The current study describes an assessment sequence that may be used to identify individualized,
effective, and preferred interventions for severe problem behavior in lieu of relying on a restricted
set of treatment options that are assumed to be in the best interest of consumers. The relative
effectiveness of functional communication training (FCT) with and without a punishment
component was evaluated with 2 children for whom functional analyses demonstrated behavioral
maintenance via social positive reinforcement. The results showed that FCT plus punishment
was more effective than FCT in reducing problem behavior. Subsequently, participants’ relative
preference for each treatment was evaluated in a concurrent-chains arrangement, and both
participants demonstrated a clear preference for FCT with punishment. These findings suggest
that the treatment-selection process may be guided by person-centered and evidence-based

DESCRIPTORS: aversive, choice, concurrent chains, developmental disabilities, evidence-
based values, functional analysis, functional communication training, punishment


Selecting interventions that are most effective
in reducing problem behavior and promoting
desirable behavior over the short and long term
has been advocated for many years (Iwata,
1988; Perone, 2003; Van Houten et al., 1988).
Nevertheless, many researchers and practi-
tioners continue to select treatments based on
structure or name alone (e.g., antecedent-based
or positive-reinforcement-based treatment) or
on values that are assumed to be in the best

interest of the person with the problem
behaviors. The current zeitgeist of providing
exclusively positive behavioral interventions
(positive behavior support [PBS]; E. G. Carr
et al., 2002) is consistent with the approach of
restricting treatment options to those that
appear to be consumer friendly. More specifi-
cally, PBS implies that antecedent-oriented and
reinforcement-based interventions should be
developed to the exclusion of interventions
involving punishment (E. G. Carr et al.).
Although this approach seems to be grounded
in the antiaversives movement (LaVigna &
Donnellan, 1986), it is also predicated on the
practices that have emerged from a behavior-
analytic approach to understanding and treat-
ing problem behavior (J. E. Carr & Sidener,

This investigation was supported in part by Grant
MCJ249149-02 from the Maternal and Child Health
Service of the U.S. Department of Health and Human

Requests for reprints should be addressed to Gregory P.
Hanley, Department of Applied Behavioral Science,
University of Kansas, 1000 Sunnyside Ave., Lawrence,
Kansas 66045 (e-mail:

doi: 10.1901/jaba.2005.6-04



Functional analysis, which is used to deter-
mine the reinforcing functions of problem
behavior and to identify influential establishing
operations and discriminative stimuli (Iwata,
Pace, Dorsey, et al., 1994), presumably sets the
occasion for a focus on positive behavioral
interventions (Pelios, Morren, Tesch, &
Axelrod, 1999). Once the reinforcer for pro-
blem behavior is identified via analysis, treat-
ments can be developed in which the
maintaining reinforcer is delivered differentially
or noncontingently and withheld following
problem behavior (i.e., extinction). Although
function-based treatments have been proven
effective for a variety of behavior disorders (e.g.,
Fisher, Piazza, & Page, 1989; Iwata, Pace,
Dorsey, et al., 1994; Mace & Lalli, 1991; Piazza
et al., 1997; Piazza, Hanley, & Fisher, 1996;
Thompson, Fisher, Piazza, & Kuhn, 1998;
Vollmer, Northup, Ringdahl, LeBlanc, &
Chauvin, 1996), several rigorous component
evaluations have shown that these treatments
may not be effective for all individuals (Fisher
et al., 1993; Hagopian, Fisher, Sullivan,
Acquisto, & LeBlanc, 1998; Wacker et al.,

For example, Hagopian et al. (1998) sum-
marized the results of 21 clinical cases involving
functional communication training (FCT) as
the primary intervention. FCT is differential
reinforcement of alternative behavior (DRA),
but the reinforcer that maintains problem
behavior, rather than an arbitrary reinforcer, is
arranged for a socially recognizable alternative
response (i.e., the response specifies the rein-
forcer). In addition, the consequence for
problem behavior is often explicitly described
in FCT treatments (i.e., extinction, punish-
ment, or continued reinforcement is scheduled
for problem behavior). Hagopian et al. found
that only 1 of 10 applications were successful
(success being defined as a reduction in problem
behavior of 80% or better) when problem
behavior and the alternative response both
resulted in reinforcement. An improvement

was seen when extinction for problem behavior
was arranged, but still only 17 of 31 applica-
tions of FCT plus extinction were successful.
Finally, the authors found that FCT was
successful when combined with punishment in
17 of 17 applications.

Although these data are compelling, a recent

review of the treatment literature suggests that

the use of programmed punishment is low

(Pelios et al., 1999). This apparent decreased

reliance on punishment may be related to the

increased dependence on functional analysis for

treatment development (Pelios et al.), but is

probably also related to the fact that the social

acceptability of punishment is low (Blampied &

Kahan, 1992; Kazdin, 1980; Miltenberger,

Suda, Lennox, & Lindeman, 1991).
Even though questionnaires or rating

scales may be appropriate for evaluating the
acceptability of an intervention with critical
stakeholders in the intervention process (care-
givers, teachers, or community members;
Miltenberger, 1990), these indirect methods
are not appropriate for individuals who cannot
readily express their preferences verbally. It
may be reasonable for friends, family, and
advocates to inform the process of selecting
behavioral interventions, as in person-centered
planning (Holburn, 1997; Whitney-Thomas,
Shaw, Honey, & Butterworth, 1998); however,
reliance on the values and preferences of others
may not always be in the best interest of the

As an alternative to both approaches, Hanley,
Piazza, Fisher, Contrucci, and Maglieri (1997)
described a method for assessing the social
acceptability of and preference for behavioral
interventions by presenting multiple treatment
alternatives in a choice arrangement to the
actual person receiving the treatment. In this
procedure, referred to as a concurrent-chains
arrangement, two function-based interventions,
one involving differential reinforcement of an
alternative response (i.e., FCT) and the other
involving the time-based delivery of the same


amount and type of reinforcement (i.e., non-
contingent reinforcement [NCR]), were evalu-
ated with 2 children with developmental
disabilities. The children were then given an
opportunity to choose from among the treat-
ment options (FCT, NCR, and extinction only)
by pressing one of three colored switches that
were associated with each of the treatments.
Each switch press resulted in a brief experience
with the selected treatment. Although FCT and
NCR were equally effective in reducing prob-
lem behavior, both children preferred the FCT

Instead of relying on a restricted set of
treatment options that are assumed to be in the
best interest of the consumer, the methods
described by Hanley et al. (1997) may be used
to identify the most effective and preferred
interventions. In other words, the values that
guide the selection of particular assessment
and treatment strategies can be data based.
Furthermore, continued direct evaluation of
child and caregiver preferences may ultimately
yield an evolving set of evidence-based values
that may provide a more solid advocacy
foundation for individuals who require or seek
evaluation and support services. Finally, the
practice of allowing individuals who cannot
readily express their biases to participate directly
in the treatment-selection process seems to be
most consistent with placing the person in the
center of the habilitative planning process
(Holburn, 1997; Whitney-Thomas et al.,
1998) and providing effective and preferred
behavioral supports (see also Hanley, Iwata, &
Lindberg, 1999).

Therefore, the preference assessment meth-
ods described by Hanley et al. (1997) were used
in the current investigation to evaluate chil-
dren’s preference for function-based interven-
tions that did and did not involve a punishment
contingency. More specifically, the effectiveness
of several function-based treatment packages
was evaluated with 2 children whose problem
behavior was sensitive to adult attention as

reinforcement. Following demonstrations of
the relative effectiveness of treatments that did
and did not involve punishment contingencies,
a concurrent-chains procedure was arranged to
evaluate children’s preferences for the treat-
ments that they had experienced.



Two children with severe behavior disorders
had been admitted to an inpatient unit special-
izing in the assessment and treatment of
problem behavior. Jay was a 5-year-old boy
who had been diagnosed with moderate mental
retardation, autism, and a seizure disorder. He
lived at home with his mother and attended a
public preschool with specialized programming
for children with autism. His problem behavior
included self-injury (hitting and slapping head
with hands, hitting head with objects, biting
arms, and eye poking), aggression (hitting,
kicking, pushing, pinching, hair pulling,
scratching, and head butting), and disruption
(throwing objects, breaking objects, knocking
objects to the floor). He followed simple
one- and two-step instructions and ambulated
without assistance.

Betty was an 8-year-old girl who had been
diagnosed with mild to moderate mental
retardation, attention deficit disorder, and
oppositional defiant disorder. She also lived at
home with her parents, attended a public ele-
mentary school with specialized programming,
was ambulatory, and followed simple one- and
two-step instructions. Betty’s aggression (hitting,
kicking, pinching, scratching, biting, pulling
hair, and throwing objects at people) was the
problem behavior in the current investigation.
Betty also engaged in pica and self-injury,
which were assessed and treated separately from
her aggression (due mainly to different beha-
vioral functions). Jay and Betty were included
in this series of evaluations because two specific
types of treatment (one involving extinction
and one involving punishment) were shown to


be effective to varying degrees in reducing
problem behavior and because each child was
available in the inpatient unit for further
evaluation of other problem behavior (Betty)
or for caregiver training (Jay).


Design, Setting, and Procedure
Functional analyses (Iwata, Pace, Dorsey,

et al., 1994) were conducted with both partici-
pants. Sessions were 10 min in duration and
were conducted in therapy rooms (3 m by 3 m)
equipped with one-way mirrors. Approximately
three to five sessions were conducted per session
block (six to 10 sessions per day), and a 5-min
break occurred between each 10-min session.
Sessions were conducted in a random order
within a multielement design for each partici-
pant. Levels of problem behavior were assessed
across three to five conditions: attention, escape,
tangible (Jay only), alone (Jay only), and play.

Prior to attention sessions, the child was
given toys and was prompted to play while the
therapist engaged in a task (e.g., reading a
magazine). During sessions, the therapist pro-
vided attention in the form of a brief (5-s)
verbal reprimand following each problem
behavior. All other responses of the child were
ignored. During the escape condition, the
therapist delivered sequential verbal, gestural,
and physical prompts to complete an academic
or self-care task every 10 s until either the child
complied with the instruction or engaged in a
problem behavior. If the child complied with
the instruction following a verbal or gestural
prompt, he or she received praise from the
therapist. If the child displayed problem
behavior, the therapist terminated the instruc-
tions and removed the task materials for 30 s
(i.e., escape was provided).

Tangible sessions were conducted with Jay
because his mother reported that she often
provided Jay with preferred toys to ‘‘calm him
down’’ during episodes of problem behavior.
Jay was allowed to play with preferred activities
(a mirror, Pla-DohH, and a rubber ball) for

2 min prior to the start of the tangible sessions.
The therapist withdrew the preferred objects at
the onset of the session and returned the items
for 30 s following each occurrence of problem
behavior. All other responses of the child were
ignored. An alone condition also was conducted
with Jay to determine if his self-injurious or
disruptive behaviors would persist in the
absence of any programmed social stimulation.
Jay was alone in an otherwise empty room
during the alone condition. Toys were available
freely, and the therapist delivered attention at
least every 30 s during the play condition,
which served as the control for the potential
reinforcement contingencies arranged in the
previously described test conditions.

Data Collection and Interobserver Agreement

Trained observers used laptop computers to
record the frequency of problem behaviors for
all participants (see topographies and defini-
tions above). Two observers scored problem
behaviors simultaneously but independently
during 54% and 32% of the sessions for Jay
and Betty, respectively. Agreement coefficients
were calculated by partitioning each session into
consecutive 10-s intervals and dividing the
number of exact agreements on the occurrence
of behavior by the sum of agreements plus
disagreements. This number was then multi-
plied by 100%. The mean exact agreement
coefficients for problem behavior were 99%
(range, 95% to 100%) for Jay and 80% (range,
46% to 100%) for Betty. Low agreement scores
for Betty in this analysis (and the treatment
analysis) were correlated with sessions during
which the highest amounts of aggression
occurred. This scoring difficulty was at least
partly due to the fact that aggression often
occurred in bursts of multiple forms of the
response (i.e., hitting, kicking, etc.).


Design, Setting, and Procedure

Several function-based treatments were eval-
uated in single-subject designs (reversal and


multielement) for each participant. All sessions
were conducted in individual treatment rooms
(3 m by 3 m) equipped with one-way mirrors.
Approximately three to five sessions were
conducted per session block (six to 10 sessions
per day), and a 5-min break occurred between
each 10-min session.

Baseline. The baseline condition was simi-
lar to the attention condition of the functional

analysis. The child was provided with activities

and was instructed to play while the therapist

attended to a task (e.g., reading a magazine).

The therapist delivered approximately 20 s of

attention in the form of mild verbal reprimands

(e.g., ‘‘Don’t do that’’) and statements of

concern (e.g., ‘‘You might hurt yourself ’’)

following problem behavior. All other responses

were ignored.
FCT training trials. Following baseline but

prior to the FCT (and NCR for Jay) evaluation,
training trials were conducted to teach the
participants alternative responses that would
result in access to adult attention. The alter-
native responses were selected based on the
individual’s expressive language abilities and the
advice of the consulting speech pathologists.
The alternative response for Jay was handing a
yellow card containing the printed word ‘‘play’’
to the therapist. The alternative response for
Betty was saying ‘‘attention, please’’ or ‘‘excuse
me.’’ Nine 10-min training sessions were
conducted with Jay, and two 10-min training
sessions were conducted with Betty to teach the
alternative responses.

Training consisted of backward chaining in
which Jay was initially physically guided to
hand the card to the therapist to obtain 20 s of
attention. No attention was provided for prob-
lem behavior (i.e., extinction was programmed
for problem behavior). The amount of guidance
provided to hand the card to the therapist was
decreased to a vocal prompt over the course of
the training sessions. Subsequently, the vocal
prompting was eliminated, and Jay indepen-
dently engaged in the alternative response

throughout the last two training sessions. The
therapist vocally prompted Betty to emit either
of the two vocal responses to request attention
every 30 s, and problem behavior no longer
produced attention (extinction) in the initial
training session. Betty independently engaged
in the alternative response during both training

FCT. The conditions were the same as
those described in baseline with the following
exceptions. If the child emitted the alternative
response (i.e., saying ‘‘attention, please’’ or
‘‘excuse me’’ for Betty; handing the card to
the therapist for Jay), the therapist delivered
20 s of attention (verbal praise and interactive
play). If the child engaged in problem behavior,
no differential consequence occurred (i.e.,
extinction). In addition, a blue laminated
posterboard (80 cm by 52 cm) was placed on
the wall during the FCT treatment sessions for
Jay. This item was included in an attempt to
establish an association with a salient stimulus
(blue posterboard) and the FCT treatment
contingencies and to promote discriminated
performances during his comparative treatment
analysis (similar condition-correlated stimuli
were not used with Betty because she experien-
ced only one intervention at a time).

NCR. This intervention was evaluated with
Jay only. The conditions were similar to those
described for the FCT sessions with the
following exceptions: The communication card
was not available, a green posterboard (80 cm
by 52 cm) was placed on the wall, both
problem behavior and alternative responding
resulted in no differential consequences, and the
therapist delivered 20 s of attention (verbal
praise and interactive play) on a time-based
schedule. The schedule of attention delivery in
the NCR sessions was yoked to the preceding
FCT session. During the FCT sessions, a data
collector recorded the occurrence of each
communicative response on a sheet that was
partitioned into 60 10-s intervals. During NCR
sessions, 20 s of attention was delivered at the


approximate times (in the same intervals) that
attention had been delivered in the previous
FCT session. This procedure resulted in the
same amount and temporal distribution of
reinforcement delivered across FCT and NCR
sessions. Both FCT and NCR were evaluated
with Jay to determine if either treatment was
more effective in reducing problem behavior
(see Kahng, Iwata, DeLeon, & Worsdell, 1997,
and Hanley et al., 1997, for similar comparative
analyses). NCR was not evaluated with Betty
because strengthening socially appropriate vocal
behavior was a primary goal of her admission.

FCT plus punishment. These conditions
were the same as the FCT conditions except
that each instance of problem behavior resulted
in a 30-s hands-down procedure for Jay (the
therapist stood behind Jay and held his hands to
his sides) and a 30-s hands-down and visual-
screen procedure for Betty (the therapist stood
behind the child and placed one arm around the
child’s arms while placing the other hand over
the child’s eyes; Fisher, Piazza, Bowman,
Hagopian, & Langdon, 1994). These particular
procedures were selected because they both have
empirical support (Fisher et al.) and could be
implemented safely and consistently by thera-
pists and caregivers with these children. The
procedures differed for each child based on
caregiver preference. Caregivers were provided
with a description of nine potential punishment
procedures (Fisher et al.) and were asked to
select the procedure they thought would be
most effective and one that they would be
willing to implement consistently. Overall
session length varied in this condition because
the session clock was stopped each time a
punishment procedure was implemented (i.e.,
each session represents 10 min in which all
target responses could occur). Also, for Jay, a
red posterboard was present during the FCT
plus punishment sessions.

Data Collection and Interobserver Agreement

During all treatment analysis sessions, trained
observers used laptop computers to record the

frequency of problem behaviors and alternative
responses. Two independent observers recorded
target responses simultaneously but indepen-
dently during 50% and 58% of the sessions for
Jay and Betty, respectively. Mean exact agree-
ment for problem behavior was 99% (range,
87% to 100%) and 88% (range, 56% to 100%)
for Jay and Betty, respectively. Mean exact
agreement for the alternative behavior was 90%
(range, 88% to 100%) and 95% (range, 87%
to 100%) for Jay and Betty, respectively. Fre-
quency data also were collected during all
waking hours on Jay’s problem behavior on
the living unit by direct-care staff using paper
and pencil. These data were collected during
baseline, FCT, and FCT plus punishment
conditions and are reported as responses per


General Description
Each child’s relative preference for several

treatments was evaluated using a modified
concurrent-chains procedure (Hanley et al.,
1997). In this arrangement, three equal
(fixed-ratio 1) and independent schedules were
arranged for pressing one of three micro-
switches; these were the initial links of the
chain. Responding on different-colored micro-
switches resulted in access to the different
treatments; these were the terminal links in
the chain. This procedure has been used to eval-
uate preference for different types or schedules
of reinforcement because responding to produce
access to the terminal links (reinforcing effec-
tiveness of the terminal links) is separated
from the contingencies that maintain respond-
ing in the terminal links (Catania, 1963). Three
switches were available in the initial links, and
three treatment procedures—FCT, FCT plus
punishment, and punishment only—were avail-
able in the terminal links. Switch pressing
outside a therapy room (initial links) resulted in
a 2-min period inside the room (terminal links)
in which the contingencies varied according to


the switch that was pressed. The treatment
contingencies were the same as those described
in Phase 2.


Three switches (22 cm by 14 cm), each
covered with a different-colored piece of
construction paper (blue, red, or white), were
located on a table outside of a therapy room.
Each colored switch was paired with a different
treatment: the blue switch with FCT, the red
switch with FCT plus punishment, and the
white switch with punishment only. Pressing
any switch resulted in immediate praise from
the therapist (e.g., ‘‘Good pressing the red
switch’’) and access to the terminal link (i.e., the
child entered the therapy room and experienced
the treatment contingencies associated with the
pressed switch for 2 min). The FCT and FCT
plus punishment arrangements were similar
to those described above for the treatment
evaluation. The only difference between these
two interventions was the presence or absence
of the punishment procedure. During the
punishment-only condition, problem behavior
resulted in a 30-s hands-down procedure for Jay
or a 30-s hands-down and visual-screen proce-
dure for Betty; attention was otherwise unavail-
able. This option was included to distinguish
between indiscriminate initial-link respond-
ing (represented by equal responding on all
switches) and no preference between the two
target treatments (represented by approximately
50% of responding to each FCT intervention)
(i.e., given the results of the functional analyses,
it was assumed that the child would not respond
for the terminal link that was devoid of atten-
tion). The child exited the room after 2 min
and was repositioned in front of the switches.
This procedure was repeated until 20 min had
elapsed for Jay or 10 initial-link responses were
recorded for Betty. The change from the time-
based to the response-based termination criter-
ion ensured that the same number of choice
opportunities would be arranged in each session
(this procedural modification was introduced by

Hanley et al., 1999; it occurred after Jay’s
assessment but before Betty’s assessment). The
materials in the terminal links were the same as
those described for all assessment conditions
(i.e., therapist, chair, and toys), except that
colored posterboards corresponding to the
treatment contingencies were posted in the
terminal links (blue for FCT, red for FCT plus
punishment, and white for punishment only).

Prior to the evaluation of treatment pref-
erence, prompted choice trials were conducted
to expose the participants to the different
contingencies arranged for pressing each of the
switches. During each participant’s first expo-
sure session, the therapist physically guided Jay
or Betty to press a switch. The order of switch
pressing was determined randomly. In addition
to exposing the children to the consequences
for pressing each of the three switches, the
contingencies also were described to Betty
to facilitate discriminated switch pressing. In
subsequent exposure sessions, the therapist
stood behind the participant and verbally
prompted him or her to press a switch once
every 20 s if the participant did not press a
switch independently. Exposure sessions were
conducted with Jay until he pressed any of the
three switches independently on five consecu-
tive trials; this occurred in the fourth exposure
session. Two 20-min exposure sessions were
conducted with Betty.

Treatment preference assessment sessions
then were conducted using similar procedures.
Participants were physically guided to press each
switch (red, blue, and white) once and contact
the contingencies associated with each switch in
the terminal links prior to the onset of each
preference assessment session. Several controls
for unwanted bias were programmed. The same
therapist implemented each of the three treat-
ments in the terminal links to insure that the
procedures were implemented similarly within a
session and to control for the participant press-
ing a switch to gain access to a particular thera-
pist (different individuals served as therapists


across sessions). The same materials also were
present in the therapy room (toys, chair) for all
treatments. The therapists were trained to issue
all prompts (‘‘Press the switch’’) in a neutral
tone of voice, to deliver all praise statements in
the same tone of voice following all switch
presses, and to implement attention and
punishment procedures in an identical manner
across treatments. Finally, the position of the
switches was altered randomly after the partici-
pant pressed a switch and entered the room.

Data Collection and Interobserver Agreement

During all treatment preference evaluation
sessions, two trained observers independently
recorded the number of switch presses for Jay
and Betty using paper and pencil. An agreement
was scored if both observers recorded the same
switch pressed for a given trial. An agreement
coefficient was calculated for each participant’s
treatment preference evaluation by dividing the
number of agreements by the total number of

agreements plus disagreements and multiplying
by 100%. Interobserver agreement was collected
for 100% of the sessions for Jay and Betty and
was 100%. Data were not collected on problem
and alternative behaviors in the terminal links.


Phase 1

Results of the functional analyses for both
participants are presented in Figure 1. Attention
was the only condition in which rates of
problem behavior were consistently higher than
the control condition for Jay (M 5 1.5 and 0.1
responses per minute, respectively), suggesting
that his problem behavior was sensitive to
attention as reinforcement. Betty’s aggression
was observed at high rates in the attention (M 5
8.4) and escape (M 5 2.9) conditions relative to
the play condition (M 5 0), suggesting both
attention and escape functions. However, the
treatment analyses focused exclusively on

Figure 1. Problem behaviors per minute during the functional analyses for Jay (top) and Betty (bottom).


Betty’s attention-maintained aggression (the
escape function was addressed in another
assessment not presented here).

Phase 2

The results of the treatment analyses are
presented in Figure 2. Jay engaged in a rate of
problem behavior in the treatment baseline
conditions (M 5 1.5 responses per minute)
similar to that observed in the …

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