journal

IMPROVING BEHAVIOR IN A RESIDENTIAL SERVICEFOR YOUTH IN DRUG AND ALCOHOL

REHABILITATION

Sarah Ann Taylor1,2* and Oliver C. Mudford1

1The University of Auckland, Auckland, New Zealand2Odyssey House, Auckland, New Zealand

A token reinforcement program, named Thumbs Up, was introduced in a residential therapeuticcommunity for drug and alcohol rehabilitation. Sixteen young people aged 1417 years participated forvarying durations. Participants were able to negotiate target behaviors and choose backup reinforcers.We evaluated the program within a multiple baseline design across participants, settings, and behaviors.Improvements occurred in positive verbal statements across settings, timely room cleaning, andleadership responsibilities. Inappropriate statements were also measured and did not change. One staffmember was trained in the use of Thumbs Up with positive results. Difculties with implementingbehavioral interventions in a non-behaviorally oriented treatment service were identied. Despite needingrenements, it was concluded that a token reinforcement program can be an effective and acceptablemeans of improving behavior within a therapeutic community framework. Copyright 2012 JohnWiley& Sons, Ltd.

In addition to interventions targeted on abusive consumption, youth with a historyof substance abuse may require behavioral interventions for various antisocialproblem behaviors; excessive swearing, vandalistic grafti production, and violentbehavior are examples. Additionally, they may lack acceptable levels of positivesocial behavior, including manners, positive statements, and promptness (Kaminer& Tarter, 2004).Token economies have been successful in addressing many of these behavioral

excesses and decits in a variety of community and residential settings for a rangeof populations. A token economy is a behavioral procedure in which a token isprovided contingent on a desired target behavior. Tokens can later be exchanged

*Correspondence to: Sarah Ann Taylor, Applied Behavior Analysis Programme, Psychology Department, TheUniversity of Auckland (Tamaki Campus), PB 92019, Auckland, New Zealand. E-mail: [email protected] thesis describing the study fullled the requirements for an MSc degree in Psychology at The University ofAuckland.

Copyright 2012 John Wiley & Sons, Ltd.

Behavioral InterventionsBehav. Intervent. 27: 109128 (2012)Published online 14 May 2012 in Wiley Online Library(wileyonlinelibrary.com) DOI: 10.1002/bin.1342

for backup reinforcers, such as highly preferred items or activities. Tokens, thereby,become conditioned reinforcers. Populations beneting from token economieshave included adolescents in residential settings (Liberman, Ferris, Salgado, &Salgado, 1975; Phillips, 1968; Phillips, Phillips, Fixsen, & Wolf, 1971) and adultsin drug and alcohol rehabilitation programs (Higgins et al., 1991; Miller, Hersen,& Eisler, 1974; Preston et al., 1997; Silverman, Chutuape, Bigelow & Stitzer,1996; Silverman, Higgins et al., 1996; Silverman, Wong et al., 1996). Behaviorstargeted in token economies have included making aggressive statements (Phillips,1968), room cleaning (Phillips et al., 1971), positive interactions (Bowers, Woods,Carlyon, & Friman, 2000), and reducing alcohol consumption (Miller et al., 1974).Despite this extensive research on token economies, there does not appear to beany research on their implementation for adolescents in residential alcohol and drugrehabilitation facilities.One residential treatment model for youth with substance abuse problems is

known as the therapeutic community (TC). TC residents move through treatmentlevels, including an assessment phase, treatment phases, and a re-entry phase (basedon De Leon, 2004). A move up the levels occurs after a resident has met criteria for asignicant period at their current level.Token reinforcement should t well within a TC and cohere with many of the TC

principles. Adolescents in residential treatment favor motivational incentives (pointor token giving) and positive feedback (Wilner et al., 1977). In the TC, the onlyimmediate positive reinforcer available is praise. Other reinforcers available in aTC are delayed, with the most signicant reinforcer being the opportunity to moveup the treatment levels (offering more responsibility and privileges). Additionalprivileges in a token reinforcement include the opportunity to negotiate individualizedbackup reinforcers.The TCs focus on right living encourages appropriate social behaviors (De

Leon, 2004), and a token reinforcement may help to improve behavior required fora move up the treatment levels. Adolescents with a substance abuse problem enteringa TC are claimed to have an inability to delay gratication (De Leon, 2004). Tokensare used to bridge the delay between the appropriate behavior and the backupreinforcer. Gratication may be further delayed by allowing participants to savetokens for larger rewards.This study implemented token reinforcement within a residential TC for adolescents

with substance abuse problems. It was of interest to see if tokens would serve toimprove prosocial target behaviors, especially positive statements. Also, wouldinappropriate statements (including swearing and complaining) decrease as a result ofrewarding positive statements? In addition, we wanted to assess if any changes in targetand non-target behavior would be maintained once the token reinforcement wasimplemented by other staff at the program.

110 S. A. Taylor and O. C. Mudford

Copyright 2012 John Wiley & Sons, Ltd. Behav. Intervent. 27: 109128 (2012)

DOI: 10.1002/bin

GENERAL METHOD

Setting

The study was conducted at a residential community for adolescents of both sexesaged between 13 and 17 years with a drug or alcohol problem. The residentialcommunity followed the TC philosophy. There was a maximum of 11 residents atany time. Admission was voluntary. The opportunity for adolescents to formally exitthe program with parental or social worker agreement was always available, as wasthe opportunity to abscond. Recently graduated residents had taken between sixand nine months to complete the treatment program. The residential communityhad a layout typical of a large modern home. The residents attended a school, whichwas at a separate site within the TC.

Participants

All participants admitted to the residential TC met criteria that included an exten-sive substance abuse history, no community vocational or educational placement, andfailure in community-based programs. Additionally, many had a diagnosed mentalhealth disorder, poor or low socialization skills, persistent criminal offending, andno stable home environment. The youth were admitted only after initial medicallydirected withdrawal programs had been successful.Of the 28 residents that participated at some point in the study, 60% were New

Zealand European, 36% were New Zealand Maori, and 4% were Pacic Islander.Their ages ranged from 14 to 17 years. Only the most complete data sets (16 residents)are presented in this paper.The rst author (researcher) was employed as a youth therapist at the TC. She had

six months experience before the study commenced. Concurrently with the study, shewas receiving post-masters degree in supervised experience in applied behavioranalysis toward professional credentials.

Materials

Tokens

The tokens were printed pieces of paper measuring 2 4 cm. A thumbs upsymbol was printed on colored paper not available in the residential community.Tokens were colored according to the setting to which they applied. Thumbs upbecame the name of the token reinforcement at the TC as it signied the positiveorientation of the intervention.

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Backup Rewards

Initial backup rewards were inexpensive, required few tokens, and were easilyconsumable (e.g., candy), so that employing frequent exchange periods would notdisrupt the overall program schedule. Once an effect had been demonstrated acrosstwo settings with small rewards and a resident had been in Thumbs Up for twoweeks, they were able to choose their own rewards. Residents were advised thatthe rewards had to be (i) affordable (costing $NZ20 per month maximum), (ii)relatively easy to provide, and (iii) permitted in the residential program. Residentscould choose material awards or activity-based rewards, such as computer time,tutoring, or help to gain his or her driving license. A notice board on a lounge wallwas dedicated to Thumbs Up and displayed information regarding the contingenciesand prices of backup items.

Interobserver Agreement

Interobserver agreement was calculated on sessions where a second observer,either a staff member or a postgraduate student who had training, observed.Observations were either direct in vivo or via audio recording of the behaviorsof interest.

Procedural Fidelity

When the token reinforcement was handed over to another staff member, theresearcher measured the integrity with which staff gave praise and tokens. Correctresponses involved giving praise for target behaviors, giving the correct number oftokens, and giving corrective feedback if required (e.g., You need to tidy yourdrawers to get two tokens), and incorrect responses involved not giving praise,giving tokens for non-target behavior, failing to give tokens for target behavior, orgiving the wrong number of tokens. Percentage of correct responses was thencalculated by dividing the number of correct responses by the sum of correctresponses and incorrect responses and multiplying by 100.

Social Acceptability

A six-item survey was completed by clients about their experience with theThumbs Up program. Items concerned whether they liked and understood theintervention and whether they recommended its continuation beyond the researchstudy. The participants marked their responses on a 10-cm visual analog scale. A



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neutral response was 50. Responses toward the negative end of the scale were values049, and responses toward the positive end of the scale were values 51100.

EXPERIMENT I: POSITIVE STATEMENTS

Following a meeting with the management, initial target behaviors were selected inareas that were considered to be important to the residents while in treatment andafter discharge. The rst of these target behaviors was positive statements.

Method

Settings

Settings in which data were collected were termed Mealtimes, Morning Meeting,and Start Group.

Dependent Variables and Measurement

Positive statements were verbal statements that (i). indicated approval, either inregular English (e.g., She always looks pretty) or slang (e.g., Sweet as, Thatwas a mean lunch); or (ii) described a desirable state or mood (e.g., Im so happy);or (iii) showed concern for another resident, gave thanks, or provided an apology toanother resident. Statements containing swear words or immediately followed by anegative (e.g., Youre so cool. . . Not!) were not scored as positive. These statementswere measured as frequency within 5-min intervals.Inappropriate statements were verbal statements that (i) contained swear words; (ii)

included venting, that is, strong disapproval of a person, the program, or an activity;or (iii) Neg-raving, that is, romanticizing positively about alcohol and drug use orcriminal behaviors. These statements weremeasured as frequencywithin 5-min intervals.Measurement of frequency within 5-min intervals was facilitated by using an

Invisible Clock (Time Now Corporation, 2004), which was programmed to signal5-min intervals with a tone or vibration. The device measured 5.5 4 cm andresembled a pager. When a session was

Procedure

Baseline. Positive statements were recorded in Mealtime, Morning Meeting, andStart Group. Positive statements were followed by praise from the researcher inall settings. During Morning Meeting, the residents were often prompted to saysomething positive in the Positive Acknowledgements section.Thumbs Up: Start Group. The researcher verbally gave the participants the

denition of positive statements and role-modeled examples. The participants wereadvised that they could earn one token per 5-min interval. Contingent upon a positivestatement, a participant generally received a token immediately. Labeled verbalpraise was also delivered with the token. If the researcher was not able to immedi-ately give the token (e.g., when across the room), she stated thumbs up orgestured a thumbs up sign to the participant. New residents who joined the StartGroup during the intervention remained in baseline for the rst two sessions.Exchange times were set immediately after each Start Group. Once participants haddemonstrated an increase in positive statements over three sessions, they had theopportunity to save their tokens until the end of the second session to gain a largerreward. Residents who had chosen individual rewards were able to save until theychose to exchange their tokens.Thumbs Up: Mealtimes. The procedure for earning and receiving tokens at

mealtimes was the same as those in Start Group. Exchange times for the initialrewards were set at about an hour after mealtime when the participants had nishedtheir post-meal cleaning jobs.Thumbs Up: Morning Meeting. Tokens were earned in the same manner as

previous settings. However, the researcher could not provide tokens immediately asthat would disrupt the ow of the meeting. Contingent on a positive statement, theresearcher made a thumbs up gesture or statement and provided labeled praise.Tokens were given out at the end of the meeting, and exchange times occurredimmediately after.Generalization: extending Thumbs Up to other staff. Following training, a staff

member (Heidi) implemented Thumbs Up in Morning Meeting. Training involvedteaching the staff member to accurately identify positive statements from a 5-mincriterion record that was created from audio recordings of Morning Meeting andMealtime settings. In addition, the staff member was taught (using modeling, rehearsal,and feedback) how to accurately record the data and conduct the exchange of tokens.

Experimental Design

The intervention was introduced rst for Jay and Lisa targeting positive statementsin Start Group once baseline data appeared stable. When an improvement in their



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behavior was shown, the intervention was introduced to Robyn. Following this initialdemonstration of apparent treatment effect, baseline lengths were then minimized inStart Group and Mealtime for ethical and practical reasons. The sequence of interven-tion for positive statements met the criteria for multiple baseline across participantsexperimental design.A return to baseline (time out from tokens) was implemented for participants

when they returned to the program after being discharged for disciplinary reasonsor had returned from absconding. Thus, there were ABA and ABAB withdrawalelements included.The intervention was introduced in Start Group once stable baseline data had been

gained. Once an increase in positive statements was shown across residents, theintervention was introduced in Mealtime. Subsequently, the intervention wasintroduced in Morning Meeting. This sequence met the criteria for multiple baselineacross settings.

Results

Figure 1 shows data for positive statements presented as a non-concurrent multiplebaseline across participants and settings (Mealtimes, Morning Meeting, and StartGroup) for positive statements and inappropriate statements. Data paths for mostparticipants were variable.In baseline, most participants showed low, stable responding, or a decreasing trend

(e.g., MealtimeBree). Some residents, however, showed increasing frequenciesduring baseline (e.g., MealtimeTim).The left panel of Figure 1 shows increases in the frequency of positive statements

from baseline to intervention for all participants except Tim (Mealtime), who left theprogram, returned briey, and then left again. Bree (Mealtime) also left the programand returned to baseline in her last session.The center panel of Figure 1 shows increases in the frequency of positive

statements from baseline to intervention for all participants except for Tim (MorningMeeting), for whom there were limited data. Some of these residents left the program(Nevil, Lisa, and Mandy) and returned (Nevil). Although there were not sufcientdata for Jay (Start Group), there was an increasing trend in his positive statementsduring the intervention.The right panel of Figure 1 shows an increase in positive statements from baseline

to intervention for most residents. Limited data were gained for Hannah (Mealtime)and Bree (Morning Meeting) but showed that the frequency of positive statementswas decreasing during intervention. For Jon (Mealtime) in session 31, the intervalwas only 30-s long and Jon said three positive statements, causing an inatedextrapolated value. Jon left the program and upon return, positive statements

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decreased to zero in a return to baseline in Mealtime and Morning Meeting and thenincreased again.Before the tokens could be introduced for subsequent behaviors, data were

analyzed to assess if Thumbs Up had served to increase positive statements. The datafor positive statements were inspected across the 16 graphs in Figure 1 that havearrows displayed. The arrows indicate the session up to which data had been gainedwhen the graphs were analyzed.Graphs were visually inspected using Millers (1997) method for visual inspection

of behavioral data or the split-middle line of progress method (White, 1974). With theuse of these methods, it was determined that 11 graphs showed an increase whencomparing baseline and intervention phases, four showed no change, and one showeda decrease. A sign test (Siegel & Castellan, 1988) was performed with these results.With an alpha level of .05, the benecial effect of tokens on positive statements wasstatistically signicant (z= 2.89, p= .006).Data for inappropriate statements showed low frequencies for all participants in

baseline, with the exception of Jay in Start Group. The frequency of inappropriatestatements remained at near-zero levels across all participants during the token phaseapart from Jay (Start Group).

Figure 1. Multiple baseline across participants and settings for positive (lled points) and inappropriate(unlled points) statements. The arrows pointing at data points are explained in the text.



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Figure 2 displays the frequency of positive statements across three participants inMorning Meeting when both the author (lled points) and Heidi (unlled points)were implementing Thumbs Up. There was no visually signicant change in thefrequency of positive statements when Heidi was implementing Thumbs Up whencompared with the researcher.Heidis average percentage of correct responses for positive statements was 85%.

She was also 100% correct on three occasions where she and the researcher role-played token exchange.

Discussion

Positive statements improved across settings for most participants in the currentstudy, supporting the results of previous studies that have also selected positivestatements or interactions as a target behavior (Bowers et al., 2000; Ervin, Miller, &Friman, 1996; Sanson-Fisher, Seymour, Montgomery, & Stokes, 1978). However,the increases in positive statements in the current study were not dramatic. This mayhave been because the frequency of positive statements was limited by the contingen-cies. The aim was to increase the frequency of positive statements to one per 5-mininterval. Having this ceiling may have prevented further improvements of positivestatements. It may have been benecial to give tokens for more than one positivestatement per 5-min or to shorten the intervals to see a more dramatic behavior change.However, this should be balanced against the possibility of teaching residents to betoo positive, that is, more so than their typical age peers.

Annabelle

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Figure 2. Positive statements data obtained from Morning Meeting comparing the sessions in whichHeidi (unlled points) and the researcher (lled points) were implementing Thumbs Up.

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The levels of inappropriate statements were socially acceptable for most partici-pants and did not change when Thumbs Up was introduced. Previous literatureshowed antisocial comments to decrease as a result of increasing prosocial comments(Sanson-Fisher et al., 1978). In the current study, inappropriate statements may havebeen low because of being under aversive control (the presence of staff in all of thesettings). Petry et al. (1998) found similar results in an outpatient substance abusetreatment center.

EXPERIMENT II: PROMPTNESS FOR DORM TIGHT

After token reinforcement demonstrated a signicant effect with positive statements,it was of interest whether similar effects could be demonstrated with room cleanliness.

Method

Setting

Bedroom areas were checked for tidiness to a set of criteria 30min after allresidents were up and dressed in the mornings. Breakfast was not announced untilall rooms met all criteria.

Response Denition and Measurement

Promptness for dorm tight was dened as the residents room clean and tidy to 11Dorm Tight criteria on time. Criteria included oors being cleared, clothes folded indrawers, and beds made neatly with sheets tucked in. Residents were given a 2-minwarning before checks occurred. This is measured as yes/no.A second observer was present for at least 20% of sessions, and interobserver

agreement was calculated by the number of agreements divided by the sum of agreementsplus disagreements and multiplied by 100. Average agreement values for Dorm Tightwere 82% (range 58100%).

Procedure

Baseline. The researcher checked a residents room and assessed whether itmet all of the Dorm Tight criteria (standards). If it did not meet all the standards,the researcher pointed out and explained what needed to be xed. A resident waspraised if his or her room was up to standard.



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Thumbs Up. A resident received two tokens and verbal praise if his or her roommet all the standards at Dorm Check time. If one standard was not met, a resident wasgiven one token with praise for the standards that had been met. The researcherinformed them what needed to be performed next time to earn two tokens. If morethan one standard were not met, corrective feedback was delivered and sometimesa TC consequence resulted (e.g., loss of a privilege).

Generalization: extending Thumbs Up to other staff. Following further training,Heidi also implemented Thumbs Up in Dorm Tight. Further training involvedteaching the staff member to accurately check dorm rooms.

Experimental Design

A multiple baseline across participants was used to assess the effects of tokenreinforcement on Dorm Tight.

Results

Figure 3 shows the days in which the participants were able to achieve the criterionduring baseline and token phases. An improvement for most participants occurredwhen tokens were introduced. However, for some participants, baseline levelsappeared to be increasing before the intervention (Ken, Edward, and Annabelle).The proportion of days that participants could meet the standards in token phaseswas higher for all participants when compared with baseline. Averaged across theparticipants, the percentage of days that standards were met in baseline was 37%(range 066%) and more than doubled to 80% (range 56100%) in intervention.However, data for the participants were variable and limited data were gained forsome participants (Nevil and Mandy).A return to baseline was implemented for Nevil and Jon upon their return to the

program and showed that both did not meet Dorm Tight standards. When returnedto the token phase, Nevil was able to meet the standards for two days then left theprogram. Jon returned to the token phase and was able to meet the standards on mostdays.Figure 4 displays data obtained from Dorm Tight across three participants

including sessions where Heidi was implementing Thumbs Up. For Annabelle andRachel, there was no visually signicant change in data when Heidi was implement-ing Thumbs Up when compared with the researcher. For Jon, there was a reductionin the number of days where Dorm Tight standards were met when Heidi wasimplementing Thumbs Up. Heidis average percentage of correct responses for DormTight was 94%.

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Discussion

In Dorm Tight, there was an improvement shown for all participants in thepercentage of days that they were able to meet all the Dorm Tight standards. Theseresults follow those of previous studies that have also improved tidiness (Phillips,1968; Phillips et al., 1971). Improving promptness to Dorm Tight also helped withthe running of the morning schedule.Despite improvements, the participants did not consistently meet Dorm Tight

standards when receiving tokens. Data were recorded as yes/no for Dorm Tight.

Rachel0

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Figure 3. Multiple baseline across participants for Dorm Tight. This shows the days in which participantsmet criterion during baseline and token phases.



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The participants often failed on more than one standard during baseline and improvedto only failing on one standard occasionally in the token phase. Failing on only one of11 standards was still recorded as no. Having an all or nothing measure made itimpossible to see improvements on different areas in the room. It would have beenbenecial to record the percentage of Dorm Tight standards that were met. Phillipset al. (1971) had divided room cleaning into 10 areas that were scored according towhether they met specic criteria.

EXPERIMENT III: ANNOUNCING JOB FUNCTION

Method

Setting

Job function occurred immediately after breakfast. Residents were required tocomplete rostered domestic activities (e.g., mopping) for approximately 20min.

Response Denition and Measurement

Job function was dened as announcing to other residents that it was time to starttheir domestic chores within 1min of breakfast ending. The resident announcing Job

Jon

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Figure 4. Dorm Tight data obtained comparing the days in which Heidi (unlled points) and theresearcher (lled points) were implementing Thumbs Up.

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Function must be moving to start his or her own rostered chore within 1min ofmaking the announcement. This is measured as yes/no. A second observer waspresent for at least 20% of sessions, and interobserver agreement was calculated bythe number of agreements divided by the sum of agreements plus disagreementsand multiplied by 100. Interobserver agreement was 100%.

Procedure

Baseline. If the resident did not announce Job Function by the required time, theresearcher prompted them (e.g., Jon, you need to be getting the others into JobFunction now). If the resident announced Job Function unprompted, the researchergave praise.Thumbs Up. Contingent upon announcing Job Function, a resident received one

token. If they announced Job Function late or announced it but continued to eat ortalk to residents, they were not awarded a token. They were also reminded of thecontingencies, Annabelle, you need to announce Job Function on time if youwant to earn a token. Initial exchange times occurred after residents had completedtheir jobs.

Experimental Design

An AB design across two participants was used to assess the effects of tokenreinforcement on announcing job function. Token reinforcement was introduced forjob function following intervention with positive statements and Dorm Tight. Thus,the overall study design also met the criteria for multiple baseline across behaviors.

Results

Figure 5 shows the number of days that Jon and Annabelle announced Job Functionduring baseline and token phases. Tokens succeeded in increasing the number of daysJon announced Job Function. Annabelle also showed an improvement in announcingJob Function. However, neither participant was 100% reliable.

Discussion

Token reinforcement also served to increase the number of days on which tworesidents announced Job Function. Improving this behavior ensured that Job Functionstarted on time without prompting from the researcher. However, neither resident wascompletely reliable at announcing Job Function. This may have been due to disruptioncaused by tokens only being available on days when the researcher was present (four



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days per week) and the residents losing the responsibility when placed on sanction.There were no data taken on these days. It would have been of interest to rewardannouncing Job Function in the evening and other scheduled events (e.g., mealtimesand meetings).

SOCIAL ACCEPTABILITY

Five participants completed the client satisfaction survey. Participants gave highratings for Thumbs Up in areas of enjoyment, (mean 87, range 72100), understandinghow to earn tokens (mean 99, range 98100), continuing Thumbs Up (mean 89, range46100), recommending new residents to participate (mean 90, range 63100),improvement of behaviors (mean 94, range 74100), and for making the stay at theresidential community more enjoyable (mean 65, range 38100).

GENERAL DISCUSSION

In summary, token reinforcement served to improve three target behaviors for mostparticipants despite poor retention in the treatment program. Another staff memberwas also able to implement token reinforcement (known as Thumbs Up in thefacility) in some settings with positive results. Residents who responded to the socialvalidity survey found the intervention highly acceptable. The token reinforcementwas inexpensive and easy to implement for both the researcher and another

DAYS1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24AN

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Figure 5. Multiple baseline across participants for Announcing Job Function.

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staff member. This study extends current literature by implementing token reinforce-ment in a residential rehabilitation facility for adolescents with substance abuseproblems. Overall, the study design was multiple baseline across participants,settings, and behaviors with some treatment withdrawal elements (Barlow, Hayes,& Nelson, 1984).Another staff member also implemented Thumbs Up with positive results in

Morning Meeting and Dorm Tight. The staff member showed correct respondingabove 80% on most training sessions; however, she occasionally neglected to givetokens out. The researcher reduced this lapse somewhat by instructing the residentsto request their tokens if they had not been given out. Training participants to requestreinforcement has been reported in previous studies (Seymour & Stokes, 1976).It was aimed to train the staff to implement Thumbs Up in other settings, however

her role was restructured before the end of the study and she was no longer present inthese settings.Some residents in the current study saved their tokens and only exchanged a small

number once before leaving the treatment program. Reasons for this may have beenthat the tokens themselves may have been reinforcing: Residents were observed tocompete with their peers in acquiring and saving their tokens. The praise providedwith tokens may have been the reinforcer for most participants rather than theeventual gain of the backup reward. Previous literature has also shown the tokenalone to reinforce behavior (Hall et al., 1972).A more probable reason for savings in the current study may be attributed to the

control over naturally occurring items or activities as backup rewards. In the currentstudy, television, board games, a weekly allowance, and basic snacks were freelyavailable at the residential community and did not need to be purchased with tokens.However, previous studies have required basic activities such as these to bepurchased with tokens before any other privilege (e.g., Phillips, 1968; Phillipset al., 1971). Including basic activities (such as television) as a backup reward mayhave ensured that token spending was maintained.Enabling participants to change their rewards or negotiate prices may have helped

to increase the motivation of participants (Barkley, 1987). Karraker (1977) reported ahigher rate of math performance for students who chose rewards from a list they hadconstructed than for students who received a teacher-selected reward. Kamon,Budney, and Stanger (2005) allowed adolescents to exchange vouchers for theirchosen appropriate reward.Exchange times in the study were at set daily times for participants in their rst two

weeks of the program. These new residents were not permitted to save tokens untilthe next day. This ensured that new participants came into contact with the backuprewards. For individualized rewards, exchange periods generally occurred when theresident had saved the required amount of tokens. Not having a specied exchange



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time on the schedule may have also resulted in high savings, as residents were notbeing prompted frequently to purchase backup rewards.Studies at Achievement Place implemented specied exchange periods (Wolf

et al., 1976). A new resident rst exchanged points at the end of the day forprivileges the next day. After demonstrating skills and self-control, the residentthen exchanged points at the end of the week for privileges the following week.Similar exchange times may have improved behavior in the current study. Partici-pants may have shown higher frequencies of target behaviors if they needed tohave a set number of tokens by a specied time. It may have also encouragedregular spending.Because of the difculty with retention, the researcher did not manage to fade the

token reinforcement for any participants. However, there was an attempt made toremove Jon from the token reinforcement by electing him as a manager. This wasonly attempted on a few occasions before he started a community-based educationalcourse and was no longer present in the settings in which the token reinforcement wasoperating. Previous studies have reported the positive results of peers acting asbehavior modiers (Bailey, Timbers, Phillips, & Wolf, 1971; Phillips, Phillips, Wolf,& Fixsen, 1973).Data did not detect generalization across settings for positive statements or

across behaviors for three residents. Other work duties meant that the researcherhad limited observation of non-intervention settings. It would have been benecialto train a staff member to record positive statements when the researcher could notbe present. Generalization across behaviors was not expected, as Dorm Tightand announcing Job Function were not similar to positive statements. Shortenedbaselines meant that generalization across participants could not be assessed.Most new participants came into the program, whereas longer-term residents werealready in the intervention phase.The rst author continued to lead the administration of Thumbs Up for one

year following the study and added further target behaviors, such as completingacademic work and participating in a job skills training program (Taylor, Mudford,& Phillips, 2011).There were several difculties in conducting the study. First, the number of

participants varied greatly during the study. At the beginning of the study, veresidents consented to being in the study. Numbers changed as new residents arrivedand other residents left. Three residents opted not to participate in Thumbs Up at rst,but two later changed their minds. One other resident who chose not to participatestayed in the program for two weeks before the residential community dischargedher because of rule violations. One resident withdrew from Thumbs Up shortly afterthe intervention started in Start Groups. Therefore, 29 out of 30 residents at theresidential community chose to participate in Thumbs Up at some stage.

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The number of residents leaving and entering the program limited the collection ofdata. Therapeutic gains for participants also may have been lost because of thelimited time spent in intervention. Gaining informed consent from parents orguardians delayed the intervention in some cases, and some residents were notexposed to tokens at all. Poor retention of residents also made individualized rewardsdifcult. Three residents who initially chose individualized backup rewards leftwithin days of the researcher purchasing the items.A second set of difculties concerned changes in rules at the residential commu-

nity, resulting in restrictions on some popular backup rewards (e.g., a new rulepreventing residents from using the computer at the facility). Hobbs and Holt(1976) reported similar organizational obstacles in implementing a token reinforce-ment. Additionally, there were days when Thumbs Up was administrativelysuspended because of participants being placed on sanction. Residents who wereon sanction in the facility could earn tokens but not exchange them for backuprewards. This meant that these residents experienced time out from exchangingtokens, which was not part of Thumbs Up. We had not experienced these administra-tive hurdles with another behavioral intervention successfully conducted in the TC(Taylor, Anderson, & Mudford, 2010). In that study, we taught residents to preparefor activities outside the TC in a more timely manner. It is likely that the ThumbsUp study ran into difculties as it extended over several activities, involved moreresidents, and was conducted over a longer time.Hobbs and Holt (1976) discussed the failure of token economies to observe the

change in behavior outside of the treatment facility. In the current study therewere no data obtained for adolescents who had left the treatment facility as thiswas against the organizations policy. Occasionally, graduated residents return tothe treatment program to visit. It would be of interest to observe behavior inthis situation.In summary, this study extends the current literature by implementing a token

reinforcement within a TC framework and with adolescents with a substance abuseproblem. Results were consistent with those of previous studies with delinquentadolescents for most of the participants and target behaviors. Despite some identieddifculties, the token reinforcement was a successful means of increasing appropriatebehaviors that generally worked within TC standard procedures.

ACKNOWLEDGEMENTS

The study was partly funded by a University of Auckland Masters Scholarship awarded tothe rst author. We thank Kerrie Anderson for her contributions to the study.



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