Chapter 2

APPLIED BEHAVIOR ANALYSIS

AND INTELLECTUAL AND
DEVELOPMENTAL DISABILITIES
Wendy Machalicek, Allaina Douglas, Christine Drew, Hannah Barton,
Buket Erturk, and Tasia Brafford
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Individuals with intellectual and developmental to mitigate any barriers to learning and meaningful
disabilities (IDD) present with deficits in intellectual participation in their lives.
functioning and support needs in adaptive behavior In the past half century, intervention researchers
such as language, motor skills, social skills, and have established a large body of evidence-based
self-care skills (American Psychiatric Association, practices (EBPs) and interventions to improve the
2013). In addition, individuals with IDD are more capacity of individuals with IDD to access the general
likely than the general population to have physical education curriculum, to communicate desires and
disabilities, sensory impairments, seizures, and needs effectively, to learn adaptive skills including
other health conditions such as infection, obesity, those needed for employment, to prevent and
diabetes, and gastrointestinal disorders (Ouellette- decrease challenging behavior, to make meaningful
Kuntz et al., 2005; van Timmeren et al., 2017). They choices, and ultimately to achieve an improved
are also at an increased risk for serious challenging quality of life (Singer et al., 2017). These EBPs and
behavior such as pica, elopement, and aggression, as interventions provide methods for effective instruc-
well as self-injury, obesity, psychiatric disorders, and tion and support for individuals with a variety of
sleep disorders (Bowring et al., 2017; Esbensen & significant support needs including varying adaptive
Schwichtenberg, 2016; Hughes-McCormack et al., behavior competencies, ASD, and profound intellec-
2017; Munir, 2016; Rimmer et al., 2010). Moreover, tual and multiple disability (Alresheed et al., 2018;
they experience poor access to health care and health Courtade et al., 2007; Machalicek et al., 2007, 2008;
care providers with the expertise needed to address Ogletree et al., 2011; Spooner & Browder, 2015).
their often complex behavioral and health needs Various theoretical approaches have formed the
(Fujiura et al., 2018; Krahn et al., 2006). Given the basis for these EBPs, including cognitive approaches,
propensity for comorbidities and the wide range constructivism, self-determination theory, and
of clinical presentations within the categories of intel- behavior analysis (Ertmer & Newby, 1993; Wehmeyer,
lectual disability (ID) and autism spectrum disorder 2005). However, applied behavior analysis (ABA),
(ASD), individuals with IDD vary in the amounts and or the application of basic behavioral principles to
types of support they require. However, all individuals issues society deems important (Baer et al., 1968;
with IDD benefit from individualized, intensive Lerman et al., 2013), is central to the design of
supports, and interventions to acquire, generalize, effective instruction and to the assessment and
and maintain requisite knowledge and skills and treatment of challenging behavior for individuals

https://doi.org/10.1037/0000195-002
APA Handbook of Intellectual and Developmental Disabilities: Vol. 2. Clinical and Educational Implications: Prevention, Intervention, and Treatment,
L. M. Glidden (Editor-in-Chief)
Copyright © 2021 by the American Psychological Association. All rights reserved.

23
APA Handbook of Intellectual and Developmental Disabilities: Clinical and
Educational Implications: Prevention, Intervention, and Treatment, edited by L.
M. Glidden, L. Abbeduto, L. L. McIntyre, and M. J. Tassé
Copyright © 2021 American Psychological Association. All rights reserved.
 Machalicek et al.

with IDD (Didden et al., 1997; Lovaas, 1987; Rush paper of the flagship Journal of Applied Behavior
& Frances, 2000). The basic principles of behavior Analysis, Baer et al. (1968) defined the working
analysis (i.e., motivating operations, stimulus control, assumptions of ABA as follows: (a) human behavior
reinforcement, punishment) are combined into is understandable, as there are fundamental principles
frequently used systematic assessment and instruc- of behavior; (b) human behavior is changeable
tional procedures, including task analysis, the use of through purposeful manipulation of the environment;
prompting hierarchies and time delay, shaping and and (c) the development of effective environments
fading procedures, and contingent reinforcement requires the active manipulation of behavioral
(Browder, 2001; Brown et al., 2015). principles, including stimulus control and stimulus
The purpose of this chapter is to introduce the control transfer, positive and negative reinforcement,
reader to these basic principles of behavior analysis positive and negative punishment, extinction,
and the manners in which they are combined into generalization, and maintenance. Additionally,
systematic instruction procedures, to selectively behavior analysts consider not only the environmental
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summarize ABA interventions across select domains variables that may affect behavior but also human
that we believe are relevant to persons with IDD, physiology, individuals’ learning histories, and the
and to provide suggestions for future research on social context in which individuals must demonstrate
the use of ABA interventions with this population. a skill or behavior.
The remainder of this chapter is organized into the Radical behaviorism includes, but is not limited to,
following sections: overview of behavior analysis, the study of operant human behavior that accounts
review of basic behavioral principles, application of for cognition and emotion, the study of verbal
ABA interventions across relevant domains, and future behavior, and the extension of behavior analysis in
directions in behavioral approaches in support of clinical applications at community and population
people with IDD. levels (Schneider & Morris, 1987). Researchers
have strongly encouraged translational research that
bridges the findings of EAB and ABA; therefore, both
OVERVIEW OF BEHAVIOR ANALYSIS
ABA and radical behaviorism are dynamic fields
This section provides a brief introduction to the influenced by novel scientific findings produced by
history of behavior analysis and the application of EAB researchers (e.g., Mace et al., 2009).
behavioral principles to issues of societal importance Application of the principles of behavior analysis
in ABA. Additionally, we discuss contemporary to humans is a relatively new development in the
applications of ABA across a variety of fields, field of psychology. In 1949, Fuller published the
including rehabilitation and education for individuals first account of a human application of operant
with IDD. conditioning (i.e., changing behavior through the
application of consequences), which consisted
History of response-shaping procedures to increase the
The term behavior analysis encompasses the three frequency of simple arm movement in an individual
overlapping arms of experimental analysis of behavior with profound ID. Additional examples of human
(EAB), ABA, and radical behaviorism (Cooper operant conditioning soon followed in the 1950s
et al., 2007). EAB includes both nonhuman animal (see Lerman et al., 2013). Researchers who first
research and human operant research focused on developed and evaluated ABA interventions for
experimental questions pertaining to basic processes humans evaluated their effectiveness with individuals
or mechanisms of behavioral change, the effects of with IDD and psychiatric disorders in institutional
drugs on behavior, and dose-dependent functional settings (Kazdin, 1978). As the field’s understanding
relations (Skinner, 1963). of the positive effects of ABA-based intervention
ABA is the application of the principles of behavior strategies on human behavior grew, alongside
analysis (discovered through EAB) to issues of elucidation of the basic mechanisms underlying
societal importance (Baer et al., 1968). In a seminal behavior change in humans, interventions became

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 Applied Behavior Analysis and Intellectual and Developmental Disabilities

more sophisticated, focused on more meaningful and intervention. Moreover, the Individuals With
outcomes and a variety of contexts, and began to Disabilities Education Improvement Act of 2004
include behavioral mechanisms beyond operant (2004) mandates the use of a functional behavior
learning. assessment and development of a function-based
behavior intervention plan when the challenging
Contemporary Applications behavior of a student with a disability disrupts
Today, ABA is applied to numerous fields of study the student’s learning or the learning of others or
including (a) behavioral medicine and health; requires a notable change in placement for the
(b) common pediatric issues such as sleep disorders, student with a disability. The school-wide positive
feeding disorders, elimination disorders, and non- behavioral interventions and supports and Pyramid
compliance; (c) mental health promotion and the Models of preventing and addressing challenging
treatment of disorders such as anxiety disorders and behavior for all children, which are based on public
attention-deficit/hyperactivity disorder (ADHD); health models of prevention and intervention, are
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(d) severe behavior disorders; (e) drug abstinence; scaled up packaged interventions and practices
(f) gerontology; (g) sports performance; (h) staff and involving ABA (Carr et al., 1999; Carr et al., 2002;
caregiver training; (i) academics; (j) organizational Fox et al., 2009; Horner & Sugai, 2015). Each of the
behavior management; and (k) animal behavior. The aforementioned exemplars of the application of ABA
science is especially robust in applications benefitting utilizes some combination of the basic behavioral
persons with IDD (Didden et al., 1997; Matson et al., principles of stimulus control, reinforcement-based
1996; McEachin et al., 1993; Peters-Scheffer et al., procedures, punishment-based procedures, and
2011; Rush & Frances, 2000). extinction.
Over the past 50 years, the effects of ABA-based
interventions on individuals with IDD across the
REVIEW OF BEHAVIORAL PRINCIPLES
lifespan have been rigorously studied, and the
development of new interventions and the discovery ABA is primarily concerned with operant behavior—
of basic behavioral mechanisms underlying behav- that is, behavior which is strengthened or weakened
ioral change continues. Lovaas (1987) carried out by reinforcing or punishing consequences within a
initial ABA research with children with ASD that four-term contingency consisting of motivational
sparked interest in the early intervention community variables, a discriminative stimulus, the response, and
and led to eventual widespread use for the treatment a consequence (i.e., positive or negative reinforce-
of ASD. Subsequently, a preponderance of literature ment, positive or negative punishment, or extinction;
has emerged that focuses on comprehensive early Skinner, 1957, 1963). Readers of this chapter may be
intensive ABA intervention (EIABA) for toddlers, familiar with the terms antecedent-behavior-consequence
preschoolers, and early elementary school age (A-B-C), which describe these contingencies more
children with or at risk for ASD (e.g., Eldevik et al., generally, and map onto the more precise ABA
2009; Howard et al., 2014; Klintwall et al., 2015; terminology of motivational variables-discriminative
Koegel et al., 2014; Landa, 2018; Peters-Scheffer stimulus-response-consequence. See Figure 2.1 for a
et al., 2011; Reichow, 2012). EIABA is an EBP for diagram of the four-term contingency; as is displayed
the treatment of ASD and is now widely funded in the figure, the response is the behavior of interest.
across the United States for children with ASD Contemporary ABA interventions for individuals
(Harvey et al., 2010), as it is linked to improved with IDD involve systematic identification and
adaptive functioning, increased IQ, and improved manipulation of motivational variables that tempo­
language abilities. rarily alter both the frequency of a behavior or
In educational settings, behavioral approaches to response and also the value of a consequence (i.e.,
academic instruction and functional skill acquisition motivating operation; Michael, 1982, 1993, 2000).
for individuals with IDD are generally well accepted The antecedent manipulation of motivational vari-
and often used in assessment, behavior management, ables affecting challenging behavior, such as a

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 Machalicek et al.

MO
Motivating
Operation Antecedent
SD Behavior of
Consequence
Discriminative Interest
Stimulus

FIGURE 2.1. Diagram of the four-term contingency.

child’s lack of sleep (e.g., O’Reilly, 1995), is increas- control over Deavin’s hitting and kicking behaviors;
ingly common in the treatment of severe behavior moreover, the presence of the siblings signals the
disorders (Simó-Pinatella et al., 2013). However, a availability of reinforcement (access to the toys) if
thorough discussion of the identification of putative he engages in past behavior that worked to obtain
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motivating operations through experimental func- that consequence. Hitting and kicking is less likely
tional analysis methodology and targeted inter­ to occur if the siblings are not present.
ventions is outside of the introductory scope of Upon repeated exposure to this sequence of
this chapter. events, Deavin may hit and kick in the presence
of a child who resembles one of his siblings, an
Stimulus Control example of stimulus generalization. Malott and Shane
Within an environment, humans are surrounded (2014) described stimulus generalization as the
by various stimuli that can come to control their process by which “the behavioral contingency in
behavior. B. F. Skinner (1974) referred to this the presence of one stimulus affects the frequency
control as stimulus control: “a stimulus present when of the response in the presence of another stimulus”
a response is reinforced acquires some control over (p. 218). Although Deavin may exhibit these
the probability that the response will occur” (p. 103). behaviors to others with similar characteristics as
A behavior that has been reinforced in the presence his siblings, he may also discriminate by not emit-
of specific stimuli is more likely to occur again in ting the behaviors in the presence of other people.
the presence of the same stimuli. Stimulus control Hitting and kicking in the presence of his siblings
plays an important role in the four-term contingency. and not in the presence of others means discrimi-
In Figure 2.1, controlling stimuli are depicted in nation is taking place.
the antecedent block, because stimuli signal the In the example of Deavin (see Figure 2.2), his
availability of reinforcement (or punishment). This siblings serve as a discriminative stimulus or SD. An
explains why some individuals with a developmental SD is a stimulus in the presence of which a particular
disability may engage in higher rates of aggressive behavior will be reinforced or punished due to
behaviors in the presence of some people more than previous learning history (Malott & Shane, 2014).
others. For example, Deavin, an individual with Deavin’s parents may walk in, see Deavin’s attempt
IDD, hits more frequently in the presence of his to kick and hit, and continue to walk through the
siblings than when only in the company of his parents. room and hold onto the preferred toy or item.
More specifically, in the presence of his siblings who Deavin’s parents would then serve as a stimulus
are playing with preferred toys, Deavin begins to hit delta or S-delta, which refers to stimuli in the
and kick his siblings, and the siblings immediately environment that signals the unavailability of
relinquish the toys to Deavin. Over time, this pattern reinforcement for a particular behavior.
of responding may reinforce Deavin’s challenging Researchers and educators arrange stimulus
behavior; therefore, he is more likely to emit the control procedures to ensure appropriate learned
same behavior (hitting and kicking) in the future behaviors are occurring at “the right times.” For
when in similar situations with his siblings. The example, Moskowitz et al. (2017) used various
presence of the siblings would have gained stimulus techniques to establish stimulus control for children

26
 Applied Behavior Analysis and Intellectual and Developmental Disabilities

behavior is positively reinforced by the contingent

SD access to his siblings’ toys when he hits and
Consequence
Siblings With
Toy
Toy Present kicks them.
Rinald and Mirenda (2012) implemented a work-
shop on rapid toilet training for six families with
Behavior
children with IDD. The workshop targeted key
Before
No Toy
Hitting and elements of toilet training such as increased fluid
Kicking intake, scheduled toilet sittings, redirection for
accidents, and positive reinforcement for toileting
correctly. Parents were taught to contingently provide
S their child with enjoyable activities (e.g., reading a
Consequence
Parents With
Toy Present
No Toy book, access to an iPad) during the times that their
child was scheduled to sit on the toilet, thereby
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positively reinforcing the behavior of correct sitting.

FIGURE 2.2. Example of a competing behavior Results of the parent workshop found an increase
pathway. in appropriate toileting behaviors for the children.
Negative reinforcement is similar to positive
reinforcement in that future frequency of behavior
with ASD who were demonstrating anxious behaviors. is increased as a result. Negative reinforcement is
Based on the function of their anxious behavior, the the removal of an aversive stimulus (any unwanted
authors designed a multicomponent treatment person, activity, item, or sensation) from a person’s
package involving gradual exposure of the children environment as a result of their behavior. Campos
to stimuli that once signaled the availability of et al. (2017) examined the use of schedules of
negative reinforcement (avoidance and escape). reinforcement for two individuals whose behaviors
They also provided techniques to increase appropriate were maintained by negative reinforcement in the
behaviors, such as reinforcing behaviors incompatible form of escape-maintained problem behavior (e.g.,
with anxious behaviors. These appropriate behaviors would engage in aggression to remove or get out
were brought under stimulus control through of an academic demand). The authors taught the
increased exposure, modeling, rule-governing individuals to exchange a card for a 30-second break
statements (e.g., “I am going to be brave,” from using least-to-most prompting; by teaching the alter-
Moskowitz et al., 2017, p. 86), and increased native response, the individuals could still escape
reinforcement. This intervention allowed the the task demands, but the aggressive response was
children to discriminate and determine when it no longer needed in order to get out of fulfilling the
was the right time to emit new appropriate behaviors demand. Results of the study found that teaching
rather than engage in anxious behaviors. the alternative response provided clinically significant
changes in the individuals’ negatively reinforced
Reinforcement aggressive behavior.
Reinforcement is the response-contingent presentation Common reinforcement procedures include
or removal of a stimulus (person, activity, item, differential reinforcement, which refers to providing
sensation) that results in increased future frequency reinforcement for appropriate, predetermined
of the response. Positive reinforcement is defined by responses, and withholding or providing a reduced
the response-contingent presentation of a stimulus amount of reinforcement for all other responses.
that results in an increase in future frequency of Differential reinforcement is an effective way to
responding. The word “positive” in reinforcement teach a new behavior and reduce unwanted or prob-
refers to something being added to the individual’s lematic behaviors. The main applications of differen-
environment after the individual exhibits a specific tial reinforcement include differential reinforcement
behavior. In the Deavin example, his challenging of alternative behavior, differential reinforcement

27
 Machalicek et al.

of incompatible behavior, and differential reinforce- (removal of a stimulus), which decreases the likeli-
ment of other behavior. hood of future occurrence (decreased responding),
Wilder et al. (2012) utilized contingent differential then the joke has been negatively punished. How-
reinforcement with two preschoolers after a modified ever, if the joke results in removed task demands
three-step guided prompt sequence (i.e., vocal, (removal of a stimulus), which increases the future
model, and physical guidance) was ineffective in likelihood of joking (increased responding), then
establishing compliance. During the differential the behavior is negatively reinforced.
reinforcement condition, children were positively Time out from positive reinforcement is a
reinforced with a preferred edible contingent on commonly used punishment procedure in educa-
handing over a toy when the researchers prompted, tional and parenting programs that requires removal
“Give me the toy.” Engaging in other behavior when of the positive reinforcement or the opportunity to
prompted did not result in delivery of a preferred gain positive reinforcement contingent upon a target
edible. Results of the study found that using behavior for a specific amount of time (Cooper et al.,
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differential reinforcement increased compliance 2007). The effective use of time outs does not require
for some children. the removal of an individual to a “time out area,”
but it requires removing the individual’s access to
Punishment reinforcement. Nonexclusionary time out refers to
Punishment is a basic behavioral principle with an the individual remaining in the environment while
undeniable role in the development and maintenance access to the maintaining reinforcer is removed. For
of adaptive behavior and in the suppression of example, limiting the number of points a student can
undesirable behavior for all humans, including earn to have access to computer time following a
those with IDD (Sidman, 1989). Similar to other verbal threat to a peer (withdrawal of the opportunity
consequence-based strategies, punishment can to earn a specific positive reinforcer during a specific
occur with two different types of stimulus change: period of time; Cooper et al., 2007), removing any
(a) positive punishment, which refers to immediate social reinforcer from any source following an unde-
presentation of a stimulus following a target response sired behavior (teacher turns head away and does not
that results in a future pattern of decreased target respond to the undesired behavior), or rearranging
response; and (b) negative punishment, which refers the student’s seating in the classroom to enable the
to immediate removal of a stimulus following a student to observe while activities are carried out
target behavior that results in a future pattern of but access to reinforcement is removed (contingent
decreased target response (Cooper et al., 2007). observation of the delivery of reinforcers), are all
Because the terms positive and negative are also examples of time out. Exclusionary time out involves
used for reinforcement and have different meanings the individual being removed from an environment
in lay language, they can be easily confused. The for a period of time. This might mean the use of a
key difference to distinguish these two principles specific area outside of the environment, such as the
is the effect the consequence has on the observed hallway, or an area within the environment but with
response. For example, if making an inappropriate limited view of the environment.
joke in a classroom results in a teacher reprimand The use of punishment-based procedures in ABA,
(addition of a stimulus) and the reprimand reduces particularly the use of aversives (e.g., facial screening,
the future likelihood of that behavior (decreased electric shock) or restrictive procedures (e.g., exclu-
responding), then the inappropriate joke has been sion, manual restraint), has produced substantial
positively punished. However, if making an inappro­ controversy over the last several decades in the treat-
priate joke results in peer attention (addition of a ment of severe behavior disorders (i.e., self-injurious
stimulus), which increases the likelihood of joke behavior or aggression with the potential to cause
telling in the future (increased responding), then serious harm to self or others; Durand, 1990; Evans
the joke has been positively reinforced. If the same & Meyer, 1990; Matson, 1987; Newsom & Kroeger,
inappropriate joke results in the removal of recess 2016; Schroeder & Schroeder, 1989). During this

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 Applied Behavior Analysis and Intellectual and Developmental Disabilities

time, researchers and professionals begin to rely generate behavior (Lattal et al., 2013). Extinction
primarily on multicomponent behavior intervention is defined as eliminating the connection between
plans and antecedent interventions, which are the behavior that has been positively or negatively
based on manipulation of motivational variables reinforced, by withholding the maintaining
and stimulus control (Carr & Carlson, 1993; Carr consequences (Keller & Schoenfeld, 1950/1995).
et al., 1990). The treatment of serious challenging The term extinction refers to the mechanism that
behavior (e.g., aggression, pica or the ingestion of produces behavior decrease, not the behavior
inedible materials) for some individuals with IDD being extinguished.
does require the use of aversives or restrictive One of the most commonly observed charac­
procedures to prevent harm (Hanley et al., 2005; teristics of extinction is an extinction burst, an
Lerman & Vorndran, 2002); however, the use of increase in the response shortly after extinction is
aversives or restrictive procedures is now uncommon implemented. In our everyday life, we engage in
in ABA intervention research even when addressing extinction bursts. For instance, when we have a
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serious challenging behavior (Erturk et al., 2018; phone conversation, we usually use a conversational
Kahng et al., 2002). tone of voice, but if the other side does not respond,
Punishment-based procedures, including the use we tend to raise the volume of our voice to ensure
of everyday punishment procedures such as time out that we are heard. The extinction burst may be more
from positive reinforcement, are not recommended serious when an individual is engaging in challenging
as a sole or first line of intervention due to potential behavior such as tantrums or aggression. In this
deleterious side effects, and when utilized, they case, if no other interventions are in place, it is
should be consistently applied and combined with highly likely that the behavior will worsen before it
a variety of teaching, antecedent, or reinforcement- decreases. Therefore, extinction should not be used
based strategies (Cooper et al., 2007). Punishment alone for severe challenging behavior. Extinction
does not teach individuals an appropriate alternative can also generate different behavioral topographies.
behavior. Punishment may suppress a targeted For example, a child with ID who screams when
behavior in a given setting; however, the individual protesting about eating during dinner may increase
might then engage in a different topography of the volume of their screaming during an extinction
challenging behavior from the same response class burst. However, during the implementation of
or engage in the same behavior in a different setting. extinction procedures (when screaming does not
Emotional responses, such as aggression, can occur result in the typical reinforcement of the parent
when punishment is applied. Finally, punishment removing the plate from the table), the child may
procedures can inadvertently punish appropriate also engage in novel behavior, such as throwing food
behavior in temporal proximity to the delivery of the items or the plate, kicking the table, or throwing
punishing consequence (Hineline & Rosales-Ruiz, their body off the chair. These new responses can
2013). Due to these common deleterious effects be explained as the child’s attempts to gain access to
and the requisite consistent implementation and their preferred reinforcement of avoidance of eating
monitoring to avoid iatrogenic effects, the Behavior by removal of the plate to the kitchen.
Analyst Certification Board (2017) mandates the use
and documented evaluation of reinforcement-based
BEHAVIORAL INTERVENTIONS FOR
interventions prior to use of a punishment-based
TEACHING NEW BEHAVIORS AND SKILLS
intervention, and when punishment procedures are
used, they must be combined with teaching an The dependent variables or outcomes of interest
alternative response. in ABA are observable, measurable, and related to
teaching a new, socially desirable response; shaping an
Extinction existing response; or changing a maladaptive response
Extinction is commonly used to decrease a target (e.g., self-injurious behavior) to a more acceptable
behavior, but it also refers to procedures used to response. These responses can be discrete responses,

29
 Machalicek et al.

such as increased frequency of spontaneous use of Forward chaining.  Forward chaining refers to

a speech-generating device to request a preferred teaching a skill or routine in the order it naturally
activity, increased frequency of social greetings, occurs, but doing so step by step. That is, each
or decreased rate of aggression. The responses can step is individually taught in the order that it is
also be chained responses, such as improved use of demonstrated in the task analysis. The first step
strategies for accepting criticism from a supervisor, that the learner cannot complete independently is
correct completion of steps involved in microwaving targeted for teaching until the learner can perform
a meal, or percentage of steps completed correctly the step independently; only then is the next step
to make a purchase or take the city bus home targeted for teaching. For example, if an individual
from work. is learning to brush her hair, the first step of picking
Behavioral approaches to teaching involve up the brush may be targeted. The interventionist
dividing a new skill into discrete tasks and teaching may use a prompting strategy (e.g., least-to-most
the individual skills within each task (i.e., chaining prompts) to teach the first skill of picking up the
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procedures), reinforcing approximations of the brush and then model the remaining steps for the
targeted behavior to teach (i.e., shaping procedures), learner. Only once the individual demonstrates
or through a combination of operant learning picking up the brush independently will the inter-
strategies in discrete trial training (DTT) and ventionist target the next skill to teach (e.g., holding
incidental or naturalistic teaching (MacDuff brush up to hair). Forward chaining continues in
et al., 2001). this sequence until the entire behavior chain task is
completed independently by the learner.
Chaining
Chaining can be defined as taking a specific routine, Backward chaining.  During backward chaining,
activity, or skill and breaking it down into discrete all behaviors within the task analysis are completed
responses that are linked together to form the termi- by the interventionist except for the last step within
nal task (Neel & Billingsley, 1989). A task analysis the task analysis. The last step is where instruction
is created to outline the expected steps and to assess begins for the learner. For example, if teaching
the ability of the individual to complete each step how to make a sandwich, the interventionist would
of the task, thereby accurately identifying steps complete all the steps for making a sandwich except
that require (a) making the stimuli more salient for cutting the sandwich in half (the last step). The
(e.g., highlighting the start button on the microwave interventionist would then prompt the individual
with a colored sticker, including picture symbols), through the last step until he or she performed
(b) adding prompts (e.g., person listens to auditory the skill independently; the next skill to be taught
recording of steps and interventionist uses gestural would be the step that came before cutting the
prompts to indicate next action) to occasion sandwich (e.g., putting the second piece of bread
responding, or (c) adapting the materials for easier on top of the first piece of bread). Backward chaining
access (e.g., using elastic waistbands for dressing continues in this sequence until the entire behavior
tasks when the individual has motor problems that chain is complete. Backward chaining is beneficial
make pulling pants up difficult). Each prior step of because it allows the individual to contact the natural
the task analysis serves as the SD for the step that reinforcer of the task (e.g., eating the sandwich)
follows, and the completion of the task or routine more quickly. Backward chaining, along with
allows the person to access a naturally occurring errorless learning (i.e., use of most-to-least prompt
potent reinforcer (e.g., eat the meal prepared, travel hierarchy to ensure that no errors are made during
to the movies via the bus). Three main techniques skills acquisition), has been used to teach a variety
have been used when teaching a skill using chaining: of skills to people with IDD, including the use of
forward chaining, backward chaining, and computer skills, specifically using a computer
total-task or whole-task chaining (Alberto & independently to access a preferred website
Troutman, 2005). (Jerome et al., 2007).

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 Applied Behavior Analysis and Intellectual and Developmental Disabilities

Total-task chaining.  Total-task chaining involves In DTT, the interventionist carefully arranges

targeting each step within the task analysis as it trials consisting of a SD/antecedent prompt (for
occurs in natural order. For example, if teaching example, the interventionist says, “Give me the black
someone to tie her shoes, the interventionist would horse with white spots”), the targeted response (the
prompt the individual through each step within child scans a messy array of nine different colored
the task analysis until the total task was complete horses, picks up the black horse with white spots,
(i.e., the individual participates in each step in the and hands it to the instructor), an immediate
task). The interventionist involves the individual reinforcing consequence (the interventionist says,
in each step of the task analysis until the task is “Excellent! You found the black horse with white
completed. Total-task chaining is helpful in including spots!”), and a short intertrial period before the
individuals in each part of the task and mimics the delivery of the next trial (Lovaas, 1981, 1987;
type of assistance that is naturally occurring. Webber & Scheuermann, 2008). When a child is
learning a new response, the SD is usually combined
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Response Shaping with an extra antecedent prompt to ensure correct

Shaping is another way to teach a new behavior. responding. For instance, in the example above, the
Shaping refers to providing reinforcement for interventionist says, “Give me the black horse with
successive approximations that resemble the target white spots” and simultaneously points directly to
response until the desired terminal behavior is the correct horse. Additionally, early learners would
demonstrated. Shaping can be compared to sculpting first learn to scan a simpler array of stimuli (e.g.,
clay until it is formed into its desired product. For a horse and an elephant) and the prompts would
example, shaping can be used to teach a student begin with less complexity (e.g., the interventionist
to raise her hand in class. First, reinforcement may says, “Give me the horse”). This is a good example
only be delivered when the student lifts her hand of more complex listener responding, as the learner
only an inch from her desk. Once the behavior must listen carefully to the prompt, which contains
occurs reliably, reinforcement may be withheld until information about the color and pattern of the
her hand is 3 inches from the desk. The shaping horse, and the specific direction to give the inter-
process continues in this fashion until the student’s ventionist the horse. The array would include black
hand is fully extended in the air (i.e., the terminal horses with and without spots of different colors.
behavior). Shaping is most beneficial when using Then, any response or stimulus prompt would
differential reinforcement. be faded (the therapist’s point to the horse would
become farther away until no longer used) within
Discrete Trial Training and across DTT sessions, until the child’s correct
DTT has a substantial evidence base for use with response is under the control of the naturally occur-
individuals with ASD and ID and is generally situated ring stimulus (e.g., “Give me the black horse with
within other intervention approaches, such as in white spots”). Interventionists should use procedures
combination with natural environment teaching that minimize learner errors, such as most-to-least
(Lerman et al., 2016). Although typically imple- prompting, wherein the interventionist pairs the SD
mented as a one-on-one intervention, DTT has with the most intrusive prompt (e.g., physically
been effectively used as group instruction (see Leaf prompting the learner to engage in the correct
et al., 2013). Taken as a whole, the current research response, using a gestural prompt indicating
suggests that children with ASD who participate in the correct response, adding a stimulus to the
DTT programs experience greater improvements in correct response such as moving the target object
intellectual functioning and adaptive skills, language closer to the learner) required to evoke the correct
and nonverbal communication, and social and play response for the learner. When the learner responds
skills, when compared with children with ASD who correctly at this level of prompting across a pre­
participate in eclectic treatment models or treatment determined number of trials, the instructor moves
as usual (Lerman et al., 2016). to a less intrusive prompt (e.g., partial physical

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 Machalicek et al.

prompt, partial gestural prompt) until the learner instruction can occur in either structured contexts—
eventually responds correctly independent of any such as in instructor-led DTT based on a structured,
response or stimulus prompts. developmentally appropriate curriculum—or in
Effective reinforcement is essential to any DTT the course of naturalistic situations wherein the
program, and a denser schedule of reinforcement individual with IDD leads the interaction, such
is preferable for optimal skill acquisition (Hausman as in incidental teaching or naturalistic behavioral
et al., 2014). Correct responses are followed by interventions (Schreibman et al., 2015).
contingent social praise, or the child is asked to
choose a preferred item or activity that is briefly Naturalistic Behavioral Approaches
provided. Correct independent responses are differ- In contrast to DTT, incidental or naturalistic teaching
entially reinforced by a higher quality or quantity of occurs in the context of learner-selected activities.
reinforcer (e.g., 30 seconds of playing with bubbles Thus, the context of the activity is thought to be a
as music plays) versus prompted responses that preferred context. Incidental or naturalistic teaching
Copyright American Psychological Association. Not for further distribution.

are followed by a lower quality or quantity of relies on interventionists to arrange or manipulate

reinforcer (e.g., 10 seconds of watching a marble the environment to improve learner motivation.
racing video). Preferred items and social interactions The interventionist presents trials throughout the
that may serve as effective reinforcers are typically interaction. The intertrial duration tends to be
identified using systematic preference assessments longer than in DTT, and SDs are varied so as to
(for a review of preference assessment procedures, increase skill generalization, but the same types
see Hagopian, Long, & Rush, 2004). of prompt hierarchies (e.g., least-to-most system of
Additionally, error correction procedures are prompts, most-to-least prompts, or errorless learning)
used when the learner responds incorrectly or fails are used to occasion independent, correct responses
to respond to the SD. A variety of approaches to in both DTT and naturalistic approaches. For
prompts and error corrections exists (MacDuff et al., instance, a paraprofessional may be coached by
2001), but they tend to include both instructor an interventionist to implement both DTT sessions
behavior (e.g., saying “no” neutrally, turning away and naturalistic instruction sessions for the same
briefly, introducing a different trial, showing the communication targets (e.g., requesting preferred
correct response) that marks the incorrect response items and commenting on observed actions using
for the learner as well as learner practice of the varied two-word phrases such as “want car” and
correct response. “walking slow”). For DTT and naturalistic instruction
In DTT, the instructor is in control of the SDs, the sessions, the paraprofessional may use the same
pace of instruction (which is typically brisk enough types of prompts (paraprofessionals provide a
to afford many teaching opportunities in a few partial verbal prompt, such as: “Say, want ______”)
minutes), the interspersing of targets, the intertrial to occasion correct responses, but the pace of
duration, the delivery of reinforcing consequence instruction and who controls the presentation of
and error correction, and the number of times a trial teaching opportunities differs in these approaches.
is repeated. Furthermore, the instructor responds Practically speaking, both approaches should be
to the response of the learner by altering stimulus flexibly used to promote skill acquisition for indi-
and response prompts as needed to elicit correct viduals with IDD, and both methods are typically
responding and to increase independent responding combined in packaged interventions involving task
over time. analysis and systematic instruction. The use of DTT
As in any effective ABA instruction, instructors has been shown to be most effective in teaching
should regularly collect data on the learner’s progress complex conditional discriminations such as those
in order to modify instruction as needed to maintain illustrated in the horse example above (Steege et al.,
progress and to continue instruction on targets 2007), whereas incidental or naturalistic teaching is
already learned to promote maintenance of newly more commonly used in functional communication
acquired skills and knowledge. Effective behavioral intervention or social skills intervention and to

32
 Applied Behavior Analysis and Intellectual and Developmental Disabilities

improve maintenance and learning (e.g., Baril & same materials depicted in the videos. Results found
Humphreys, 2017; Hart & Risley, 1974; Ingersoll that students were able to better generalize in the
et al., 2005; Ingersoll & Schreibman, 2006). second condition; however, students still generated
correct performance in the first condition. These are
promising results for the effects of video modeling on
ACQUISITION RESEARCH IN
generalized skill use. Using video models also allows
INTELLECTUAL AND DEVELOPMENTAL
for independence of the learner since the method does
DISABILITIES
not require an interventionist to be present.
ABA interventions are further characterized by Money management skills are essential for the
(a) the use of specific strategies such as prompting promotion of independence (Browder & Grasso,
hierarchies, video modeling, picture activity schedules, 1999), and many individuals with IDD need to be
and verbal instructions to prompt responses; able to independently access their money through
(b) adaptation of intervention procedures to fit electronic banking accounts. Scott et al. (2013)
Copyright American Psychological Association. Not for further distribution.

the local context such as changing prompt strategies taught three individuals with IDD to withdraw
used during community outings to decrease intru- money from an ATM using iPod technology. The
siveness and improve social validity; and (c) the use intervention consisted of video modeling and
of multicomponent, packaged interventions (Lerman auditory prompts, which were self-operated by the
et al., 2013). Due to the broad nature of what individual with IDD. Generalization probes were
constitutes priority skills for individuals with IDD, conducted after training at novel ATMs at local banks.
this section will summarize a few relevant areas of Maintenance sessions were conducted 1, 3, and
functional life skills, as well as research on safety 5 weeks after the individual met training criterion.
skills and health promotion interventions. The term Results of the intervention found that all individuals
functional life skill typically refers to a curricular were able to meet training criterion and maintain
focus in one of three areas: (a) recreation/leisure, skills at 5 weeks posttraining. In addition, individuals
(b) independent/supported living skills, or were able to generalize skills to local ATMs and
(c) community participation (Alwell & Cobb, withdraw $20. These findings support the use of
2009). The purpose of functional life skills training electronic devices as platforms for teaching functional
is to teach academic, social, and vocational life skills to individuals with IDD.
competence (Alwell & Cobb, 2009). McKissick et al. (2013) taught three third and
fourth grade children with ASD map-reading skills
Independent and Supported Living Skills using a computer-assisted explicit instruction lesson.
Teaching individuals with IDD how to care for their The children were taught specific symbols that are
home environment is important in order for them typically seen on a map or directory (i.e., exit,
to maintain an optimally independent lifestyle. bathroom, food, school, mall, park). The intervention
Depending on motor abilities and age, housekeeping program consisted of a presentation of a slide show
skills may include putting away dishes after washing depicting a map and symbols locations. On each
them, making the bed, vacuuming, laundry skills, slide, a written and verbal SD (e.g., “My turn. Click
and cooking a meal. One example of teaching a mall legend”) was presented. Fading of prompts
valued home skill was conducted by Mechling et al. occurred systematically as children progressed
(2015). They taught four high school-age students through the instruction. The intervention was
two types of tasks: loading the dishwasher and effective for all children; however, findings were not
recycling. The intervention consisted of using video as robust for one of the three children. Two children
models to demonstrate the targeted tasks. In the were able to generalize the skills they learned to
first condition, students were asked to perform the an untrained map of North Carolina. This study
video-modeled tasks using materials that were demonstrates high usability in that the children
different than those in the video. In the second completed the lessons independently on computer
condition, students performed the tasks using the software and the teachers were able to assist other

33
 Machalicek et al.

children in the class while these selected children sanitary napkin and underwear as needed. To our
worked on map-reading skills. knowledge, this is only the second example of such
Similarly, Price et al. (2018) addressed the use of a skill being included in ABA research (Veazey et al.,
public transportation by teaching four individuals 2016). Community providers may be teaching these
with IDD to navigate to locations around a college skills in ABA programs without the benefit of recent
campus using Google Maps and public transportation. research to guide their practice. In spite of instruc-
Three of the four participants were able to master, tional and behavioral interventions in ABA and the
generalize, and maintain their skills. ability to effectively teach these skills, very little
research is being conducted on the most efficient or
Self-Care socially valid ways to do so.
Individuals with IDD who lack independent self-care Due to the use of different prompts and their
have a higher likelihood of increased lifetime cost different sequences, Donnelly and Karsten (2017)
of care, of being victims of abuse, and of their care- conducted multiple investigations to identify errors
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givers experiencing heightened stress levels (Barrett that are often made while teaching self-care skills.
et al., 2015; Macias et al., 2006; Sevlever et al., 2013). They found errors consisting of prompting steps
ABA is particularly adept at teaching self-care skills out of order, delivering the reinforcer after a step dif-
through the use of chaining, modeling, prompts, ferent than the training step, and failure to prompt
and reinforcement. However, these skills have been completion of all steps in a chain in a trial. The
relatively neglected in the ABA literature. Only authors found that these errors affected acquisition of
13 studies that addressed self-help skills in participants behavior and disrupted performance. These findings
with ASD were found in a recent review (Wertalik & highlight the need for consistent and complete
Kubina, 2017). Despite the dearth of studies in these prompting when teaching self-care skills to indi-
essential areas, this body of research suggests the viduals with IDD. If prompting errors occur, they
effective application of ABA to self-care skills that are may influence whether the individual is able to
important across the lifespan. acquire the independent skill or result in partial
Developing independent toileting skills is the participation.
first step to being independent in one’s first social
environment (e.g., one’s family; McManus et al., Safety Skills
2003). In 1971, Azrin and Foxx created the intensive Individuals with IDD, especially those with a dual
toilet training method. Since then, many investigations mental health diagnosis, are more likely to become
have adapted the original method to decrease the victims of crimes, experience social victimization
intensity of the practice. Ardiç and Cavkaytar (2014) (coercion, theft, teasing, and abuse), and suffer
investigated the use of the modified intensive toilet adverse events, but also more likely to be offenders
training method with three children with ASD. This (Fogden et al., 2016). Additionally, as Shi et al.
approach consisted of increased fluids and scheduled (2015) discovered in their review of unintentional
toileting sit times; however, overcorrection procedures injuries in children with a disability, children with
(a punishment-based procedure) were not used IDD are at a significantly higher risk of unintentional
(see Azrin & Foxx, 1971). Results of the investigation injury than typically developing peers. Kearney
found that all three children were able to learn to et al. (2018) taught three adolescents with IDD and
use the toilet and keep their pants dry in a short ASD first aid skills by implementing literacy-based
period of time. behavioral interventions (LBBIs) and using peers
Mays and Heflin (2011) used prerecorded auditory as the interventionists. The authors first created a
prompts to increase independent completion of task analysis of the skills to teach in first aid, then
tooth brushing and hand washing. In another study, created a storybook consisting of 15 pages, with
researchers used forward and total task chaining each page corresponding to a step of the task analysis.
to teach one participant to change a soiled sanitary The intervention consisted of a peer first reading
napkin and another participant to change her soiled aloud the sentence on each page, pointing to the

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 Applied Behavior Analysis and Intellectual and Developmental Disabilities

picture, and then gesturing to the needed materials prerequisites: ability to follow three-step instructions,
(e.g., latex gloves). The researchers then gestured to ability to imitate gross motor actions and echo
a simulated cut and stated, “He’s hurt. Can you do phrases, ability to answer simple intraverbals, and
first aid?” If the participant did not respond within ability to identify familiar people. Following the
30 seconds, a prompting hierarchy was initiated to intervention, each participant acquired targeted skills,
ensure correct responding. Follow-up sessions were and two of the three participants maintained
conducted without the LBBI storybook to assess skills at follow-up. Ledbetter-Cho et al. (2016)
whether skills could be maintained in the absence of successfully replicated these procedures with four
the book. Following the intervention, each adolescent school-age boys with ASD (3 boys with ASD and
was able to clean and dress a wound using the peer- 1 boy with ASD and Jacobsen syndrome), and also
mediated LBBI, and skills were maintained after the included male confederate strangers; their absence
storybook was removed. These findings add to the was a limitation of the Gunby and Rapp intervention
literature on the use of peers to teach safety skills to study. Other safety skills such as fire safety (e.g.,
Copyright American Psychological Association. Not for further distribution.

children with IDD. leaving the building, reporting the fire, staying at
Ozkan et al. (2013) taught five children with least 20 feet away from the building) have also been
mild to moderate ID the skills of correctly identifying taught using behavior skills training. Garcia et al.
the emergency service to call in different emergency (2016) taught these skills to three boys with ASD
situations and reciting their respective telephone between the ages of 4 and 5 years old. To be eligible
numbers. Computer-based instruction consisted of for participation in the study, the children had to be
36 clickable cards illustrating various accidents. For able to follow one- to two-step instructions, commu-
example, one of the cards depicted a child who nicate vocally, answer basic questions, score Level 3
had fallen off a bike, and the question “Who do on the Verbal Behavior Milestones Assessment and
you call in case of electric shock, poisoning, or traffic Placement Program, and had to lack both safety
accident?” would appear in vocal and written form. skills and challenging behavior. Garcia et al. (2016)
The child would then click through the cards to find also included a generalization phase in which the
the answer to the questions. Probe sessions were participants were placed in a new setting, a fire alarm
conducted to determine whether the children learned was tripped, and no feedback or reinforcement were
any of the emergency service phone numbers or provided. All three participants performed 100% of
situations in which to call them. Maintenance and the skills during follow-up sessions. These findings
generalization sessions were held to determine advance the research on identifying efficient and
whether skills were maintained postintervention and effective ways to teach children with IDD safety
whether the children were able to answer questions and independent skills that are based on ABA.
accurately if they were delivered in a different format.
Findings from the intervention determined that Health Promotion
computer-based instruction was effective in teaching Individuals with IDD often have worsened health
emergency contact discrimination and number recall outcomes, including higher rates of obesity and
to children with ID. diabetes, lower life expectancies, and higher rates of
Safety interventions such as abduction prevention chronic conditions in comparison with the general
are rare but do exist (Gunby & Rapp, 2014; population (see Chapter 18, this volume). In one
Ledbetter-Cho et al., 2016). These interventions review of health expenditures for individuals with
include behavior skills training, with in situ coaching, IDD, Fujiura et al. (2018) found that chronic condi-
on abduction skills that include learning the correct tions and poor mental health status were predictors
response of verbally refusing to leave with a confed- of increased service utilization. Also, for individuals
erate stranger, moving away, and telling a trusted with IDD, medication accounts for a higher per-
adult. Gunby and Rapp (2014) examined these centage of spending (36% vs. 21%) than it does for
procedures with two 6-year-old boys with ASD and their same-age typically developing counterparts.
one 5-year-old girl with ASD who met the following While some of this difference may be attributable to

35
 Machalicek et al.

comorbid disorders, there is also a pronounced ser- her comorbid psychiatric symptoms (Cromartie
vices gap for this population (Fujiura et al., 2018). et al., 2014). A recent book chapter reviewed
One related disparity centers on the administration of both behavioral and nonbehavioral interventions
screening and diagnostic procedures. For example, to increase compliance with medical procedures
studies conducted in Canada, the United Kingdom, (Allen & Kupzyk, 2016) and found that the most
and the United States have found that women with commonly used intervention consisted of graduated
IDD receive health assessments and screenings such exposure (often with the use of a task analysis) and
as mammograms and Pap smears at much lower contingent reinforcement. The authors also concep-
rates than their typically developing counterparts tualized avoidance of medical procedures as a
(Cobigo et al., 2013; Havercamp et al., 2004; Reynolds phobia or a fear. Other common components of the
et al., 2008; Sullivan et al., 2003). These routine 27 studies reviewed were modeling (including video
medical procedures can increase the likelihood of or in vivo), distraction/relaxation techniques, and
early detection and therefore treatment for diseases response prompting. Still others used high probabil-
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such as breast and cervical cancers (Cobigo et al., ity request sequences in order to gain compliance. In
2013). In a population review, Cobigo et al. (2013) order to manage challenging behavior during these
found that women with IDD were twice as likely procedures, researchers have used three types of
to be unscreened using Pap smears and 1.5 times procedures: escape extinction/full physical prompting,
as likely to be unscreened using mammograms. breaks from the procedure, or terminating trials.
Moreover, a recent study using case review methodol- Each of these procedures was used in conjunction
ogy found that women with IDD and reproductive with a reinforcement procedure. The authors
cancers were generally younger and required longer provided practice recommendations that included
hospital stays (Parish et al., 2018). The researchers prevention strategies (making visits more reinforcing
recommended targeted programs to increase cancer and less aversive), preparation strategies (how to
screenings among this population. create a task analysis and prepare for visits), and
For some individuals with IDD, access to health treatment of noncompliance (providing reinforce-
care can be doubly impacted by patient noncompli- ment, teaching/modeling, and graduated exposure).
ance with routine medical procedures such as blood However, there is limited high-quality ABA research
draws and physical exams. ABA interventions are into the use of EBPs such as reinforcement, escape
uniquely equipped to target increased compliance extinction, and systematic desensitization for these
with medical procedures. There is a large body of procedures.
research showing that increasing compliance with
medical procedures, including blood draws, is pos- Employment-Related Skills
sible with appropriate intervention. These targets Individuals with IDD have lower employment rates
are especially important for individuals with IDD, than those without IDD (National Center for Educa-
as they often participate in medical office visits tion Statistics, 2015; see Chapter 13, this volume).
more frequently than their typically developing Therefore, it is important to target skills to allow
peers, across their lifespans (Fujiura et al., 2018). individuals with IDD to obtain and retain employment.
There has been research into compliance with One way to include individuals in selecting a job
needle sticks, most of which includes desensitiza- for training is to conduct a preference assessment.
tion, reinforcement, and escape extinction (Wolff In 2011, Morgan and Horrocks conducted a video-
& Symons, 2013). Cromartie et al. (2014) used based preference assessment with three individuals
a task analysis and a changing criterion design to in a post–high school special education program.
increase completion of steps of a blood draw pro- Each individual watched videos that demonstrated a
cedure. The 21-year-old woman with IDD was able person doing a specific job. After watching the videos,
to progress from 0% compliance to 100% compli- each individual selected a thumbs up or thumbs
ance with blood draws. This enabled her to begin down. Highly preferred and nonpreferred jobs were
taking a medication that was predicted to address then identified for each individual. Based on the

36
 Applied Behavior Analysis and Intellectual and Developmental Disabilities

preference assessment results, individuals were then acquisition probing session. Results of the interven-
taught to perform highly preferred and nonpreferred tion found a functional relation between emailing
jobs. Randomly, individuals were then exposed to skills and instruction across devices. In addition,
highly and nonpreferred jobs, leading to the last all individuals maintained their emailing skills once
component of the assessment, in which individuals instruction was concluded.
were able to select the job they wanted. Results of Multiple exemplar training is an intervention used
the intervention found that highly preferred and to promote generalization of job-related skills. Smith
nonpreferred preference assessment results were et al. (1999) taught four children with moderate
associated with high and low job performance, to severe ID table-cleaning skills using least-to-most
respectively. These findings support the notion of prompts and multiple exemplars. The study involved
including individuals with IDD in the selection a three-part task analysis surrounding the activity
process for future employment. of cleaning a table (i.e., preparing materials to clean,
Once preferences for a job have been established, cleaning the table, and putting away materials).
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teaching the job role is important to ensure that the Students were trained on cleaning tables in
individual can continue to work the job. Cavkaytar different locations; however, the tasks of preparing
(2012) examined the Café Waiter Education Program and putting away materials were considered to be
(CAWEP) for three individuals with IDD. The nontargeted and picked for observational learning.
CAWEP is a vocational program which aims to help Observational sessions consisted of the teacher
individuals acquire skills to work in a café. The demonstrating the skills and praising the student for
program consists of four phases: (a) pretraining, looking or watching while the skill was demonstrated.
(b) prevocational skills, (c) training on café skills, After the teacher demonstrated the skill, probes were
and (d) generalization and follow-up. The author conducted to see if the student was able to complete
used least-to-most prompting during training and the skill of preparing and putting away materials
provided feedback while the individuals were in based on observation. Results of the intervention
skill acquisition. Results of the intervention found demonstrated that the speech-language pathologist
that the CAWEP was effective at teaching serving and multiple exemplar training was effective for all
skills to individuals with IDD when using least-to- students. The skills of preparing materials, cleaning
most prompting in real settings. Skills taught during tables, and putting away materials were maintained
the program were also maintained and generalized 4 weeks following the conclusion of the study and
to different settings. The author reported that each were able to be generalized to different locations.
individual in the study was able to obtain café-
related employment. Leisure Skills
As technology use in jobs and in individuals’ day- Although the definition of leisure skills may vary
to-day lives increases, it is important to teach the across people and contexts, the idea that all people
use of computers and mobile devices to individuals have the right to access pleasurable leisure activities
with IDD to allow them to access information and of their choice is not a concept often debated. Teaching
become more independent (McMahon & Smith, leisure skills can have implications for individuals
2012). Cihak et al. (2015) taught four individuals with IDD across numerous contexts, including
with IDD how to access and send emails on a desk- gaining the opportunity to socialize with their peers
top computer, laptop, and iPad. The intervention or others around them, providing them ownership
consisted of the use of a task analysis for the skills, over the decision to engage in specific activities
verbally describing the total-task chaining proce- throughout their day, and accessing activities
dure, and a sequence-prompting strategy used once through partial participation.
the individuals began to practice. After the individuals Teaching leisure skills can positively impact other
met criteria on the desktop computer, instruction aspects of a person’s life, including social skills,
was delivered using the laptop, then iPad. Mainte- communication, and overall quality of life (Felce &
nance data were collected 9 weeks after the initial Perry, 1995; Garcia-Villamisar & Dattilo, 2011).

37
 Machalicek et al.

Opportunities to engage in leisure activities are built implementation of the leisure program, which were
into everyday life, but people with IDD who are reported as direct links to the quality of meaningful
not taught leisure skills are not given the skills staff interactions, and the implementation of the
and opportunities to engage in these activities. To program was expanded to nine residential facilities.
encompass all opportunities for leisure activities, Data were not collected on the participants’
teaching leisure skills should not be limited to either preferences for specific leisure activities or their
social or solitary activities; both should be com- engagement in these activities over time, with
bined so that the person with IDD has autonomy to the intervention focusing more on the interaction
decide what and when to engage in during leisure between staff than the clients’ gains in leisure skills
opportunities. throughout the program. Furthermore, due to
Though there is an increasing amount of research the principles of the program, all leisure activities
on the topic of leisure skills, targeted skills reflect offered during this time were socially mediated.
different aspects of social skills, such as interactions Individuals with disabilities were, therefore, not
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with staff, instead of instruction on leisure activities given the opportunity to engage in independent
and building the capacity of individuals with IDD or solitary activities, such as listening to music or
to engage in and decide for themselves what they playing an online game, if they preferred to do so.
would like to do during leisure time activities. Confounding social skills with leisure activities
Dattilo et al. (2003) utilized a computer program can prevent persons with disabilities from engaging
to provide instruction on leisure activities and their in these tasks independently and determining when
relation to social skills for three male youths with they choose to do so, limiting leisure activities to
ID. The computer program targeted specific behaviors times when someone else is around to engage in
during social interactions, including nonverbal and the activity with them or assist them in setting up
verbal behaviors, in an interactive story narrative. and completing the activity. Though technological
Other targeted instructional goals included identifying advances can allow individuals with IDD to engage
the definitions of communication, the role of friends, in activities they previously would not have had
and how to initiate an interaction. Although social the opportunity to engage in, they can also limit
validity and accuracy of response measures were the independence of individuals to engage in these
completed and the participants demonstrated engage- activities when and where they want to. For example,
ment with and understanding of the concepts Yalon-Chamovitz and Weiss (2008) delivered a
presented in the program, direct observations of virtual reality gaming experience and the opportunity
the participants’ social interactions and the changes to engage in physical activities previously inacces-
from baseline were not conducted to evaluate the sible to participants. All participants had cerebral
generalizability of these concepts to real-life palsy and ID, were between the ages of 20 and 39,
situations. attended a day care facility for clients with cerebral
Working with adults with IDD in a residential palsy, and were randomly assigned to either the
care placement, Fox et al. (2013) utilized a program virtual reality gaming intervention or control
in which participants were given options regarding conditions. Questionnaires and instructor obser-
leisure activities in which to engage in during vations were completed at the end of each session,
their free time. Focusing on the staff’s fidelity of which were conducted 2 to 3 times a week, with
implementation of the program procedures during the instructors reporting on their perception of the
daily, 1-hour sessions, data collection included the participants’ enjoyment during each 30-minute ses-
amount of time staff engaged in a leisure activity sion. Participants also reported their enjoyment and
with the individual with a disability. The effectiveness success with the virtual reality program. Self-esteem
of this program was measured using the Meaning­ measures were conducted before intervention and
ful Client and Staff Interaction Assessment, which after completion, with no significant differences
was adapted from Parsons et al. (2004) for the reported between the control and treatment groups
study. Significant gains were reported in the at the conclusion of the program.

38
 Applied Behavior Analysis and Intellectual and Developmental Disabilities

This study demonstrates the need to not only instruct and reinforce leisure skills for individuals
offer leisure activities to individuals with disabilities with IDD.
but also teach individuals how to engage in these Although interventions that increase access to
activities or similar activities independently. For community settings are important, relevant research
example, if a participant enjoyed playing the soccer is not plentiful. Studies have included treatments
virtual reality game during the program, introducing for challenging behavior such as decreasing pica in
them to different ways to access the game of soccer, public settings or decreasing challenging behavior
such as watching a soccer game on television, going related to or increasing tolerance of getting into a
to a college soccer game, or playing a soccer-related public pool to swim (Kern et al., 2006; Rapp et al.,
video game, would provide the opportunity for the 2005). However, these research studies do not
individual to be more likely and able to engage in teach skills that are valuable in their own right, but
these activities on a regular and independent basis. rather treatments making community outings less
There is also leisure-focused research focusing on dangerous and more manageable for caregivers.
Copyright American Psychological Association. Not for further distribution.

aspects of self, including self-esteem, self-awareness,

and self-expression, rather than on specific behaviors
BEHAVIORAL ASSESSMENT AND
that encompass leisure skills or how to teach those
INTERVENTION TO ADDRESS
skills. The focus is, instead, on whether the individual
CHALLENGING BEHAVIOR
with a disability has an increased sense of self after
engagement in a leisure activity (Garcia-Villamisar Function-based treatments directly address the
& Dattilo, 2011). reinforcers maintaining challenging behavior as
Using simultaneous prompting, task analyses, identified by a functional behavior assessment.
and systematic error correction procedures, Dollar Function-based assessment methods are utilized to
et al. (2012) taught three different independent identify the purpose, or function, of an individual’s
living and leisure skills to adult participants with challenging behavior. The foundation of function-
severe ID. Massed practice and visual cues were based treatment is to eliminate the source of reinforce-
added to assist in the acquisition of particularly ment for challenging behavior (extinction) while
difficult steps of the tasks, based on participant teaching functionally equivalent behaviors as an
performance. For example, a sticker was placed on alternative to challenging behavior. Function-based
the play button of a CD player as a visual stimulus treatments can also include arrangement of the
prompt highlighting the correct button to press to environment so that reinforcement is delivered in
listen to music. These strategies were effective in the absence of challenging behavior or delivered
teaching three separate skills to the participants, and independently of the challenging behavior (non­
skills were maintained up to 4 weeks after instruction. contingent reinforcement). Challenging behavior
Finally, video prompting packages have been used to serves one (or more) operant functions: (a) social pos-
teach three leisure skills to an adult participant with itive reinforcement (access to attention, food, or lei-
Down syndrome attending a day treatment program. sure items), (b) social negative reinforcement (escape
Targeted skills were focused on independent activities or avoidance), (c) automatic positive reinforcement
that could include other individuals, such as painting, (stimulation), and (d) automatic negative reinforce-
listening to music, and taking digital pictures. ment (pain attenuation; Carr, 1977). Function-based
Video prompting, instructional prompts, and task assessment methods are utilized to identify the
analyses were utilized during instruction and faded function or functions of an individual’s challenging
by the conclusion of the study after a functional behavior, as well as the antecedents and motivating
relationship was demonstrated between the video operations associated with the challenging behavior.
prompting package and increased accuracy and
completion of the steps in the task analysis for Functional Behavior Assessment
each task. This study demonstrates the importance Functional behavior assessment is a systematic
of using a variety of evidence-based techniques to process and set of strategies used to gather

39
 Machalicek et al.

information on the underlying function or functions of aberrant challenging behaviors (e.g., self-injurious
of individuals’ behavior in relation to aspects of their behavior) in individuals with IDD (e.g., Iwata
environment, so that effective intervention plans et al., 1994). This structured assessment procedure
can be developed (e.g., Gresham et al., 2001; Iwata arranges a series of brief test (counter test and control)
et al., 1994; O’Neill et al., 1997). The term functional conditions in which antecedent stimuli and the
behavior assessment refers to a continuum of availability of reinforcement and consequence for
measurements and assessments aimed at identifying target challenging behavior is held constant within
underlying reinforcement contingencies related to each type of session to test for a particular operant
challenging behavior. function of challenging behavior. Conditions are
Three types of methods are typically utilized presented systematically and in an alternating
when conducting functional behavior assessments: sequence, in comparison with the control condition
(a) indirect assessment, (b) descriptive assess- within an experimental single-case research design
ment, and (c) experimental functional analysis. (alternating treatments design, ABAB design).
Copyright American Psychological Association. Not for further distribution.

Indirect assess­ment refers to interviews, question- Traditional FAs (Iwata et al., 1994) typically include
naires, and scales used to hypothesize behavior three or more test conditions (e.g., contingent atten-
function. Indirect assessments are quick and easy tion, to test for challenging behavior maintained
to complete but are not recommended as a primary by positive reinforcement in the form of access to
assessment method. Descriptive assessment refers to adult attention; contingent escape, to test for chal-
direct observation and repeated measurement of the lenging behavior maintained by negative reinforce-
behaviors in the natural environment. This includes ment in the form of escape from academic demands;
antecedent-behavior-consequence (A-B-C) recording, alone or limited attention conditions, to test for
narrative recording, and scatterplots (Cooper et al., auto­matically reinforced challenging behavior; and
2007). Descriptive assessment uses correlations play as a control condition, when we would not
between environmental events and the occurrence of expect challenging behavior [unless automatically
challenging behavior to determine a hypothesized maintained] as there are no demands, attention is
function of the problem behavior. While more provided in a dense, noncontingent manner, and
rigorous than indirect assessments, descriptive preferred items are freely available). High levels of
assessments are not recommended as a stand-alone challenging behavior in a test condition relative to
functional assessment for challenging behavior and the other test and control conditions suggests that
may result in spurious assessment results (Newcomer the target challenging behavior is maintained by the
& Lewis, 2004). Individuals with IDD are more reinforcer and provided contingently in that condi-
prone to exhibit challenging behaviors due to tion. An example task analysis of FA conditions is
deficits in communication, social functioning, and provided in Exhibit 2.1.
adaptive functioning. Therefore, the assessment FA has been replicated and extended in hundreds
and treatment of challenging behaviors is of great of studies with children and adults with IDD across
relevance to those interested in working with and settings (e.g., hospitals, schools, homes) and topo­
researching interventions for individuals with IDD. graphies of challenging behavior in over 30 years’
worth of research (Beavers et al., 2013; Hanley et al.,
Experimental Functional Analysis 2003). Recent advancement to FA procedures
Experimental functional analysis (experimental FA) (e.g., Iwata et al., 1994) include additional test and
refers to the direct manipulation of environmental control conditions (e.g., Bowman et al., 2013;
variables (antecedents and consequences) to Fahmie et al., 2013), shortened session duration
determine their effects on challenging behavior. (e.g., trial-based; Bloom et al., 2011; Rispoli et al.,
This method is considered the gold standard for 2014), and novel measurement of behavior (e.g.,
functional assessments, as FA can show causation response latency; Thomason-Sassi et al., 2011).
between environmental variables. Early research Trial-based, or brief, FAs alternate paired test
introducing FA procedures focused on the reduction and control conditions in natural environments.

40
 Applied Behavior Analysis and Intellectual and Developmental Disabilities

Conditions are typically 1 minute in length and can

EXHIBIT 2.1
be conducted for a few minutes each day, eliminating
Anticipated Therapist Behaviors During Each the need to set aside longer periods of time or arrange
Functional Analysis Condition clinical test environments (e.g., Sigafoos & Saggers,
1995). Traditional FA procedures have also been
Attention Condition (test for challenging behavior maintained adapted for use for challenging behaviors that, once
by adult attention) emitted, cannot easily reoccur within a test session.
1. The therapist directs the child towards toys and other items. Latency FAs have been developed for use with
Y N
difficult behaviors such as elopement (i.e., individuals
2. The therapist tells the child what they can do (e.g., play with requiring supervision leaving the caregiver-
items) while the therapist pretends to work. supervised area). In latency FAs, latency serves as
Y N the index of challenging behavior (e.g., Neidert
3. The therapist sits down at a place visible to the child. et al., 2013). FA has been reported as effective when
Copyright American Psychological Association. Not for further distribution.

Y N implemented by caregivers and teachers in natural

4. The therapist ignores the child if they do not engage in settings (e.g., Austin et al., 2015) and when
challenging behavior.
conducted by caregivers with supervision from
Y N
5. If the child engages in challenging behavior, the therapist
behavior analysts (e.g., Wacker et al., 2013). A wealth
contingently provides verbal and positive physical attention of research exists on the use of traditional and adapted
for 10 seconds. FAs with individuals with IDD across settings.
Y N Functional analyses were first described by Iwata
Play Condition (control condition) et al. (1994) in a study of nine individuals with IDD
and self-injurious behaviors. The first comprehensive
1. The therapist directs the child toward their preferred toys
and other items.
FA involved the systematic arrangement of the
following conditions: (a) social disapproval (i.e.,
Y N
2. The therapist engages the child in pleasurable activities attention/social reinforcement), (b) academic
and delivers attention to the child noncontingently every demand (i.e., social negative reinforcement), and
10 seconds. (c) alone (i.e., automatic reinforcement) and
Y N unstructured play (i.e., test condition). Conditions
3. If the child engages in challenging behavior, the therapist were compared using a single-case alternating
ignores the behavior.
treatments design until the levels of challenging
Y N
behavior in one or more test conditions consistently
Demand Condition (test for challenging behavior maintained exceeded the levels exhibited during the control
by escape from demands)
condition. Six of nine subjects exhibited behavioral
1. The therapist directs the child to sit at a table. sensitivity between conditions, suggesting that
Y N variability was a function of the environmental
2. The therapist provides the child with a clear task direction. condition. The first published studies describing
Y N FA were used to identify the behavioral function of
3. If the child does not respond within 5 seconds, the therapist
restates the task direction and uses least-to-most prompting
self-injury, a behavior on which there was previously
to promote task completion. limited and mixed research.
Y N Variations to the traditional Iwata et al. (1994)
4. If the child engages in challenging behavior, the therapist FA procedures have included shortened treatment
immediately removes instructional materials from the table conditions. Bloom et al. (2011) evaluated a trial-based
and sits with back to the child for 10 seconds.
approach to conducting functional analyses carried
Y N out in classroom settings compared with traditional
5. After 10 seconds, the therapist presents the child with
another task demand. functional analyses across 10 participants (ages 6–13)
Y N
with ASD and ID. Trial-based functional analyses
included a series of probes embedded into classroom

41
 Machalicek et al.

activities, spread across 5 days. The trial-based differential reinforcement procedure for reducing
procedures consisted of a 1-minute segment during challenging behavior. Differential reinforcement
which an establishing operation and contingency of alternative behavior is used in FCT and is
for challenging behavior was presented, followed characterized by the provision of reinforcement
by a 1-minute segment during which the reinforcer for an alternative behavior and the simultaneous
was available continuously. Sessions were spread withholding of reinforcement for an inappropriate
across 5 days, in comparison with 10- to 15-minute behavior. This procedure has been used to reduce
sessions also conducted over the course of 5 days unwanted behaviors and teach more appropriate
during the traditional functional analyses condition. alternative behaviors. For example, an individual
The results of the trial-based functional analyses may demonstrate aggressive behaviors in order to
were in agreement with the results of traditional gain adult attention. An appropriate alternative to
functional analyses in only 60% of cases. This low aggressive behaviors is to tap the adult on the
level of reliability is concerning for those participating shoulder. In the future, using a DRA procedure,
Copyright American Psychological Association. Not for further distribution.

in research and practice. More research is needed the individual may be taught to tap an adult on
on the validity of trial and latency-based functional the shoulder and be provided with attention (the
analyses as well as adaptations to traditional alternative response). Using this procedure, if the
functional analyses that allow for assessment in individual demonstrates aggressive behaviors
the natural environment. (the unwanted response), attention will no longer
be provided. Using this approach “weighs” the alter-
Behavior Intervention Plan Development native behavior at an advantage in that only that
Following the identification of the contingencies behavior will provide reinforcement for the individual,
maintaining challenging behaviors, a behavior and aggressive behaviors will no longer result in
intervention plan or behavior support plan is adult attention.
developed. As the name implies, function-based In most cases, FCT interventions consist of two
treatments involve manipulating the contingencies components: (a) differential reinforcement of alter-
maintaining challenging behavior. The strongest native behavior and (b) extinction procedures
function-based treatments combine operant to extinguish the challenging behavior (Fisher
conditioning procedures such as differential et al., 2015), as past research suggests that FCT is
reinforcement and punishment with extinction most effective when combined with other operant
procedures. Treatments are referred to as component procedures such as extinction or punishment-based
packages and are individualized to meet the needs of procedures (e.g., Hagopian et al., 1998; Wacker et al.,
the individual (e.g., behavioral repertoire) and his or 1990). The target, or alternative response (i.e., mand),
her environment (e.g., schedule of reinforcement). is a request reinforced by the consequence identified
Accurate assessment, such as the use of experimental by an experimental functional analysis of the
FA, is essential for the success of a function-based challenging behavior (Wacker et al., 1990). The
treatment package. success of FCT interventions depends on the accurate
assessment of the function of the challenging behavior
Functional Communication Training and the selection of a functionally equivalent
Effective interventions for addressing challenging communicative response.
behavior, including serious challenging behavior, Successful FCT interventions progress through
exist in the ABA literature (Erturk et al., 2018). In three stages. First, a functional behavior assessment
this section, we focus on functional communica- is conducted to identify the function of the challenging
tion training (FCT), an intervention with a strong behavior and the establishing operations (i.e., condi-
evidence base and wide application across topogra- tions that evoke the problem behavior; Fisher et al.,
phies, intensity of challenging behavior, and com- 2000; Tiger et al., 2008). Next, a socially acceptable
municative functions of challenging behavior. FCT communicative response that serves the same
(Carr & Durand, 1985; Durand & Carr, 1987) is a function as the target challenging behavior is

42
 Applied Behavior Analysis and Intellectual and Developmental Disabilities

selected. FCT differs from other differential FCT is initially introduced, the communicative
reinforcement procedures in that the target response response is typically reinforced with the consequences
is a form of communication (Tiger et al., 2008). that previously reinforced problem behavior on a
Different types of mands (requests) have been dense, fixed-ratio schedule (continuous reinforcement;
used in FCT packages with individuals with IDD, e.g., Fisher et al., 2015). An initial, dense differential
including gestures, signs, vocalizations, augmentative reinforcement of alternative behavior schedule may
communication systems, and verbalizations produce greater and more rapid reductions in problem
(Kurtz et al., 2011). behavior, may weaken the establishing operations of
The following should be considered when the problem behavior, and may mitigate extinction
selecting communicative responses: the response effects. However, it is not likely that the individual’s
effort to engage the response, the likelihood that responses can be reinforced on a continuous rein-
others will recognize and respond to the response, forcement schedule in natural conditions. Therefore,
and the individual’s current behavioral repertoire it is important to program for delayed and intermit-
Copyright American Psychological Association. Not for further distribution.

(Tiger et al., 2008). In order to be effective, alter- tent reinforcement when thinning reinforcement for
native responses need to be less effortful than the the communicative response.
challenging behavior. Communicative responses Sufficient empirical support exists to characterize
that required more effort than the challenging behavior FCT as a well-established intervention of the
are less likely to be successful than responses that treatment of challenging behaviors for individuals
were more efficient than the problem behavior with IDD (Durand & Moskowitz, 2015; Kurtz et al.,
(Horner & Day, 1991). However, high-effort 2011; Tiger et al., 2008). FCT component packages
responses have been reported as being more likely have been used to decrease a variety of topographies
to promote generalization. Response effort is an of challenging behavior, including serious challenging
important consideration when programming the behavior such as self-injurious behavior and
initial stages of FCT. Responses that are easily aggression maintained by social (positive or negative)
recognizable, such as voice-output devices, as sources of reinforcement (Kurtz et al., 2011; Tiger
compared with arbitrary responses (e.g., gestures), et al., 2008). Kurtz et al. (2011) conducted a literature
are more likely to be reinforced by novel communica- review on the use of FCT to treat challenging behavior
tion partners. Socially acceptable and recognizable in individuals with ID and ASD. In a review of
communication responses increase the likelihood 28 single-case research studies, FCT was reported
that the individual will access reinforcement for to be an effective treatment of challenging behaviors
his or her response outside of the teaching context across different settings, therapists, functions of
(Durand & Carr, 1992). The individual’s behavioral problem behavior, and treatment packages. FCT
repertoire must be taken into consideration when was commonly combined with extinction and
selecting a communicative response. Preliminary reinforcement schedule thinning.
research reports that individuals with IDD are more The relative simplicity of FCT interventions makes
adept at acquiring topography-based responses them especially well suited to address challenging
(i.e., form of the response differentiates one verbal behavior in home and community-based settings.
response from another) than selection-based Lindgren and Wacker (2011) coached parents to
topography (i.e., form of each response is the same; conduct experimental functional analyses and to
Tiger et al., 2008). Prerequisite skills, such as implement FCT packages in home settings for
matching-to-sample and motor imitation, must be 23 children, 22 of whom had mild to profound ID.
considered when selecting alternative communicative Child participants ranged from 2 to 6 years old,
responses. The topography, effort, and skills of and the most common challenging behaviors
the learner are important factors to consider when reported were aggression, destruction, and self-
selecting a communicative response. injurious behavior (84% maintained by social
Finally, the communicative response or mand is functions). FCT treatment included differential
taught to replace the challenging behavior. When reinforcement of alternative behavior in regard

43
 Machalicek et al.

to communicative responses and extinction. The employment, and postsecondary education opportu-
average percent reduction of intervals of destruc- nities (Bouck, 2012; Hendricks & Wehman, 2009;
tive behavior between baseline and the final three Shattuck et al., 2012; Wagner et al., 2005; see also
sessions across children was 84.78%, with a single Chapters 13–15, this volume). Moreover, safety and
participant not showing a reduction in destructive skill deficits in the areas of personal safety, household
behavior between pretreatment and posttreatment. skills, and medication assistance remain relevant
The majority of parents rated the intervention pro- barriers to independent living for individuals with
cedures as acceptable to highly acceptable. disabilities and their families (DiGennaro Reed et al.,
Recent research on FCT has focused on reinforce- 2014), and there is a relative dearth of intervention
ment schedule thinning and generalization across research focused on individuals with significant ID,
stimuli and therapists. This includes variations from including severe and profound ID and multiple
Carr and Durand’s (1985) procedures, including disability, resulting in lagging improvements for
systematic fading of reinforcement (e.g., Hagopian, this group of individuals (Courtade et al., 2014).
Copyright American Psychological Association. Not for further distribution.

Toole, et al., 2004) and discrimination training There also remains a pressing need for further ABA
(e.g., Fuhrman et al., 2016). The effectiveness of research on education and compliance related to
reinforcement fading procedures continues to be routine medical procedures such as dental services.
an area of growth, with early research favoring sys- A survey of parents of children with ASD in the
tematic thinning of schedules of reinforcement that United States found that parents reported difficulty
are dense and predetermined (e.g., Austin & Tiger, finding dental providers who were willing to work
2015; Hagopian, Toole, et al., 2004). Continued with individuals with disabilities and problem behavior
research is needed to determine the effectiveness (Brickhouse et al., 2009). One treatment review found
of discrimination training, schedule thinning, that individuals with IDD are more likely to require
and generalization procedures used in conjunction a general anesthesia for dental work and are often
to FCT. referred for general anesthesia due to behavioral
difficulties during procedures. While there is a paucity
of research concerning dental procedures and
CURRENT STATUS AND FUTURE
possible behavior interventions, there is none that
DIRECTIONS IN BEHAVIORAL
the authors are aware of on Pap smear, mammogram,
APPROACHES TO INTELLECTUAL
or prostate screening compliance.
AND DEVELOPMENTAL DISABILITIES
For some specific domains or applications, there
The science of behavior analysis and the application may be insufficient evidence for individuals with ID
of these principles in ABA have been influential in but sufficient evidence supporting use for individuals
the development of functional assessment practices with ASD or vice versa. For instance, behavioral
and effective interventions for individuals with IDD parent training for parents of children with ASD has
of all ages with varying levels of support needs. With strong evidence supporting its use for addressing
consistent application of EBPs, individuals with IDD challenging behavior (Postorino et al., 2017), but
who have varying intensities of support needs can be there is a relative lack of research with children with
successful in a variety of content areas and adaptive ID on the same topic (Machalicek et al., 2015). For
behavior domains, including academics and functional areas of future research, ABA should focus on inter-
life skills (Browder & Spooner, 2011; Carter et al., ventions that teach skills that will reliably be used
2010; Jameson et al., 2012; Knight et al., 2012; by the individual to increase acquisition, general-
Spooner et al., 2011). However, research to date has ization, and maintenance of skills in these aforemen-
not exhausted the application of ABA to the socially tioned areas. Another area of need for future ABA
important issues affecting individuals with IDD and research includes effective teaching strategies for
their families. safety skills such as sexual assault prevention (see
Outcomes for individuals with IDD remain less Chapter 17, this volume), abduction prevention,
than ideal, with low rates of independent living, and fire safety techniques. Additionally, compliance

44
 Applied Behavior Analysis and Intellectual and Developmental Disabilities

with medical procedures should be a priority, as Alwell, M., & Cobb, B. (2009). Functional life skills
individuals with IDD are more likely to need medical curricular interventions for youth with disabilities.
Career Development for Exceptional Individuals, 32(2),
services, be left out of screening and preventative 82–93. https://doi.org/10.1177/0885728809336656
care, and have worsened outcomes as a result. Activ-
American Psychiatric Association. (2013). Diagnostic
ities for daily living are socially important goals and and statistical manual of mental disorders (5th ed.).
are an area that ABA is uniquely situated to address. American Psychiatric Publishing.
These activities can increase quality of life, increase Ardiç, A., & Cavkaytar, A. (2014). Effectiveness of the
the likelihood that individuals can receive medical modified intensive toilet training method on teaching
treatment, increase independence in self-care routines, toilet skills to children with autism. Education and
and help individuals with IDD remain safe in their Training in Autism and Developmental Disabilities,
49(2), 263–276.
communities.
The current instructional and behavioral inter- Austin, J. E., & Tiger, J. H. (2015). Providing alternative
reinforcers to facilitate tolerance to delayed reinforce-
vention toolbox is sufficiently stocked for inter­
Copyright American Psychological Association. Not for further distribution.

ment following functional communication training.

ventionists to address many of the learning and Journal of Applied Behavior Analysis, 48, 663–668.
support needs of individuals with IDD; however, https://doi.org/10.1002/jaba.215
professionals working with individuals with IDD Austin, J. L., Groves, E. A., Reynish, L. C., & Francis, L. L.
will benefit from a better understanding of the (2015). Validating trial-based functional analyses in
basic behavioral principles underlying the design mainstream primary school classrooms. Journal of
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