples t-test indicated a
significant difference between the initial and final rates of scripting. Initially, Zack engaged in scripting
during an average of 44% of partial intervals. At the end, he engaged in scripting during an average of
only 29% of the intervals. This was a substantial decrease.
This study extends the existing literature on the use of DRO, behavioral momentum and selfregulation by demonstrating their combined implementation in a school setting during academic activities
and social opportunities. These procedures appeared to be effective in reducing this participant’s
scripting behavior. Moreover, reductions in scripting were usually maintained, even when the length of
fixed intervals increased, resulting in less frequent opportunities for reinforcement.
Although positive results were observed in the data, there are some important limitations to this
study. First, the intervention was based on a functional assessment and not a functional analysis.
However the results of the functional assessment combined with he results of the DRO intervention
support the hypothesis that escape and automatic positive reinforcement (self-stimulatory behavior) were
the maintaining reinforcers for the participants’ scripting behavior.
A second limitation was the case study design, which included only one participant and only one
phase (i.e., intervention). As such, there is no way to determine whether changes in the dependent
variable (scripting) were due to the combined effect of the independent variables (DRO, self-regulation,
behavioral momentum) or whether they were due to maturation over a 4-month period. If changes in
behavior had been demonstrated systematically through another type of single subject design (e.g.,
multiple baseline across participants; multiple baseline across targets), there would have been clearer
evidence that the reducing in scripting was due to the interventions. As it stands, this case study design
does not allow us to rule out the effects of maturation.
Also, the case study was conducted in a school environment which was heavily staffed by an
instructor and one-on-one aide at all times. It may become more difficult to implement similar
procedures in a generalized setting with fewer resources, especially given the resources required to
maintain data collection. This limitation was accounted for in this study through the use of teaching
85
strategies for self-regulation, thereby teaching the participant the data collection process. Continued
research in more applied settings should address issues such as the effectiveness of different schedules of
DRO thinning as well as the application of this program among a broader range of individuals and a
greater number of participants.
Future research should assess the impact of the combined interventions (DRO, behavioral
momentum, self-regulation) using a single subject design with greater control than a case study.
Additionally, future research should examine the use of the combined interventions for decreasing other
types of self-stimulatory target behaviors. For example, it would be interesting to see if the use of these
interventions can reduce the frequency of nonverbal self-stimulatory behaviors such as rocking and hand
flapping.
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Author Contact Information
Vanessa Ann Silla -Zaleski, Ed.D., BCBA
The University of Scranton
Education Department
139 McGurrin Hall
Jefferson Avenue
Scranton, PA 18510
Phone: 570-941-5810
Fax: 570-941-5515
E-Mail: [email protected]
Mary J. Vesloski, MA, BCBA
Autism Behavioral Services, Inc.
620 Wyoming Avenue
West Pittston, PA 18643
Phone: 570-655-1667/570-947-5363
Fax: 570-602-4100
E-Mail: [email protected]
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