Impact of treatment integrity on intervention effectiveness

Treatment integrity has cogent implications for intervention effectiveness. Understanding these implications is an important, but often neglected, undertaking in behavior analysis. This paper reviews current research on treatment integrity in applied behavior analysis. Specifically, we review research evaluating the relation between integrity failures and the efficacy of behavioral interventions. Avenues for future research are provided.     

THE EFFECTS OF THE QUESTION “WHAT IS THIS?” ON TACT-TRAINING OUTCOMES OF CHILDREN WITH AUTISM

Tact training is a common element of many habilitative programs for individuals with developmental disabilities. A commonly recommended practice is to include a supplemental question (e.g., “What is this?”) during training trials for tacts of objects. However, the supplemental question is not a defining feature of the tact relation, and prior research suggests that its inclusion might sometimes impede tact acquisition. The present study compared tact training with and without the supplemental question in terms of acquisition and maintenance. Two of 4 children with autism acquired tacts more efficiently in the object-only condition; the remaining 2 children acquired tacts more efficiently in the object + question condition. During maintenance tests in the absence of the supplemental question, all participants emitted tacts at end-of-training levels across conditions with no differential effect observed between training conditions.Key words: autism, language training, stimulus control, tacts, verbal behaviorSkinner (1957) defined the tact as a response “evoked by a particular object or event or property of an object or event” (p. 82) and considered it to be one of the most important verbal operants. Tacts are maintained by generalized social reinforcement and, thus, they are central to many social interactions. For example, the tact “That cloud looks like a horse” (under the control of a visual stimulus) could evoke a short verbal interaction about the sky or horses. The tact “My tummy hurts” (under the control of an interoceptive stimulus) could evoke soothing statements from a parent. A child who tacts “doggie” in the presence of a cat likely would evoke a correction statement from an adult, further refining two stimulus classes (i.e., dog and cat). These examples illustrate that, despite their topographical differences, the tact relations share antecedent control by a nonverbal discriminative stimulus (S^D) and are maintained by generalized social reinforcement.In habilitative programs for individuals with language impairments, autism, and intellectual disabilities, tacts often are taught for objects (e.g., ball), object features (e.g., color, size, shape), activities (e.g., jumping), prepositions (e.g., between), and emotions (e.g., sad) among others. Although conceptualized differently among therapeutic approaches, the tact relation occupies a central position in many early-intervention curricula. For example, Lovaas (2003) and Leaf and McEachin (1999) describe these relations as expressive labels and recommend that they be taught early in language training using three-dimensional objects accompanied by the supplemental questions “What is it?” or “What''s this?” Alternatively, Sundberg and Partington (1998) explicitly refer to the relation as a tact and recommend beginning instruction by including the question “What is it?” before eventually fading the question. In addition to these clinical manuals, the use of supplemental questions during tact training has appeared in some empirical studies on tact or expressive-label training (e.g., Braam & Sundberg, 1991; Coleman & Stedman, 1974), but not others (e.g., Williams & Greer, 1993). Regardless of whether tact training initially includes supplemental questions prior to response opportunities, tacts ultimately should be emitted readily under the sole control of the nonverbal S^D as well as when it happens to be accompanied by a question.Conceptually, at least four potential problems could arise from introducing supplemental questions early and consistently in tact training. First, the acquired responses might not be emitted unless the question is posed (i.e., prompt dependence). This problem would lead to few spontaneous tacts occurring outside the explicit stimulus control of the training environment. Williams and Greer (1993) compared comprehensive language training conducted under the stimulus control specified in Skinner''s (1957) taxonomy of verbal behavior to a more traditional psycholinguistic perspective with supplemental questions and instructions embedded within trials. For all three adolescents with developmental disabilities, the targets taught from the verbal behavior perspective were maintained better in natural contexts than those taught from the psycholinguistic perspective. However, because data were not reported for each individual verbal operant, it is unclear what specific impact their tact-training procedures had on the outcomes.The second potential problem is that the supplemental question might acquire intraverbal control over early responses and interfere with the acquisition of subsequent tact targets. For example, Partington, Sundberg, Newhouse, and Spengler (1994) showed that the tact repertoire of a child with autism had been hindered by prior instruction during which she was asked “What is this?” while being shown an object. The supplemental question subsequently evoked previously acquired responses and blocked the ability of new nonverbal S^Ds (i.e., objects) to evoke new responses. Partington et al. then showed that new tacts were acquired by eliminating the supplemental question from instructional trials.The third potential problem is that learners might imitate part of or the entire supplemental question prior to emitting the target response (e.g., “What is it” → “What is it … ball.”). For example, Coleman and Stedman (1974) demonstrated that a 10-year-old girl with autism imitated the question “What is this?” while being taught to label stimuli depicted in color photographs. Such an outcome results in a socially awkward tact repertoire and requires additional intervention to remedy the problem.Finally, including supplemental questions during tact training might impede skill acquisition, perhaps via a combination of the problems described earlier. Sundberg, Endicott, and Eigenheer (2000) taught sign tacts to two young children with autism who had prior difficulty acquiring tacts. In one condition, the experimenter held up an object and asked, “What is that?” In the comparison condition, the experimenter intraverbally prompted the participant to “sign [object name]” in the presence of the object. Sundberg et al. demonstrated substantially more efficient tact acquisition under the sign-prompt condition than when the question “What is that?” was included in trials; the latter condition sometimes failed to produce mastery-level responding.Teaching an entire tact repertoire while including supplemental questions (e.g., “What is it?”) during training trials could produce a learner who is able to talk about his or her environment only when asked to do so with similar questions. To the extent that this is not a therapist''s clinical goal, teaching the tact under its proper controlling variables may eliminate such problems. Of course, inclusion of supplemental questions during the early phases of language training could be faded over time such that the target tact relation is left intact prior to the end of training (Sundberg & Partington, 1998). However, the aforementioned studies have documented problems with using supplemental questions during tact training. Given the ubiquity of tact training in habilitation programs, the numerous problems that may arise when supplemental questions are included in training trials, and the limited research on the topic, further investigation is warranted. Thus, the purpose of the present study was to compare directly the rate of acquisition and subsequent maintenance of tacts taught using only a nonverbal S^D (i.e., object only) with tacts taught using a question (“What is this?”) in conjunction with the nonverbal S^D (i.e., object + question). The present study extends earlier research by examining both acquisition and maintenance and by including individuals with no prior history of formal tact training.     

DISCRIMINATION ACQUISITION IN CHILDREN WITH DEVELOPMENTAL DISABILITIES UNDER IMMEDIATE AND DELAYED REINFORCEMENT

We evaluated the discrimination acquisition of individuals with developmental disabilities under immediate and delayed reinforcement. In Experiment 1, discrimination between two alternatives was examined when reinforcement was immediate or delayed by 20 s, 30 s, or 40 s. In Experiment 2, discrimination between 2 alternatives was compared across an immediate reinforcement condition and a delayed reinforcement condition in which subjects could respond during the delay. In Experiment 3, discrimination among 4 alternatives was compared across immediate and delayed reinforcement. In Experiment 4, discrimination between 2 alternatives was examined when reinforcement was immediate and 0‐s or 30‐s intertrial intervals (ITI) were programmed. For most subjects, discrimination acquisition occurred under immediate reinforcement. However, for some subjects, introducing delays slowed or prevented discrimination acquisition under some conditions. Results from Experiment 4 suggest that longer ITIs cannot account for the lack of discrimination under delayed reinforcement.     

A computer-based program to teach braille reading to sighted individuals

Instructors of the visually impaired need efficient braille‐training methods. This study conducted a preliminary evaluation of a computer‐based program intended to teach the relation between braille characters and English letters using a matching‐to‐sample format with 4 sighted college students. Each participant mastered matching visual depictions of the braille alphabet to their printed‐word counterparts. Further, each participant increased the number of words they read in a braille passage following this training. These gains were maintained at variable levels on a maintenance probe conducted 2 to 4 weeks after training.     

OBSERVER TRAINING REVISITED: A COMPARISON OF IN VIVO AND VIDEO INSTRUCTION

We compared the effects of 2 observer‐training procedures. In vivo training involved practice during actual treatment sessions. Video training involved practice while watching progressively more complex simulations. Fifty‐nine undergraduate students entered 1 of the 2 training conditions sequentially according to an ABABAB design. Results showed that the 2 training methods produced almost identical scores on a posttraining observational test; however, the video method required fewer training sessions to complete.     

Relational learning in a context of transposition: a review

In a typical transposition task, an animal is presented with a single pair of stimuli (for example, S3+ S4−, where plus and minus denote reward and nonreward and digits denote stimulus location on a sensory dimension such as size). Subsequently, an animal is presented with a testing pair that contains a previously reinforced or nonreinforced stimulus and a novel stimulus (for example, S2–S3 and S4–S5). Does the choice of a novel S2 instead of previously reinforced S3 in a testing pair S2–S3 indicate that the animal has learned a relation (i.e., “select smaller”)? This review of empirical evidence and theoretical accounts shows that an organism''s behavior in a transposition task is undoubtedly influenced by prior reinforcement history of the training stimuli (Spence, 1937). However, it is also affected by two other factors that are relational in nature—a similarity of two testing stimuli to each other and an overall similarity of the testing pair as a whole to the training pair as a whole. The influence of the two latter factors is especially evident in studies that use multiple pairs of training stimuli and a wide range of testing pairs comprising nonadjacent stimuli (Lazareva, Miner, Young, & Wasserman, 2008; Lazareva, Wasserman, & Young, 2005). In sum, the evidence suggests that both prior reinforcement history and relational information affect an animal''s behavior in a typical transposition task.     

Evaluation of "the incredible years" in Sweden: the transferability of an American parent-training program to Sweden

Structured parent training has been proven to be effective in reducing disruptive behavior problems (DBP) in children. Most of the programs that are used in Sweden have their origin in North America, and there is an ongoing debate over the transferability to Sweden of manual-based programs developed in other contexts. The goal of the present study was to study effectiveness of the Incredible Years parent-training program (IY), developed in the US, in regular clinical work in Sweden, using a randomized controlled design. Parents of 62 four to eight-year-old children diagnosed with Oppositional Defiant Disorder participated in the study. Parents of 38 children were assigned to parent training (PT) and 24 to a waiting list (WL). The results indicate that the IYS retains the positive effects on children's disruptive behavior problems when translated and transferred to Swedish. There was a statistically significant difference in reduction of DBP in children between the groups in favor of the PT. The improvement in the PT group was sustained at the one-year follow-up. The improvement also, at least to some extent, generalized over time to the school context. There was also a statistically significant difference in mothers' report of pre to post change in parenting alliance between the PT and WL groups. The IYS program was appreciated and well received by the participating mothers.     

Training the brain: fact and fad in cognitive and behavioral remediation

Putatively safe and effective for improving cognitive performance in both health and disease, products purported to train the brain appeal to consumers and healthcare practitioners. In an increasingly health-centered society, these applications constitute a burgeoning commercial market. Sparse evidence coupled with lack of scientific rigor, however, leaves claims concerning the impact and duration of such brain training largely unsubstantiated. On the other hand, at least some scientific findings seem to support the effectiveness and sustainability of training for higher brain functions such as attention and working memory. In the present paper we provide a tectonic integration and synthesis of cognitive training approaches. Specifically, we sketch the relative merits and shortcomings of these programs, which often appeal to parents who must choose between side-effect-laden medication and other less conventional options. Here we examine how neuroplasticity allows the healthy as well the impaired to benefit from cognitive training programs. We evaluate the evidence and consider whether brain training can be a stand-alone treatment or an adjunct to pharmacotherapy, outline promising future prospects, and highlight what training outcomes are plausible in line with available data. Future research would determine whether the field of brain training realizes its potential to revolutionize education and rehabilitation or withers away engulfed in controversy.     

Evaluation of a Combined Cognitive Behavioural Therapy and Interpersonal Process Group in the Psychotherapy Training of Clinical Psychologists

It is now widely acknowledged that both content and process elements of psychotherapy play a part in client treatment outcomes. Despite this, there are pressures on Australian clinical psychology training programs to teach evidence‐based approaches in a relatively short time frame. Producing clinical psychology graduates who have an adequate level of competence in evidence‐based practice and meeting the demands of professional accreditation requirements can mean that less time is available to teach the process elements of psychotherapy. The aim of this study was to conduct a preliminary evaluation of a clinical psychology psychotherapy training program that combines an interpersonal process group with a cognitive behavioural therapy training model that incorporates self‐reflection and self‐practice. Eleven participants who participated in the training in 2008 completed the Counseling Self‐Estimate Inventory at pre‐ and post‐training. Significant improvements on the majority of the subscales of this inventory were found. A separate sample of nine trainees and clinical psychology registrars who also previously completed the program attended individual interviews in 2010 aimed at gaining their perspective regarding various aspects of the program. Self‐practice of cognitive behavioural therapy techniques was found to be important in the identification and management of trainees’ own core beliefs, and to their appreciation of how challenging this process may be for clients. The interpersonal process group was described by participants as enhancing their competency as psychotherapists. Common themes included the experience of anxiety and a high level of emotion, and understanding how this experience might be similar for clients; increased self‐awareness; and increased competence in process issues. Many participants believed the process and content components of training were equally important to their development as psychotherapists.     

Stress in Clinical Psychology Trainees: Current Research Status and Future Directions

The purpose of this article is to present the current status of the literature related to stress in clinical psychology trainees (CPTs), and to offer research directions for investigating stress in this population and ways to enhance self‐care in these individuals. The following conclusions emerge from the review: (1) CPTs are vulnerable to elevated stress; (2) undue stress can negatively impact CPTs' personal and professional functioning and, in turn, result in less than optimal standards of care for clients; (3) there is a dearth of studies on stress in this population and no published intervention studies; (4) incorporating self‐care strategies into clinical psychology training is recommended; and (5) “third‐wave” cognitive behaviour therapy stress management interventions have been efficacious in comparable populations. In view of the potential costs of elevated stress to trainees themselves and their clients, research on stress and stress management in this population is of a high priority. Broad research agendas are proposed for these two domains. Modifications to clinical training programmes to reduce trainee stress are required and should be evidence‐based and systematically revaluated.