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Using the prevent-teach-reinforce method with families of children with autism
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by Kacie Sears.
[Tampa, Fla] :
b University of South Florida,
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Thesis (MA)--University of South Florida, 2010.
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ABSTRACT: This study involved families of young children with autism spectrum disorders to examine the feasibility of implementing an adapted version of the school-based Prevent-Teach-Reinforce (PTR) model. This research included two families who developed and implemented the intervention for their children in collaboration with the researcher. The PTR manual was modified for use in a family context. The PTR intervention was tested using a multiple baseline design across routines. Procedural fidelity was assessed during training and coaching, as well as family implementation fidelity and social validity. To examine the potential efficacy of the adapted PTR intervention, the children's target problem behavior and functionally equivalent alternative behavior were measured using video observation across experimental conditions including a generalization probe. Results indicated that the adapted PTR model is associated with reduction in child problem behavior and increases in alternative behavior. This study expanded the current research on the PTR model and extended its use to a novel setting and population so that a standardized model for positive behavior support implementation can be developed in the family context.
Advisor: Kwang-Sun Cho Blair, Ph.D.
Family Based Behavior Intervention
Functionally Equivalent Alternative
x Child & Family Studies
t USF Electronic Theses and Dissertations.
Using the Prevent-Teach-Reinforce Model With Families of Children With Autism by Kacie M. Sears A Thesis submitted in partial fulfillment of the requirements for the degree of Master of Arts Department of Child and Family Studies College of Behavioral Sciences University of South Florida Major Professor: Kwang-Sun Cho Blair, Ph.D. Kim Crosland, Ph.D. Rose Iovannone, Ph.D. Date of Approval October 20, 2010 Key Words: Problem Behavior, Family Based Behavior Intervention, Functional ly Equivalent Alternative, Generalization, Implementation Fidelity Copyright 2010 Kacie M. Sears
i Table of Contents List of Tables iii List of Figures iv Abstract v Introduction 1 Parental Training Interventions 2 Family Centered Positive Behavior Support 2 Maintenance 5 Generalization 5 Treatment Fidelity 6 Social Validity Measures 7 Prevent Teach Reinforce Model 9 Purpose and PTR Modifications 9 Research Questions 10 Method 11 Participants 11 Setting 12 Measures 13 Family Implementation Fidelity 13 Problem Behavior 13 Replacement Behavior 14 Social Validity Measures 15 Procedural Integrity 16 Data Collection and Inter-Observer Agreement 17 Design 18 PTR Intervention Procedures 18 PTR Initial Meeting 18 Nicky 18 Michael 19 Baseline Data Collection 20 Functional Assessment and Behavior Intervention Planning 20 Nicky 20 Michael 21 Family Training 22 BIP Implementation and Evaluation 22 Follow-up 23 Generalization 23
ii Results 25 Family Implementation Fidelity 25 Child Problem and Replacement Behavior 26 Social Validity 27 Discussion 32 References 37 Appendices 40 Appendix 1: Extra Table 41 Appendix 2: PTR Implementation Fidelity Checklists 43 Appendix 3: PTR Social Validity Self Evaluation 48 Appendix 4: Novel Rater Evaluation Social Validity 50 Appendix 5: PTR Integrity Checklist 51 Appendix 6: PTR Goal Setting Worksheet 52 Appendix 7: Functional Behavior Assessment 53 Appendix 8: PTR Assessment Organizational Table 58 Appendix 9: PTR Interventions Checklist 59 Appendix 10: Intervention Plan 60
iii List of Tables Table 1: Definitions of Target Behaviors 15 Table 2: Mean Percentage of Interobserver Agreement 18 Table 3: Social Validity Questionnaire Results 30 Table 4: Novel Rater Social Validity Pre & Post Intervention 31 Table 5: Summary of Intervention 40
iv List of Figures Figure1: Percentage of family implementation fidelity and percentag e of intervals, percentage of steps completed, and number of bites for Nickys target behaviors across routines and phases 28 Figure2: Percentage of mother implementation fidelity and percentage o f intervals and number of repetitions for Michaels target behaviors across routin es and phases 29
v Abstract This study involved families of young children with autism spectrum disor ders to examine the feasibility of implementing an adapted version of the school -based Prevent-TeachReinforce (PTR) model. This research included two families who developed and implemented the intervention for their children in collaboration with the researc her. The PTR manual was modified for use in a family context. The PTR intervention was tested using a mul tiple baseline design across routines. Procedural fidelity was assessed during train ing and coaching, as well as family implementation fidelity and social validity. To examine the potential efficacy of the adapted PTR intervention, the childrens target problem behavior and functionally equ ivalent alternative behavior were measured using video observation across experimental co nditions including a generalization probe. Results indicated that the adapted PTR model i s associated with reduction in child problem behavior and increases in alternative behavior. Thi s study expanded the current research on the PTR model and extended its use to a novel setting and popula tion so that a standardized model for positive behavior support implementation can be dev eloped in the family context.
Introduction Problem behaviors, which are often exhibited by children with autism, can be a per vasive challenge to family life. With the increasing numbers of children diagnos ed with autism (Rice, 2009), it is becoming imperative to provide services within many areas th at encompass the childs life, especially the area of family functioning where problem behaviors c an cause major impairment to family and child quality of life (Lucyshyn, Albin, Horner, Mann, Mann, & Wadsworth, 2007; Moes, & Frea, 2002). Problem behaviors often develop because of environmental issues, which can result in reinforcement for undesirable behaviors, lack of reinforcement for desirable behaviors, and communication impairment for both the child and parent. These problems can occur when parents do not know how to effectivel y communicate to the child and the child cannot communicate wants or needs to the parent (D unlap, Ester, Langhans, & Fox, 2006; Frea, & Hepburn, 1999). Because children with autism spend the majority of their time in the family setting, it is important to equip par ents as well as extended family members and siblings with the necessary tools to create a de sirable family environment (Meadan, Ostrosky, Zaghlawan, & Yu, 2009). Another important aspect when providing support to children with autism and their families is early intervention. Families can often wait to access intervention concerning problem behavior until the child is older and the problem behavior cannot be controll ed by the parents, instead of seeking intervention that would curb problem behavior at the onset. St udies have shown that giving families the tools for change earlier in the childs life can provide for greater familial success (Bailey et al. 1998). This may be partially due to the fact that once routines and methods of dealing with problem behaviors are established within the parenting repertoire;
2 whether they work or not, it is more difficult to change the parenting behaviors than if early intervention is provided (Bailey et al., 1998). Parent Training Interventions Parent training has emerged over the past 20 years as an important target for interventions regarding children with autism. Parents are recognized as the best int ervention agents because of the amount of time they spend with their child as well as the variety of se ttings they have the chance to teach skills in. Two basic systems have developed for parent tra ining interventions; one is the expert-driven model and the other is the ecological or enabling m odel (Becker-Cottrill, McFarland, & Anderson, 2003; Brookman-Frazee, 2004). The expert driven model is often designed and implemented by someone considered an expert in parent training in a c linic or home setting, with a focus on training the parents how to decrease behaviors. Thi s can include teaching the basics of behavior analysis, such as reinforcement and punishment, in a classroom-type setting, or teaching the parents to implement specific behavioral str ategies that the expert has deemed necessary (Becker-Cotrill, McFarland, & Anderson, 2003). The eco logical, or enabling model generally focuses on familial needs with interventions and servi ces designed to include and support the specific family that the expert is working with, the focus is on collaboration more than provider management. These interventions generally endeavor to enabl e caregivers with the skills necessary to change behaviors on their own without the persistent need f or an intervention specialist (Brookman-Frazee, 2004). Family-Centered Positive Behavior Support Positive Behavior Support (PBS) is considered an ecological model of pa rent training, and is derived from the fundamental concepts of operant learning theories of appl ied behavior analysis (Carr et al., 2002). The goal of the PBS approach is to enable parents, and in some cases teachers and other caregivers, to implement strategies that will re sult in decreases in problem behavior and improved family and child functioning by promoting effective, meani ngful, acceptable, and durable changes in the behavior in the context of family r outines (Dunlap & Fox,
3 1999; Lucyshyn et al., 2007). This is done by collaboration between the professionals and family members to ensure that the values of the family are addressed as wel l as their desired outcomes. Functional assessment is used to comprehend the function of problem behaviors, and a multi-faceted individualized intervention is then incorporated into exi sting family routines (Moes & Frea, 2000). PBS specialists seek to create a good contextual fit for e ach family they work with so that families are able to successfully incorporate the support pl ans into their routines; support plans are often revised during intervention to ensure that family val ues, desires, and abilities are addressed (Buschbaker, Fox, & Clark, 2004; Lucyshyn & Albin, 1993). Developing these pla ns typically occurs in several stages, and the intervention components g enerally include antecedent manipulations, teaching replacement behaviors or engagement in incompat ible responses, and contingency management, this may include a variety of strategies for each routine and behavior targeted (Dunlap, Wilson, Kincaid, & Strain, 2009). During the past 15 years, researchers who focus on family-centered inte rvention for children with autism have actively used PBS as a framework for improving family ecology and child behavior (Buschbacher, Fox, & Clark, 2004; Dunlap, & Fox, 2010; Marcus, Swanson, & Vollmer, 2001, Vaughn, Clark, & Dunlap, 1997). However, only a limited number of research studies report the efficacy of family-centered PBS (Lucyshyn, Horne r, Dulap, Albin, & Ben, 2002). In particular, only a handful of studies to date have aimed at supporting fam ilies of young children. Marshall and Mirenda (2002) described four phases that they progressed thro ugh while working with a family of a four year old child with autism. The first stag e was building relationships with the family, which involved developing trust and openness be tween the family and specialist, as well as getting to know the families routines, strengt hs, and desires. The second stage was conducting the functional assessment with the family to under stand the problem behaviors and their function, and selecting routines that could be target ed for intervention. The third included developing the support plan that would be implemented during each routin e
4 identified. The fourth and final step involved implementing the strategi es and adjusting the plan. They incorporated several antecedent and teaching strategies, inclu ding providing snacks that might negate the setting event of the child being hungry, and providing a food choice board so that the child could ask for and receive the foods he wanted without resort ing to problem behavior. A visual schedule was used to help the child learn the expectations of t he routine. Contingency strategies such as praise and attention for completing tasks a nd not providing reinforcers for problem behavior were also used. Although parent training and support remain vital aspects of family-cente red PBS, it is quite challenging for professionals to engage in the reciprocal process o f developing an understanding of the childs problem behavior, developing family goals in probl ematic family contexts, developing a contextually fit behavior support plan based on the function al assessment, and providing the families with necessary training and support in the process of implementing the plan. The complex process of assessment and intervention design and implementa tion that are required to implement family-centered PBS would not be easy without practi cal tools for use by professionals. Furthermore, professionals are likely to fail to develop a suc cessful intervention plan if the plan is developed without the knowledge of parent goals for the chil d and family, family strengths, available resources, and daily family routines ( Lucyshyn & Albin, 1993). As such, there is a need for development and evaluation of the feasibility and ef ficacy of using training or intervention manuals for professionals who work with families i n the family context. Dunlap and Fox (1999) reported preliminary efficacy of the Individualized Support Project (ISP), a manualized, comprehensive family-based intervention model of behavior support f or children ages 2-4 with autism. The model focuses on the delivery of early interventi on for young children with autism through the family-professional partnership. The model sugges ts the process of assessment and planning for one month, intensive intervention and support for 3-5 months, and transition planning for one month to support young children with autism. The model shows s ome
5 promise in supporting young children with autism and their families. However, cur rently there is a very limited number of manualized PBS interventions tested with familie s of children with autism. Maintenance An important goal of family-centered PBS is that family and child outcome s are effective, meaningful, acceptable, and durable (Lucyshyn et al., 2007). Maintenance of the outcomes of implementation of PBS is an important measure when considering t he ultimate goal of providing support is maintenance of the behavior changes. Providers and fami lies want changes in behavior that endure long after the intervention has passed (Lucy shyn et al., 2007). This goal is inherent to PBS because the family is considered the primary interventionist. Several studies have shown that PBS does provide durable changes that increase c hild and family functioning within the routines that the plan was implemented (Duda, Clarke Fox, & Dunlap, 2008; Buschbacher, Fox & Clarke, 2004; Marcus, Swanson, & Vollmer, 2001). Lucyshyn et al. (2007) demonstrated the durability of the PBS approach over a 7-year period afte r the intervention had come to an end. The authors conducted maintenance probes at 6, 18, 36, 67 and 86 months post-intervention, all of which had near zero levels of problem behavi or, and desired levels of participation, which was comparable to the results during the in tervention stage. Generalization One important area of consideration that can be often overlooked when it c omes to family-centered intervention is generalization. Whether to novel people, settings, or routines, generalization is an important measure to consider and plan for when designing a PBS plan. Moes and Frea (2002) found that teaching parents functional communication tec hniques in order to decrease childs tantrum behavior successfully generalized to novel routines. Parents of children with autism chose two routines in which tantrum behavior occurred. F or one routine, parents were trained how to teach their children functional communicat ion, the other routine was videotaped during the treatment conditions and follow up to see if parents ge neralized the skills to
6 the routine that was not programmed for. The generalization of increases i n functional communication and decreases in tantrum behaviors maintained through the follow up probes, which suggests that giving parents the tools to teach their childre n in a specific routine can result in positive outcomes for multiple routines. In the study by Lucyshyn et al. (2007) generalization promotion training sessions were conducted with the family members of a five-year-old child with autism. The team met approximately eight times over a three-month period and discussed issues central to generalization including use of the worksheets and checklists central to t heir manual for PBS, strategies for selecting routines and plans for implementation in those routines, and encouragement to use all learned knowledge in novel settings and routines. T he researchers then took generalization probes during a novel routine and found that problem behaviors dec reased to near zero levels. These studies suggest that most caregivers are c apable of using strategies taught to design and implement interventions in order to reduce problem behavior and in crease functionally equivalent desirable behavior during novel routines. As few studies implemented family-centered PBS with young children with a utism, there is a need for more studies to examine the maintenance and generalization eff ects of PBS intervention within the context of family routines for young children with aut ism. More research is needed to show if the families can implement the intervention without prof essional or consultant support resulting in the maintenance of improved behaviors on the child s part, as well as family ability to successfully generalize the intervention str ategies in non-trained routines resulting in changes in the childs behavior. Treatment Fidelity Marcus, Swanson, and Vollmer (2001) showed that child behavior corresponded with correct implementation of intervention procedures by teachers, thus ma king treatment fidelity an extremely important measure for behavioral researchers. This illus trates the need for researchers to take data on the correct execution of all steps in the behavior plan to make s ure that the full
7 benefit of the plan can be seen. In research by Duda and her colleagues (2008), proce dural fidelity was measured by using checklists of the steps necessary to cor rectly implement the plan. The baseline and intervention portions of the intervention were videotaped a nd then scored based upon if the intervention agent correctly implemented the steps. They found that overall correct implementation was only 55% for intervention components although the overall inter vention was successful. The authors discussed that the behavioral plan encompassed four routines with 8-14 steps per routine so fidelity may have been low due to the intensive interv ention steps. Dunlap and his colleagues (2009) measured fidelity prior to, and during, implementation t o ensure that the behavior support team was comfortable with the intervention steps and to g uarantee that the team continued to implement steps correctly. Findings from the studies above indicate that developing contextually fit behav ior support plans that are simple to implement by natural change agents and providi ng technical assistance in the form of coaching and feedback are essential to increa se treatment fidelity (Fox, Dunlap, & Powell, 2002; Kohler, Strain, Hoyson, & Jamieson, 1997). Although family training tools or intervention implementation manuals are important to implement t he intervention with fidelity, providing on-the-spot suggestions or in-vivo performance feedbac k would be an essential component to ensure treatment fidelity and increase the effectivenes s of the intervention (Koegel, Robinson, & Koegel, 2009). Social Validity Measures Social validity measures within the field of PBS have generally taken t wo routes: 1) naive observers rating video of the intervention to see if effects can b e seen or behaviors are socially acceptable/unacceptable; 2) self report of satisfaction with the i ntervention from individuals involved in the process. For example, Bushbacher, Fox, and Clarke (2004) added a socia l validity component in which parents who had no knowledge of the individuals in the inte rvention rated different aspects of videotaped sessions of the interventions to s ee if non-related parents found the childrens behavior to be acceptable. The study reported that all p arents rated the
8 problem behavior and subsequent behavior of the parents as unacceptable in the ba seline condition, and acceptable in the intervention portion. Becker-Cottrill, McFarland, and Anderson (2003) evaluated social validity by means of contextual fit, and quality of lif e surveys in which the parents rated the success of the behavioral plan in a self reporte d method following the intervention. The self-report scale indicated the current level of functioning, following the intervention, and pinpointed success and stressful times during a post-interve ntion daily routine. The self report of the family provides the researchers with impor tant information about what is and is not acceptable to families when it comes to design and implementation of PBS plans. Social Validity is a vital measure to ensure that interventions ar e acceptable to the team members or to people that might observe the behavior in a public setting. Although social validity measures are regularly used by PBS researche rs, self-report has been the main method of assessment (Lucyshyn et al., 2007; Moes & Frea, 2002; Beck er-Cottrill et al., 2003). Self-report is important because it addresses the level of functioning the family was able to attain due to the intervention, the acceptability of the stra tegies used during the intervention, and the ease with which the intervention could be implemented. These all work to create a goodness of fit measure, which identifies if the interventi on was not only successful but if the family was comfortable with the strategies used and the out comes attained. However it does not suggest that interventions and their outcomes are acceptable on a w ider-scale, such as the general population. Of the fourteen examined studies only two measured the social validity of the intervention by having novel parents, those without knowledge of PBS intervent ions or the families involved in the research, rate the intervention components. Havi ng novel parents rate the social validity of intervention will demonstrate that interventions can be acceptable to the general population. Prevent-Teach-Reinforce Model Prevent-Teach-Reinforce (PTR) is a model of positive behavior support designed for use in school settings (Dunlap, Iovannone, Kincaid, Wilson, & Christiansen, 2009). It is av ailable in a
9 manual form for use with school staff to address problem behavior by a) preventi ng the behavior; b) teaching socially appropriate alternative behavior; c) reinfor cing all appropriate behavior. The model is based on the PBS approach in that it addresses the collaboration among teachers, staff, and a behavior specialist who design and implement the plan as a team, focusing on the strengths of the student and the function of problem behavior. The process occurs in five st eps including: 1) team development, 2) goal setting, 3) functional assessment, 4) inter vention development and implementation, and 5) evaluation. These steps are designed for ease a nd simplicity of identifying appropriate behaviors, both problem and replacement, to address, designing a pl an that encompasses prevention, training, and reinforcement, and evaluation of soci al validity and fidelity of the plan and implementation. The PTR manual provides a comprehensive plan for clinicians to gather, utilize and train a team of people surrounding the individual of concern. The manual includes checklist s and worksheets that facilitate the clinician in getting to know the team me mbers better, identifying the problem behaviors and variables surrounding them, planning an acceptable inter vention with the team, surveying the team on their perceived validity of the intervention, and taking data on the problem and replacement behaviors. Dunlap et al. (2009) found that using this model was efficacious in decreasing inappropriate school related behaviors and i ncreasing appropriate behaviors across two teams. Although the use of the PTR model sounds promisin g in the school setting, there is no current research to demonstrate the feasibili ty of PTR in the family setting, and it is not known whether the manualized PTR intervention can be adapted to the fa mily context, particularly to the families of young children with autism. Purpose and PTR Modifications The purpose of this research was to examine the feasibility of imple menting the adapted PTR intervention with families of young children with autism. Before test ing the feasibility, the study adapted the current PTR model by modifying specific components of the w orksheets included in the manual, such as specific behaviors, antecedents, and settings which were tailored
10 to the school setting, were changed so that they encompassed home based options. For example, the worksheet suggested curricular changes as a prevent strateg y were modified to replace that option with family routine changes. Steps 1 and 2 as described in the ma nual were collapsed as well as Steps 3 and 4 so that there are fewer meetings required in or der to develop and implement the intervention. The suggested data collection method, caregiver rati ng following the routine, were not utilized, instead parents took video of the routines for late r scoring by the researcher. These and other practical changes were addressed in order to att end to the differences between caregiver use in the family context and school personnel use in the class room context. Research Questions This study extended the literature by a) examining the feasibility of implementing the adapted PTR model with families of young children with autism who have problem beha vior; b) including a secondary caregiver as a design and implementation agent; c) a ssessing family generalization of the PTR intervention in a novel routine; and d) assessing social validity of the intervention with nave parents. The research addressed the following que stions: a) can family members including the secondary caregiver implement the behavior support pl an, developed through the PTR process, with fidelity?; b) will the childs problem beha vior decrease and functionally equivalent behavior increase across routines as result s of the PTR intervention?; c) will family members be able to generalize the PTR intervention to a non-trained routine resulting in collateral changes in the childs target behaviors? ; and d) will the adapted PTR intervention be rated as acceptable by novel parents?
11 Method Participants Two families of children with autism spectrum disorders participa ted in this study. Both were recruited from a local business providing in clinic academic se rvices for children with autism spectrum disorders. Family A included a four year old male child, Ni cky who had been diagnosed with PDD-NOS (Pervasive Developmental DisorderNot Ot herwise Specific) and his parents. Nicky had been diagnosed with PDD-NOS at 33 months of age. His stan dard scores on the Battelle Developmental Inventory II (BDI -2; Newborg, 2005) wer e reported to be 80-98 in the adaptive, personal/social, and motor domains which suggests typical funct ioning levels. His scores in the cognitive and communication domains were 69-71, suggesting mode rate delays. He was also tested in receptive and expressive language areas using the Pr eschool Language Scale-4 (PLS-4; Zimmerman, Steiner, & Pond, 2002) which reported that he communicated at a n average age equivalent of 11 months. Nicky had been receiving a Verbal Behavior based therapy as well as phys ical therapy for a year prior to this intervention. In the clinical setting he was able to make a variety of sounds, such as mama, dada, and tee tee, but no formal words. He was also able to use up to 6 signs fluently. Nicky also attended a public preschool half time. Ni cky frequently engaged in chewing his shirt or nonfood items, inability to go to the bathroom independently or n o self-initiation of bathroom routine, and refusing to eat non-preferred food. Nickys family consi sts of his parents and 6 year old sister. Both parents had Bachelor's degrees. His mother was a graphic artist and father was an engineer. Both parents shared responsibilities for the ir children. However, they took care of different routines. For example, Nickys father was respons ible for the morning meal and other morning routines. His mother generally took care of the routines that occ ur in the afternoon.
12 Family B included a 6 year old male child, Michael and his parents. M ichael had been diagnosed with autism at 18 months of age by a licensed psychiatrist. Informat ion on his current developmental levels was not available However, when he was assesse d at age three, the standard scores on the Vineland II (Sparrow, Cicchetti, & Balla, 2005) was 86 in the communication domain, which was labeled at adequate. However scores in the other domains fell below 79, which indicated functioning in a moderately low to low capability. Those sc ores were 78 in daily living abilities, 65 in socialization, 79 in motor skills, and 73 in adaptive behav ior. Michaels scores on the Mullen Scales of Early Learning (MSEL; Mullen, 1995) indic ated that at 36 months of age he functioned at an average level of 22 months. Michael had been recei ving Verbal Behavior based therapy in home since the age of 18 months. Michael frequentl y engaged in tantrums and repetitive stereotypic behavior. Michaels family consi sted of his parents and 8 year old brother. His mother had a Masters degree in Business Administration and w orked in that field. His father had double Bachelors in History and Education and was a high s chool teacher. Michaels parents were also responsible for child care at home. His mothe r took care of the morning routine and father took care of afternoon routines. Michaels aunt of ten came to help and took the children to school. His father picked them up and took care of afte rnoon routines until Mom got home Setting This study took place primarily in home with both families. The specific routines that the families selected for intervention included bathroom, independent play and meal time for Nicky. The bathroom routine for Nicky occurred in the afternoon right after Nick y came back from school. Nicky never initiated bathroom routine and would often toilet i n his pull-up. Independent play occurred after bathroom routine. During the play routine (generally te levision viewing, but also toy play), Nicky often put non-edible objects such as his shirt o r other toys in his mouth and chewed on them. The mealtime routine occurred in the morning and at lunch dur ing which Nicky refused or spit out nonpreferred food.
13 Michaels routines included car riding and the morning routine, which took pl ace in the car and at the home. The car ride routine for Michael occurred when the fa mily took him shopping, to grandparents house, and to the public pool. During this time, Michael often engaged in repetitive, stereotypic behavior. During the morning routine Michael often engaged in t antrum behaviors. Measures To evaluate the feasibility of implementing the PTR model in the home se ttings, we measured family implementation fidelity and child problem behaviors t hat the team deemed severe enough to warrant intervention as well as functionally equival ent replacement behaviors that were taught and reinforced. Family implementation fidelity Family implementation fidelity was measured to assess the extent to which a parent and/or second caregiver implemented the beha vior support plan as designed. Implementation fidelity was calculated as a percentage based on the number of correct steps implemented divided by the total number of steps that were applica ble for each routine. Plans developed for Nicky contained 13 steps for the potty routine, 6 s teps for the chewing routine and 6 steps for the meal routine. The plans for Michael conta ined 9 steps for the car routine and 8 steps for the morning routine. All fidelity checklists wit h specific steps for each routine can be seen in Appendix 2. Problem behavior Problem behavior for Nicky included inappropriate chewing and forced completion. Inappropriate chewing was defined as chewing his s hirt or other non-food items during the play routine. Forced completion was defined as completi on of bathroom steps with full physical prompts resulting from unwillingness to go to the bathroom. P roblem behavior for Michael included repetition and tantrum. Repetition was defined as verbalizing repeated questions or phrases pertaining to destinations. Tantrum behavior was defi ned as kicking, hitting, screaming, crying, and whining. Percentage of intervals was measured fo r inappropriate chewing
14 and tantrums. Percentage of steps completed was measured for completi on of bathroom steps independently or using physical prompts. Rate per minute was measured for repe titions during car rides. Replacement behavior The replacement behaviors to be increased for Nicky included independent completion of bathroom steps and eating unfamiliar food. The repla cement behavior selected for Michael was following directions. Percentage of steps completed independently, number of bites of unfamiliar food, and percentage of intervals with appropria te or no-chewing were measured for replacement behaviors. Definitions of problem and repl acement behaviors are presented in Table 1.
15 Table 1: Definitions of Target Behaviors Target Behavior Topography Definition Michael Problem Behavior Screaming Vocalizations in a high-pitched tone, above the normal vocal level required to hear the individual from a 20 foot distance Hitting Using an open or closed fist in an attempt to make contact with the another individual Kicking Using any part of the foot or leg in an attempt to make contact with another individual or object Stomping Lifting the foot off of the floor and returning it to the floor in a forceful manner Whining Vocal utterances that have a high pitched sound Crying Squinting the eyes and furrowing the brow which may or may not result in emitting tears, accompanied by high pitched sobbing sounds Repeating Repeating requests, questions, or statements pertaining to the preferred activity more than one time Replacement Behavior Following directions Complying with a request from a family member or caregiver independently, for example eating breakfast when asked Nicky Problem Behavior Inappropriate Chewing Putting any non-food object (e.g., shirt) in his mouth Forced completion of bathroom steps Being taken to the bathroom and completing potty steps (e.g., entering the bathroom, pull clothes down, sit on toilet, stand up, pull clothes up, flush toilet, wash hands) with full physical prompts, without any initiation of finishing the steps on his own Appropriate Behavior Independent completion of bathroom steps Completing potty steps without the need for any gestural, verbal, or physical prompts from caregivers Appropriate chewing Any food item that is in the mouth, or no items in the mouth Accepting unfamiliar food Accepting unfamiliar or non-preferred food past the plane of the lips, food that has either never been eaten before or has previously been associated with refusal Social validity Two types of social validity were assessed in this study: Selfrating by family members and rating by nave parents. Self-rated social valid ity was assessed during the
16 follow-up phase. The family members (i.e., parents, secondary care giver ) were asked to fill out a modified version of the PTR Self Evaluation: Social Validity form (se e Appendix 3) which was adapted from the Treatment Acceptability Rating Form-Revised (TA RF-R; Reimers & Wacker, 1988) and was designed to measure perceived ability to implement the plan, sa tisfaction with the plan, and ability/confidence to design a plan without the researcher. The sca le consists of 15 items which uses a five point Likert-type scale to rate accept ability of the PTR intervention from 1 to 5, with counterbalanced questions (i.e. for some questions 1 indicates accepta bility and 5 indicates an unacceptable score). Novel parents also rated the intervention acceptability while vie wing videos of the baseline and intervention components using a 5-item rating scale. The r aters included three parents of children with autism, who did not have any previous experience wi th the family they were rating. They rated the before and after intervention video-tape d data with questions concentrating on acceptability of child behavior, parent behavior, and imple mentation. The raters viewed two 2-4 minute video clips (one from baseline and one from inter vention) taken during Nickys mealtime and video clips taken during Michaels morning routine to assess the intervention acceptability. The scale items were adapted from the s ocial validity measure by Buschbacher, Fox, & Clarke (2004) (see Appendix 4). Procedural integrity. To ensure the researcher delivered the PTR process as planned, researcher procedural integrity was assessed during the impleme ntation of the PTR process. Each session with team members was audio taped and scored by an independent observ er using an integrity checklist. The independent observer was a graduate student in t he University of Floridas ABA masters program. The observer used a yes/no checklist (see Appendix 5) adapted from the PTR manual, in order to assess if the researcher addressed all steps necessary during the team meetings. The procedural integrity checklist included a total of 15 steps (2-7 steps in each meeting). Percentage of procedural integrity was computed by dividing the number of steps addressed by the total number of steps in each session. The independen t observer scored the
17 researchers procedural integrity at 100% across both families ind icating that all PTR steps were correctly delivered in each meeting. IOA for procedural fidelity, assessed by using a point-bypoint method (item by item), was 100% for families across sessions. IOA w as assessed for 100% of the sessions. Data Collection and Inter-observer Agreement Child target behaviors were observed using a 10-second partial inte rval recording system or an event recording system for 5-10 minute sessions. Target behaviors for Nickys bathroom routine were recorded using a task analysis worksheet which noted how many steps were completed independently versus with physical prompts. Meal time for Nic ky was video recorded and scored by observing bites per meal of non-preferred foods. All applicable s essions were videotaped by parents for later scoring by the researcher and an independen t data collector in order to score child target behaviors and to assess family implementa tion fidelity and interobserver agreements. 50% of the sessions were assessed for IOA. The family implementation fidelity was scored using the Family Implementati on Checklist (see Appendix 2). The independent observer and researcher practiced data collection unti l they achieved 90% agreements, using video and audio recording of the selected family routines As shown in Table 2, the mean IOAs were 100% across participants, routines, phases, a nd target behaviors except the IOAs for Michaels target behaviors during mor ning routine in baseline and intervention. The IOA during morning routine averaged between 93% and 97%. IOA for problem behavior was 93-100% in baseline and 82-100% in intervention. IOA for appropriat e behavior was 87-100% in baseline and 72-100% in intervention.
18 Table 2. Mean percentage of interobserver agreement Design The feasibility of using the PTR intervention in home settings was tested using a concurrent multiple baseline design across routines for each family The family team identified over the course of the PTR process which routines were problematic. T he family implemented the intervention staggered across target routines. PTR Intervention Procedures PTR initial meeting. An initial team meeting was conducted in each familys home. The initial two hour meeting covered Steps 1 and 2 of the PTR process, which e ncompassed teaming and goal setting. The first meeting focused on identifying routines in ne ed of intervention and defining target behaviors for the individual. The team members used the PTR Goal Setting worksheet (see Appendix 6) in order to identify short-term and long-term goals for the individual in the areas of behavioral functioning, social functioning, and independent functio ning. This worksheet helped team members identify deficits or problem behaviors and potential replacement behaviors that helped individual and family functioning. Nicky Nickys team members consisted of his parents, his sister, and the researcher. During this first meeting Nickys family identify three routine s that posed problems; the bathroom routine, independent play, and meal time. During the bathroom routine, parents reported that Nicky would often toilet in his pull-up and then remove it and con tinue to engage in
19 activities. The parents would take him to the bathroom and put on a new pull up when Nicky toileted in his pull-up. They also often physically prompted Nicky to go to t he bathroom. During this time, the parents forced Nicky to complete all the steps by providing f ull physical prompts. Nickys no self-initiation of bathroom routine and relying on pull-ups had be en one of the major concerns Nickys parents had. During the independent play routine (g enerally television viewing, but also toy play) Nicky would put in-edible objects such as his s hirt or other toys in his mouth and chew on them. Parents would verbally reprimand him and remove the item, which often led to them not putting shirts on him at all while at home. For the mealtime routine parents reported that they might try to give hi m less preferred or unfamiliar food but he would either refuse or spit the food out after one bite and then refuse any further bites of that food, so they would stop attempting to feed it to him. Two of the routines, bathroom and independent play were selected for intervention, and the meal time routine was selected for generalization evaluation. The team members identifi ed and defined the behaviors that occurred during the problematic routines which were targeted for decrease and increase. Michael. Michaels team initially consisted of his parents and his aunt. Michaels family identified two routines that were problematic, riding in the car t o preferred destinations, and the morning routine. They reported that during car rides he would repeat the sa me phrase and/or question about the destination multiple times, for example were going to Publi x, were going to Publix, mom, were going to Publix. When can we go to Publix mom? They would often reply by saying yes, were on our way, or were going right now, Ive already told yo u were going to Publix. During the morning routine parents reported that Michael would often ki ck and scream when asked to comply with morning tasks which included getting dressed, br ushing hair, eating breakfast, taking medicine, brushing teeth, and putting on shoes. They would continue to place verbal demands and would try to get him out of the bad mood by tickling or ch asing, and would eventually revert to yelling, holding him down if he was kicking excessiv ely, or leaving him alone and trying again a few minutes later.
20 Baseline data collection. After the initial meeting, baseline data on the childs target behaviors and family implementation fidelity were obtained for a period o f one week across routines. Families were asked to provide activities, food, or assistanc e, and interact with their child as they would normally. This phase was conducted with each family unti l a stable level of data was achieved across child target behaviors and in family impleme ntation fidelity across routines. Observation sessions were 5-15 minutes depending on the target routi ne. Functional assessment and behavior intervention planning. Following the baseline data collection, the team members participated in the second meeting, whic h encompassed Steps 3 and 4 of PTR process. A different three hour meeting was held for each rou tine so that intervention would be staggered across the routines. The meetings focused on determining the functions of the childs problem behavior. The PTR Functional Behavior Assessment form (see Appendix 7), which helps the team members break down the antecedents and consequences for particular behaviors, was used. Nicky. Nickys family determined that the function of Nickys problem behavi or during the bathroom routine was access to tangibles. Using PTR Assessment O rganization Table (see Appendix 8), Nickys family hypothesized that when Nicky had access to prefe rred activities (T.V. or computer) he was more likely to go pee outside of the bathroom, which gav e him continued access to the preferred reinforcers until his parents noti ced what had happened. They also found that the function of chewing behavior that occurred during independe nt play was automatic. They hypothesized that when Nicky was playing alone without dire ct adult supervision he was more likely to chew on his shirt and other items in order to gain the automatic reinforcement associated with the act of chewing. Based on this information the team members completed the PTR Interv ention Checklist (see Appendix 9), and determined which behavior support strategies were most helpful in addressing Nickys problem behavior and teaching new skills in three spe cific components Prevent, Teach, and Reinforce. The team decided that for the bathroom r outine the most helpful
21 prevent strategy would be to have environmental supports such as not having acce ss to the T.V. until after he goes potty in the toilet, and having an if/then board with photogra phs of toilet and TV, which parents could use to signal to him that going to the potty would result in access to the TV. The pictures prepared for if/then board were detachable so that Nic ky was able to use the pictures in order to request going to the potty by handing the picture to his par ents. Nickys team decided that teaching specific communication and ind ependence skills would be appropriate targets for the Teach component, and they elected to teach him to use the picture to request potty and to teach him to be able to go through all bathroom step s independently using visual prompts. The team developed a visual sequence of the bathroom routine to prompt Nicky to complete the bathroom steps independently. For the Reinforce component the team decided to discontinue reinforcement of the problem behavior a nd reinforce the appropriate behavior. The team focused on selecting interventions t hat were well-liked, functionally equivalent, and acceptable to the family members (see T able 5 in Appendix 1for specific strategies selected). The team members then developed the PTR Intervention Plan (see Appendix 10). Each team went through this process for each routine selecte d. The specific steps were then broken down and a concrete plan was designed with steps that were i mplemented during intervention phase. Michael. Michaels family completed three hour assessment and behavior plan me etings for each target routine. It was determined that repetitions in the car oc curred to gain attention, and tantrum behavior during the morning routine functioned to delay the onset of les s preferred activities (dressing, eating, brushing teeth etc.) and to gain attention f rom adults and his sibling. For the car ride routine, parents decided to provide alternative item s (e.g., books, toys, music, videos) that might help prevent repetitions by engaging Michael i n alternative activities. Parents also felt that excitement about destinations contributed to t he attention gaining behavior. Therefore, they wanted to teach him alternative statements or question s about destinations that could serve the same function as repeating did. Thus the team decided to i nterrupt repetitions,
22 require a few seconds of silence so that repetitions werent reinforc ed, and then prompt or provide questions which would lead to appropriate statements which could be reinfo rced with attention. In this manner engagement in alternative activities and appropriate st atements/questions were reinforced while repetitions ceased to be reinforced. During the morning routine the family decided to use a timer to signal when tr ansitions were about to occur and when engagement in the expected activity was to s tart. They also decided use a sticker board to reinforce completed activities and show Mich ael his progress toward preferred interactions (tickles and spinning). Parents also chose to ignor e all tantrum behaviors and physically prompt Michael through the routines if necessary, and reinf orce following directions with praise. A complete table of routines, functions, and hypothe sis and intervention components was completed in order to delineate the behavior plans developed. T able 3, Appendix 1 shows the summary of intervention developed for each child. Family training. After the intervention plan was developed during the second meeting, the researcher provided approximately 30 minutes of training to the fa mily members on the implementation steps using verbal and written instructions, modeling, rehear sal, and feedback. The training occurred separately for each family. Using the PTR Fami ly Implementation Fidelity Checklists (see Appendix 2), the researcher scored each member on their percentage of correct use of intervention steps. The researcher and family practiced using t he steps until each family member (parent) was able to implement the steps with 90% accuracy. Behavior intervention plan implementation and evaluation Upon completion of training, the family members began implementation of the behavior plan i n each target routine. For Nicky, both his parents implemented the intervention across routines During the intervention implementation phase, coaching sessions were to be scheduled if implementat ion scores of any implementer fell below 80%. No coaching sessions occurred for Nickys pa rents since the primary interventionist, his mother, and secondary interventionist, his father, fidelity scores never fell below 80% except in the generalization routine. The interventi ons for the bathroom routine
23 and the play routine were implemented for a period of six weeks, and interventio n for the meal (generalization) routine was implemented for a period of one month. The interventions for Michael were implemented by his mother. Two in -situ coaching sessions were conducted with Michaels mother during morning routine. The fi rst coaching session lasted about 3 minutes and was simply a reminder and explanation f or only giving stickers in the absence of tantrum behaviors. The second coaching sessi on lasted 15 minutes and included feedback on the routine that had just occurred (medicine), discus sion, and role play. She had failed to physically prompt Michael to the appropriate location and inste ad took the medicine and followed him to their sofa where he was engaging in tantrum behaviors and refusing to take medicine, she began attending to the tantrum behaviors so the session was t erminated and in-situ training began. Although a booster session was needed during the car routine, th e family was unavailable to meet in a timely manner, thus the researcher simply rem inded them during the final meeting not to provide any conversation/attention for repetitions. The interventions for the car routine and the morning routine were implemented for a period of one month. The intervention ended when each familys primary interventionist (mother) demonstrat ed that they could implement plans with fidelity scores above 80% and when a stable pattern in c hild behaviors was seen. Follow-up. At two weeks following the intervention, four follow-up data points were collected during bathroom routine for a period of two weeks during bathroom routin e for Nicky. The researcher took four probes of child target behaviors and famil y implementation fidelity to determine if changes in behavior were maintained. Generalization. During the first team meeting session Nickys parents were as ked to identify one additional routine that was problematic. The parents s elected the meal time routine, and they were asked to use the worksheets to design their own inter vention for the generalization routine. The intervention strategies selected for the meal time rout ine were based on functional behavioral assessment, the team conducted a meeting which lasted approxim ately two hours and
24 took place after the team designed two behavior plans for the other selec ted routines. The purpose was to determine if the family could successfully generalize what the y had learned in the previous meetings. The researcher only provided small amounts of input when aske d by the family for specific suggestions. Since the goal of generalization evaluation was to determine if families could develop and implement without the researcher involvement, no discussi on, modeling, and role-play were provided. The researcher assessed procedural fide lity to the steps completed by the family members. Family procedural fidelity to each step was 100%. The identified target behavior was accepting unfamiliar or non-preferr ed food (e.g., apples, hamburger, carrots, and eggs). It was hypothesized that Nickys refusi ng or spiting food out was escape from food demand or non-preferred food. Strategies selected wer e using sibling modeling, providing food choices, and reinforcing each bite of food with preferred food. Du ring family implementation of the generalization intervention, the res earcher did not provide any implementation support. For Nicky, data were collected on the number of bites of unfamiliar or non-preferred food. Generalization data were collected across baseli ne and intervention phases. No Generalization data was taken for Michael due to scheduling and time c onstraints.
25 Results Figure 1 and Figure 2 show the levels of occurrence of each familys implementation fidelity and each childs target behaviors across routines and experimenta l phases. Nickys familys use of intervention strategies during the generaliza tion routine is also presented in Figure 1. Family Implementation Fidelity As shown in Figure 1, Nickys family use of intervention steps was 0-10% a cross routines in baseline. Once the PTR intervention was introduced, Nickys parents use of intervention steps immediately increased. His mothers implementa tion fidelity was an average of 92% for the bathroom routine and 100% for the play routine. In follow-up, his mother implemented the intervention steps correctly 100% of the time during the ba throom routine. No booster sessions were given to Nickys mother or father for eith er target routine since the fidelity did not fall below 80%. Nickys father implementation fidelity data also shows that he imple mented less that 10% of the intervention steps in baseline across routines, but his use of i ntervention strategies during the two target routines immediately increased to an average of 90% (a range of 83% to 100%) across routines in intervention, demonstrating high levels of implementa tion fidelity. During meal time routine in which family generalization of intervention was assess ed, parent fidelity averaged 0% during baseline and 82 % during intervention. However, their implementa tion fidelity was variable. Both parents fidelity fell below 80 % during four sessions. As shown in Figure 2, average fidelity of implementation for Michaels f amily (mother) was 0% prior to intervention for the car routine and 2% for the morning rout ine and increased during intervention to 89% for the car riding routine and 88% for the morni ng routine.
26 Child Problem and Replacement Behaviors As shown in Figure 1, Nicky was able to complete only 14% of the steps in t he bathroom routine independently on average during baseline. After the behavior plan was implemented, the steps completed independently increased to 53.3% during the last four s essions. His levels of independent completion of bathroom routine remained stable at about 57% as intervention progressed. Some steps in the bathroom routine seemed to be more of problem for N icky to complete independently on a regular basis. They included pulling down pants and pull-up, pull ing up pants and pull-up, and washing hands which required specific motor skills and we re difficult to complete for his young age. This may have been why he did not achieve independence on m ore than 57% of the steps, during the intervention portion. For the independent play routine, where chewing was targeted, Nicky engag ed in chewing his shirt or other objects an average of 93% of intervals (a range of 71-100%) during baseline (see Figure 1). As intervention was introduced, chewing ina ppropriate items decreased to an average of 3% of intervals per session and appropriate chewing increased to an average of 98% of intervals in intervention. During the generalization routine, during which the Nickys number of bite s of unfamiliar or non-preferred food was measured, his parents failed to offer any non-preferred or unfamiliar food to Nicky during baseline; the number of bites of target fo od per meal was 0%. However, during intervention bites per meal increased to 3 bites per me al on average (a range of 0-9 bites). As shown in Figure 2, Michaels repeating behavior during car rides occurr ed an average of 3.3 times per minute in baseline and decreased to an average of .4 times per minute during intervention. Tantrum behavior in morning routine occurred an average of 75% of intervals during baseline, and decreased to an average of 19% during intervention. Following directions occurred an average of 25% during baseline and increased to 81% during inte rvention.
27 Social Validity The results of social validity ratings indicated that the family-bas ed PTR intervention had high levels of social validity. The overall ratings of acceptabili ty were high, with a range of 3-5. Nickys parents ratted on average 4.3 for the independent play routin e and a 4.5 for meal time routine. Michaels parents rated on average 4.6 for car riding and 4.5 for morning routine. The social validity ratings by novel parents on video segments of basel ine and intervention sessions showed that raters found the success of the routines during baseline was very low. However, they responded that during intervention the childrens behavior was acceptabl e and that the children were participating in the routine appropriately. The families were r ated as being very comfortable in the routine. Overall mean ratings by the nave observers across child ren and routines were 1.3 in baseline 4.7 in intervention. Table 3 shows the social validity rati ng scores by the child participants parents and Table 4 shows the rating scores by the na ve observers.
28 Figure 1. Percentage of family implementation fidelity and percentage of i ntervals, percentage of steps completed, and number of bites for Nickys target behaviors across r outines and phases.
29 Figure 2. Percentage of mother implementation fidelity and percentage of i ntervals and number of repetitions for Michaels target behaviors across routines and pha ses.
30 Table 3: Social Validity Questionnaire Results Nicky Mom Nicky Dad Michael Mom Potty Play Potty Play Car Morning 1. Given the childs behavior problems, how acceptable did you find the PTR behavior plan? 5 5 5 4 5 5 2. How willing were you to carry out this behavior plan? 5 4 4 4 5 5 3. To what extent were there disadvantages to following the behavior plan? 5 4 5 5 5 4 4. How much time was needed each day for you to carry out the behavior plan? 3 3 4 3 3 3 5. To what extent do you think the behavior plan was effective in reducing problem behaviors? 5 5 5 4 5 5 6. Do you feel that following this plan will result in permanent improvements in the childs behavior? 5 5 4 4 5 4 *7. How disruptive was it to carry out the behavior plan? 4 4 4 5 4 4 8. How much did/do you like the procedures used in the behavior plan? 5 5 4 4 5 5 9. How likely is it that you will continue to implement the procedures in the plan after this research is terminated? 5 5 5 5 5 5 10. To what extent did you observe undesirable side effects as a result of the behavior plan? 5 4 5 5 4 5 11. How much discomfort did the child experience during the behavior plan? 5 5 5 1 4 3 12. How willing were you to change routines in order to carry out the behavior plan? 4 5 4 4 5 5 13. How well did carrying out the plan fit into your current routines? 4 4 4 3 4 5 14. How effective was the intervention in terms of teaching the child appropriate behavior? 4 5 4 4 5 5 15. How well did the goal of the intervention fit with the teams goal for improvement of the childs behavior? 4 5 4 5 5 5 Note: *Reverse score items (i.e., 1 becomes 5, 2 becomes 4)
31 Table 4 : Novel Rater Social Validity Pre and Post Intervention Rater 1 (Nicky Mealtime) Rater 2 (Michael Morning) Rater 3 (Michael Morning) Pre Post Pre Post Pre Post 1. The childs behavior is acceptable in this routine 1 5 1 4 1 5 2. The child is participating in this routine 1 5 1 4 1 5 3. The child appears comfortable with how the routine is going 1 4 2 5 1 5 4. The strategies used by the parents are working in this routine 1 4 1 5 1 5 5. The parent appears comfortable with how the routine is going 2 5 1 5 2 5 6. The strategies used by the parent are practical for families to implement 2 5 3 5 2 5
32 Discussion This study assessed the feasibility of implementing an adapted PTR mode l for use in home with families of young children with ASD. The results suggest that t he school-based PTR model is adaptable and can be used with success with families of children with ASD. This research shows that two families of children with autism were able to successfully create two behavior plans in collaboration with the researcher and implement them w ith fidelity across routines. The families implementation of the PTR intervention positive ly affected the two childrens behaviors. Both childrens problem behaviors were dramatica lly reduced and alternative or replacement behaviors increased during intervention. Th e PTR model also had high social validity; both self-validity and novel rater validity indica ted that the PTR intervention was acceptable to both families and the community at large. This sugge sts that a manualized parent training program using the PTR model may be helpful for service providers. The current PTR model was adapted to include fewer worksheets and meet ings than the original PTR model. The initial meeting lasted about an hour and half with both f amilies, and subsequent meetings during which behavior plans were developed and BST was conduc ted lasted a maximum of three hours. In the current study the behavior planning and BST we re done in the same meeting, and parents generally had 100% fidelity after two rehears al/feedback sessions. The BST portion of the meeting was fairly short and didnt require a separate m eeting date. Although the behavior plans created with the researcher were successful i n reducing the childrens problem behaviors and teaching their replacement skills, the family (Ni ckys parents) who participated in the generalization routine were able to develop and implement the interv ention plan with skills acquired through training and implementation support received during target ro utines. Their implementation of the plan resulted in collateral effects by increas ing the childs acceptance of
33 non-preferred food. However, the familys implementation fidelity showed l ower rates than those of during target routines, showing a variable trend. Although adhesion to P TR steps was high, fidelity of implementation was variable. Increases in the number of the childs bites of nonpreferred food did occur, which suggests that partial fidelity was su ccessful in changing the childs behavior. This suggests that parents may be able to design eff ective plans using intervention options they are familiar with. However they may not be abl e to correctly implement the plans with fidelity without specific BST training. This was also s een in research by Rosales, Stone, and Rehfeldt (2010) during which they assessed the skills of imple menting a picture exchange system with caregivers who had only written instruction and were the n given behavior skills training. The results of the current study suggest that a generalization promotion may be needed in order to facilitate families successful implementation of PBS in tervention with fidelity during non-trained routines (Blair, Lee, Cho, & Dunlap, in press; Lucyshyn et al., 2007) A few studies found that parents could generalize specific PBS or function-based inte rvention strategies that had been previously taught (Blair et al., in press; Lucyshyn et al., 2007; Moes & Frea, 2002), but thus far the current study is the only research that attempted to exa mine if parents could generate and implement their own behavior plan successfully. Further research shoul d look at how much experience creating behavior plans parents may need before being able to not onl y generalize strategies previously learned but to develop and implement specific pla ns with fidelity. An alternative solution to the generalization promotion may be to consider l ooking at the adequacy of the intervention created by the parents. It is possible that the intervention strategies themselves were not necessarily strategies that would have been inc luded had there been professional help. This study extends the literature on PBS function-based intervention by providi ng evidence of outcomes of the family-centered process for children. The results suggest that familycentered intervention is essential in supporting children with ASD who have c hallenging
34 behaviors. This study demonstrates that behavior support using the PBS approa ch or functionbased intervention can have powerful effects on outcomes for children w ith ASD when intervention is implemented in multiple routines through the family-profe ssional collaborative process. A collaborative problem solving process that involves team building and addressing childrens challenging behavior and promoting alternative skills in multiple f amily contexts could promote the childrens long term success (Lucyshyn et al., 2007 ). One important implication of current study findings for future resear ch and practice is that families should collaborate in the entire behavior support process. Ni ckys entire family including his father and sister participated in the process of PTR inter vention. Nickys sister who was six years old participated in the modeling procedures promoting and dem onstrating appropriate eating during mealtime routine. Involving sibling in the proces s of implementing the intervention was imperative to increase the effectiveness of int ervention. However it proved very difficult to involve all family members in the process, particul arly getting parents to switch their current routines to implement intervention during routines they would not nor mally be responsible for. For example Nickys father was usually the person in char ge of feeding Nicky in the morning, since his mother was getting ready and taking care of his sist er. This resulted in fewer data points when it came to assessing the mothers fidelity dat a for that routine. This was also seen with Michaels family. Michael regularly went to pref erred locations with his mother and not his father, so repeating data was only assessed with one caregiver It was also found that behavioral problems deviated depending on the routine and parent in charge, for exa mple Michael was more likely to engage in tantrum behaviors when his mother was present versus when he was with his father alone. Therefore, when designing intervention, environmenta l stimuli and functions of problem behavior should be addressed within the family context shoul d be emphasized. Another interesting occurrence concerning Michaels behavior was the spike in tantrum behavior during the morning routine task of taking medicine in sessions 10 and 15 During the
35 functional assessment several morning tasks were assessed and it wa s found that during all routines there were similar amounts/types of tantrum behavior. Howeve r during intervention it became apparent that Michael responded well to the intervention str ategies during all tasks except the task of taking medicine. This may have been due to the taste of medi cine, which was a combination of fish oil, vitamins and minerals, and frozen orange juice concentrate (which supposedly cut the fish oil flavor). The increases in the childs tantrum behaviors during this specific task suggests that potential setting events that se t up problem behavior should be identified during functional assessment to develop an effective behavior i ntervention plan. This study suggests that adapting the PTR model for family contexts is import ant because service providers outside of the research environment need established met hods with which to address problem behaviors, with families of children with ASD and othe r disabilities. The PTR method is a comprehensive method, including worksheets and possible strate gies that encourage family participation which could be very helpful for providers who truly wa nt to create plans that have great contextual fit, as verified by the social validity. One of the bigger challenges faced during this study was the unpredic tability of parents. A total of eight meetings were necessary between the two families. How ever, families cancelled and rescheduled 50% of those meetings, which led to time constraints and short er implementation periods for the latter routines. One family was able to reschedule meetings in a timely manner. However, their data collection was very inconsistent despite the off ers of the researcher to videotape. The other family took several days to reschedule and reschedu led meetings were all at least a week after the originally planned date. Although it was understand able for families with employed parents and multiple children, it still poses difficulties for re searchers. Future researchers should anticipate parent unpredictably and research techni ques that might combat that occurrence. One limitation of this study is limited data collected during int ervention due to families inconsistent data collection. It was found that parents often did not foll ow baseline standards for
36 data collection, but did not readily accept offers for help with videotapi ng. Tapes were too short, parents often wanted to report following the incident, or simply they di d not tape the amount of sessions requested. During this research Nickys parents used a record ing system with pen and paper for the bathroom routine and videotaped for the other two routines. They took significantly more data during the bathroom routine. Future research should investigate t he fidelity of using the data collection method that is suggested by the original PTR model, whic h uses a rating scale system that parents can easily and accurately record target behavi ors during routines. This study used a small number of participants and thus the results should be interpreted with caution. Further research that includes a larger sample will be ne cessary to provide further validation of the adapted PTR model that focuses on family-professional co llaboration. Overall this research is consistent with the original PTR research (Dunlap e t. al., 2009) which demonstrates that the PTR method is highly adaptable In addressing challe nging behavior in young children with ASD and promoting their alternative behaviors in home settin gs.
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38 Dunlap, G., Iovannone, R., Wilson, K. J., Kincaid, D. K., & Strain, P. (2009). Prevent-Teach Reinforce: a standardized model of school-based behavioral interventio n. Journal of Positive Behavior Interventions, 12, 9-22. Dunlap, G., Ionvannone, R., Kincaid, D., Wilson, K., Christiansen, K., Strain, P., & English, C (2009). Prevent-Teach-Reinforce: A school based model of positive behavior su pport Baltimore, MD: Paul H. Brookes. Frea, W. D., & Hepburn, S. L. (1999). Teaching parents of children with autism t o perform functional assessments to plan interventions for extremely disruptiv e behaviors Journal of Positive Behavior Interventions, 1 112-116. Kohler, F. W., & Strain, P. S. (1992). Applied behavior analysis and the movement to r estructure schools: Compatibilities and opportunities for collaboration. Journal of Behavioral Education 2 367390. Lucyshyn, J. M., & Albin, R. W. (1993). Comprehensive support to families of childre n with disabilities and problem behaviors: Keeping it "friendly." In G. H. S. Si nger & L. E. Powers (Eds.), Families, disability, and empowerment: Active coping skills and strategies for family intervention (pp. 365-407). Baltimore: Paul H. Brookes. Lucyshyn, J. M., Albin, R. W., Horner, R. H., Mann, J. C., Mann, J. A., & Wadsworth, G. (2007). Family implementation of positive behavior support for a child with auti sm: Longitudinal, single-case, experimental, and descriptive replication a nd extension Journal of Positive Behavior Interventions, 9 131-150. Marcus, B. A., Swanson, V., & Vollmer, T. R. (2001). Effects of parent training on parent and child behavior using procedures based on functional analysis. Behavioral Interventions, 16 87-104. Marshall, J. K., & Mirenda, P. (2002). Parent-professional collaboration for positive behavior support in the home. Focus on Autism and Other Developmental Disabilities, 17 216-228.
39 Meadan, H., Ostrosky, M. M., Zaghlawan, H., & Yu, S. Y. (2009). Promoting the social and communicative behavior of young children with autism spectrum disorders: A re view of parent-implemented intervention studies. Topics in Early Childhood Special Education, 29 90-104. Moes, D. R., & Frea, W. D., (2002). Contextualized behavioral support in early int ervention for children with autism and their families. Journal of Autism and Developmental Disorders, 32 519-533. Mullen, E. M., (1995). Mullen Scales of Early Learning. Circle Pines, MN: American Guidance Services, Inc Newborg, J., (2005). Battelle Developmental Inventory--Second Edition. Itas ca, IL: Riverside Reimers, T., & Wacker, D. (1988). Parents ratings of the acceptability of behavioral treatment recommendations made in an outpatient clinic: A preliminary analysis of the influence of treatment effectiveness. Behavioral Disorders, 14, 7-15. Rice, C. (2009). Prevalence of autism spectrum disorders. Center for Disease Control and Prevention Retrieved from http://www.cdc.gov/mmwr/preview/mmwrhtml/ss5810a1.htm Rosales, R., Stone, K., & Rehfeldt, R. A., (2010). The effects of behavioral skills training on implementation of the picture exchange communication system. Journal of Applied Behavior Analysis, 42 541-549. Schopler, E., Reichler, R. J., & Renner, B. R., (1988). The childhood autism rating scale (CARS). Los Angeles: Western Psychological Services. Sparrow, S. S., Cicchetti, D. V., & Balla, D. A. (2005). Vineland Adaptive Behavior Scales (2nd ed.). Circle Pine, MN: AGS Publishing Zimmerman, I. L., Steiner, V. G., & Pond, R. E. (2002). Preschool Language Scale (4th ed .). San Antonio, TX: Harcourt Assessment, Inc.
41 Appendix 1: Extra Table Table 5: Summary of intervention
42 Appendix 1 (Continued)
43 Appendix 2: PTR Implementation Fidelity Checklists Routine: ____Potty__________ Child: _____Nicky_____________ Team member: ______________ Consultant:____________________ Task Analysis of Interventions r# Demo #1 S Demo #2 #2 PREVENT STEPS 1. No T.V. Yes No Yes No 2. 5-10 minute of No T.V. on to self-initiate Yes No Yes No 3. Taken to sign say 1 st potty, then Little Einstein Yes No Yes No 4. Physically prompt him to hand you the potty picture Yes No Yes No TEACH STEPS 1.Nicky goes or is physically guided to the bathroom Yes No Yes No 2. Stand blocking the exit Yes No Yes No 3.Head/Eye gesture to the pictures Yes No Yes No 4. Given 10 seconds to self-initiate step Yes No Yes No 5. Physically prompted after 10 seconds Yes No Yes No 6. Repeat for each step Yes No Yes No REINFORCE STEPS 1. Reinforce selfinitiation of bathroom routine or expressing bathroom needs with gestures with a high amount of praise Yes No Yes No 2. Reinforce completion of each step with verbal praise Yes No Yes No 3. Reinforce completion of routine with preferred T.V. Show Yes No Yes No Total Correct Steps Percentage of Correct Steps
44 Appendix 2 (Continued) Consultant :_______________________ Child: ____Nicky ______________ Team member: ____________________ Routine:___Play______________ Instructions: Enter each detailed step that will need to be completed in ord er to correctly implement the behavior plan, then score yourself or another caregiver as t hey implement the behavior plan. Add the number of correct steps and divide by the total number of ste ps in the plan to find out what percentage of time the plan was implemented correctly. Task Analysis of Interventions Tr# Demo #1 S Demo #2 #2 PREVENT STEPS 1. Have alternative appropriate chewing item available 2. Provide choices TEACH STEPS 1. Remove inappropriate item Yes No Yes No 2. Redirect to appropriate item Yes No Yes No 3. Redirect to activity Yes No Yes No REINFORCE STEPS 1.provide praise for chewing on appropriate item Yes No Yes No Total Correct Steps Percentage of Correct Steps
45 Appendix 2 (Continued) Routine: _____Mealtime ___________ Child: ___Nicky ________________ Team member: ____________________ Consultant: ________________ Task Analysis of Interventions Tr# Demo #1 S Demo #2 #2 PREVENT STEPS 1. Non preferred food and a highly preferred reinforcer available Yes No Yes No TEACH STEPS 1. Nicky is given presented with non preferred food first Yes No Yes No 2. He is told first eat _(non preferred)___ then you can have __(high preference__) Yes No Yes No REINFORCE STEPS 1. Given highly preferred food for each bite of non preferred food Yes No Yes No 2. Given praise for each bite of non preferred food Yes No Yes No 3. No verbal redirection given for not eating non preferred food Yes No Yes No 4. Yes No Yes No 5. Yes No Yes No 6. Yes No Yes No Total Correct Steps Percentage of Correct Steps Bites Swallowed
46 Appendix 2 (Continued) Routine: _______Car____________ Child: __Michael________________ Team member: ____________________ Consultant: __________________ Task Analysis of Interventions Tr# Demo #1 S Demo #2 #2 PREVENT STEPS 1. Have books, music, toys, or movies ready 2. Provide choice of book, music, toy, or movie at onset of car ride (provide at least 2 choices) Yes No Yes No TEACH STEPS 1.Interrupt repetitions with a noise Yes No Yes No 2.Count down with fingers from 5 (requiring 5 seconds without repetitions) Yes No Yes No 3.Prompt 2-3 appropriate statements/questions pertaining to the desired location if not engaged with item Yes No N/A Yes No N/A 4.Redirect to item if previously engaged Yes No N/A Yes No N/A REINFORCE STEPS 1.Reinforce appropriate statements with praise/conversation Yes No Yes No 2.Reinforce periods of quiet when Michael is not engaged with preferred items (approx. every 60 sec) with praise Yes No Yes No 3.Reinforce engagement with preferred items with praise and conversation pertaining to the items when he is finished with them Yes No Yes No Total Correct Steps Percentage of Correct Steps
47 Appendix 2 (Continued) Routine: ___Morning____________ Child:____Michael____________ Team member: ____________________ Consultant: __________________ Task Analysis of Interventions Tr# Demo #1 S Demo #2 #2 PREVENT STEPS 1. Have the timer ready Yes No Yes No 2. Tell child, When the timer goes off it is time to _______ and sets timer for appropriate amount of time (30s to 1m) Yes No Yes No TEACH STEPS 1. When timer goes off parents physically prompt Michael to the correct location for the task demand Yes No Yes No 2.Parent verbally prompts Michael to engage in the task while ignoring other behaviors, if necessary the parent can verbally prompt from outside of the room Yes No Yes No REINFORCE STEPS 1. Parent ignores all tantrum behaviors and removes themselves if necessary Yes No Yes No 2. Verbal praise is given for following directions, especially for independently following directions Yes No Yes No 3. 1 sticker is placed under the appropriate reinforcing activity for each demand that Michael completes Yes No Yes No 4. Stickers are given when Michael is not currently engaged in tantrum behavior Yes No Yes No Total Correct Steps Percentage of Correct Steps
48 Appendix 3:PTR Self-Evaluation Social Validity Directions: Please score each item by circling the number that best i ndicates how you feel about the PTR intervention(s). 1. Given the childs behavior problems, how acceptable did you find the PTR behavior plan? __________1____________2_____________3____________4____________5________ Not acceptable Neutral Very acceptable 2. How willing were you to carry out this behavior plan? __________1____________2_____________3____________4____________5________ Not willing Neutral Very willing 3. To what extent were there disadvantages to following the behavior plan? __________1____________2_____________3____________4____________5________ No disadvantages Neutral Many disadvantages 4. How much time was needed each day for you to carry out the behavior plan? __________1____________2_____________3____________4____________5________ Little time Some time Much time 5. To what extent do you think the behavior plan was effective in reducing problem behaviors? __________1____________2_____________3____________4____________5________ Not effective Somewhat effective Very effective 6. Do you feel that following this plan will result in permanent improvements in t he childs behavior? __________1____________2_____________3____________4____________5________ Unlikely Possibly Very likely \
49 Appendix 3 (Continued) 7. How disruptive was it to carry out the behavior plan? __________1____________2_____________3____________4____________5________ Not at all disruptive Slightly disruptive Very disruptive 8. How much did/do you like the procedures used in the behavior plan? __________1____________2_____________3____________4____________5________ Not at all Somewhat Very much 9. How likely is it that you will continue to implement the procedures in the plan after this research is terminated? __________1____________2_____________3____________4____________5________ Unlikely Somewhat likely Very likely 10. To what extent did you observe undesirable side effects as a result of the beha vior plan? __________1____________2_____________3____________4____________5_______ No side effects Neutral Definite side effects 11. How much discomfort did the child experience during the behavior plan? _________1____________2_____________3____________4____________5_________ Little discomfort Some discomfort Significant discomfort 12. How willing were you to change routines in order to carry out the behavior plan? __________1____________2_____________3____________4____________5________ Not willing Somewhat willing Very willing 13. How well did carrying out the plan fit into your current routines? __________1____________2_____________3____________4____________5________ Not at all Somewhat Very well 14. How effective was the intervention in terms of teaching the child appropria te behavior? __________1____________2_____________3____________4____________5________ Not effective Somewhat effective Very effective 15. How well did the goal of the intervention fit with the teams goal f or improvement of the childs behavior? __________1____________2_____________3____________4____________5________ Not at all Somewhat Very well
50 Appendix 4:Novel Rater Evaluation Social Validity Directions: Please score each item by circling the number that indica tes how you feel about the parent and child behavior. 1. The childs behavior is acceptable in this routine. __________1____________2_____________3____________4____________5____ No Somewhat Yes 2. The child is participating in the routine appropriately. __________1____________2_____________3____________4____________5____ No Somewhat Yes 3. The child appears comfortable with how the routine is going. __________1____________2_____________3____________4____________5__________ No Somewhat Yes 4. The strategies used by the parent(s) or family member(s) are work ing in this routine. __________1____________2_____________3____________4____________5__________ No Somewhat Yes 5. The parent appears comfortable with how the routine is going. __________1____________2_____________3____________4____________5__________ No Somewhat Yes 6. The strategies used by the parent are practical for families to implement. __________1____________2_____________3____________4____________5__________ No Somewhat Yes
51 Appendix 5: PTR Integrity Checklist
52 Appendix 6:PTR Goal Setting Worksheet
53 Appendix 7: Functional Behavior Assessment
54 Appendix 7 (Continued)
55 Appendix 7 (Continued)
56 Appendix 7 (Continued)
57 Appendix 7 (Continued)
58 Appendix 8: PTR Assessment Organizational Table
59 Appendix 9: PTR Intervention Checklist
60 Appendix 10:Intervention Plan