Research in Developmental Disobiliries, Vol. 13, pp. 43-55, 1992 0891.4222/92 $5.00 + .CQ Printed in the USA. All rights reserved. Copyright 0 1992 Pergamon Press Ltd. Some Issues in Staff Training and Improvement Willy-Tore MGrch Vestre Hougen Treatment Center, Oslo, Norway Svein Eikeseth University of Kansas In 1988, Norway’s parliamen1 instituted the systematic deins1itutionalizationof Ihe nation’s health care system for mentally retarded persons. Professionals have recognized that deins1iru1ionalization will succeed only if treatment per- sonnel can provide effective 1reatmen1 for their clienrs. A study is presented in which 152 hands-on staff members were assigned to 76 clien1s with moderate to severe menial retardation. The study asked whether sraff training in behavioral- ly oriented treatment and assessment would produce greater improvement in the behavior of clients and s1aff than would (raining in treatment alone. Data failed to support this hypothesis, but did provide clear evidence (ha1 borh clients and staff improved with staff training. The assessmen of such programs is seen 10 be of great importance in view of the fac1 that deins(itu1ionalization will leave the majority of mentally retarded clients in Norway in (he care of persons who have received such limi1edforms of training. The first organized educational system for the mildly mentally retarded in Norway was established near Oslo in 1874 and was called the Afternoon School for Spiritually and Intellectually Abnormal Children. This was a partially private, partially public school program funded by A larger version of this study was submitted to Lhe Department of Psychology at the University of Oslo by the first author in partial fulfillment of the requirements for the degree of Doctor of Psychology. The authors appreciate the help in designing this research offered by Douglas Anglin and extensive editorial comments by Tristram Smith, 0. Ivar Lovaas, and Donald M. Baer. This research was supported by grants from J.E. Isberg’s Fond and Oslo Sanitetsforening. Requests for reprints should be sent to Willy-Tore March, Vcstre Haugen Treatment Center, Vestre Haugen 17, N-1054 Oslo 10, Norway. 43
Transcript
Research in Developmental Disobiliries, Vol. 13, pp. 43-55, 1992 0891.4222/92 $5.00 + .CQ Printed in the USA. All rights reserved. Copyright 0 1992 Pergamon Press Ltd.
Some Issues in Staff Training
and Improvement
Willy-Tore MGrch
Vestre Hougen Treatment Center, Oslo, Norway
Svein Eikeseth
University of Kansas
In 1988, Norway’s parliamen1 instituted the systematic deins1itutionalization of Ihe nation’s health care system for mentally retarded persons. Professionals have recognized that deins1iru1ionalization will succeed only if treatment per- sonnel can provide effective 1reatmen1 for their clienrs. A study is presented in which 152 hands-on staff members were assigned to 76 clien1s with moderate to severe menial retardation. The study asked whether sraff training in behavioral- ly oriented treatment and assessment would produce greater improvement in the behavior of clients and s1aff than would (raining in treatment alone. Data failed to support this hypothesis, but did provide clear evidence (ha1 borh clients and staff improved with staff training. The assessmen of such programs is seen 10 be of great importance in view of the fac1 that deins(itu1ionalization will leave the majority of mentally retarded clients in Norway in (he care of persons who have received such limi1edforms of training.
The first organized educational system for the mildly mentally retarded in Norway was established near Oslo in 1874 and was called the Afternoon School for Spiritually and Intellectually Abnormal Children. This was a partially private, partially public school program funded by
A larger version of this study was submitted to Lhe Department of Psychology at the University of Oslo by the first author in partial fulfillment of the requirements for the degree of Doctor of Psychology. The authors appreciate the help in designing this research offered by Douglas Anglin and extensive editorial comments by Tristram Smith, 0. Ivar Lovaas, and Donald M. Baer. This research was supported by grants from J.E. Isberg’s Fond and Oslo Sanitetsforening.
Requests for reprints should be sent to Willy-Tore March, Vcstre Haugen Treatment Center, Vestre Haugen 17, N-1054 Oslo 10, Norway.
43
44 W. -T. M&h and S. Eikeseth
the State Church. As early as 188 1, the State Church approved obligatory school for blind, deaf, and mentally retarded children. However, severely mentally retarded children were excluded. In 1898, the first private nurs- ing home for the mentally retarded was established with 60 clients. By 1915, such homes had multiplied enough to attract government support for their operation.
In 1945, the Norwegian parliament’s Social Law Committee argued that mental retardation was a medical issue and placed the nursing homes under the jurisdiction of the health department. Due to the state’s postwar rebuild- ing costs, most of the institutions established after the war were built by private and humanitarian institutions. In 1949, the Federal Law of Payment was enacted, specifying the state’s share of the running expenses for these institutions. However, the expenses for establishing these institutions were not included in the law.
In 1952, a nationwide plan for the care of mentally retarded persons was proposed. Norway was divided into sections, each section with a director of medicine responsible for the development of institutions for the mental- ly retarded. In 1961, a loan agreement simplifying the building of new state hospitals was passed by the Norwegian parliament. In 1964, the loan agreement was extended to include the building of small, community- based group homes, though until the beginning of the 1970s construction was limited primarily to large institutions designed to hold as many clients
as possible. By 1974, a general dissatisfaction with the conditions in these institu-
tions had developed. The Department of Health appointed a committee to propose goals and guidelines for the development of an improved health care system for mentally retarded individuals. In 1975, the committee rec- ommended a deinstitutionalization and integration process that would depend on the development of a community group home system.
Despite the committee’s recommendation, the deinstitutionalization pro- cess proceeded very slowly. The reasons for this stagnation included dis- agreements about the burden of economic responsibility, loss of tax incomes to certain counties, variance with current nursing philosophy, and lack of planning regarding the reorganization process. A new committee was appointed by the Department of Health in 1954 and completed a report in 1986 that proposed that, within 10 years, the government close down the existing system of health care for mentally retarded persons, including state hospitals. Services for mentally retarded individuals were to be provided by local health, school, occupation, and recreation offices. Systematic deinsti- tutionalization was begun January I, 1991 and is to be completed by 1996. As of this date, the mentally retarded of Norway will be placed in the care of non or paraprofessional persons in local communities. The training of most of these individuals will be limited to participation in short-term,
Issues in Staff Training 4s
workshop-style programs in behavioral techniques similar to the training programs described in this study. Thus, the empirical validation of such training programs and the assessment of how they can be improved are of immediate importance.
Norway’s ongoing deinstitutionalization process requires adequate com- munity programs for the clients who will soon be mainstreamed. The phi- losophy that people with mental retardation should live under normal con- ditions in average environments may tempt some politicians (and some professionals) to press onward without adequate teaching and treatment techniques, appropriate assessment tools, and community preparation. The behavioral literature, however, emphasizes the importance of training hands-on staff and other members of the community to provide newly-rele- vant, possibly unfamiliar services to newly mainstreamed clients (e.g., Christian, Hannah, & Glahn, 1984; Wolf, et al., 1976).
Fortunately, it is already well appreciated that shaping, maintaining, and generalizing new client behaviors depend strongly on relevant staff training (e.g., Lovaas, Koegel, Simmons, & Long, 1973; Koegel, Russo, & Rincover, 1977). However, less emphasis has been placed on the need for behavior-assessment instruments to guide the teaching efforts of hands-on staff. Historically, most diagnostic work has been done in a disease-orient- ed treatment model that has not routinely suggested how to treat clients. Adequate treatment, however, always should proceed on the basis of ade- quate assessment of prior treatment outcome.
In order to enhance and maintain staff competence in assessment-guided
treatment techniques, a Behavior Assessment and Training Manual was developed. The manual was intended to be used to increase staff’s practi- cal and theoretical comprehension of behavioral principles and to teach staffs how to assess changes in clients’ social skills, language, and mal- adaptive behaviors.
The present study asked whether a course in assessment and treatment (Assessment/Treatment group) would produce and maintain greater client and staff improvement than training in treatment alone (Treatment Only group). The study further asked which combination of particular staff train- ing techniques would yield the best outcome.
METHOD
Subjects
The research program involved 76 clients with moderate to severe men- tal retardation who lived in typical institutions in Norway. Eighty-three per- cent of the clients resided in institutions with day and night staff, 12% lived in institutions with only day staff, and 5% lived with their parents. Eleven
46 W. -T. Miirch and S. Eikeserh
percent lived in units with four or fewer residents or with their parents, 53% lived in units of four to six residents, 26% lived in units of seven to nine residents, and 10% lived in units with more than nine residents. Clients’ ages ranged from 3 to 55 years.
Two hands-on staff members were assigned to each client in the study. Prior to data collection, one staff member was designated as “pri- mary” and one was designated as “secondary.” The primary staff mem- ber had responsibility for the day-to-day care of the client; the sec- ondary staff member substituted if the primary caregiver was absent. Eighty-eight percent of the staff had more than 1 year of relevant work experience. Eighty-two percent had more than 1 year of formal educa- tion in special nursing.
Training
A 12-hour course based on The Behavior Assessment and Training Manual was developed. The manual gave instruction in (1) how to develop individual written treatment protocols and schedule clients’ activities on both daily and weekly bases, (2) how to select target behav- iors and assess clients’ performance of these behaviors independent of prompts (In particular, the Manual described how to determine the clients’ levels of prompt independence by identifying the least intrusive prompt needed to evoke the target behavior. These observations served as later baseline data.), (3) how staff could construct a prompt-fading
procedure for each target behavior using any of 36 different prompt options described by the Manual (e.g., physical guidance, verbal instruc- tions, verbal reminders, visual signs, position prompts, etc.), (4) how to reinforce clients’ behaviors differentially according to the above speci- fied prompt-fading procedures, and (5) how to monitor client improve- ment by continuously assessing current levels of prompt independence. Rate of client improvement also provided the staff with feedback on the effectiveness of their teaching.
In order to test the assessment component of the Assessment/Treatment Course, a 12-hour Treatment Only Course was designed for comparison. This course also taught hands-on staff how to provide correct SDs, use rein- forcers, use prompts, fade prompts, use shaping, select target behaviors, and individualize treatment protocols. Although it alerted the participants to assessment, the Treatment Only Course did not incorporate the Assessment Manual.
We hypothesized that the Assessment/Treatment Course would produce greater improvement in client and staff performance than the Treatment only Course.
Issues in Staff Training 47
Design and Procedure
Clients were matched in groups of three on six variables: (1) level of functioning as determined by the complexity of the tasks that each client’s staff chose to teach; (2) responsiveness to reinforcers and the availability of these reinforcers as reported in a questionnaire completed by each client’s staff; (3) level of self-stimulation (high, medium, or low) as report- ed in a questionnaire completed by each client’s staff; (4) client-staff ratio, (5) institutional factors including number of clients on the ward, staff turnover, access to school placement, and availability of supervision by psychologists; and (6) age. Matched clients then were assigned randomly to three groups.
Group 1 (client n = 25, staff n = 50) received the Assessment/Treatment Course. Group 2 (client n = 25, staff n = 50) received the Treatment Only Course and, 6 months later, received the Assessment/Treatment Course. Group 3 (client n = 26, staff n = 52) served as a wait-list-control for 6 months and then received the Assessment/Treatment Course. All groups were given pretreatment-treatment assessments. Groups 1 and 2 were retested 2 weeks after receiving their initial training (Assessment 1). Group 3 was not tested at this point because it received no initial treatment. It was assumed that the performance of clients and staff in Group 3 would not vary significantly during the 2-week period and that the $20,000 cost of testing the group was not warranted. All groups were retested after 6 months (Assessment 2) and 12 months (post-test).
Measurements
A modified version of Koegel, Russo, and Rincover’s (1977) assessment procedures was used to measure (1) clients’ performance of selected target behaviors, and (2) hands-on staffs’ skills in the behavioral treatment of their clients.
Staff and clients were tested while performing six target behaviors selected for training by each client’s staff. During each assessment, each behavior was taught for one lo-minute period. Sessions were videotaped.
It is important to note that these six target behaviors were not practiced between assessment sessions, so any improvement between assessments presumably could be attributed to improvement in clients’ functioning and/or staff skills.
The clients’ performance of the target behaviors was scored as correct if the target behavior occurred promptly after the presentation of its discrimi- native stimulus. For example, if a staff member asked the client for a cup and the client promptly presented a cup, a correct response would be
48 W. -T. Mdrch and S. Eikeseth
scored. Scores for clients’ performance represent the percentage of correct responses occurring during the IO-minute training sessions.
The staffs’ treatment skills were assessed by identifying whether tech- niques such as Prompting, Prompt Fading, Approximation, Close Approximation, use of Discrete Trials, and Reinforcement were imple- mented correctly. A Prompt was scored as correct if it evoked the target behavior. Any prompt was also scored as Prompt Fading if it was less intrusive than the prompt on the previous trial. Approximation was scored if the staff reinforced a response that approximated the target response. Any approximation was scored as a Close Approximation if the staff rein- forced a response that was a more accurate approximation than the approxi- mation in the previous reinforced trial. Any trial was scored as Discrete if the staff presented an SD preceding the response, a consequence following the response and a discrete intertrial interval. Correct Reinforcement was scored if the consequence for a behavior was contingent on a correct response. The staffs’ skills in Prompting, Approximation, use of Discrete Trials, and Reinforcement were calculated as percentages of trials in which that technique was used correctly. Prompt Fading was the percentage of all correct prompts that were faded, Close Approximation was the percentage of all correct approximations.
Observers scored the videotapes of the assessment sessions in a random order and were unaware of when in the study the recordings had been made. The observers had been trained previously to an interobserver relia- bility level of 90% or better. Subsequently, 5% of the tapes scored were recorded by two observers. Their interobserver agreement, calculated by Cohen’s Kappa, yielded a mean correlation of .90.
RESULTS
Client Perjiormunce
Clients with missing data were dropped, leaving a total of 62 (Group 1 n = 20; Group 2 n = 17; Group 3 II = 23). The data on client performance, presented in Figure 1, were analyzed for differences between the treatment groups at each assessment point. Figure 1 reveals that, at the pretest, client performance was very poor and similar across groups. In all groups, clients gave fewer than 5% correct responses.
In the 2 weeks between the pretest and Assessment 1, Group 1 received the Assessment/Treatment Course, Group 2 received the Treatment Only Course, and Group 3 received no training. Contrary to the hypothesis that Group 1 would perform better than the other groups at Assessment 1, Figure 1 shows that Group 2 actually performed best. Clients in Group 2 responded at a mean rate of about 20% correct, compared with 10% correct
Issues in Staff Training 49
30 -
25 .
Pretest Assess. 1 Assess. 2 2 Weeks 6 Months
Assessment Points
Posttest 12 Months
FIGURE 1. After Pretest, Group 1 received the Assessment/Treatment Course and Group 2 received the Treatment Only course. After Assessment 2, Groups 2 and 3 received the Assessment/Treatment Course.
in Group 1 (Group 3 was not assessed). However, the difference between Group 2 and Group 1 was not quite statistically significant, F( 1, 37) = 3.19, p = .08. Thus, the findings from Assessment 1 suggest that the training given to Group 2 may have been superior to the training given to Group 1,
though the findings fall short of statistical significance. During the 6 months between Assessment 1 and Assessment 2, none of
the groups received training. As seen in Figure 1, Group 2 still exhibited the best performance. However, the difference between the groups was not statistically significant, F(2, 59) = 1.254, N.S.
During the 6 months between Assessment 2 and post-test, Group 2 and Group 3 received the Assessment/Treatment Course, while Group 1 received no training. At post-test, Group 2 clients responded correctly at a rate of about 25%. This was a fivefold increase over their performance at pretest, but it was still far below what is optimal for developmentally dis- abled clients (Koegel & Egel, 1979). By comparison, clients in Groups 1 and 3 responded correctly at a rate of lo-15%. The differences between groups was statistically significant, F(2, 59) = 3.24, p < .05. Thus, the two training packages that Group 2 received may have been associated with superior client performance, relative to the Assessment/Treatment Course alone, as given to Groups 1 and 3.
50 W. -T. Mtirch and S. Eikeseth
In summary, the analyses of client performance revealed the following: (1) there was a nonsignificant trend for the Treatment Only Course given to Group 2 to be superior to the Assessment/Treatment Course given to Groups 1 and 3; (2) the combination of both training programs, which Group 2 received, may have been superior to the Assessment/Treatment Course alone; and (3) neither training program, administered alone or in combination, led to satisfactory rates of correct responding from clients.
Staff Competence
Data were collected on one of the two staff members assigned to each client who was included in the data analysis. The primary staff member was used if attainable; otherwise, the secondary staff member was used. Table 1 presents the data on 62 staff members (Group 1 n = 20; Group 2 n = 19; Group 3 n = 23). Table 1 shows that, prior to training, there were no significant differences between Group 1, Group 2, and Group 3 in how well they performed in one-to-one teaching situations with developmentally dis- abled clients. Table 1 also reveals that staff already used reinforcers and discrete trials correctly most of the time. However, they seldom made cor- rect use of other behavioral techniques (SDs, prompts, approximations, prompt-fading, and close approximations).
Table 2 presents the results of subsequent evaluations of staff perfor- mance in implementing behavioral treatment techniques. Between Pretraining and Assessment 1, Group 1 received the Assessment/Treatment Course, Group 2 received the Treatment Only Course, and Group 3 received no training. Contrary to the hypothesis that Group 1 would per- form best at Assessment 1, Table 2 shows that Group 1 and Group 2 did not differ on most measures (Group 3 was not evaluated). On the one mea-
TABLE 1
Retraining Assessment of Staff Performance in Treatment Techniques: Percentage of Trials
in Which Staff Correctly Used Behavioral Treatment Techniques
sure in which the groups did differ, Group 2 evidenced superior perfor- mance, making correct use of SDs more often than Group 1. Both groups showed a marked increase in how often they correctly used approximation and discrete trials, relative to the Pretraining Assessment. Group 2 also showed a marked increase in its use of SDs and reinforcers. In sum, these results indicated that (1) Group 1 and Group 2 performed at about the same level despite receiving different training packages, and (2) both groups improved following the training they received.
TABLE 2 Assessment of Staff Competence in Treatment Techniques: Percentage of Trials in Which
Staff Correctly Used Behavioral Treatment Techniques at Assessment 1, Assessment 2, and Post-training
Percentage of Correct Use of Techniques
Group 1 Group 2 Group 3
M SD M SD M SD F-test
Assessment la
SD 18.0 14.0 36.6 28.2 NA NA 4.60 Prompt 33.2 20.5 38.0 34.8 NA NA 0.00 Approximation 48.4 22.5 44.9 26.0 NA NA 0.21 Prompt fading 30.6 30.1 39.8 29.1 NA NA 1.56 Close approximation 5.4 5.1 5.8 4.3 NA NA 0.01 SR 49.7 1.3 93.4 9.1 NA NA 2.71 Discrete trials 95.4 12.3 93.5 16.0 NA NA 0.55
adf= 1.38, "df= 2.61. *p < .05 NA = not applicable.
52 W. -T. Mfirch and S. Eikeserh
Between Assessment 1 and Assessment 2, none of the groups received any training. As can be seen in Table 2, Groups 1 and 2, which previously had received training, made significantly more use of approximations, prompt fading, and discrete trials than did group 3, which had not received any training. These findings suggested that the training given to Groups 1 and 2 improved staff’s treatment techniques in some, but not all, areas that were evaluated.
Between Assessment 2 and the Post-training evaluation, Groups 2 and 3 received the Assessment/Treatment Course and Group 1 received no train- ing. From Table 2, it can be seen that at the Post-Training evaluation there were no significant differences between the groups except in their use of discrete trials. All three groups used discrete trials correctly more than 90% of the time, but Group 2 approached 100% while Group 1 and Group 3 were a little below this level. In general, the groups performed at a higher level on most measures than they did at Pretraining. On the other hand, they did not show improvements in their use of prompts and close approxi- mation, and most of the time they still failed to use correct treatment proce- dures other than reinforcers and discrete trials.
The data can be summarized as follows:
1. Pretest measures revealed no significant differences in staff performance between the three groups.
2. At Assessments 1 and 2, when Group 2 had received only the Treatment Only Course and Group 1 had received the Assessment/Treatment Course, staff in Group 1 and Group 2 performed similarly, with staff in Group 2 perhaps performing slightly better.
3. All groups made large gains on most (but not all) measures of staff per- formance between Pretest and Post-test after receiving either the Assessment/Treatment Course or both the Assessment/Treatment and the Treatment Only courses. These gains were comparable across groups.
DISCUSSION
This study asked whether a course combining assessment and training techniques would be more effective in teaching staff and client skills than a course in training techniques alone. We assumed that staffs trained in assessment techniques would be better able to monitor their own perfor- mance and continue to improve their treatment skills over time.
Contrary to our predictions, Group 2, which initially received the Treatment Only Course and 6 months later received the Assessment/Treatment Course, showed the greatest gains in client improvement at all assessment points.
Issues in Staff Training 53
Group l’s relatively small changes may have been due to the complexity of the Assessment and Training Manual, which may have exposed staff to too much information at one time. In contrast, Group 2 received two train- ing sessions, an initial 12-hour course in behavioral treatment and another course 6 months later in behavioral treatment and the use of the Assessment Manual.
Perhaps the staff in Group 2 understood the manual better and were more motivated to use it after they had received training and 6 months of experi- ence in behavioral treatment techniques.
Perhaps a better way to structure the training would be to assign small, relevant portions of the Assessment Manual at a time. It may be important in future research to assess whether spacing training in assessment is supe- rior to massed presentation of information. The gains of Group 2 also sug- gest that two separate exposures to training courses in treatment and assess- ment/treatment may be optimal.
We cannot conclude that the assessment component of the Assessment/Treatment Course contributed to any client or staff improve- ment because assessment training was always presented with treatment training. Had Group 1 been significantly superior to Group 2 at Assessment 2, then it might have been agreed that the assessment component of the Assessment/Treatment Course was effective. This did not occur.
The reader should note that, at Assessment 2, 6 months into the study, Groups 1 and 3 appeared to be associated with the same clinical outcome. This suggests that the training provided in the Assessment Manual had lit- tle clinical significance.
An interesting question involves why the relatively short (12-hour) train- ing session improved clients’ target behaviors. Looking at the data in Table 2, we see that the staff quickly changed after the training course, improving their use of reinforcement, reinforcement of approximations, and use of discrete trials. Even so, it seems unlikely that the staff could have targeted and taught just the right set of new behaviors (those sampled by Assessment 1) to their clients during the short 2-week interval. The clients’ “overnight” changes may have been due to the staffs’ new demands for attention and participation in a structured learning situation. However, this hypothesis does not by itself explain why Group 2 improved more than Group 1.
Another interesting question involves why we observed significant dif- ferences in client performance between Groups 1 and 2 at Assessments 1, 2, and 3, yet we saw very little difference in staff performance. One pos- sible explanation is that the skills we did measure (use of Discrete Trials, Prompting, etc.) did not contribute to the improvement in client perfor- mance. Another possibility is that our measures of staff performance
54 W. -T. Mdrch and S. Eikeseth
were not sensitive enough to detect differences between the groups in the skills measured.
We also wondered why clients failed to improve between Assessments 1 and 2. One explanation may be that the staffs failed to generalize newly acquired treatment skills to the natural treatment setting. The present study did not assess the extent to which the staff applied these techniques outside the Assessment points. Future research should monitor such compliance.
Data shows that staffs’ prompt-fading techniques and reinforcement of successive approximations were quite low. In fact, only about 30% of the prompts were faded. Failure to fade prompts while providing contingent reinforcement may cause prompt dependency. When staff data shows a sig- nificant increase in correct prompt fading, a significant improvement in client behavior is also seen (as was the case for Groups 2 and 3 between Assessment 2 and Post-test). These findings suggest that prompt-fading is an important therapeutic process for improved client outcome and may merit further study.
The behaviors measured to assess client improvement and staff perfor- mance were not the same behaviors the staff targeted and taught between assessment periods. Measured behaviors were intended to represent global improvements in areas such as language, social skills, and self-help skills rather than the acquisition of specific behaviors. Using such a conservative design, a client improvement of lo-20% can be statistically significant (though its clinical validity may remain to be determined). Conversely, such a design may have been insensitive to the staff training that was pro- vided. Perhaps we also should have assessed improvements in the behaviors that the staffs were explicitly teaching.
When deinstitutionalization is completed in 1996, the majority of the hands-on staff caring for the mentally retarded in Norway will have train- ing limited to the type of short-term programs described in this study. Although we demonstrated that staff training resulted in measurable gains, the primary conclusion we can draw is that there is a pressing need for additional empirical research on the development of staff training pro- grams. Immediate topics to pursue include the content of training pro- grams, optimal time spent in training, optimal spacing of training, and means of assessing staff and client improvement.
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Christian, W. P., Hannah, G. T., & Glahn, T. J. (1984). Programming effective human services. New York: Plenum Press.
Koegel, R. L., Russo, D. C., & Rincover, A. (1977). Assessing and training teachers in the gener- alized use of behavior modification with autistic children. Journal of Applied Behavior Analysis, 10, 197-205.
Lovaas, 0. I., Koegel, R. L., Simmons, J. Q., & Long, S. S. (1973). Some generalization and fol- low-up measures on autistic children in behavior therapy. Journa/ of Applied Behavior Analysis, 6, 131-166.
Wolf, M. M.. Phillips, E. L., Fixsen, D. L., Braukmann, C. J., Kirigin, K. A., Willner, A. G., & Schumaker, J. B. (1976). Achievement place: The teaching family model. Child Care Quarterly, 5.92-103.
