Peer instruction of home glucose monitoring.

During a 2-wk summer camp for insulin-dependent children aged 9-15 yr, a voluntary program of home glucose monitoring using an Ames' Dextrometer was offered. The primary instructors were campers who had mastered the procedure and who, with limited staff assistance, tutored naive campers. By camp's end, 96% of all naive campers had practiced this new home glucose monitoring procedure. Procedural errors were infrequent and decreased as a function of practice. No significant differences were found in error rates as a function of either the age or sex of the user. The data suggest that home glucose monitoring could be incorporated into the treatment regimen of many young patients and that peer instruction is an effective method of introducing the procedure to young children.

Improving adherence to fluid restrictions in male hemodialysis patients: a comparison of cognitive and behavioral approaches.

A cognitive intervention and a behavioral intervention were compared to determine their relative effectiveness in reducing interdialytic weight gain (IWG) among eight adult male hemodialysis patients. The behavioral model consisted of positive reinforcement, shaping, and self-monitoring. The cognitive model consisted of a counseling intervention designed to modify health beliefs. Three small-sample experimental studies showed that both interventions produced immediate reductions in IWG. However, the behavioral intervention was superior to the cognitive intervention in producing maintenance of reduced weight gain. Combining the interventions resulted in no improvement over the behavioral intervention alone. Continuation of self-monitoring procedures produced maintenance of improvements up to 2 months posttreatment. Repeated-measures analysis of variance showed changes for only the "barriers" dimension of the health belief model (Hartman & Becker, 1978) (p < .001), and this occurred only following or concurrent with adherence behavior change. Suggestions for treatment and future research are offered.

The effects of contingent music and differential reinforcement on infantile colic.

Infantile Colic is a behavioral syndrome characterized by paroxysms of excessive crying and increased motor activity, hypertonicity of the musculature, excessive flatus and erratic sleeping and feeding patterns. Ten to 40% of all infants are diagnosed as having Colic. The medical evidence to date does not justify any conclusions regarding the etiology or treatment of Colic. Typically, parents are advised to simply wait until Colic has run its course which is often 3-4 months. The behavioral program reported here was designed to increase behavior that competed with crying by reinforcing quiet alertness with music and parental attention. Concurrently, it attempted to inhibit excessive crying by a brief time-out procedure. A group of 8 infants diagnosed as Infant Colic were included in this study. The dependent variable, crying, was measured through direct observations based on hourly samples involving 30 observations of 2-min intervals. The independent variable consisted of a behavioral treatment package. A within-S reversal design was used to assess the functional properties of the treatment. The results show that across all 8 infants the introduction of the treatment package led to a substantial decrease in excessive crying of about 75% of the initial baseline. Further, a functional relationship was identified between the treatment and excessive crying behavior: crying decreased when the treatment was initially introduced, it resumed when the treatment was withdrawn and decreased again when the treatment was reinstated.

Parental versus professional perceptions of obstacles to pediatric diabetes care.

Parents of children with insulin-dependent diabetes mellitus (IDDM) (n = 38) were surveyed to identify common and difficult obstacles to diabetes care. A list of these obstacles was cross-validated by a second parent sample (n = 47) who rated each item according to how common and difficult each item was for them. The list then was rated by a sample of diabetes professionals (n = 15) to evaluate the extent of agreement between parents and health care professionals regarding the frequency with which these obstacles occur and the difficulty they pose to everyday diabetes care. Professionals disagreed with parents regarding which obstacles were most common and difficult, generally rating problems as significantly more common and difficult (t = 5.20, P = < .001) than did the parents who experienced them. The results of the survey underscore the importance of health care providers evaluating the concerns of the local patient community when developing educational and treatment services for these patients.

Punishment as a discriminative stimulus and conditioned reinforcer with humans.

Mental hospital patients were reinforced for responding in a two-response operant situation. When a noise was used to punish one of the responses, all subjects shifted to the unpunished one. When the noise was then paired with positive reinforcement, the subjects responded to produce the noise. Also, a novel response was reinforced by noise in the absence of other reinforcers. This study with humans extends the findings of previous studies with animals in revealing how a punishing stimulus can acquire discriminative or conditioned reinforcing properties.

The effects of "do", "don't" and "wait" requests training on compliance behavior and stimulus generalization.

Previous implementation of compliance training has involved the use of aversive behaviors, as consequents, which bear neither a topographical nor a functional relationship to the behaviors under training. The present study explores compliance training in which training behaviors, used as consequents, are both topographically and functionally identical to the target behaviors. This study extends the compliance literature through: (1) an analysis of the effects of compliance training in long-term institutionalized mentally retarded adults, (2) the investigation of a third response class "Wait" requests, and (3) an assessment of stimulus generalization. Findings discussed include (a) the treatment effects of compliance training, across response classes, within treatment sessions; (b) the spontaneous generalization of treatment effects outside the treatment conditions; (c) the collateral effects of training upon aggressive outbursts; (d) the heightened potential for the utilization of these techniques in long-term care institutions.

Eye movement desensitization across images: a single case design.

The use of Eye Movement Desensitization (EMD) was investigated in a multiple baseline across two images. The subject was diagnosed as suffering from Post Traumatic Stress Disorder (PTSD) and had suffered from two distinct traumas which continued to generate intrusive disturbing images. Dependent variables included self-report information (Subjective Units of Distress, behavioral symptoms reports) and physiological data (heart rate and systolic blood pressure). Subjective and physiological data both demonstrated significant changes during the course of treatment which were maintained at a 2-month follow-up. This study represents the first investigation of EMD with multiple images within a single subject experimental design. Findings suggest that generalization across the images under investigation was not demonstrated. EMD treatment gains were clinically significant. However, the immediate and profound effects often cited in the literature were not demonstrated.

Eye movement desensitization across subjects: subjective and physiological measures of treatment efficacy.

Eye movement desensitization (EMD) was investigated in an experimental multiple baseline across subjects design. Six subjects who met the diagnostic criteria for Posttraumatic Stress Disorder (PTSD) were included in the study. While the EMD technique advanced by Shapiro has been reported to be clinically effective, major methodological issues have been raised which remain to be addressed. One issue raised is whether exposure to the traumatic image is sufficient to account for the reported clinical effects of EMD or whether the addition of saccadic eye movements is central to the treatment. This study attempted to address this concern by comparing two EMD-based procedures: a Non-saccade phase (without the saccadic eye movements) which functioned as a control and a second that included saccadic eye movements. Dependent variables included self-report information (SUDs, behavioral symptoms reports) and physiological data (heart rate and systolic blood pressure). The results showed no significant decreases in SUDs level with the EMD minus the saccadic eye movements procedure. However, five of the six subjects reported clinically significant decreases in their SUDs levels with the inclusion of the saccadic eye movements. This study appears to corroborate previous work employing single-case design as well as pre and postcomparisons.

Matching verbal repertoires: understanding the contingencies of practice in order to functionally communicate with clinicians.

The low utilization rate of empirically proven treatment techniques, the lack of adequate training being received by practitioners in such techniques, and the systemic resistance within the APA to changes designed to increase the dissemination of and support for empirically validated psychological service delivery lead to one conclusion: changes need to be made to increase the knowledge of and use of empirically supported treatment techniques. Such changes are unlikely to come from traditional psychology organizations. This article focuses on how scientist-practitioners can increase both the knowledge base and the utilization rate of empirically validated treatments by practitioners through understanding the contingencies under which practitioners must operate.

Positive practice routines in overcoming resistance to the treatment of school phobia: a case study with follow-up.

The treatment is described of a 6-year-old first grade girl who refused to attend her classroom without adult accompaniment. For eight weeks an attempt was made, using different adult escorts, to prompt/shape classroom attendence through classroom exposure. However, the outcome was the development of an unwavering preference to remain in the principal's office after the child would not tolerate separation from these adults. Rather then continue to take her to the classroom, an intervention was initiated designed to structure her daily experiences and provide instruction. In this she was expected to practice several educational activities at designated times in the principal's office. This intervention resulted in a complete elimination of the child's classroom avoidance within five weeks and concomitant improvements in both social and academic functioning. Although the child's mother suddenly died during intervention, follow-up at one and 12 months in a different school indicated the maintenance of all therapeutic gains. Unique aspects of the procedures pertaining to refractory problems and some tentative behavioral guidelines to overcoming resistance to treatment are discussed.

Behavioral treatment of childhood neurosis.

The present study attempted to use behavioral treatment to eliminate the neurotic symptoms of a 5-year-old child. The child's symptoms were assessed on a pre- and post-treatment basis, and in addition, on going observations of the child's symptoms allowed daily evaluation of the treatment program. Behavior therapy focused on altering the current symptom-environment relationships experienced by the child. Follow-ups on the resolution of the child's problems were conducted two months and two years after behavior therapy and indicated that the child was systom free. Therapeutic attempts to resolve the historical conflicts of early childhood and to resolve the contemporary corflicts of current social interaction are discussed as viable but not mutually exclusive therapeutic strategies.

The ethics of using contingency management to reduce pressure ulcers: data from an exploratory study.

Although there is a widely held argument that pressure ulcers are preventable, they continue to cause major healthcare and financial problems. The blame for pressure ulcers has typically focused on the patient's self-neglect or self-destructiveness. However, more recently, there has been a call for a paradigm shift from the current "paternalistic" medical model to one that includes the patient as a participant in his or her own care. Contingency management, a procedure well known in behaviorism, is presented as one such possibility. Controversy about the use of monetary reward, as well as discussion of initial efficacy in a current study, are discussed.

Effects of reinforcement on standardized test performance.

The effects of two different motivational conditions upon standardized test performance were explored for two student populations. The first study involving 12 trainable retardates showed a significant increase in score on the Metropolitan Readiness Test given under reinforcement conditions when these results were compared with scores taken under standard testing conditions. In a second study, these same results were obtained with a group of 30 normal fourth-graders. An additional study was conducted to determine the effect of different experiences with token reinforcement procedures on test performance. It was found that a group of children with six weeks' exposure to reinforcement for daily academic performance scored higher under both conditions of test administration (standard and reinforcement) than a control group. However, in a single exposure to token reinforcement for correct performance on the Metropolitan Test, both the experimental group and its match control showed a parallel increase in test performance. These findings offer a procedure that yields a more representative assessment of a student's academic achievement than does testing under standard conditions.

Eliminating discipline problems by strengthening academic performance.

Behavior modification procedures have typically been used to eliminate discipline problems in the classroom through reinforcement of nondisruptive behavior. This report demonstrates an alternative approach whereby discipline problems are eliminated by reinforcing relevant academic skills. Five fifth-grade boys, identified by their teacher as discipline problems, were observed. The teacher conducted 15-min performance sessions in her reading class during which written academic performance and disruptive behavior were recorded. These measures indicated that the boys' average level of disruption was 34%, while their reading performance was below 50%. When systematic token reinforcement was applied to reading performance only, the rate of disruption fell drastically, and reading performance increased. When the reinforcement procedure was withdrawn, disruption again rose, and reading performance declined. The reinstatement of reinforcement doubled reading performance and eliminated disruption.

Reinforcer sampling: a technique for increasing the behavior of mental patients.

Mental hospital patients in a motivating ward environment were using the available reinforcers less than was desired. A procedure for increasing the frequency of using reinforcers was developed: all patients were required to engage in the reinforcing event each time it was available but the duration of this required participation was limited so that the event was merely sampled. The effect of this required sampling was experimentally evaluated for three different reinforcers: going for a walk, watching a movie, and attending a music session. More patients used each of the three reinforcers and to a greater extent when the sampling procedure was used. Participation was increased even for those patients who had already been using the reinforcers, demonstrating that the technique did more than provide simple familiarization. Some familiarization was involved since the participation was slightly increased even after the sampling procedure was discontinued. The technique appears to be especially applicable when reinforcers are being delivered infrequently.

Reducing time limits: a means to increase behavior of retardates.

A common assumption in special education is that temporal limits for a task should be expanded so that ample time is provided for completing the work. This study describes the opposite strategy of restricting temporal limits to augment academic performance. Three educable retarded children received token reinforcement contingent on the number of correct math problems answered during daily sessions. A reversal design was used to assess the effects of an abrupt reduction in time limits (20-5-20 min) and a graduated sequence of reductions (20-15-10-5-20 min). The graduated sequence resulted in rate increases of correct responding ranging from 125% to 266% and these gains endured when temporal limits were again expanded. In contrast, the abrupt shift produced interfering emotional behaviors and rate decreases in academic performance of 25% to 80%. The findings indicate that systematically restricting temporal limits for an academic task can further enhance the performance of slow learners already maintained by a token system.

Behavioral coaching in the development of skills in football, gymnastics, and tennis.

A review of the literature indicates that methods of skill acquisition based on the operant paradigm have been scientifically validated with many motor behaviors. However, these procedures have been limited to the use of positive reinforcement for correct performance when applied to the acquisition of complex sports skills in natural settings. To find complementary procedures to enhance skill acquisition, a coaching method involving several behavioral techniques was developed that focused on remediation of errors. This coaching method combined the following components: (1) systematic use of verbal instructions and feedback, (2) positive and negative reinforcement, (3) positive practice, and (4) time out. Three sports, football, gymnastics, and tennis, were selected to determine the effectiveness and generality of this behavioral coaching method. A total of 23 male and female subjects, ranging in age from 11 to 35, was included in this study. Baseline data were first collected for each sport under standard coaching conditions. Next, the behavioral coaching method was evaluated depending on the sport in either a multiple baseline or a reversal design. The behavioral dimensions selected were blocking in football; backward walkovers, front hand springs, and reverse kips in gymnastics; and the forehand, backhand, and serve in tennis. Behavioral coaching was immediately effective in increasing the correct execution of complex skills in all three sports. Gains of up to 10 times the baseline performance were achieved in each sport. In football, behavioral coaching resulted in an increase in correct blocking performance from a baseline average of 5% to 51.3%. Gymnasts' performances increased from baseline averages of 2.7% to 52.6% across the three skills. In tennis, standard coaching produced an average of 6% correct performance which increased dramatically under behavioral coaching to 57% across the three strokes. The success of the behavioral coaching package used here suggests that a technology of behavior may offer additional and complementary strategies to the acquisition of motor skills in the natural environment.

A behavioral-educational alternative to drug control of hyperactive children.

A behavioral procedure for controlling hyperactivity without inhibiting academic performance is described. Using a time-sample observational method, the hyperactivity displayed by three school children was recorded during math and reading classes. Concurrently, math and reading performances were measured. The study consisted of two baselines, one while the children were on medication and the second while they were off medication. A multiple-baseline design across the two academic subject matters was used to assess the behavioral intervention, which consisted of token reinforcement for correct academic responses in math and subsequently math and reading. Discontinuation of medication resulted in a gross increase in hyperactivity from 20% to about 80%, and a slight increase in math and reading performance. Introduction of a behavioral program for academic performance, during no medication, controlled the children's hyperactivity at a level comparable to that when they were on drugs (about 20%). At the same time, math and reading performance for the group jumped from about 12% during baseline to a level of over 85% correct. Each child performed behaviorally and academically in an optimal manner without medication. Contingency management techniques provided a feasible alternative to medication for controlling hyperactivity in the classroom while enabling the children to grow academically.

Behavioral engineering: postural control by a portable operant apparatus.

Recent studies suggested a general behavioral engineering approach to behavioral disorders by portable operant treatment instruments. The approach was applied to the problem of poor posture, specifically rounding of the back or slouching. An apparatus was developed that provided a warning stimulus followed by an aversive tone for the duration of slouching. Slouching was thereby punished by onset of the tone, and non-slouching was reinforced by tone termination and postponement. Twenty-five adults wore the apparatus during their normal working day during alternate periods in which the aversive tone was connected and disconnected experimentally. A miniature time-meter recorded the duration of slouching. The results showed that slouching decreased for each subject during each period in which slouching produced the aversive tone. For two subjects, a second control procedure was applied in which slouching terminated the tone. The result was an increase of slouching, demonstrating that the postural changes were controlled by the scheduled relation between the aversive tone and the response, and not by other factors such as simple response feedback. The substantial changes in posture indicate that the present procedure may prove to be an effective treatment alternative and suggests the general value of the behavioral engineering approach.