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An experimental analysis of prevent teach reinforce for families (PTR-F)

Material Information

Title:
An experimental analysis of prevent teach reinforce for families (PTR-F) effects on challenging behaviors, appropriate behaviors, and social validity
Creator:
Joseph, Jaclyn D. ( author )
Place of Publication:
Denver, Colo.
Publisher:
University of Colorado Denver
Publication Date:
Language:
English
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1 electronic file (144 pages) : ;

Thesis/Dissertation Information

Degree:
Doctorate ( Doctor of philosophy)
Degree Grantor:
University of Colorado Denver
Degree Divisions:
School of Education and Human Development, CU Denver
Degree Disciplines:
Education and human development

Subjects

Subjects / Keywords:
Behavioral assessment of children ( lcsh )
Problem children -- Family relationships ( lcsh )
Behavioral assessment of children ( fast )
Problem children -- Family relationships ( fast )
Genre:
bibliography ( marcgt )
theses ( marcgt )
non-fiction ( marcgt )

Notes

Review:
The purpose of this study was to examine the effects of behavior support plans (BSPs) developed through the Prevent Teach Reinforce for Families (PTR-F) process on changes in child behaviors. The level of fidelity at which families implemented BSPs was also considered in addition to family social validity ratings regarding the PTR-F process and the BSPs that families developed and implemented during their participation in the PTR-F process. A single case withdrawal research design was used across three families with children between the ages of 3 years 1 month and 3 years 9 months. Results indicated that the families implemented BSPs with high levels of fidelity and that functional relations existed across families between their implementation of the BSPs and changes in their children's challenging and desirable behaviors. Results also indicated that familial routine satisfaction and familial confidence with implementing the BSPs improved throughout their participation in the PTR-F process and with their implementation of the BSPs. Social validity findings indicated that families favorably rated the PTR-F process and the BSPs that were developed and implemented. A discussion of results, study limitations, recommendations for future research, and implications for practice are presented.
Bibliography:
Includes bibliographical references.
System Details:
System requirements: Adobe Reader.
Statement of Responsibility:
by Jaclyn D. Joseph.

Record Information

Source Institution:
University of Colorado Denver Collections
Holding Location:
Auraria Library
Rights Management:
All applicable rights reserved by the source institution and holding location.
Resource Identifier:
985117545 ( OCLC )
ocn985117545
Classification:
LD1193.E35 2016d J67 ( lcc )

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Full Text
AN EXPERIMENTAL ANALYSIS OF PREVENT TEACH REINFORCE FOR FAMILIES
(PTR-F): EFFECTS ON CHALLENGING BEHAVIORS, APPROPRIATE BEHAVIORS,
AND SOCIAL VALIDITY by
JACLYN D. JOSEPH
B.A., Washington and Jefferson College, 2008 M.S.W., University of Pittsburgh, 2010
A thesis submitted to the Faculty of the Graduate School of the University of Colorado in partial fulfillment of the requirements for the degree of Doctor of Philosophy Education and Human Development
2016


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2016
JACLYN JOSEPH
ALL RIGHTS RESERVED


Ill
This thesis for the Doctor of Philosophy degree by Jaclyn D. Joseph Has been approved for the Education and Human Development Program by
Phillip S. Strain, Advisor Elizabeth Steed, Chair Nancy Leech Glen Dunlap
July 30, 2016


IV
Joseph, Jaclyn Danel (PhD, Education and Human Development)
An Experimental Analysis of Prevent Teach Reinforce for Families (PTR-F): Effects on Challenging Behaviors, Appropriate Behaviors, and Social Validity
Thesis directed by Professor Phillip S. Strain
ABSTRACT
The purpose of this study was to examine the effects of behavior support plans (BSPs) developed through the Prevent Teach Reinforce for Families (PTR-F) process on changes in child behaviors. The level of fidelity at which families implemented BSPs was also considered in addition to family social validity ratings regarding the PTR-F process and the BSPs that families developed and implemented during their participation in the PTR-F process. A single case withdrawal research design was used across three families with children between the ages of 3 years 1 month and 3 years 9 months. Results indicated that the families implemented BSPs with high levels of fidelity and that functional relations existed across families between their implementation of the BSPs and changes in their childrens challenging and desirable behaviors. Results also indicated that familial routine satisfaction and familial confidence with implementing the BSPs improved throughout their participation in the PTR-F process and with their implementation of the BSPs. Social validity findings indicated that families favorably rated the PTR-F process and the BSPs that were developed and implemented. A discussion of results, study limitations, recommendations for future research, and implications for practice are presented.
The form and content of this abstract are approved. I recommend its publication.
Approved: Phillip S. Strain


V
DEDICATION
This is for you, Jace. Well all float on okay.


VI
ACKNOWLEDGEMENTS
This dissertation would not have been possible without the encouragement and support that I have been blessed to receive throughout the last few years from a number of individuals who deserve much more than the written thanks that follow.
To my friends, I am better for having each and every one of you in my life, and I am forever thankful that you understood schedule conflicts and time demands.
To the individuals who directly contributed to this study, you deserve so many thanks. To the three families who participated in this study, thank you for opening your homes to me, for your dedication to our partnerships, for the love that you have for your children and families, and for making this dissertation process not only meaningful but also fun. To my independent observer, thank you for watching and re-watching so many videos, for completing tasks at the drop of a hat, and for your support.
To my committee, I am so grateful and fortunate to have had your brilliance, practicality, down-to-earth styles, passion for what you do, and friendships throughout my entire program and especially as I completed this dissertation work. It is truly an honor to acknowledge you all here.
To my advisor, Phil, thank you for always advocating on my behalf, for believing in me and pushing me to do more than what I think I am able to do, and especially thank you for sharing so many opportunities with me that continue to shape me for the better as a professional and also as a person. Most importantly, thank you for the laughs and for your continued friendship.
To my parents, my biggest fans and supporters, not one minute goes by that I am not thankful for you. I would not have accomplished half of what I have done if it werent for your modeling of hard work, perseverance, and compassion for children with special needs and their families throughout much of my life. You are truly my best friends, and both of you in your individualized ways have made life so much better because were in it together.
And finally, to Jace (even though I already dedicated this entire dissertation to you and Im not sure what more you could want), thank you for working so hard to get us through these last few years and for never complaining when I get all of the credit for it. You shine brighter than anyone I know, and it has been your steadfast, unwavering support and positivity (and also your humor) that kept me going through the tough times.


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TABLE OF CONTENTS
CHAPTER
I. INTRODUCTION AND LITERATURE REVIEW 1
Understanding Challenging Behaviors and Importance of PBS 1
Review of Literature 3
Social Emotional Development in Young Children 3
Programs to Support Families 5
Family-Centered Positive Behavior Support 5
Conceptual Framework and Key Components 6
Theory of Change 14
The Efficacy of Family-Centered Positive Behavior Support 15
Practical Significance of Programs 17
Prevent Teach Reinforce for Families (PTR-F) 18
Key Features of PTR-F 18
Practical Significance of PTR-F 21
Purpose and Research Questions 22
II. METHODOLOGY 24
Participants 24
Sampling Procedure 24
Henry and His Family 26
Olivia and Her Family 27
Nathan and His Family 28
Settings and Routines 29
Henry and His Family 29
Olivia and Her Family 30
Nathan and His Family 30


Vlll
Prevent Teach Reinforce for Families Process 31
Independent Variable: PTR-F BSP 35
Henry and His Family 35
Olivia and Her Family 42
Nathan and His Family 49
Dependent Variables 56
Percentage of Fidelity of Intervention Checklist Components Implemented 57
Measurement 57
Childrens Challenging and Desirable Behaviors 58
Percentage of Intervals 58
Family Behavior Rating Scales (BRSs) 59
Eyberg Child Behavior Inventory (ECBI) 59
Family Perception of the PTR-F Process and BSP (Social Validity) 60
Familys Implementation of the BSP 60
Experimental Design 61
III. RESULTS, DISCUSSION, AND RECOMMENDATIONS 64
Interobserver Agreement 64
Results 66
Familys Implementation of the Comprehensive BSP 67
Childrens Challenging and Desirable Behaviors 67
Henry and His Family 68
Olivia and Her Family 70
Nathan and His Family 71
Family Behavior Rating Scales 72
Eyberg Child Behavior Inventory 73


IX
Family Perception of the PTR-F Process and BSP (Social Validity) 74
Discussion 77
Replication of Function-Based Intervention and Prevent Teach Reinforce Model 78 Percentage of Fidelity of Intervention Checklist Components Implemented 79
Childrens Challenging and Desirable Behaviors 80
BRSs 81
ECBI 82
Family Perception of the PTR-F Process and BSP 83
Study Limitations 83
Recommendations 85
Implications for Practice 86
Conclusion 88
REFERENCES 90
APPENDIX
A 96
B 107
C 118
D 127
E 128
F 130
G 132


X
LIST OF TABLES
TABLE
1. Mean Fidelity Scores and Ranges Across Baseline, Intervention, and
Withdrawal Phases 67
2. Mean BRS Scores Across Families Across Study Phases 73
3. Social Validity Ratings Across Families Across Social Validity Questionnaire
Items 76
4. Estimated Average Time Spent with Each Family Across Study Phases 87


XI
LIST OF FIGURES
FIGURE
1. PTR-F theory of change diagram. 15
2. Percentage of desirable behavior for Henry across study phases. 130
3. Percentage of desirable behavior for Olivia across study phases. 130
4. Percentage of desirable behavior for Nathan across study phases. 131
5. Percentage of challenging behavior for Henry across study phases. 68
6. Percentage of challenging behavior for Olivia across study phases. 69
7. Percentage of challenging behavior for Nathan across study phases. 71
8. Pre and post Eyberg Child Behavior Inventory Intensity scores across children. 74
9. Pre and post Eyberg Child Behavior Inventory Problem scores across children. 74
10. Family BRS ratings for Henry across study phases. 132
11. Family BRS ratings for Olivia across study phases. 132
12. Family BRS ratings for Nathan across study phases. 133


CHAPTER I
INTRODUCTION AND LITERATURE REVIEW
During their early childhood years most young children (ages birth through five) experience and demonstrate behavioral difficulties as they advance through developmental stages (Dunlap et al., 2006). It is not uncommon for young children to intermittently exhibit behaviors such as tantrums, noncompliance, withdrawal, and aggression, which often cause parents to question whether observed child behaviors are developmental^ appropriate and momentary or whether they warrant more serious concern (Fox & Armstrong, 2004; Powell, Dunlap, & Fox, 2006). As young children grow older, and through facilitative and appropriate parenting and instruction, many of them will become more capable of selfregulating their emotions and behavior by the time they enter elementary school (Fox, Dunlap, & Cushing, 2002; Powell et al., 2006). For some young children and families, however, sustained behavioral difficulties that are more intense than what is considered developmentally appropriate might persist despite the best efforts of parents and early childhood professionals (Fox et al., 2002). There is a growing number of toddlers and young children who exhibit severe challenging behaviors that place strain on their families and that can limit instructional opportunities and optimal social-emotional development (Buschbacher, Fox, & Clarke, 2004; Fox, Dunlap, & Powell, 2002; Powell et al., 2006).
In addition to these more direct consequences for challenging behaviors, the likelihood of positive long-term outcomes also declines if challenging behaviors are not ameliorated at an early age (Fox, Dunlap, & Philbrick, 1997; Fox et al., 2002). Furthermore, the earlier in life that children and families receive support for reducing challenging


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behaviors, the greater is the likelihood that positive, long-term outcomes will occur (Bailey, 2013; Campbell, 1995).
One approach that has shown great promise in reducing the challenging behavior of young children is positive behavior support (PBS) (Fox, Dunlap, & Powell, 2002; Lucyshyn et al., 2007). PBS promotes the likelihood that successful future outcomes will occur by focusing on the provision of supports that lead to meaningful outcomes (Fox et al., 2002; Fox et al., 2002). When used with families during the early intervention and preschool years, PBS (referred to as family-centered PBS herein) assists families in the use of skills outlined in comprehensive behavior support plans (BSPs; Fox & Armstrong, 2004). These plans are constructed to positively impact family quality of life by reducing challenging behaviors while simultaneously improving the social and communicative skill repertoires of young children (Fox & Armstrong, 2004; Dunlap & Fox, n.d.).
As noted by Fettig, Schultz, and Sreckovic (2015), the family-centered PBS literature is limited in regard to the number of studies that consider the ability of practitioners and families to use the approach in an efficient and effective manner. This scarcity of research is most likely due to the fact that the information surrounding the family-centered PBS process requires a specific set of knowledge and skills that oftentimes only experts and researchers have. The skills associated with this expertise (e.g., performing functional assessment, developing function-based BSPs) are difficult to transfer to practitioners and families due to limited available resources outlining the family-centered PBS process in a simple, manualized way. In order to mitigate this issue, a manualized model of individualized family-centered PBS (i.e., Prevent Teach Reinforce for Families; PTR-F) has been developed for home-visitors and practitioners to use with the families of young children with


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challenging behavior. This dissertation presents an experimental analysis of PTR-F through a single case withdrawal research design replicated across three families of young children with challenging behaviors and their families. The following sections of this chapter will review the relevant literature.
Review of Literature
The purpose of this section is to serve as a review of the literature surrounding family-centered positive behavior support. The following sections will review: (a) social emotional development in young children and challenging behavior; (b) programs to support families in addressing young childrens challenging behaviors; (c) a conceptual framework and key components of family-centered PBS; (d) a theory of change for family-centered PBS; (e) the efficacy of family-centered PBS; (f) the practical significance of family and parent-focused social-emotional programs and family-centered PBS; (g) a manualized model of family-centered PBS (PTR-F); and (h) the purpose and research questions pertinent to this study.
Social Emotional Development in Young Children
It is typical and expected that most young children will demonstrate challenging behaviors (e.g., tantrums, noncompliance, aggression) during their early childhood years (Dionne, 2005; Dunlap et al., 2006; Fox & Armstrong, 2004; Lucyshyn et al., 2002; Powell et al., 2006; Seguin & Zelazo, 2005). As they develop skills for language, cognition, socialization, and self-regulation, childrens abilities to control their own behaviors increase, which generally associates with decreases in their challenging behaviors (Dionne, 2005; Fox et al., 2002; Lucyshyn et al., 2002; Seguin & Zelazo, 2005). When they are young, children are rapidly developing an ability to more independently navigate their social worlds through


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their own biological development and also through the assistance of the adults in their lives (Lucyshyn et al., 2002; Seguin & Zelazo, 2005). Through maturation and developmentally appropriate parenting and caregiving, most childrens challenging behaviors resolve; however, some families note challenging behaviors that are persistent and severe and that necessitate individualized intervention above and beyond what is typically provided for most children (Fox et al., 2002). In order for families and professionals to know what behaviors are considered typical and which ones warrant more individualized, intensive intervention, it is important to understand what behaviors constitute severe and persistent challenging behaviors.
Challenging behavior has been defined as any repeated pattern of behavior, or perception of behavior, that interferes with or is at risk of interfering with optimal learning or engagement in pro-social interactions with peers and adults (Smith & Fox, 2003, p. 6). Severe and persistent challenging behaviors tend to fall in the destruction, disruption, or adaptive responding categories, and can include a range of behaviors such as physical and verbal aggression, withdrawal, self-injurious behavior, and sleeping problems (Powell, Dunlap, & Fox, 2006; Dunlap & Fox, n.d.; Smith & Fox, 2003). What is challenging for one family may not be for another. Therefore, in family-centered PBS, the childs family members ultimately define the challenging behaviors of young children based on the impact the behaviors have on familial relationships and experiences (Smith & Fox, 2003).
Prevalence figures regarding the number of children who demonstrate challenging behaviors vary (Qi & Kaiser, 2003). In a review of research Campbell (1995) concluded that 10 to 15% of children demonstrate challenging behaviors, and Qi and Kaiser (2003) noted that up to 30% of children from families with low-incomes might demonstrate challenging


behaviors. In a review of research focusing on behavioral and emotional disorders in young children, Egger and Angold (2006) concluded that the average prevalence rate of psychiatric
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disorders, most of which included the demonstration of challenging behavior, was 19.5%. Therefore, it can be concluded that approximately 10 to 30% of young children exhibit challenging behaviors.
Programs to Support Families in Addressing Young Childrens Challenging Behaviors
A variety of family and parent-focused social-emotional programs have been developed to promote the social-emotional development of young children. In a recent analysis, Barton et al. (2004) reviewed eight parenting interventions that focus on the social-emotional development of young children. Of the eight interventions that were reviewed, two programs (i.e., Child FIRST, Family Check Up) had a medium level of evidence and four programs (i.e., Incredible Years, Triple P Standard, Triple P Stepping Stones, Parent Child Interaction Therapy) had a high level of evidence according to the efficacious adoption criteria originally used by Joseph and Strain (2003). As noted by their medium to high levels of evidence, these models have proven to be effective in producing parent-and-family-facilitated reductions in childrens challenging behaviors. However, despite their efficacy, there are noted limitations for each intervention, and each differs considerably from the model used in this study (i.e., PTR-F) in regard to the implementation of family-centered PBS to reduce severe and persistent challenging behaviors demonstrated by young children. The unique characteristics of family-centered PBS are outlined below.
Family-Centered PBS
PBS is a collaborative, assessment-based approach to developing effective, individualized interventions for people with problem behavior (Lucyshyn et al., 2002. p. 7).


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Family-centered PBS promotes the use of positive as opposed to aversive familial strategies and consequences to change the behavior of children (Lucyshyn et al., 2002). The intent of family-centered PBS is to improve the familys quality of life by reducing the challenging behaviors of young children in ways that are acceptable to the family and that lead to stable, long-lasting outcomes (Fox et al., 1997). The key components of family-centered PBS are discussed next.
Conceptual Framework and Key Components of Family-Centered PBS
PBS draws on applied behavior analysis, the inclusion movement, and person-centeredness as its main foundational sources (Carr et al., 2002). While extending the foundations of PBS, family-centered PBS also builds on the behavioral parent training literature (Buschbacher et al., 2004). In family-centered PBS, person-centeredness is expanded to include family-centered practices, and families are provided with comprehensive supports that are individualized to their needs and strengths in order to encourage optimal functioning within the family system (Dunlap & Fox, n.d.). Since each member of the family impacts the family system, family-centered PBS focuses on the development of comprehensive and multicomponent intervention plans that consider the social context of the family and that promote the ability of family members to support young children by resolving behavioral difficulties (Dunlap & Fox, n.d.). Family-centered PBS also involves a multitude of key features that have been described in the literature and that further define its theoretical framework and delineate the practical implications of the approach (Lucyshyn, Homer, Dunlap, Albin, & Ben, 2002). These key features include: collaborative partnerships, family-centeredness, meaningful lifestyle outcomes, functional assessment, multicomponent BSPs with systemic perspective, challenging behaviors as learning problems, foundation of


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communication, contextual fit, activity setting with routines as a unit of analysis and intervention, support for implementation, continuous evaluation, and sincerity and humility of professionals (Lucyshyn, et al., 2002). Each of these features will be discussed next in the order given.
Collaborative partnerships. Different from expert or professional driven models, family-centered PBS promotes the use of family-professional partnerships in which parents actively participate in the development and implementation of interventions (Brookman-Frazee & Koegel, 2004; Carr et al., 2002; McLaughlin, Denney, Snyder, & Welsh, 2011). Research has shown that when families are actively involved in the PBS process, the likelihood that interventions will be successful increases (Carr et al., 1999; Powell et al., 2006). Both families and professionals are considered to have expertise that is both valuable and necessary for an effective family-centered PBS process (Fettig, Schultz, Ostrosky, 2013; Lucyshyn et al., 2002).
Collaborative partnerships involve a reciprocal exchange of information in a process that strives to empower families by not only equipping them with skills to prevent or target future occurrences of challenging behavior, but also by giving them the ability to advocate for child and family supports that may be needed as the child continues to grow and develop (Buschbacher, 2002; Carr et al., 2002; Lucyshyn et al., 2002; McLaughlin et al., 2011). By empowering families through partnerships, lifelong, durable support systems for children with special needs are generated, which include an optimistic and long-term outlook of family quality of life (Bushbacher, 2002; McLaughlin et al., 2011).
Family-centered. The family system is frequently cited as the most influential and important learning context for young children (Barton & Fettig, 2013; Dunst, Trivette, &


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Hamby, 2008; Powell & Dunlap, 2010). Extending collaborative partnerships, the family-centered supports provided through family-centered PBS are individualized and promote family strengths and capabilities (Fox, Dunlap, & Philbrick, 1997; Harrower, Fox, Dunlap, & Kincaid, 2000). Support is also provided through the use of solution-focused collaboration to problem-solve any issues that may be blocking the family from achieving their goals (Harrower et al., 2000). Fox, Dunlap, and Powell (2002) note that family-centered, individualization of intervention is concentrated around the incorporation of all relevant dimensions of the family system which can and should include aspects such as culture, beliefs, and child and family priorities.
Meaningful lifestyle outcomes. By addressing the challenging behaviors of young children in family-centered and collaborative ways, family-centered PBS ultimately creates durable changes in the family system (Buschbacher et al., 2004). Skills are strategically transferred to members of the childs family so that they will eventually be able to problem-solve difficulties without requiring the direct support of practitioners (Harrower et al., 2000). Through this process, families are able to maintain lifestyle changes that work to prevent and target future occurrences of challenging behavior and that promote continued positive outcomes as children develop (Buschbacher, et al., 2004; Harrower et al., 2000). Carr et al. (2002) concluded that such changes in lifestyle ultimately improve the quality of life for the entire family in addition to the lives of children with challenging behaviors.
Functional assessment. A main difference between family-centered PBS and common beliefs about behavioral difficulties is the understanding that challenging behaviors are the result of contextual variables present in the childs environment as opposed to the view that such behaviors are caused by inherent child issues (Carr et al., 2002; Fox, Dunlap,


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& Philbrick, 1997). In regard to the direct support of young children, the process of family-centered PBS starts when the team (i.e., practitioner, family, and other individuals who are invited to participate) completes a functional behavioral assessment to determine which variables in the environment correlate with the childs demonstration of challenging behaviors (Fox et al., 2002; Peck Peterson, Derby, Berg, & Horner, 2002). Some experts believe that formalized procedures (i.e., functional analysis) should be used to determine behavioral functions; however, others have argued that, particularly for toddlers and young children, such protocols are not necessary due to brief learning and intervention histories (Dunlap & Fox, 1996; Fox, Dunlap, & Philbrick, 1997; Harrower, Fox, Dunlap, & Kincaid, 2000).
Once functional assessment information has been obtained, hypotheses, or summary statements, are created that describe what the team learned about the challenging behavior in regard to antecedents and setting events and consequences (Harrower, Fox, Dunlap, Kincaid, 2000; Marshall & Mirenda, 2002). The hypothesis statements are then used to develop multicomponent BSPs that are based on, and directly related to, the information obtained through the functional assessment process (Harrower, Fox, Dunlap, & Kincaid, 2000).
Multicomponent BSPs and systemic perspective. Family-centered PBS emphasizes a comprehensive approach to intervention that involves the development of a multicomponent BSP that addresses all challenging behaviors demonstrated by the child and that uses a variety of regularly and consistently implemented function-based interventions (Carr et al., 2002; Harrower, Fox, Dunlap, Kincaid, 2000; Horner & Carr, 1997). This approach has proven to be more appropriate and functional for families given the dynamic and multi-faceted nature of real-life home and community settings (Carr et al., 2002).


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Moreover, it takes into consideration the importance of changes in the family system that need to occur for long-term and meaningful improvements (Carr et al., 2002). By including all relevant support plan components that create pervasive behavior changes for the young child, family-centered PBS provides access to a new lifestyle for families that ultimately ensures continued use of learned strategies, supports, and interventions because family members experience improvements in their quality of life as challenging behaviors decrease, replacement skills increase, and as they begin to believe in their own self-efficacy and ability to impact the behavior of the young child (Harrower et al., 2000; Marshal & Mirenda, 2002; McLaughlin et al., 2011).
Challenging behaviors as learning problems. A cornerstone of family-centered PBS, and PBS in general, is the understanding that challenging behaviors occur due to learning problems and problematic learning histories during which young children realize that their demonstration of challenging behavior results in a want or need being met (Lucyshyn et al., 2002). In other words, young children see challenging behaviors as functional behaviors in that they result in responses from others that meet some want or need (e.g., getting attention when yelling, having shoes put on by a parent when crying; Fox, Dunlap, & Philbrick, 1997). To target these learning problems, the family-centered PBS process incorporates teaching strategies that increase the functional skill repertoires of young children by replacing challenging behaviors with more socially appropriate behaviors that meet their wants and needs more efficiently and effectively (Lucyshyn et al., 2002). For example, children are taught to use communication skills to request desired items or to use self-calming strategies and to ask for help when upset as opposed to engaging in tantrum behavior (Fettig, Schultz, Ostrosky, 2013; Fox, Dunlap, & Philbrick, 1997).


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Foundation of communication. Just as practitioners and families work collaboratively through the use of positive communication, as previously alluded to, the childs team identifies ways that the BSP can incorporate opportunities for the child to learn and practice communication skills to replace challenging behavior (Lucyshyn et al., 2002). Further, such communication skills are taught and practiced in natural environments and social contexts that promote the social competence of young children in addition to targeting their communicative abilities (Fox, Dunlap, & Philbrick, 1997). The instruction of functional communication skills forms the basis of BSPs (Lucyshyn et al., 2002).
Contextual fit. Through collaborative partnerships and family-centered practices, practitioners can ensure that BSPs have good contextual fit with families (Harrower, Fox, Dunlap, & Kincaid, 2000; McLaughlin, Denney, Snyder, & Welsh, 2011; Moes & Frea, 2002). Contextual fit refers to the level of agreement the family experiences in regard to the BSP and its ability to effectively meet their needs (McLaughlin, Denney, Snyder, & Welsh, 2011; Moes & Frea, 2002). Contextual fit can be assessed in numerous ways (e.g., Lucyshyn & Albin, 1997) and incorporated into all components of the BSP (e.g., Moes & Frea, 2002). BSPs that fit well into a familys ecology are more likely to be implemented consistently with fidelity and to be generalized (McLaughlin, Denney, Snyder, & Welsh, 2011). Family ecology refers to concepts such as values, parenting practices, and resources, and it illuminates a significant concern of contextual fit, which is cultural competence in the family-centered PBS process (McLaughlin et al., 2011).
The families of young children are diverse in regard to their ecological contexts, and practitioners need to consider the cultural competence of practices when assessing the contextual fit of the family-centered PBS approach. Cultural competency includes the


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process (i.e., how practitioners interact and communicate with families) in addition to the products (i.e., BSPs) that comprise the family-centered PBS approach. Chermshynski, Lucyshyn, and Olson (2012) recommend the use of a cultural assessment or cultural guide to improve and promote cultural competence and contextual fit (Lynch & Hanson, 2011). As described next, one of the ways to ensure contextual fit is through the use of family routines as contexts through which to understand challenging behavior and as settings and times during which interventions can be implemented.
Activity setting and routines as a unit of analysis and intervention. In order for families to view interventions as useful ways to complete routines and tasks such as bathing, eating, and bedtime routines, practitioners work collaboratively with family members to determine supports that can be provided for children during daily routines that are practical and easily performed and that result in more successful routines (Marshall & Mirenda, 2002). Lucyshyn et al. (2002) note, activity settings represent a microcosm of family ecology (p. 25). Therefore, practitioners implementing family-centered PBS perform essential tasks (i.e., functional assessment, BSP implementation) with families at the time that the routine occurs (Harrower et al., 2000). By further supporting necessary and naturally occurring routines, the contextual fit of a support plan is enhanced, which increases the likelihood that families will consistently implement strategies across environments (Harrower et al., 2002). The consistent implementation of BSPs increases the likelihood of success and behavior reduction strategy generalization because more learning opportunities are provided for the young child.
Support for implementation. In order to ensure a familys success with family-centered PBS and to promote their ability to generalize family-centered PBS skills to


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untrained environments in the future, practitioners are committed to providing the level of support that is required for this to happen (Lucyshyn et al., 2002). Lucyshyn and colleagues (2002) define phases of support that move from a strong reliance of the family on the skills and support of the practitioner to a period in which the family is able to primarily work through the family-centered PBS process independently. The practitioner performs multiple roles (i.e., teacher, resource coordinator, observer) and uses a variety of techniques (i.e., modeling, specific feedback, encouragement) that are eventually faded as families exhibit more independent success with routines and challenging behaviors (Park, Alber-Morgan, & Fleming, 2011). Levels and types of support are individualized based on a particular familys needs, and even when practitioners are no longer working intensively with families, it is recommended that continued follow-up occur to ensure that families are maintaining their progress (Lucyshyn et al., 2002).
Continuous evaluation. Once a sound BSP has been developed, it is important that teams continuously evaluate the young childs progress to ensure that the plan is being implemented as intended and that it is having the desired impact and enabling the family to meet their goals (Harrower et al., 2000; Marshall & Mirenda, 2002). Practitioners support families with continuous evaluation by transferring skills, strategies, and tools and by encouraging their independent use of progress-monitoring skills surrounding the childs challenging behaviors and the implementation of the BSP (Marshall & Mirenda, 2002).
Tasks that maintain the process of continuous evaluation such as using data to make decisions and communicating regarding BSP adjustments are also collaboratively implemented (Harrower et al., 2000).


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Sincerity and humility of professionals. Although not largely discussed in the literature, Lucyshyn et al. (2002) highlight the importance of being sincere and having humility with families going through the family-centered PBS process. They recommend a number of qualities that are necessary in regard to this key component of family-centered PBS. These qualities and skills include listening, validation, responsiveness, valuing family input, changing BSPs based on needs and errors, and encouragement. The authors also note that family-centered PBS outcomes are much likelier to be positive and in line with family goals when practitioners are able to demonstrate these qualities.
Theory of Change
The family-centered PBS process is completed by families, initially with the support of a home visitor, to create changes in child behavior. More specifically, family-centered PBS creates changes in family behavior that result in changes in the childs behavior. Family-centered PBS incorporates a number of elements described in the literature (and explained in the prior section) that lead to more positive outcomes for families such as family engagement and active involvement and the development of a comprehensive BSP that has contextual fit with the family ecology (Brookman-Frazee & Koegel, 2004; Carr et al., 2002; Harrower, Fox, Dunlap & Kincaid, 2000; Homer & Carr, 1997; McLaughlin, Denney, Snyder, & Welsh, 2011; Moes & Frea, 2002). Figure 1 includes the Family-Centered PBS (i.e., PTR-F) Theory of Change Diagram.


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r 1 r ^ r " r ^
Issue(s) to be Addressed in Early Intervention / Early Childhood Special Education L. J Evidence-Based Strategy/ies L. ^ Intermediate Outcomes and Processes L Child Outcomes for Young Children with or at Risk of Disabilities (0 5) L. U

/ \ Limited Parental Ability to Effectively and Efficiently Reduce Challenging Behavior of Young Children L. J PTR-F Intervention Process S 4 f > Family Implements Comprehensive Behavior Support Plan with Fidelity / \ Improved Child Outcomes: Decreased Challenging Behavior & Increased Desirable Behavior
V V V
/ > Young Children with Challenging Behavior in the Home & Community f \ Family Engagement & Active Involvement in 5 PTR-F Steps f \ Increased Family Efficacy To Reduce Child Challenging Behavior
it J l J
V V
/ \ Development of Comprehensive Behavior Support Plan That Has Contextual Fit With Family Ecology t 4 f > Family Continues to Implement Learned Strategies, Supports, and Interventions ^ 4
Figure 1. PTR-F theory of change diagram.
The Efficacy of Family-Centered PBS
Family-centered PBS has been effective for a variety of populations of children and families with needs ranging from issues involving eating and food acceptance, to self-regulatory skill difficulties, and to the significant needs of children and families who have experienced neglect and abuse (Binnendyk & Lucyshyn, 2009; Buschbacher, 2002; Hardaway, Wilson, Shaw, & Dishion, 2012). A majority of the studies completed with young children and families have focused on children diagnosed with autism spectrum disorder (Boyd, Odom, Humphreys, & Sam, 2010; Conroy, Dunlap, Clarke, & Peter, 2005).
Ample research exists for the ability of families to succeed in practitioner-family partnerships. It has consistently been found that families are able to successfully implement BSPs and that greater treatment gains and generalization of such gains have been noted with


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participation of families in the PBS process (Barton & Fettig, 2013; Buschbacher, Fox, & Clarke, 2004; Koegel, Koegel, & Schreibman, 1991; Lucyshyn & Albin, 1997). Research has also shown that the maintenance of interventions increases when families are involved in the PBS process (Buschbacher et al., 2004).
Studies have shown that family-centered PBS creates positive immediate and longterm parental and family outcomes (Brookman-Frazee & Koegel, 2004; Buschbacher, Fox, & Clarke, 2004; Smith-Bird & Turnbull, 2005). Family-centered PBS has been shown to reduce stress levels and promote parental self-efficacy (Brookman-Frazee & Koegel, 2004). Additionally, anecdotal reports from studies have suggested that family perspectives and outlooks for their future and for the future of their children improve with family-centered PBS (Buschbacher et al., 2004). In a follow-up study, Lucyshyn and colleagues (2007) found that positive outcomes associated with family-centered PBS for the challenging behaviors of a young child endured seven years post implementation.
Research also indicates that the families of young children with challenging behavior need more support in regard to ways to effectively target their childs and familys needs, and they seek collaborative partnerships in order to learn how to do this (Fox, Vaughn, Wyatte, & Dunlap, 2012). Fox et al. (2002) suggest that the typical services provided to families for the challenging behaviors of young children are most likely not sufficient to support families. Related to this need, multiple researchers have called for increased research involving the best way to support parents with young children with challenging behaviors in regard to participation in the intervention process, parent training and coaching procedures, and increasing the contextual fit and individualization of interventions and supports (Boettcher,


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Koegel, McNerney, & Koegel, 2003; Brookman-Frazee & Koegel, 2004; Buschbacher,
Fettig & Barton, 2014; Buschbacher, Fox, & Clarke, 2004; Lundhal et al., 2006).
Practical Significance of Family and Parent-Focused Social-Emotional Programs and Family-Centered PBS
Although effect size does not directly measure the practical significance of research findings, it can be used in conjunction with other factors (e.g., cost, context) to determine the importance of research findings beyond a demonstration of statistical significance (Leech, Barrett, & Morgan, 2011). The family and parent-focused social-emotional programs previously mentioned (see Barton et al., 2014) have established their practical effectiveness in reducing the challenging behaviors of young children with most efficacy studies demonstrating small to moderate effect sizes (Dishion et al., 2014; L. Fox & C. Vatland, personal communication, July 2015; Lowell, Carter, Godoy, Paulicin, & Briggs-Gowan, 2011; Menting, Orobio de Castro, & Matthys, 2013; Sanders, 2008; Tellegen & Sanders, 2013; Thomas & Zimmer-Gembeck, 2007).
In a literature search for studies calculating an effect size for family-centered PBS, no study was identified. This dearth of available literature is likely due to the fact that most of the empirical evidence for family-centered PBS has been demonstrated through the use of single case research designs. In order to establish an effect size for family-centered PBS, as recommended by Parker (2011), a Percent of All Non-Overlapping Data (PAND) analysis was completed for each of the 13 studies in Fettig and Bartons (2014) recent review of parent-implemented function-based interventions. Effect sizes for these interventions ranged from .01 to 1.0 with a moderate mean effect size of .70 (P. Strain, personal communication, June 2015; Scruggs & Mastropieri, 1998).


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It is clear that a multitude of programs exist that can effectively reduce the challenging behaviors of young children. As noted, however, to establish the practical significance of an intervention and/or program, additional factors must be considered (Leech et al., 2011). The factors that distinguish the model employed in this study from the programs noted in this section are outlined below. These factors may lead to greater practical significance for this studys intervention, PTR-F.
Prevent Teach-Reinforce for Families (PTR-F): A Manualized Model of Family Positive Behavior Support
Given a noted need for efficient, collaborative, specialized support for families of young children with challenging behavior, PTR-F was designed as a manualized, family-centered PBS process for home visiting professionals to use with the families of young children with challenging behaviors. The PTR-F manual outlines the five-step PTR-F process (each step outlined more thoroughly in the methods section) by dedicating a chapter to each step that provides in-depth information in addition to all of the necessary documentation that the step requires. The process is scripted as much as possible for home visitors and families, and each step includes a team-and-self-check evaluation to ensure implementation fidelity. In addition to these efforts to descriptively outline and simplify the family-centered PBS process, PTR-F includes the key features that are summarized next.
Key Features of PTR-F. The PTR-F model is comprised of a number of key features that differentiate it from other family and parent-focused social-emotional programs and that, although PTR-F incorporates all of the key features of family-centered PBS, distinguish it from other studies that have implemented family-centered PBS in clear ways. These key features and distinguishable factors are outlined below.


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Manualizedprotocol PTR-F has manualized the family-centered PBS process to promote the ability of home visitors and families to implement not only comprehensive BSPs but also the family-centered PBS process with high levels of fidelity. In their review on parent-implemented function-based interventions, Fettig and Barton (2014) found that although all of the studies produced child behavior change, they did not necessarily lead to high levels of intervention and implementation fidelity. In order to improve the efficiency and efficacy of family-centered PBS, PTR-F streamlines the family-centered PBS process in an effort to increase intervention and implementation fidelity.
Family teaming. As noted, two key features of family-centered PBS are collaborative partnerships and family-centeredness. To promote practices in line with these key features, the PTR-F manual dedicates a chapter to the importance of family participation in the PTR-F process. Additionally, considerations for family involvement in the PTR-F process are described in order to encourage maximum family involvement.
Individualized, function-based intervention through PTR-F Checklists. Another key feature of family-centered PBS is the use of functional assessment. There are varying ways of performing functional behavioral assessment (FBA; e.g., functional analysis, descriptive FBA, indirect FBA) that require more or less skill and time depending on the method chosen (Cooper, Heron, Heward, 2007). PTR-F uses three PTR-F checklists (i.e., Prevent Checklist, Teach Checklist, Reinforce Checklist) that teams complete together. In that PTR-F streamlines the FBA process, the FBA can be completed during one meeting (compared to other processes that can take much longer) along with the summary of FBA information and the formation of hypothesis statements regarding the perceived function of the childs behavior. With the hypothesis statements in mind, practitioners and families use the


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intervention menu (described below) to create a function-based comprehensive BSP that outlines interventions that have been individualized for the child and that are based on the specific function of the childs behavior.
Multi-component, menu driven BSPs. In order to increase the efficiency of the PTR-F process and the likelihood that families implement BSPs with fidelity, PTR-F provides a menu of intervention strategies that includes research-supported interventions for reducing challenging behaviors and increasing desirable behaviors in home and community settings. Through detailed instruction, practitioners and families develop BSPs that include at least one intervention from each of the Prevent, Teach, and Reinforce categories. Detail including factors teams should consider when choosing interventions and information regarding the actual implementation of each intervention is also provided in the manual.
PTR-F coaching. PTR-F emphasizes the importance of practitioner coaching for families to promote implementation and intervention fidelity. That is, coaching is provided for families to ensure that the steps of PTR-F are followed as intended (i.e., implementation fidelity) and that the comprehensive BSP is implemented as designed (i.e., intervention fidelity; Barton & Fettig, 2013). The coaching used in PTR-F is consistent with the recommended and evidence-based practices outlined in the literature for supporting families (McWilliam, 2010; Rush & Sheldon, 2011) and teachers (Fox, Hemmeter, Snyder, Binder, & Clarke, 2011) with their implementation of social-emotional-behavioral interventions (L. Fox & C. Vatland, personal communication, July 2015). In addition to team-and-self-check evaluations to ensure implementation fidelity, the PTR-F process also employs the use of PTR-F Fidelity of Intervention Checklists that outline the comprehensive BSP and that can


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be used by families and coaches to ensure that the plan is being implemented as intended. Coaches can also use these checklists to structure coaching sessions with families.
Practical significance of the prevent teach reinforce model when used with families. As previously noted, with the addition of these key features, it is likely that PTR-F may have greater practical significance when compared to existing family and parent-focused social-emotional programs. Although the PTR-F model has not been empirically studied to date, two studies (e.g., Bailey, 2013; Sears, Blair, Iovannone, Crossland, 2013) have extended a school-based PTR model for young children with severe and persistent challenging behaviors (i.e., Prevent Teach Reinforce for Young Children) into home settings. Using single case research design, both studies concluded that the PTR model was efficacious in producing child behavior change and that parents were able to implement comprehensive BSPs with fidelity. Both studies found high levels of family and naive observer social validity. The studies further demonstrated effect sizes of .84 (Bailey, 2013) and .91 (Sears et al., 2013) indicating that the PTR process and BSPs were acceptable to participants and observers and that meaningful outcomes occurred for all of the families who participated (P. Strain, personal communication, June 2015). At the same time that this study was being implemented, the PTR-F model was being used with one family across three routines. The primary researcher of this second PTR-F study reported that desired changes in child behavior occurred through the completion of the PTR-F process and that the family favorably viewed the PTR-F process and the BSP (C. Vatland, personal communication,
April 2016).


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Purpose and Research Questions
The purpose of this study was to conduct an experimental analysis of a manualized, family-centered PBS process (i.e., PTR-F) with three families of young children with challenging behavior. The aims of this study were to (a) examine the effect of the PTR-F process on the familys level of fidelity in implementing the comprehensive BSP; (b) determine the effect of the BSP on child behavior; (c) determine the effect of the PTR-F process and the family's implementation of the BSP on the familys ratings of their self-confidence and of their satisfaction with the routine; and (d) determine how families perceive the PTR-F process and the BSP developed through the PTR-F process.
The effect of PTR-F, and specifically of a comprehensive BSP designed through the process, has not previously been empirically evaluated. Therefore, it was appropriate to perform a single case withdrawal design replicated across three families to investigate the following research questions:
(1) Does completing of the PTR-F process result in families high fidelity implementation of the BSP?
(2) Does a functional relation exist between the familys implementation of the comprehensive BSP and decreased child challenging behaviors and increased child desirable behaviors?
(3) Do family ratings of their self-confidence with implementing the BSP and of their satisfaction with the routine improve through the PTR-F process and their implementation of the BSP?
(4) Is there a difference between pre-test and post-test Eyberg Child Behavior Inventory (ECBI) scores?


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(5) What is the average family social validity rating for the PTR-F process and for the BSP?
(6) How do families rate the PTR-F process and the BSP when provided the opportunity to do so qualitatively?


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CHAPTER II METHODOLOGY
The purpose of this chapter is to describe the methodology associated with this dissertation study. Participants, settings, and routines are discussed, and the PTR-F process is explained. The independent variable and dependent variables are also described in addition to the measurement procedures associated with each variable. Finally, the studys experimental design is summarized.
Participants
Three young children (ages 3 years 1 month through 3 years 9 months) with challenging behavior and their families participated in the study. Children and family participants were chosen using the following sampling procedure.
Sampling Procedure
The sampling process outlined by Gliner, Morgan, and Leech (2009) was used. Sampling was completed in two ordered steps. The first step was to identify children and families from a larger selected sample. The second step was to select families with children who exhibit the most severe and persistent challenging behavior to participate in the study. Both sampling steps are described more fully in the sections that follow.
Step 1. Preschool/child care center level: Pre-screening assessment. Given the limited availability of resources for this study, the accessible population was comprised of young children with challenging behavior who attended (or who had a family member who attended) a child care center in a suburb of a large metropolitan city in the western United States. The selected sample was determined through this initial, convenience, pre-screening sampling step of the sampling process. Teachers and staff members of the child care center


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recommended children and families to participate in the study based on the families reporting the occurrence of challenging behavior in the home setting to child care and staff members. Following such reporting, these families were encouraged to contact the researcher. Initial contact was made by interested families through e-mail. The researcher used an e-mail recruitment script and scheduled a phone meeting during which the researcher briefly described the purpose of the research study and of the pre-screening process. The Eyberg Child Behavior Inventory (ECBI) was used for pre-screening purposes (Eyberg & Pincus, 1999). Each family completed and returned an ECBI to indicate their interest to participate in the study. The ECBI has 36 Likert-type scale questions that are rated by parents to indicate the intensity of their childs challenging behavior and to indicate whether or not the family considers the challenging behavior to be a problem (Eyberg & Pincus, 1999). Previous studies have found data from the ECBI to have adequate discriminant validity and convergent validity, and it has been shown to be sensitive to changes in challenging behaviors (Boggs, Eyberg, & Reynolds, 1990). Further, and directly related to its purpose in this study, the ECBI has been noted for its utility as a screening assessment tool given high concurrent validity with other established behavioral assessments (Boggs et al., 1990).
The selected first-step sample, then, was comprised of families who returned an ECBI to the researcher. After three weeks the time period for receiving questionnaires was closed, and the questionnaires that were returned were scored to determine a range of intensity scores for the selected sample. ECBI raw intensity scores ranged from 111 to 163 and raw problem scores ranged from 8 to 14 across participants.
Step 2. Child with challenging behavior and family level. The purpose of the second step of the planned sampling process was to identify the actual sample to participate


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in the study (Gliner et al., 2009). That is, this step was taken to narrow the selected sample down to the children and families who were invited to participate in the study. Only three families returned ECBIs to the researcher; consequently, all three families were invited to participate, and all accepted the invitation. Each family received a stipend of $100.00 for participating in the study. Children and family participants are described next.
Henry and His Family
Henry was 3 years 8 months old when his family enrolled in the study. He was attending preschool at a non-profit child care center two days per week in the morning for three hours. He was also attending outpatient play therapy one time per week for one hour for his tantrum behavior. His parents noted improvement in regard to a decrease in his tantrum behaviors during most routines other than the routine that the family chose to target through the PTR-F process. That is, despite attending play therapy for five months, Henrys parents noted that leaving the house was still challenging for the family. Henrys parents discontinued his play therapy approximately two months into the familys participation in the study.
Henry resided with his family in their family home in a suburban neighborhood approximately twenty miles from a large metropolitan city in the western United States. All meetings and sessions took place in the family home. Henrys father, who was thirty-six years old, worked outside of the home as a software engineer, and his mother, thirty-seven years old, referred to herself as a stay-at-home parent. At the time of their entry into the study, Henrys parents were meeting two times per month with a family support person at the preschool. They had met this person while attending classes for parents to learn how to reduce challenging behavior in the home setting. Henrys parents noted that they found the


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classes useful, but that the strategies did not seem to work for the routine that they chose to target through the PTR-F process. They also reported that since the classes did not reduce all of Henrys challenging behaviors, meeting with the family support person was more for their overall well-being and ability to cope with Henrys challenging behavior than for gaining information about shaping Henrys behavior. In order to increase consistency and reduce the likelihood of confounding external advice, Henrys parents agreed that they would not discuss the routine that they chose to target during the PTR-F process with any outside support individuals.
Henry had two siblings residing in the home with him. His older sister was six years old and in the first grade at a local elementary school. His younger brother was 8 months old. Henry had positive relationships with his siblings and his parents. The family spent regular time together, and they enjoyed playing together in their home and engaging in local activities outside the home as well.
Olivia and Her Family
Olivia was 3 years 9 months old when her family began participating in the study.
She resided with her family in their suburban family home that was located approximately 15 miles from a large metropolitan city in the western United States. Also residing in the family home was Olivias sister (age six), Olivias mother (age thirty-seven), and Olivias father (age forty-six). Olivias mother was employed full-time in restaurant marketing, and her father was employed full-time in restaurant operations. In addition to the caretaking that was provided by her parents, Olivias family had a nanny who cared for Olivia and her sister five days per week while Olivias parents were working. Olivia had positive relationships with all


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of her family members. In their spare time Olivias family enjoyed traveling and taking weekend trips together. Olivia was also learning how to ski and to ride her scooter.
Olivia was attending preschool three afternoons per week at a non-profit child care center when the family enrolled in the study. Approximately two months into the study Olivia started attending preschool four afternoons per week. Olivia was diagnosed with childhood apraxia of speech for which she was receiving speech and language therapy at the child care center three times per week. She was also diagnosed with developmental delays related to her motor skills, and she received occupational therapy one time per week at the child care center. Olivias mother reported that Olivias occupational therapist had informed the family that her motor skills placed her in the seventeenth percentile for coordination and the twenty-fifth percentile for fine motor skills. Olivias family had also enrolled her in a speech and movement class through the child care center. Her mother indicated that she attended approximately 50% of these classes due to her involvement with a gym and swim class through a local recreational center that promoted gross motor development. When Olivia attended the gym and swim class, she did not attend the speech and movement class at the child care center.
Nathan and His Family
Nathan was 3 years 1 month old when his family entered the study. He resided with his family in a suburban home located approximately 15 miles outside a large metropolitan city in the western United States. Nathans parents and his sibling also resided in the home. Nathans mother, a graphic designer who worked from home, was thirty-six years old, and his father was 45 years old and worked as a publisher. Nathans older brother (age four) attended preschool three and a half-days per week at which time Nathan and his mother spent


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one-on-one time with one another. Nathan was not attending preschool or child care when his family entered the study, but he did attend a recreational swimming class and regular play groups with his mother while his brother was at school. Prior to entering the study Nathans parents had previously attended classes provided by his brothers school for parents to learn how to reduce challenging behavior in the home setting. They noted that the strategies were useful for his brother but that they were not as useful for reducing Nathans challenging behavior in the home setting.
Settings and Routines
The settings involving Henry, Olivia, and Nathan included the interior spaces of each of their families homes. Each family chose a particular target routine (i.e., the most difficult routine of the familys day) on which to focus PTR-F facilitation, and the spaces associated with the routines (e.g., bathroom, bedroom) were the settings for all steps associated with the study and with PTR-F. The settings and target routines for each family are described next. Henry and His Family
The setting for Henrys family consisted of the upstairs, downstairs, and garage spaces of the family home. All PTR-F meetings and planning occurred in the familys kitchen and living room. Henrys family indicated that the most difficult routine of their day was the one that occurred in the afternoon directly before Henry and his mother left to pick up his sister from school. The family indicated that leaving the house was always somewhat difficult for Henry, but that this particular routine was the most difficult due to the time restrictions associated with his mothers need to leave the house within a certain timeframe to ensure a timely pick up for his sister. For most days this routine started upstairs in Henrys play area and ended once he was buckled into his carseat in the familys minivan.


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Olivia and Her Family
Olivias bedroom and shared bathroom made up the setting for Olivias family. PTR-F meetings took place in the familys kitchen at their kitchen counter. The routine that Olivias family chose to target through the PTR-F process was their second most difficult routine, Olivias morning routine. The familys most difficult routine was bedtime.
Following a discussion of the familys upcoming schedule changes, and due to the research plan and the nature of a single case withdrawal design, the researcher and family decided that targeting the familys second most difficult routine would create less stress for the family. It was determined that the anticipated difficulties associated with a changing schedule coupled with withdrawing a bedtime BSP and then re-implementing it could be avoided if the family focused on the second most difficult routine for the study. The researcher and family agreed that the researcher would provide support for the bedtime routine after the family had completed all of the experimental phases for the single case withdrawal design for the morning routine. Information regarding the bedtime support that was provided for Olivia can be found in the Monitoring Plan Implementation and Child Progress section specific to Olivias PTR-F process.
Nathan and His Family
The setting for Nathan and his family consisted of the first floor and upstairs spaces of his familys home. The PTR-F meetings and planning occurred in the familys dining room. Nathans family reported that the most difficult routine of their day was Nathans bedtime routine. Nathans family indicated that if both his mother and father were home, Nathan would insist that his mother complete his bedtime routine with him. Nathans family also reported that if Nathans mother completed his routine with him, she would have to lie


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down with him until he fell asleep. When Nathans mother was not home and his father completed his routine with him, Nathan would fall asleep independently after his father left the room without having to lie down with Nathan. When the family chose bedtime as their target routine, Nathans mother indicated that if she wanted to work during the evening hours she would leave the family home at bedtime so that Nathan would not require her to lie next to him until he fell asleep.
Prevent Teach Reinforce for Families Process This study is differentiated from other family PBS studies because it implements a manualized family PBS process, PTR-F (Dunlap, Strain, Lee, Joseph, Vatland, Fox, in press). The PTR-F intervention process is a revised version of Prevent Teach Reinforce (PTR), an evidence-based, manualized form of PBS for school-aged children (Dunlap et al., 2010; Iovannone et al., 2009) and Prevent Teach Reinforce for Young Children (PTR-YC), a manualized form of PBS for young children in preschool and child care settings (Dunlap,
Lee, Wilson, & Strain, 2013) that is currently being studied through a randomized controlled efficacy trial. As with PTR-YC, PTR-F does not add novel information to the field in regard to PBS; however, it provides a user-friendly, comprehensive, five-step model for practitioners to follow that can improve the fidelity with which BSPs are implemented by families (Dunlap, Lee, Joseph & Strain, 2015). Home-visiting professionals and PTR-F facilitators (and, in the case of this study, the researcher) utilize the PTR-F process with families to develop comprehensive PTR-F BSPs by following an intervention process that includes the following five steps: (1) Initiating the PTR-F Process, (2) PTR-F Assessment (3) PTR-F Intervention (4) Coaching, and (5) Monitoring Plan Implementation and Child Progress. Each step of the PTR-F process is outlined in more detail below, and it is implicit


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that during each step of the PTR-F process the facilitator works collaboratively with the family in order to complete all tasks associated with each step as outlined in the PTR-F manual.
PTR-F Step 1: Initiating the PTR-F Process
Step 1 occurs during the initial meeting for PTR-F in which the family and PTR-F facilitator decide which members of the family will be involved in the PTR-F process to develop and implement the BSP. This step also involves a discussion of the long-term goals for the child. Additionally, a specific short-term behavior goal is outlined for the child in regard to his/her challenging behavior that the family wants to target for decrease.
Step 1 of PTR-F also involves the development of a data collection method that is feasible for the family to implement on a regular basis. The PTR-F process employs behavior rating scales (BRSs) that are individualized for the childs challenging and desirable behaviors. For the purpose of this study, two standardized BRSs were used by families to track changes in family satisfaction and confidence implementing the routine over time. The BRSs are described at more length in the dependent variable section.
PTR-F Step 2: PTR-F Assessment
During step 2 the family completes a functional behavioral assessment by answering questions on the PTR-F Functional Behavioral Assessment Checklists (i.e., Prevent Checklist, Teach Checklist, Reinforce Checklist). Following the completion of these checklists, the information is summarized and a hypothesis statement is formulated regarding the familys perceived function of the challenging behavior (i.e., the familys belief about the childs purpose in exhibiting challenging behavior). Once the family and PTR-F facilitator have formulated a hypothesis statement, the family sets a short-term behavior goal for a


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target desirable behavior to increase. The desirable behavior short-term goal is set after a hypothesis statement has been developed to ensure that the target desirable behavior is a functional replacement for the challenging behavior. An operational definition is then developed for the desirable behavior to increase.
PTR-F step 3: Intervention
In step 3 the family uses the hypothesis statement that was developed in step 2 to create a function-based BSP using the menu of intervention strategies provided in the PTR-F manual. This step requires that the family develop a detailed plan that targets the antecedents and consequences of challenging and desirable behaviors and that includes planning for the teaching of functional skills that can replace the childs challenging behaviors. During the final task of step 3, the BSP can be transferred to the PTR-F Fidelity of Intervention Checklist that can be used for coaching the family to fidelity on the BSP. For this, the team also decides on a feasible schedule of facilitator coaching.
PTR-F Step 4: Coaching
Following the completion of Steps 1 through 3 of the PTR-F process, the PTR-F facilitator provides coaching for the family on the BSP until a sufficient level of fidelity (a minimum of 80%) has been reached, and then until sufficient changes are noted in the childs behavior (i.e., decreased challenging behavior and increased desirable behavior). Coaching sessions last for the duration of the routine. If necessary, the PTR-F facilitator can use evidence-based coaching strategies and document the use of particular strategies during coaching sessions on a coaching log. The families in this study required very little coaching in order to implement the BSP. Therefore, the PTR-F Coach Planning and Reflection Log
was not used with the families.


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PTR-F step 5: Monitoring Plan Implementation and Child Progress
Like Step 4, Step 5 of PTR-F commences when the family begins implementation of the BSP. During this step, the data collection measure developed in step 1 and the PTR-F Fidelity of Intervention Checklist are used to obtain ongoing data for data-based decision making. The family uses these data in step 5 to determine whether any changes need to be made to the BSP and when supports might be faded if desirable trends are noted in the childs challenging behavior data.
Steps 1 Through 3 Meetings
For those following the PTR-F process, Steps 1 through 3 occur during meetings that last for approximately 45 to 60 minutes at a time that is convenient for the family and PTR-F facilitator. Families are permitted and encouraged to invite individuals who are able to provide meaningful input during these meetings. At these meetings, the PTR-F facilitator supports each family in their completion of the sub-steps associated with each primary step (i.e., steps 1 through 3) as outlined in the PTR-F manual. Each primary PTR-F step involves the completion of specific procedural elements and associated documentation to ensure that each step of the PTR-F process is completed as efficiently and effectively as possible.
PTR-F meetings for steps 1 through 3 and subsequent step 4 facilitative coaching sessions are scheduled based on family need and on the familys and PTR-F facilitators mutual availability, with more frequent coaching sessions tending to occur at the start of the familys implementation of the BSP. Additionally, to ensure that the PTR-F process occurs as planned (i.e., steps 1 through 5 are implemented as intended by the manual authors), the PTR-F manual checklists associated with each step of the process are referred to during each step and completed by the PTR-F facilitator and family after each step has been completed.


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Independent Variable: Prevent Teach Reinforce for Families BSP
The independent variable in this study was the BSP developed during step 3 of the PTR-F process and implemented by each family. The PTR-F process and details regarding the development and implementation for each child and familys BSP are described next. Henry and His Family
From the initial, in-person meeting until the close-out meeting, Henrys family participated in the study for 15 weeks. PTR-F meetings occurred over the course of three weeks (one meeting per week) after which the family began implementing the BSP. Over the course of the familys participation in the study, the family and primary researcher met one time per week other than one week during Henrys holiday break. Most often, only Henrys mother and the researcher met for meetings; however, on at least two occasions Henrys father was present. Henrys familys PTR-F process is outlined next.
PTR-F Step 1: Initiating the PTR-F Process. For Henrys family, the PTR-F Step 1 meeting lasted for approximately 30 minutes. During this meeting Henrys mother chose his refusal behavior as the target challenging behavior to decrease. Through a discussion with the researcher, refusal behavior was operationalized to include the following behaviors: making non-compliant comments (e.g., never, no, I want to play), yelling, throwing himself onto the floor, crying, screaming, whining (high-pitched, nasal sound without words), running away, and hiding. A number of desirable behaviors that Henrys mother would like to see him demonstrate during this routine were also discussed during this goal setting meeting. Henrys mother noted that most days when leaving the house she had to carry Henry into the car, which meant leaving his younger brother alone upstairs because she could not carry both of the children to the car at the same time. Therefore, her primary, initial goal


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was for Henry to exit the home and get into the car independently regardless of any whining or grumbling that might occur once he was told that it was time to leave the home. Henrys Goal Sheet can be found in Appendix A.
In regard to family data collection, as previously noted, for the purposes of this study, standard BRSs were used for family data collection. Therefore, individualized BRSs were not created during this step of the PTR-F process for Henry. It was decided that the family would complete the standardized BRSs each time Henry left the family home and make any notes on the data collection form regarding unique circumstances that might be related to the routine. For example, Henrys family made notes on the BRSs if his sister helped him complete his routine, if he demonstrated any particular challenging behaviors that were unusual (e.g., on one occasion Henry did not want his mother to talk to him while he completed his routine), and if the family did not leave the home for a day. The purpose of note tracking was to determine whether or not any patterns in antecedent variables, and specifically setting events, could be identified in regard to Henrys challenging behavior.
PTR-F Step 2: PTR-F Assessment. During step 2, the researcher and Henrys mother met for approximately one hour to complete the PTR-F assessment checklists and to develop a hypothesis statement regarding the perceived function of Henrys challenging behavior. Through the completion of the Prevent checklist, it was determined that activities when Henrys challenging behavior is very likely to occur include leaving the family home, arriving at the family home, toileting and diapering, and transitions. It was also determined that transitioning from preferred to less preferred activities was difficult for Henry.
Generally, antecedent events tended to include a prompt to transition to something that is not


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preferred for Henry (e.g., toileting) or to terminate a preferred activity such as playing on the iPad or playing legos.
The Teach checklist indicated that communication skills that Henry could be taught were those related to expressing preferences when given a choice. It was also determined that it would be beneficial for Henry to develop his problem-solving skill repertoire by learning how to control his anger, control impulsive behavior, use strategies for calming down, follow directions, follow schedules and routines, choose appropriate solutions, make choices from appropriate options, and follow through with choices once made. Generally, Henrys mother indicated that a primary skill for him to learn is to stop playing when a direction is given (even with warnings) and to begin following the direction. During this conversation Henrys mother indicated again that she would accept his complaining and expressing of his emotions as long as he did not demonstrate his refusal behavior.
By completing the Reinforce checklist it was determined that common consequences for Henrys challenging behavior included a delay in the non-preferred activity, termination of the direction, a verbal warning, verbal reprimanding, physical guidance, and, at times, access to a preferred or desired activity. Henrys mother was very honest in that she noted that approximately one time per week she responded to his challenging behavior by yelling and screaming. Henrys mother also noted that his challenging behavior was very likely to result in acknowledgement. She stated that she acknowledged and validated Henrys challenging behavior each time it occurred. She reported that she ignored his challenging behavior in the past and that it would last for hours. Henrys mother also noted that he could not be left alone while demonstrating challenging behavior because he would destroy his room, for example, by ripping items off of the wall. Potential reinforcing activities for


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Henry that were identified through the completion of the Reinforce checklist included verbal praise, physical interaction such as rough-housing, social interaction with his sister, television time, time on the iPad, and family outings. Henrys mother noted that he responded well to token economies such as the one the family was using for toilet training.
With the checklists complete, Henrys mother and the researcher developed a hypothesis statement regarding the perceived function of Henrys challenging behavior. It was determined that the challenging behavior occurred when directions to terminate preferred activities or to transition to non-preferred activities occurred and that the challenging behavior was likely to result in delay or termination of the activity. Attention was also noted as a likely consequence for Henrys challenging behavior. Therefore, the hypothesis for Henrys challenging behavior was: when Henry is directed to terminate a preferred activity or to transition to a non-preferred activity, then he will demonstrate refusal behavior, and as a result, the transition or non-preferred activity will be delayed or terminated and/or Henry will receive attention.
Once the researcher and Henrys mother determined the perceived function of Henrys challenging behavior, a desirable behavior to increase was chosen that would serve as a functional replacement for the challenging behavior. The target desirable behavior the family chose was following the routine. The operational definition for following the routine was following the steps of the routine without being carried to the car by a parent. While the actual steps of the routine had not been identified yet, the team agreed that step identification would occur during step 3 of the PTR-F process and that it was acceptable to include the steps in the operational definition of the target desirable behavior. Henrys PTR-F Assessment Checklists and PTR-F Assessment Summary Table can be found in Appendix A.


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PTR-F step 3: Intervention. Henrys mother and the researcher met a third time for approximately an hour to develop the BSP. The meeting started with a review of the function of Henrys challenging behavior. Then, they discussed the intervention strategy options from the PTR-F menu of intervention strategies. Henrys mother and the researcher chose three Prevent strategies to include in the BSP: enhance predictability, use visual supports, and use a scripted social story. The Teach strategies that were chosen included teach independence with visual schedules and calendars and teach self-monitoring. Henrys mother and the researcher also followed the steps for designing a plan for reinforcement based on the recommendations from the PTR-F menu of intervention strategies. That is, a functional reinforcer was identified and a plan was designed to reinforce the desirable behavior and to remove reinforcement for Henrys challenging behavior. At this time, Henrys mother and the researcher had a discussion regarding attention as a function of Henrys challenging behavior. Henrys mother indicated that she did not feel comfortable removing attention for his challenging behavior, but that she would be able to ensure that the transition would not be delayed and/or that escape from the direction would not occur following his demonstration of challenging behavior. Given the family-centered nature of the PTR-F process, the researcher and Henrys mother worked together to develop a strategy for the Reinforce component of the PTR-F process. She indicated that she felt comfortable with the strategy and would be capable of implementing it. The specifics of Henrys BSP were written on his PTR-F BSP Summary form, which can be found in Appendix A.
PTR-F Step 4: Coaching. Due to the familys involvement, and primarily to his mothers involvement, in the PTR-F process, minimal coaching was needed for the family to begin implementing the BSP. During the BSP development meeting, Henrys mother and the


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researcher spoke extensively about how the plan would be implemented and used problemsolving to determine PTR-F Reinforce intervention strategies Henrys mother would be most comfortable implementing. Following the BSP development meeting, the researcher and Henrys mother communicated through e-mail over the course of the next week. The researcher developed a number of supports for the family (i.e., social story, visual schedule, typed BSP) and e-mailed all of these documents to Henrys mother for her feedback. Henrys mother indicated that she would be most comfortable if the researcher was present the first time she implemented the BSP. A date was chosen to begin plan implementation, and the researcher arrived approximately 45 minutes prior to the time that the routine would occur to review the plan and to allow the researcher to model the BSP for Henrys mother.
Following the initial coaching session, the researcher visited the family home one time per week approximately 15 minutes to 30 minutes before the routine would begin to engage in problem-solving discussions regarding the familys implementation of the plan during the week since the researchers last visit. Following the pre-routine meeting, the researcher would observe Henrys mother implement the BSP and provide side-by-side support most often in the form of prompts for Henrys mother to use verbal praise upon his completion of routine steps. Following the routine, the researcher spoke with Henrys mother briefly (for approximately three to five minutes) to indicate any additional noteworthy observations.
In all, the researcher visited the home eight times for coaching sessions after the BSP was developed. A pre-routine meeting did not occur for two of the coaching sessions. Additionally, during one coaching session, the researcher did not observe the routine. This session took place over a holiday break at which time the researcher met with Henrys


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mother and father to discuss a plan for the remaining sessions and to answer questions the family had about fading supports for Henry.
PTR-F step 5: Monitoring Plan Implementation and Child Progress. Once the family had implemented the BSP, a functional relation had been established between the BSP and changes in Henrys behavior, and the family noted overall increased confidence and satisfaction with the routine, the researcher and family agreed that it would be acceptable to reduce the frequency of researcher visits to an as-needed basis. A meeting was scheduled to plan for the steps that Henrys family would follow to increase his independence with the routine and to fade reinforcement for his following the routine. At the meeting, a plan involving three phases was designed by Henrys mother and the researcher. The first phase was designed to decrease Henrys continued whining by providing a warning that if Henry continued to whine and did not use a big strong voice (the familys terminology for appropriate verbal behavior), then he would not earn his reinforcer (i.e., being allowed to watch a DVD in the car). The second phase included a similar, preventative warning that Henrys family provided him with at the same time he received pre-transition warnings. The difference in this second phase was that the warning was given before the routine started and if, during the routine, Henry engaged in whining behavior, then he would not earn reinforcement. The third phase consisted of the development of a token economy system for Henry to earn reinforcement. The family and researcher knew that Henry understood token reinforcement and that he responded well to it, so it was decided that once he was consistently completing the routine without whining, the family would begin requiring that Henry complete more than one routine to earn the reinforcer. The plan stated that as Henry more successfully completed the routine, the family would slowly increase the number of


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tokens he would have to earn in order to earn his reinforcer. Henrys family indicated that they felt comfortable implementing these changes themselves, but it was agreed that the researcher would be available for any follow-up concerns or needs the family might have. Consequently, the meeting during which this plan for fading was developed was the last meeting the researcher had with Henrys family.
Olivia and Her Family
Olivias family participated in the study for a total of 15 weeks from the initial meeting with the researcher until a close-out meeting. That meeting occurred during week 15 to review the familys continued progress with Olivias morning routine and to discuss a second routine for which the researcher provided support to the family. The three meetings pertinent to the PTR-F steps occurred over the course of three weeks. During each meeting both Olivias father and mother were present. Once the family started implementing the BSP, the researcher and family continued meeting one time per week for coaching purposes. On most days both of Olivias parents were present for these meetings. However, on some occasions only her mother or her father was present for the coaching meeting with the researcher due to work-related travel.
PTR-F Step 1: Initiating the PTR-F Process. During Step 1 the researcher and Olivias mother and father met for approximately 40 minutes to develop behavior goals and to review the BRS. Olivias family had a number of challenging behavior concerns that were brought up at this initial meeting in regard to Olivias challenging behavior during her morning routine. The family reported that Olivia was very needy and clingy in that she touched other people, constantly requested hugs and to sit on the laps of others, and frequently sought adult attention and reinforcement. The family also reported that Olivia


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would respond to directions by talking about her boo boos (i.e., scrapes or scratches), crying, or by making comments to engage in other activities such as I have to go potty. Ultimately, the family determined that the challenging behavior that would be targeted during the morning routine was noncompliance. Noncompliance was operationally defined as when given a direction, Olivia will make comments (e.g., ask for a hug; ask to be held; ask for attention or reinforcement; saying not ready, no buttons, or my boo boo) or engage in behaviors (e.g., cry, yell, scream, flop to the floor, run away, jump on the bed) that are unrelated to the direction that was given. Olivias mother and father indicated that in regard to desirable behaviors, they wanted her to follow the routine without demonstrating noncompliance. The family noted that eventually they hoped that Olivia would be able to follow the morning routine independently; however, they indicated that much improvement would have been made if the routine occurred without noncompliance each morning.
As with Henrys family, the PTR-F process for developing challenging and desirable BRSs was not followed in step 1 with Olivias family. At the end of the goal setting meeting, the researcher reviewed with the family how to collect data using the BRSs that were developed for the study. Olivias mother and father agreed that they understood how to use the data collection system, and it was agreed that they would complete the BRSs each day after the occurrence of the morning routine. Olivias PTR-F Goal Sheet can be found in Appendix B.
PTR-F Step 2: PTR-F Assessment. Olivias family and the researcher scheduled an initial meeting to complete the PTR-F assessment; however, due to weather issues, the meeting had to be cancelled. In order to efficiently progress through the PTR-F steps, the family and researcher agreed to complete step 2 during a phone meeting that occurred while


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the family was visiting Olivias grandparents in Florida. The meeting occurred while Olivias mother and father were in a car. The researcher was placed on speaker phone and read the items on each PTR-F checklist to the family, who responded verbally.
In regard to the Prevent checklist, Olivias family indicated that the challenging behavior was most likely to occur while Olivia was alone or during transitions, and especially during clean-up transitions. While completing this checklist, a discussion also occurred around Olivias tendency to be what her parents described as a time checker.
They noted that she frequently and repeatedly asked questions such as How many sleeps? How many times? What time? and Whens mommy coming home? They also noted that Olivia did not like surprises and that she needed to understand whats coming next.
The completed Teach checklist indicated that Olivia would benefit from learning how to express her preferences when given a choice. Further, the family noted multiple problemsolving skills that could be taught to Olivia to reduce the likelihood that the challenging behavior would occur. These problem-solving skills included using visuals to support independence; following directions, schedules, and routines; choosing appropriate solutions; making choices from appropriate options; and following through with choices. Additional discussion that occurred while the family was completing the checklists involved the familys observations that Olivia seemed to exhibit a low level of nervousness at all times regarding not understanding what is going on around her when her family was not present to interpret what Olivia was saying and to answer her questions. The family reported that it was their belief that Olivias nervousness corresponded to her historical and continued difficulties with expressive language. It was also noted, though, that even when the family was present Olivias frequent questioning and seeking of adult attention continued.


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While completing the Reinforce checklist, the family noted that Olivias challenging behavior was usually followed by a variety of consequences that included being sent to timeout, being sent to a quiet spot or to a corner, a delay or change in the direction, provision of adult assistance, verbal warning or reprimanding from adults, physical guidance, and being provided with access to a desired activity. The family recalled that most often the challenging behavior resulted in acknowledgement and attention from adults or a delay in a transition. It was also reported that Olivias use of appropriate behavior was sometimes acknowledged but not as often as the challenging behavior was. The family completed the Reinforce checklist and noted a number of reinforcing items and activities. Olivias mother and father identified the following as reinforcers: social interaction and praise from adults and Olivias sister, special activities (e.g., getting donuts with the family, being a helper), small toys and prizes, and time on electronic devices. At the end of this meeting, the researcher reviewed the information that had been obtained, and it was decided that because the family was on the phone and almost at their destination, a hypothesis statement regarding the perceived function of Olivias challenging behavior would be developed by the team at the next meeting prior to developing a BSP.
When the team reconvened to develop a BSP, the researcher and family summarized the information from the PTR-F assessment checklists and developed the following hypothesis statement: when Olivia does not receive adult attention and/or when she is directed to transition, she will demonstrate noncompliance, and as a result, she will receive adult attention and/or the direction to transition will be delayed or terminated. Next, the team agreed upon a desirable behavior short-term goal for the morning routine. The family chose to focus on Olivias ability to follow the routine, which was operationally defined as doing


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what parent/schedule tells Olivia to do (with adult prompting) without the demonstration of noncompliance (see definition of challenging behavior) Olivias PTR-F Assessment Checklists and her PTR-F Assessment Summary Table can be found in Appendix B.
PTR-F Step 3: Intervention. The meeting to develop Olivias familys BSP lasted for approximately one hour including the time it took for the team to complete the step 2 activities previously discussed. During this meeting, the team chose three Prevent strategies from the PTR-F Menu of Intervention Strategies for the BSP. The team agreed to enhance predictability with calendars and schedules by developing a visual schedule that was individualized for the steps of Olivias morning routine, and the family decided to provide clothing choices for Olivia while she was getting dressed as opposed to requiring that she wear particular shirts or pants. The third Prevent strategy the team chose was to provide a warning for Olivia during hair brushing so that she knew when this non-preferred activity would end. The family agreed that this warning could be done by counting down from 10 while brushing Olivias hair 10 times. Directly related to these Prevent strategies, the team agreed that teaching independence with visual schedules would be the best Teach strategy to focus on in the BSP. Finally, the team followed the PTR-F process for identifying a functional reinforcer for desirable behavior and for ensuring that reinforcement was removed for challenging behavior. Olivias family agreed to use multiple forms of reinforcement for desirable behavior by providing verbal praise and attention during each step, physical attention following Olivias completion of each step (e.g., hugs, high-five), and a tangible reinforcer (i.e., a small prize from a snowman cookie jar) following her completion of the entire morning routine. Reinforcement for challenging behavior was removed by ignoring challenging behavior. The familys BSP Summary form is included in Appendix B.


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Step 4: Coaching. The researcher and Olivias family met twice to develop the morning routine BSP. One meeting involved the previously discussed Step 3 activities, and the second meeting was held to ensure that the family was comfortable implementing the plan. Between the first and second meetings, the researcher developed supports for the visual schedule that was used during the routine and typed BSP for the familys reference. Olivias family purchased small prizes that she would be able to earn for completing her morning routine between the two meetings. At the second meeting the researcher reviewed the plan that the team had developed, and the team engaged in problem-solving around any questions or issues posed by the family regarding their implementation of the BSP. It was agreed that the family would begin implementing the BSP on the morning of Olivias next school day and that the researcher would meet with the family after they had been implementing the plan for two days.
After these planning meetings the researcher visited the family home one time per week directly before the morning routine was about to occur (i.e., at the same time the family was waking up). The researcher observed the morning routine while making minimal comments due to the distraction this caused Olivia. At the end of the routine the researcher met with the family for approximately 30 minutes to review any observations that were made and to engage in problem-solving with the family regarding any issues that the family might have been experiencing.
The researcher visited the home 10 times after the family began implementing the BSP. Seven of these sessions were coaching sessions around the morning routine, two of these sessions pertained to the previously discussed follow-up support provided by the researcher for the bedtime routine, and one of these sessions consisted of a close-out meeting


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pertaining to both routines. The researcher observed the morning routine during all seven coaching sessions.
PTR-F Step 5: Monitoring Plan Implementation and Child Progress. Once Olivias family was implementing the BSP with confidence and noting satisfaction with the routine, and once a functional relation was established between the BSP and changes in Olivias behaviors, the team agreed that it was acceptable to stop coaching sessions for the morning routine. The researcher continued to meet with the family to develop a BSP and to provide any needed support around the familys most difficult routine, Olivias bedtime routine. To plan for the bedtime routine, the researcher and family met and reviewed a manualized protocol for improving sleep for young children with special needs (e.g., Durand, 2013). The team chose to use the Graduated Extinction strategy as outlined by Durand (2013) and to provide a reinforcer (i.e., a trip to Olivias favorite donut store) for Olivia when she woke from sleeping in her own room. The family and researcher agreed that the researcher would visit the family home on the first night that the family implemented the bedtime BSP. As recommended by Durand (2013), the family began implementing the bedtime BSP on a Friday night. The researcher arrived at the family home at approximately 8:15 pm, and left at approximately 10:30 pm when Olivia fell asleep. The family took anecdotal data that was sent to the researcher in the form of text messages for the first week of bedtime BSP implementation. On the first two nights of plan implementation, Olivia continuously left her room, cried, screamed, and hit and bit her parents for over an hour each night, and on the second night, she threw up three times. Despite these noted challenging behaviors, Olivias family indicated that they believed the plan was working and that, based on previous discussions with the researcher regarding the likelihood that an extinction burst would occur,


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they wanted to continue implementing the plan. Olivias middle of the night waking ceased by the second night of plan implementation, and the family reported that she was sleeping-in later than she had for the last few years by the second night as well. From the third night on, the family reported that Olivia would cry for approximately 10 to 15 minutes while staying in her room and that she would fall asleep and then remain asleep for the remainder of the night.
After the family had been implementing the BSP at bedtime for 10 days, the researcher met with the family to review morning and bedtime routines and to gain team consensus around the fading of the researchers support for the family. At this meeting, Olivias family indicated that they were comfortable in discontinuing meetings and coaching with the researcher. The family reported that in the morning Olivia seemed generally happier and that the family had discontinued the use of the tangible reinforcer Olivia was receiving when she finished her morning routine. Also, the family reported that they were no longer providing a reinforcer each morning Olivia woke from sleeping in her own bed. They indicated that they continued to provide verbal praise and attention when Olivia woke, but that they intermittently provided other forms of reinforcement for Olivia (e.g., skiing alone with a parent for the morning, watching a cartoon). At the end of this close-out meeting, the researcher and family engaged in a problem-solving discussion regarding what the family would do should challenging behavior increase again (i.e., re-establish reinforcement, implement the BSP strategies as originally planned), and the team also agreed that the researcher would remain available to the family should any other questions or concerns arise. Nathan and His Family
Nathans family participated in the study for a total of 20 weeks from the time that the initial meeting was held until a close-out meeting that occurred during week 20. The


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researcher did not meet with the family each week during this 20-week timespan. During the first three weeks of the familys participation, the primary researcher met with Nathans mother to complete steps 1 through 3 of the PTR-F process. Once Nathans family began implementing the BSP, the researcher and family met approximately every week and a half for coaching sessions. Nathans mother and father were both present during all coaching sessions.
PTR-F Step 1: Initiating the PTR-F Process. During step 1 of the PTR-F process Nathans mother and the researcher met to develop Nathans behavior goals and to ensure his familys understanding and level of comfort with the BRSs. Nathans mother chose his tantrum behavior as his challenging behavior to reduce during the bedtime routine. The team then developed an operational definition for the challenging behavior that included the following behaviors: screaming, crying, yelling, hitting, kicking, lying on the floor, stomping feet, attempts to injure others, escaping the routine (e.g., running to other rooms, running to the bed), and refusing to engage in routine expectations (e.g., refusing to stand on the toilet to brush teeth). Nathans mother also discussed desirable behaviors that she would like for Nathan to use during this routine. She stated that she would like Nathan to let his dad do the bedtime routine and to follow the routine expectations without engaging in tantrum behavior.
At the end of the step 1 meeting, Nathans mother and the researcher briefly reviewed the BRSs. The team decided that Nathans family would complete the BRSs each evening after the routine had occurred or in the morning as soon as the family woke up in the case that Nathans mother fell asleep with him in his bed prior to recording her satisfaction and/or


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BSP implementation confidence on the data collection sheet containing the BRSs. Nathans Goal Sheet is included in Appendix C.
PTR-F Step 2: PTR-F Assessment. During step 2, the researcher and Nathans mother met for approximately 1 hour and 30 minutes to complete the PTR-F assessment, to develop a hypothesis statement regarding the perceived function of Nathans challenging behavior, and to choose and operationalize a desirable behavior to serve as a functional replacement for Nathans tantrum behavior. Prior to the meeting Nathans father completed the PTR-F assessment checklists, and the researcher and Nathans mother incorporated this information into the assessment that was completed by his mother. The Prevent checklist indicated that his tantrum behavior was most likely to occur during meals and at bedtime. Nathans mother stated that it most frequently occurred when both parents were home and that his yelling was often related to his wanting his mother to hold him or to do something for him. The Prevent checklist also led his mother to the conclusion that his challenging behavior tended to occur across activities when he doesnt want to do something and if he wants something and it cant happen. Moreover, a discussion occurred around the fact that Nathans challenging behavior did not occur at bedtime if his mother was not home. Furthermore, if Nathans father completed the routine with him while his mother was not home, Nathan would fall asleep on his own without his father in his room (something that did not happen if his mother was home). The team also discussed Prevent checklist data that revealed that his challenging behavior did not occur at naptime. Each day his mother would fall asleep in his bed with him during naptime.
Nathans Teach checklist indicated that he could learn to request wants and needs, express emotions and aversions, and express preferences when given a choice to reduce the


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likelihood of challenging behavior. His family also identified social skills such as getting attention appropriately, sharing, taking turns, and waiting for acknowledgement or reinforcement that, if taught to Nathan, could reduce challenging behavior. Further, Nathans mother and father identified a number of problem-solving skills that, if learned, could reduce the likelihood of the challenging behavior occurring in the future. These problem-solving skills included controlling anger and impulsive behavior, strategies for calming down, following directions and routines, accepting no, managing emotions, choosing appropriate solutions, and making choices from appropriate options.
Upon completing the Prevent checklist, Nathans family noted a number of consequences that usually followed his challenging behavior. It was reported that he was at times sent to time-out or a quiet spot and that at other times the activity was ended or he was removed from the activity. It was also determined that Nathan received verbal attention in the form of calming, talking about what happened, warnings, redirections, reprimands, and sibling reactions. He would also receive physical guidance and restraint when challenging behavior occurred. Additionally, Nathans family reported that there were occasions during which Nathan would receive desired items and/or access to desired activities following his demonstration of challenging behavior. The family also determined that the challenging behavior occurred more in the presence of his mother. Reinforcing items and activities that were identified included: all interaction (e.g., physical, social), extra time in preferred activities, device time, and toy cars. Because he could not participate in the PTR-F Assessment meeting, Nathans father provided the following written comment regarding his frustration with Nathans challenging behavior:


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Nathan has a severe case of the mommys. He refuses to let me do much of anything as long as his mom is around. Whether Im super sweet and praise him, love on him, or scold him, it really doesnt matter. When mom is gone, hes like a totally different kid. He does what I ask, we have fun and he even goes to bed and eats without issue most of the time.
Once the checklists were complete, the team summarized the PTR-F assessment checklists and developed the following hypothesis statement: When Nathan is given a nonpreferred directive or told that an activity that he wants to happen will not occur, then he engages in tantrum behavior, and as a result he gains access to what he wants, receives adult attention, and/or escapes having to complete the non-preferred directive. With this knowledge, the desirable replacement behavior that Nathans mother chose to target was following the bedtime routine, which was operationally defined as: using a quiet voice and following the steps of the bedtime routine (with prompting) without the demonstration of challenging behavior. The PTR-F Assessment Checklists and the PTR-F Assessment Summary table can be found in Appendix C.
PTR-F Step 3: Intervention. Nathans mother and the primary researcher met for approximately 1 hour and 30 minutes to develop the BSP. An initial BSP was developed during this meeting that the family implemented during one bedtime routine after which they determined that multiple aspects of the plan had to be changed. The primary issue with the original BSP was that the reinforcer that was chosen (earning access to highly-preferred toy cars in the morning) for Nathan was not delivered immediately enough or at a dosage level that was strong enough to elicit the desirable behavior. Moreover, it became apparent to the
team that the functional reinforcer that best fit the context of the routine would be for him to


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earn time with his mother at the end of the bedtime routine. Therefore, another meeting was scheduled that occurred for approximately 1 hour to develop a second BSP. This meeting and the second BSP that was developed (and ultimately consistently implemented by Nathans family) are described next.
At his second BSP meeting the team reviewed, chose, and planned for intervention strategies that would be used in Nathans BSP. Three Prevent strategies were chosen (i.e., enhance predictability with calendars and schedules, reduce distractions or competing events or materials, use scripted social stories to describe problematic situations and potential solutions), one Teach strategy was chosen (i.e., teach independence with visual schedules and calendars), and all of the Reinforce strategies were followed. Nathans BSP Summary form is included in Appendix C.
PTR-F Step 4: Coaching. After the BSP development meeting, the researcher communicated with the family through e-mail about the details of the BSP and regarding varying materials that were developed by the primary researcher. Nathans family implemented the BSP for the first time when the primary researcher was present. No meeting occurred prior to this initial BSP implementation. Nathans father did not use the visual schedule during this initial implementation of the BSP, so a meeting was scheduled during which the team could meet to review how the BSP should be implemented. The meeting was scheduled at a time that would have minimal distractions and when Nathans mother and father could be present and it lasted for approximately 75 minutes. Problem solving and role-playing were used during this meeting to ensure that both of Nathans parents reported feeling confident and able to implement the BSP. Following this meeting, Nathans father implemented the BSP with 100% fidelity. Nathans family required minimal coaching to


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continue implementing the BSP at a high level of fidelity. Further coaching sessions occurred every one and one-half weeks on average at which time the primary researcher would arrive at the family home approximately 30 minutes prior to the beginning of the bedtime routine. During these short meetings, problem-solving discussions would occur. Then the researcher would observe Nathans family implementing the BSP and provide side-by-side support primarily in the form of verbal praise for BSP strategies the family used during the routine.
In all, the researcher visited Nathans familys home 8 times for coaching sessions once BSP implementation began. Each time the researcher met with the family to observe the bedtime routine, the team met for pre-routine meetings that lasted for approximately 30 minutes. The researcher left the family home immediately after the bedtime routine ended.
PTR-F Step 5: Monitoring Plan Implementation and Child Progress. When Nathans family was able to implement the BSP with fidelity, a functional relation was established between the BSP and changes in Nathans behavior. His family reported that they were confident implementing the BSP and satisfied with the routine. Consequently, the researcher and family made a mutual decision that the researchers support for the bedtime routine was no longer required. It was agreed that the researcher would be available for any further support that the family felt was necessary. Two close-out meetings were scheduled for Nathans family. During one meeting Nathans mother completed all post-intervention study requirements (i.e., ECBI, social validity questionnaire), and simple, broad strategies were discussed regarding the familys future fading of his mothers reinforcement. At the second meeting, the researcher and Nathans mother met to discuss strategies for continued challenging behaviors that occurred during other routines of the day. A reinforcement system was developed for the afternoon and evening hours to encourage Nathans use of desired


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behavior (e.g., putting his plate in the sink when he was done eating). Also, the team reviewed strategies that Nathans family had learned at the class provided by his brothers child care center to reduce challenging behavior in the home. Nathans mother indicated that she would continue to review and practice implementing these strategies throughout the familys daily routines and that she would contact the researcher if she had any further questions or if Nathans challenging behavior increased during the bedtime routine.
Dependent Variables
The dependent variables measured in this study included: (a) childrens challenging and desirable behaviors; and (b) Eyberg Child Behavior Inventory scores. Social validity was also measured. Each dependent variable is described below.
Childrens Challenging and Desirable Behaviors
The studys dependent variables related to the children included the childrens challenging and desirable behaviors. Families created operational definitions for challenging and desirable behaviors, and these individualized operational definitions were further defined by the primary researcher and used for data collection. Specifics regarding each operational definition can be found in the measurement section. Families also completed BRSs after each target routine that measured their satisfaction with the routine and their BSP implementation confidence over time. Further, families completed standardized pre and post-test questionnaires (ECBIs) to rate their childs overall challenging behavior and the amount of perceived problems that they experienced due to their childs challenging behavior (Eyberg & Pincus, 1999).


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Familys Perception of the PTR-F Process and BSP
Family perception of the PTR-F process and of the BSP was indicated by their numerical ratings and written comments on the social validity questionnaire. Families completed the social validity questionnaire at the close-out meeting after it was decided that the team should fade and/or terminate support provided by the researcher.
Percentage of Fidelity of Intervention Checklist Components Implemented by the Family
In order to ensure that the independent variable was implemented as it was designed to be, family BSP implementation was also evaluated. This measure included the average percentage of fidelity of intervention checklist components implemented by each family during each observation session. A PTR-F Fidelity of Intervention Checklist that lists the steps of the BSP was developed and individualized for each family based on the PTR-F strategies the family chose in their design of the individualized BSP.
Measurement
Videotaped observational data (i.e., percentage of intervals with challenging and desirable behaviors, families implementation of the BSP) were collected with a digital video camera. Video data were obtained during the target routine on days that the PTR-F facilitator met with the family for meetings or to provide coaching. The family BRSs are family measures that were completed by the family each day. Each family completed an ECBI twice, once at pre-test and again at post-test.


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Childrens Challenging and Desirable Behaviors
The percentage of intervals with challenging and desirable behaviors, family BRSs, and ECBI scores were the measures used for collecting data for childrens challenging and desirable behaviors.
Percentage of intervals with challenging and desirable behaviors. To promote consistency with the family behavioral measure, videos were scored for occurrence of challenging behaviors by using modified, more explicitly defined operational definitions of the behaviors that were chosen by the family and researcher. A 10-second partial-interval recording system was used to score video segments for challenging and desirable behaviors. A binary coding system with only two possibilities for intervals (i.e., challenging behavior or appropriate routine behavior) was developed and used. That is, each interval was scored as a challenging behavior or desirable behavior interval. If challenging behavior occurred during the interval, it was scored as a challenging behavior interval. If challenging behavior did not occur during the interval, it was scored as a desirable behavior interval. The operational definitions used for video coding of challenging behaviors are as described next.
The operational definition for Henrys challenging behavior included the following behaviors: refusal comments (e.g., never, no, I want to play), throwing self onto the floor, crying, whining, running away, and doing something other than what mother instructed to do. Olivias challenging behavior operational definition included the following behaviors: doing something other than what parent instructed, refusal comments (e.g., saying, Olivia not ready, No buttons, I dont want that shirt), making comments to distract adult (e.g., asking for hugs; saying, my boo boo), flopping to the floor, and running away. The behaviors included in the operational definition for Nathans challenging behavior were:


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crying, yelling, screaming, saying no mommy, negotiating for mother to perform the routine, avoiding dad (e.g., hugging mom, grabbing for mom, running away from dad to other room), engaging in behaviors not related to the routine (e.g., running to brothers room, jumping on bed, hiding in closet), and being held by an adult to perform particular routine steps (e.g., parent holds for teeth brushing).
Family BRSs. The family BRSs are perceptual scales used by the family to track family confidence in their own implementation of the BSP and family satisfaction with the target routine. The collection of BRS data has been shown to be a promising, practical strategy for tracking changes in salient child behaviors (Iovannone, Greenbaum, Wang, Dunlap, & Kincaid, 2013). Each family used the same two BRSs to track progress over time. After the occurrence of the routines, the families completed the BRSs by rating (on a scale of 1 through 5) their satisfaction with the routine and their confidence with implementing the BSP. On the confidence BRS, families were provided with the following possible responses: (1) I cant do this; (2) Im not sure of myself; (3) I am ok at this; (4) Im good at this; (5) I got this and I can do this! Responses on the satisfaction BRS included: (1) extremely frustrated; (2) frustrated; (3) OK; (4) satisfied; and (5) extremely satisfied. The BRSs can be found in Appendix D.
Eyberg Child Behavior Inventory (ECBI). As previously noted, the ECBI is a questionnaire that is comprised of 36 Likert-type scale questions (ranging from 1 to 7) that parents rate to indicate the intensity of their childs challenging behavior and whether or not they consider the challenging behavior to be a problem (Eyberg & Pincus, 1999). Each item corresponds with a particular behavior (e.g., dawdles in getting dressed, has temper tantrums, yells or screams) that parents rate based on the frequency of the behavior from


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never (1) to always (7). They also rate whether or not the behavior is a problem by circling yes or no. Families completed the ECBI twice during study participation at pre and post assessment. The two ECBI scales (i.e., the Intensity scale, the Problem scale) were scored based on manual recommendations for each family (Eyberg & Pincus, 1999).
Family Perception of the PTR-F Process and BSP (Social Validity)
Families completed a modified version of the social validity measures that are currently in use by researchers conducting the randomized controlled trial of PTR-YC. The first ten items were answered based on the familys agreement with a 5-point Likert-type scale. For most items, a score of one indicated low social validity and a score of five indicated high social validity depending on the nature of the question. Some items were reverse scored (i.e., a score of one indicated high social validity with a score of five indicating low social validity). Items assessed areas such as the familys satisfaction with changes in their childs behavior, the familys perception of the amount of effort and time required to implement the BSP, and whether the family believed that the BSP fit contextually with their familial norms. The eleventh item was open-ended with a prompt inquiring whether the family had additional information to share that was not assessed on the social validity questionnaire. The social validity questionnaire can be found in Appendix E. Families Implementation of the Comprehensive BSP
Once BSPs were created and Fidelity of Intervention Checklists were developed, all videos were scored using the checklists to note a Yes or No for each BSP step associated with the strategy-fidelity (e.g., Prevent-Implemented as intended, Teach-Implemented as intended) components. After scoring was completed for child behaviors, videos were scored on a later date a second time to obtain fidelity of intervention checklist scores. In order to


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reduce ambiguity in scoring, Fidelity of Intervention Checklists were made as simple as possible by including the minimal number of strategies each family had to implement in order to reach high-fidelity implementation of the BSP. Only the Fidelity of Intervention Checklist components regarding the familys behavior (i.e., strategy implemented as intended, strategy implemented as frequently as intended) were scored due to the fact that observational data for child behaviors were collected and scored separately. An overall average fidelity of intervention checklist percentage score was obtained for each observation by dividing the total number of obtained Yes scores by the total number of possible Yes scores and multiplying the answer by 100.
Experimental Design
A single case research withdrawal (ABAB) design replicated across three families was used to examine the effect that implementing a comprehensive BSP developed through the PTR-F process had on child challenging behaviors and child desirable behaviors (Kennedy, 2005). The single case withdrawal research design has been established in the literature (e.g., Cheremskynski et al., 2012; Clarke, Dunlap, & Vaughn, 1999; Crozier & Tincani, 2005) as a feasible and efficient single case research design for use with similar populations of children and their families. Unlike other more temporally extended single case research designs that can delay intervention for prolonged periods of time, the withdrawal design was considered superior for use in this study because an experimental effect was demonstrated through a brief removal of the independent variable causing minimal disruption for children and
families.


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Baseline
An uncontrolled baseline was employed in this study. That is, during baseline, families were encouraged to engage in their typical, existing routine without being given any instruction. Baseline observation sessions were videoed using a digital video camera and lasted for 10 minutes. Each baseline observation session occurred during the familys target routine. All four planning steps in the PTR-F process involved in developing each BSP occurred during baseline, but no intervention implementation occurred until the onset of the first intervention phase.
Intervention 1
Following the completion of steps 1 through 4, the PTR-F facilitator met during the target routine chosen by each family. The PTR-F facilitator engaged in coaching with the families to support their implementation of the BSPs and to establish fidelity of intervention. Withdrawal
During the withdrawal phase, each family routine was briefly returned to baseline conditions. The researcher instructed the families not to implement the BSP during the withdrawal phase. As soon as a sufficient pattern of behavior (i.e., a return of child behavior to baseline [or close to baseline] rates) was noted, the intervention phase was readministered. A replication of baseline during the withdrawal phase was critical to determine that a functional relation existed between the intervention and the childs behavior (Kennedy, 2005).


Intervention 2
During this second intervention phase, the PTR-F facilitator again met during the target routine chosen by each family. Coaching and feedback was provided on the family implementation of the BSP in order to re-establish fidelity of intervention.


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CHAPTER III
RESULTS, DISCUSSION, AND RECOMMENDATIONS
The following sections outline study results, discussion, and recommendations. First, interobserver agreement for each scored observational measure is discussed. Next, intervention fidelity and findings from all dependent variables are detailed. Then, a discussion that includes a summary of pertinent results and findings, study limitations, recommendations for future research, and implications for practice is provided.
Interobserver Agreement
A primary independent observer scored all observational measures. The primary independent observers scores were used for all phase change decisions. The primary independent observer was a doctoral student in the same program as the primary researcher. The researcher was the secondary observer. The secondary observer was trained using the process outlined by Kennedy (2005) that includes the following steps: (a) memorization of observational codes and operational definitions for behaviors; (b) discussion of occurrence and non-occurrence behavioral examples; (c) practice scoring using observational codes; (d) independent scoring of video examples; and (e) calculation of interobserver agreement with the primary observers coding. Once a minimum interobserver agreement (10A) of 85% was reached, both observers were permitted to score observational measures. The secondary observer scored an average of two videos per family to establish sufficient IOA.
In order to ensure that observations were independent each observer scored all sessions at different times and the secondary observer was trained using videos that were not used for calculating interobserver agreement. The primary observer noted on each scoring sheet the exact moment (i.e., the time stamp including the hundredths of the second) of the


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video when coding began. If the secondary researcher noted any issues in IOA once video scoring had occurred, the primary and secondary observers would discuss such issues after the video scoring was complete. Once it was determined that a video would be scored for calculating IOA for the study, no changes in scoring were made. That is, discussions between the primary and secondary observer that occurred over time did not influence previously scored videos that were designated as study IOA videos. IOA was calculated and reported for a minimum of 33% of the observational measures for all participants and families distributed evenly across all study phases.
Occurrence/nonoccurrence IOA was calculated using the following recommendations outlined by Kennedy (2005, pp. 116-117): (1) a check is made each time the secondary observer agrees with the primary observer regarding whether or not an occurrence of the behavior occurred; (2) the number of agreements are tallied; (3) the number of possible agreements are tallied; (4) the number of agreements is divided by the number of possible agreements and multiplied by 100.
In regard to the familys fidelity of intervention checklist scores, the mean occurrence interobserver agreement for Henry across all study phases was 96.5 % (range 82- 100%), and the mean nonoccurrence interobserver agreement across all study phases was 100 %. For challenging behavior, the mean occurrence interobserver agreement for Henry across all study phases was 95.2 % (range 87-100%), and the mean nonoccurrence interobserver agreement across all study phases was 94.7 % (range 82-100%). The mean occurrence interobserver agreement for Henrys desirable behavior across all study phases was 94.7% (range 82-100%), and the mean nonoccurrence interobserver agreement across all study phases was 95.2% (range 87-100%).


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In regard to Olivias familys fidelity of intervention checklist scores, the mean occurrence interobserver agreement across all study phases was 98.3 % (range 90 100%), and the mean nonoccurrence interobserver agreement across all study phases was 91.3% (range 57-100%). For challenging behavior, the mean occurrence interobserver agreement for Olivia across all study phases was 85.6% (range 78% 97%), and the mean nonoccurrence interobserver agreement across all study phases was 92.6% (range 67% 100%). The mean occurrence interobserver agreement for Olivias desirable behavior across all study phases was 92.6% (range 67-100%), and the mean nonoccurrence interobserver agreement across all study phases was 85.6%% (range 78-97%).
The mean occurrence interobserver agreement for fidelity of intervention checklist scores across all study phases for Nathan was 100%, and the mean nonoccurrence interobserver agreement across all study phases was 96% (range 80-100%). For challenging behavior, the mean occurrence interobserver agreement for Nathan across all study phases was 98.9 % (range 94% 100%), and the mean nonoccurrence interobserver agreement across all study phases was 100%. The mean occurrence interobserver agreement for Nathans desirable behavior across all study phases was 100%, and the mean nonoccurrence interobserver agreement across all study phases was 98.9% (range 94-100%).
Results
The purpose of this section is to discuss study results across children and families. First, a discussion of BSP implementation across families is provided. The remaining sections describe the results for all dependent variables including: (a) percentage of challenging and desirable behaviors per routine; (b) BRS scores; (c) ECBI scores; and (d) social validity.


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Family Implementation of the Comprehensive BSP
Each family was able to achieve a pre-established criterion (i.e., 80% or more) level of fidelity of BSP implementation score during intervention phases through their participation in the PTR-F process. Across families, elements of the BSPs were implemented during the baseline phases indicating that the families were already using some of the strategies that were chosen as PTR-F strategies to include in the BSPs prior to their developing the BSPs. Some of the strategies were also used during the withdrawal phase indicating that a complete withdrawal of the BSPs did not occur during the withdrawal phases. Table 1 shows the mean fidelity scores and ranges for each family across baseline, intervention, and withdrawal phases.
Table 1
Mean Fidelity Scores and Ranges Across Baseline, Intervention, and Withdrawal Phases
Baseline Intervention 1 Withdrawal Intervention 2
Mean Range Mean Range Mean Range Mean Range
Henry and His 66% 39- 100% N/A 65% 59- 100% N/A
Family 81% 71%
Olivia and Her 51% 43- 86% 63- 70% 70- 86% 62-
Family 59% 100% 71%) 95%
Nathan and His 56% 54- 95% 92- 50% N/A 100% N/A
Family 58% 100%
Childrens Challenging and Desirable Behaviors
A functional relation was noted for all child participants in regard to the reduction of child challenging behavior that occurred once each family began implementing the BSP. When the BSPs were withdrawn, all three participants demonstrated increases in challenging behavior that subsequently decreased with the re-implementation of their families BSPs.


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Desirable behavior intervals were scored as the inverse of challenging behavior intervals. Therefore, a functional relation was identified for all children and their families for desirable behavior as well. Across all families, the introduction of the BSPs resulted in an increase in desirable behavior for all child participants. During the withdrawal phase, desirable behavior decreased for all participants. Once the BSPs were re-implemented, desirable behavior again increased for all participants. Appendix F contains Figures 2 through 4, which illustrate the percentage of intervals with desirable behavior across study phases and participants. Figures 5 through 7 show the percentage of intervals with challenging behavior for each participant across sessions. Challenging behavior results for each participant and his/her family are described next.
Percentage of Challenging Behavior: Henry
Figure 5. Percentage of challenging behavior for Henry across study phases.
Henry and His Family
During the initial baseline phase, Henrys mean challenging behavior was 60.4% of intervals (range 11-84%). On one occasion, Henry engaged in 11% challenging behavior,


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which was well below his other challenging behavior scores (52.7% lower than his next lowest challenging behavior score). The team had no explanation for the occurrence of this low score. Excluding this outlier, Henrys percentage of challenging behavior during baseline was stable and demonstrated a low, upward trend. During intervention, Henrys challenging behavior rapidly decreased to a mean score of 14.75% (range 0-33%). Intervention data showed low to medium variability with a low, downward trend. When the intervention was withdrawn, Henrys challenging behavior scores increased rapidly again to a mean of 70% (range 68-72%). Withdrawal challenging behavior data showed low variability with a low decreasing trend. This downward slope was not concerning given the stability of the withdrawal data and the shortened duration of the withdrawal phase to minimize familial stress. When the BSP was re-implemented again, Henrys challenging behavior decreased rapidly to a mean of 12.3% (range 0-25%). Intervention data demonstrated low to medium variability and a low to medium, decreasing trend.
Percentage of Challenging Behavior: Olivia
Intervention 2
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17
Session
Figure 6. Percentage of challenging behavior for Olivia across study phases.


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Olivia and Her Family
During baseline, Olivias mean challenging behavior was 70.5% of intervals (range 50-78%). Her baseline percentage of challenging behavior data had medium variability and a moderate to high increasing trend. Once the intervention was implemented, Olivias challenging behavior rapidly decreased to a mean of 30.1% (range 13-45%). Intervention data showed medium variability due to a break that occurred between the third and fourth intervention data point. The family went on a 5 day trip to visit Olivias grandparents, at which time the BSP was not implemented. The family began implementing the BSP upon their return home, and a brief increase in Olivias percentage of challenging behavior scores occurred. With this increase in challenging behavior, Olivias intervention data demonstrated a medium upward trend. However, eventually, Olivias challenging behavior reached pre-trip levels, and the last three data points in the intervention phase had a medium to high downward trend. Olivias withdrawal challenging behavior data indicate a rapid increase to a mean of 66% (range 67-65%). Withdrawal data were stable with a low decreasing trend. The downward slope was not concerning given the low variability of Olivias withdrawal data and the shortened duration of this phase to prevent unnecessary stress on the family. With the re-introduction of the BSP, Olivias percentage of challenging behavior rapidly decreased to a mean challenging behavior score of 35% (range 27-54%). On one occasion during intervention, Olivia exhibited 54% challenging behavior, which was 23% higher than her next highest challenging behavior score. There were a number of changes occurring at this time for Olivia (e.g., her school schedule changed, her mother was out of town for work), but no particular explanation for this increase in challenging behavior was identified. Olivias percentage of challenging behavior during intervention was otherwise stable and


demonstrated a low, upward trend through the third to last data point. Then a decrease in challenging behavior was noted between the second to last and last data point indicating a rapid downward trend.
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Figure 7. Percentage of challenging behavior for Nathan across study phases.
Nathan and His Family
Throughout the baseline phases Nathans mean percentage of challenging behavior was 96.1%. During the last two baseline sessions, Nathan demonstrated challenging behavior for the entire duration of each videotaped observation period. His percentage of challenging behavior scores, therefore, demonstrated high rates of challenging behavior with a low, increasing trend. Once his family began implementing the BSP, Nathans mean percentage of challenging behavior immediately decreased by 25% between the last two baseline data points and the first intervention data point, and then by 75% between the first and second intervention observation period. A meeting occurred between the primary researcher and Nathans family between the first and second videotaped intervention observation period during which the team thoroughly discussed the BSP and broke the steps of the BSP down


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into even more concrete tasks for Nathans father. Following this meeting Nathans challenging behavior decreased to 0% and his percentage of challenging behavior remained low and stable throughout the remaining duration of the intervention phase with a mean score of 3.3% (range 0-10%) not including his 75% score mentioned above. Nathans mean challenging behavior score for intervention across all scores was 21.3% (range 0-75%).
When the intervention was withdrawn, Nathans percentage of challenging behavior rapidly increased to a mean of 85% (range 75-95%), and his withdrawal data showed a medium upward trend. The withdrawal data appear to have medium variability; however, this is difficult to determine based on the limited number of videotaped observations that occurred during the withdrawal phase in order to reduce familial stress. Once the BSP was reimplemented, Nathans percentage of challenging behavior immediately decreased to 0% and remained stable at 0% across all four videotaped intervention observations.
Family BRSs
Appendix G contains graphs illustrating data from the BRSs completed by each family throughout their study participation. Each family reported different issues in regard to their completing the BRSs. Olivia and Nathans family consistently had difficulties in completing the BRSs over time, and Henrys family lost approximately three weeks of data when they misplaced their BRSs and could not find them. Improved routine satisfaction was reported across all families from the baseline to the second intervention phase. Both families who reported their BSP implementation confidence during the first intervention phase reported an increase in their confidence during the second intervention phase. All families reported high rates of BSP implementation confidence by the second intervention phase. Table 2 shows each familys mean BRS scores across study phases.


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Table 2
Mean BRS Scores Across Families Across Study Phases
Baseline Intervention 1 Withdrawal Intervention 2
Satisfaction Confidence Satisfaction Confidence Satisfaction Confidence Satisfaction Confidence
Henry 2.9 N/A 3.2 3.2 3.9 4.2
Olivia 3.4 N/A 4.6 2 5 4.5 5
Nathan 2.4 N/A 4.3 4.3 2 5 4.8 5
Eyberg Child Behavior Inventory
Figures 8 and 9 provide the pre and post raw intensity and problem scores for all three child participants as rated by their families during pre-assessment and post-assessment. During pre-assessment, only the intensity of Nathans challenging behavior fell in the clinical range. Henry and Olivias challenging behaviors were within a typical range of challenging behavior according to the ECBI. No families reported perceived challenging behavior problems in the clinical range during pre or post-assessment.
During post-assessment, Olivia and Nathans families both reported decreased challenging behavior intensity and problem scores. During post-assessment, Henrys family rated his challenging behaviors to be slightly more intense and slightly more problematic than during baseline. However, at post-assessment, all families rated child challenging behaviors and perceived problems to be within a typical range.


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ECBI Intensity Scores
Child Participant
Prc Raw Score Post Raw Score
Figure 8. Pre and post Eyberg Child Behavior Inventory Intensity scores across children.
ECBI Problem Scores
Child Participant
Prc Raw Score Post Raw Score
Figure 9. Pre and post Eyberg Child Behavior Inventory Problem scores across children. Family Perception of the PTR-F Process and BSP (Social Validity)
All three families favorably rated both the PTR-F process and the BSPs that were developed and implemented. On questionnaire items with a rating of 5 indicating the most


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favorable score, average social validity ratings for Henry and his family, Olivia and her family, and Nathan and his family were 4.83, 4.83, and 5, respectively. On questionnaire items with a rating of 1 representing the most favorable score and a rating of 5 the least favorable score, average social validity ratings for the families included a score of 2 for Henry and his family, a score of 2.25 for Olivia and her family, and a score of 1 for Nathan and his family.
The most highly rated questionnaire items indicated that families found the BSPs acceptable, the BSPs fit well into their existing routines, the children learned desirable behaviors through the families implementation of the BSPs, and the BSPs were congruent with each familys goals for their child. Items related to the familys willingness to carry out the BSPs and the amount that families liked the BSPs were also highly rated. Families rated items regarding BSP disadvantages, side effects, and child discomfort more variably. Henrys family reported that they rated the questionnaire item addressing undesirable side-effects a 3 out of 5 because their children now watched a DVD in the car (Henrys reinforcing activity for completing his routine), which prevented their ability to listen to music while driving. Olivias family noted that they rated the questionnaire item addressing child discomfort that might occur through their BSP implementation a 3 out of 5 because the first time [implementing the BSP] was rough.
The last item on the social validity questionnaire offered families the opportunity to write in any additional comments about the PTR-F process or the BSP that were not addressed by questionnaire items. No families made additional comments. Table 3 shows the social validity ratings for each family across all items on the social validity questionnaire.


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Table 3
Social Validity Ratings Across Families Across Social Validity Questionnaire Items
Henry and His Family Olivia and Her Family Nathan and His Family
Question 1: Acceptability of the PTR Plan 5 5 5
Question 2: Familys Willingness to Carry Out Plan 5 4 5
*Question 3: Disadvantages in Following the Behavior Plan 2 3 1
*Question 4: How Disruptive is it to Carry Out the Plan 2 2 1
Question 5: How Much Do You Like the Proposed Plan Procedures 4 5 5
*Question 6: Extent that Undesirable Side-Effects Result from the Behavior Plan 3 1 1
*Question 7: How Much Discomfort is Your Child Likely to Experience During the Behavior Plan 1 3 1


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Table 3 (cont.)
Question 8: How Well Does The Behavior Plan Fit Into Existing Routine 5 5 5
Question 9: Effectiveness of Plan In Teaching Child Appropriate Behavior 5 5 5
Question 10: Fit of Plan With Familys Goals to Improve Childs Behavior 5 5 5
Note: Questions marked with an asterisk were rated inversely with a score of 1 indicating the most favorable rating and a score of 5 indicating the least favorable rating.
Discussion
The purpose of this study was to experimentally analyze the PTR-F process with three families having young children with challenging behavior. A single case research withdrawal design across three young children and their families was implemented to examine the effect of the PTR-F process on the level of fidelity at which each family implemented the BSP, the effect of the BSP on child challenging and desirable behaviors, and the effect of the PTR-F process and the familys implementation of the BSP on family ratings of self-confidence and satisfaction with the routine. How families perceived the PTR-F process and the BSPs that were developed and implemented was also considered.
Through the use of the PTR-F process, all families achieved a satisfactory level of fidelity in regard to their implementation of the BSPs that were developed, and functional relations were established between each familys implementation of the BSP and positive changes in their childs behaviors. Families also reported increased satisfaction with their


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target routines, increased self-confidence regarding their ability to implement the BSPs, and positive perceptions of the PTR-F process and the BSPs. This section summarizes results and noteworthy findings as they relate to family-centered PBS. A limitations section will follow this summary in addition to sections outlining recommendations, implications for practice, and concluding remarks.
Replication of Function-Based Intervention and the Prevent Teach Reinforce Model
This study supports existing studies that have demonstrated that families are able to implement function-based BSPs with their young children with challenging behavior in ways that produce desired outcomes (Fettig & Barton, 2014). The results of this study are consistent with an ever-increasing literature base (e.g., Buschbacher et al., 2004; Clark et al., 1999; Fettig & Barton, 2014; Fettig, Schultz, & Sreckovic, 2015; Fox & Clarke, 2004;
Koegel et al., 1991; Lucyshyn & Albin, 1997) that provides support for the use of family-centered PBS to effectively decrease child challenging behaviors and improve the quality of life of young children and their families in home settings.
The findings of this study also add support for the efficacy of the PTR model when used with families of young children with challenging behavior in home settings (Bailey, 2013; Sears et al., 2013). Currently, only two studies have been conducted using the PTR-F model with families. In addition to the efficacy of the PTR-F model demonstrated in this study across three families with a focus on one routine per family, the model has also proven effective in reducing challenging behavior for one family across three routines (C. Vatland, personal communication, April 2016). Thus, the results from this study extend current research by providing evidence of the effectiveness of the PTR-F model when used with families of young children with challenging behavior.


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Percentage of Fidelity of Intervention Checklist Components Implemented by the Family
The current study replicates findings that families can and do implement BSPs with high levels of fidelity when using the individualized support and coaching provided through family-centered PBS (Cheremshynski et al., 2013; Fettig et al., 2015). Furthermore, it adds support for existing studies indicating that families high-fidelity implementation of BSPs leads to desired changes in child behavior (Barton & Fettig, 2013). All of the families who participated in this study reached a satisfactory level of intervention fidelity. Interestingly, no families had to be coached to use BSP strategies that are considered to be general positive parenting practices (e.g., Dunlap et al., in press) such as providing praise for a childs desirable behavior and reducing excessive demands and negative comments throughout the routine.
In regard to the families fidelity of intervention scores across phases, as previously noted, each family used some of the strategies that were included in the BSPs during baseline and withdrawal phases. The inclusion of these strategies in the BSP was important for the family-centered nature of the PTR-F process because it ensured that the plan built on the strengths of the family and on practices that were already in place in the home setting. Further, all families indicated that including specific strategies in the BSP served as a reminder for them to use the strategies during the routine. For example, while Henrys mother was using verbal praise during baseline, her use of this strategy increased during the intervention phase, and she used it more regularly across varying steps of the routine. It could be concluded that even without large changes in fidelity of intervention scores, behavior change was observed across families. It is more likely, though, that the comprehensive nature


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of the BSPs led to the inclusion of some strategies that were not necessarily critical for child behavior change to occur. No experimental manipulation occurred to determine which strategies from the BSPs led to changes in child behavior. However, overall, the strategies that were used across families during baseline and withdrawal phases were related to the families use of verbal praise and positive attention during the routines and to the families following of the individual routine steps in a specific order. None of the families used visual schedules at baseline or during the withdrawal phase, and access to functional, individualized, tangible reinforcers (e.g., Henrys DVD, Olivias prize jar, Nathans mothers lying with him in bed when the routine was finished) did not occur the during baseline or withdrawal phases.
In regard to each familys ability to reach high-fidelity implementation of the BSP, across all videotaped observation sessions, only Olivias family did not reach 100% fidelity of intervention at least once. Her familys inability to reach 100% fidelity might have been related to Olivias continued demonstration of challenging behavior during each morning routine across baseline, withdrawal, and intervention phases. That is, Olivias percentage of challenging behavior did not reduce to 0% at any time during the study like the challenging behavior of the young children from the other two families did. Nonetheless, the PTR-F process effectively led to each familys high-fidelity use of the BSP, which in turn led to observed and reported desired changes in the young childrens behaviors.
Childrens Challenging and Desirable Behaviors
The findings of this study are consistent with other studies examining the impact of family-centered PBS on changes in child behavior. Like other studies with family-centered PBS as their focus (e.g., Clarke et al., 1999; Dunlap et al., 2006; Fettig et al., 2015), this


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study showed that the familys implementation of the BSP led to decreased percentages of child challenging behaviors and increased percentages of child desirable behaviors across families. As previously noted, two of the families (i.e., Henrys family, Nathans family) had multiple sessions during which their child demonstrated 0% challenging behavior. Olivias family had no sessions during which she demonstrated 0% challenging behavior, which might be associated with the familys fidelity of intervention scores. Additionally, Olivias family indicated that she had been diagnosed with fine and gross motor delays in addition to motor planning issues that could have also led to her continued demonstration of challenging behavior. Fine motor tasks such as undressing and dressing, which took up a large portion of the target routine, were extremely difficult for Olivia. Overall, functional relations were noted across families between the familys implementation of the BSP and resulting changes in child behaviors
BRS. All families reported increased satisfaction with the target routine and increased self-confidence regarding their ability to implement the BSP during the PTR-F process. This finding is consistent with findings from other studies that have shown that parent training is correlated with increased familial satisfaction and self-confidence (Boettcher Minjarez, Mercier, Williams, & Hardan, 2012; Durand et al., 2013; Graf, Grumm, Hein, Fingerle, 2014). Changing perspectives over time was noted for Henrys family. That is, Henrys mother indicated that throughout her familys participation in the PTR-F process, increased expectations developed based on their learning that Henry was capable of exhibiting high levels of desirable behavior. Durand (2011) has noted this phenomenon (i.e., changing familial perspectives) as well.


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As previously noted, overall, each family experienced difficulties with their consistent tracking of BRS data. Along with these difficulties, each family also noted their own frustration with themselves in regard to the difficulties that they were experiencing. Problem solving discussions did occur around solutions to difficulties that were reported by families (e.g., lost BRSs, forgetting to complete the BRSs); however, these discussions did not seem to impact the families actual data collection. Further, despite families indicating their willingness to receive reminders to collect BRS data, the researcher was unaware of any impact constant, or even regular, reminders had on the families difficulties. In a personal communication (C. Vatland, 2016) with the researcher responsible for the other experimental analysis of the PTR-F model, family data collection issues were also reported.
ECBI. Two of three families had decreased ECBI scores from pre to post-test. Henrys family noted an increase in his challenging behavior from pre to post-test and an increase in the perceived problems that his challenging behaviors cause for the family. These score increases might be in some part related to the previously discussed changes in Henrys familys perceptions about his challenging behavior. Additionally, based on further review of the ECBIs that were completed by Henrys family, one of his scores increased around a routine that was not targeted (e.g., bedtime). Henrys family reported that only three additional behaviors (i.e., argues about rules, gets angry when doesnt get own way, yells or screams) increased and were problems for the family. It is hypothesized, although unable to be confirmed, that these challenging behaviors result in attention from Henrys family. It follows that if the function of these behaviors is attention, given Henrys familys previously discussed preference to attend to his behaviors rather than ignore them, the behaviors may continue due to the reinforcement that Henry receives for his using the behaviors.


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The decreased ECBI scores for the other two families are somewhat surprising. The ECBI measures a wide variety of challenging behaviors that are not specific to the target challenging behavior chosen by each family to reduce for study purposes. Additionally, the ECBI measures challenging behaviors across many routines as opposed to maintaining a focus on each familys target routine. Consequently, a lack of change in ECBI scores from pre to post-intervention would not necessarily indicate that the intervention did not reduce a specific challenging behavior in a particular, target routine. However, the decreased scores noted by these two families indicate that some more generalized changes in their childrens challenging behaviors may have occurred following their participation in the PTR-F process and implementation of the BSP.
Familys Perception of the PTR-F Process and BSP
The social validity findings of this study substantiate similar findings from previous research that suggest that families favorably rate family-centered PBS (Binnendyk & Lucyshyn, 2009; Buschbacher et al., 2004; Fettig et al., 2015). Overall, positive ratings were noted for the PTR-F process and for the BSPs that were developed by each team. It is noteworthy that no family chose to provide additional written comments while completing the social validity questionnaire. Perhaps families perceived their discussions with the researcher over time and during the close-out meeting to be sufficient. Or, families may have thought that the items on the social validity questionnaire sufficiently assessed all of their thoughts and concerns regarding their participation in the study.
Study Limitations
There are several limitations to this research study. First, the generalizability of study findings is limited given the small sample size and limited participant diversity. Second, this


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single case withdrawal design implemented only two withdrawal data points per family. Although clear and immediate level changes were observed for each childs percentage of challenging behavior between intervention and withdrawal phases, results should be interpreted with caution due to the limited number of data points that were used to establish the functional relation between the withdrawal and re-implementation of the BSP. Third, the BRS measure was inconsistently used across families, and, therefore, the conclusions that were made from these data should be interpreted with caution. Fourth, due to family data collection issues, it is not possible to calculate the actual number of sessions that occurred between videotaped observations. Therefore, there is no ability to determine the exact number of times that the BSP was implemented between videotaped observations in order to confirm the actual dosage of intervention that each child received throughout his/her familys participation in the study. Fifth, although it might be extremely difficult to have a blind coder score the videos for these particular families given the number of changes to the routines that were made from baseline to intervention, the primary video observation scorer was not blind to study conditions. Therefore, the video observation scorer may have had some knowledge of the phase changes that occurred. It is unknown whether or not this impacted scoring. However, IOA between observers was sufficient, which adds support for scoring validity. Sixth, no generalization, maintenance, or follow-up data were collected after the primary researchers final close-out meeting with the families. Therefore, no information is available regarding the families use of BSP strategies during other routines or the families continued implementation of the BSP once their regular visits with the primary researcher stopped. Lastly, the primary research and PTR-F facilitator has expertise in the PTR-F model and in working with families around severe and persistent challenging behavior in the home setting.


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The intent of PTR-F is to be used by home visiting professionals and families who may not have such expertise. While the findings of this study provide support for the model, they do so for the implementation of the model with a highly skilled team. This studys findings do not, however, provide information about the effectiveness of the PTR-F model when used by typical home-visiting professionals working with families in the field.
Recommendations
Given the findings and also the limitations of this study, a number of recommendations can be made for future research studies. It is important that the efficacy of the PTR-F model continue to be studied with young children and families. Future studies should, for example, focus on the implementation of the model across children with a variety of disabilities and special needs, across families from varying culturally and linguistically diverse backgrounds, and with families of different socioeconomic statuses. Future studies should also consider how family data collection issues might be mitigated. Although the use of a pre-post measure would likely eliminate these issues, the intent of SCRD is to track changes over time, and, therefore, some regular measurement of the familys perceptions of the routine, satisfaction, or the childs challenging and desirable behaviors throughout their engagement in the PTR-F process is necessary if SCRD is used. Perhaps reducing the number of times the family is expected to complete the BRSs would increase their consistent collection of these data over time. Or, for families who may experience more data collection issues than others, it might be useful for the PTR-F facilitator and family to complete the BRSs one time per week during coaching sessions. Further, it would be interesting to determine what type of reminders (e.g., texts from facilitator, e-mails from facilitator, smart phone alerts) lead to the most consistent completion of the BRSs by families. Along these


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lines, as Iovannone et al. (2013) did for the use of the BRS in school settings, future research should consider the effectiveness of the use of the BRSs with families in home settings to track changes in child behavior over time.
While all families noted relatively rapid changes in their childrens behaviors, future research should consider the average number of sessions that are required for families to report changes in child behaviors in practice-based settings in which home-visitors and families are using the PTR-F model. It is likely that the PTR-F process might be even more efficient in these practice-based settings without the research study requirements that were dictated by the single case research withdrawal design that was employed in this study. Additionally, it is recommended that future studies consider the generalization of the families learned skills to other routines and settings and also the changes in child challenging and desirable behaviors that might occur in routines that are not directly targeted through the PTR-F process. Finally, BSP implementation maintenance and follow-up data should also be collected in future studies.
Implications for Practice
The results of this study indicate that families can successfully participate in the PBS process when used in home settings and that their participation and implementation of BSPs can lead to desired changes in child behavior and increased family satisfaction and confidence implementing BSPs. All three families successfully participated in all steps (including PTR-F Assessment) of the PTR-F process implemented in this study. The results also indicate that family-centered PBS, and specifically the PTR-F model, may be an efficient and effective way to reduce challenging behavior in the home settings of families of young children with challenging behavior.


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A primary implication for practice emerging from this study was the need for flexibility and availability from the researcher in order to support the families who participated in the most efficient and effective way possible. For example, the researcher was present for each family during the time that the actual routine occurred. This meant that the researcher arrived at the families homes during very early (e.g., 6:30 a.m.) and somewhat late (e.g., 8:30 p.m.) hours. Meeting times tended to fluctuate throughout the research process. Further, families were not always available on the same day every week, so the primary researcher met with families when they were available as opposed to meeting with each family on the same day and at the same time each week. Additionally, there were multiple occasions during which the researcher was en route to a familys home when the family had to cancel the session at the last minute. The researchers ability to reschedule with families during the same week that sessions were canceled contributed greatly to the efficiency of the process. Table 4 shows the estimated average amount of the primary researchers time that was spent with each family across study phases. The averages in Table 4 include estimations of the number of indirect hours the researcher spent with each family but they do not include estimations of the researchers travel time.
Table 4
Estimated Average Time Spent with Each Family Across Study Phases
Child and Family Estimated Average Time Spent With Each Family Across Study Phases
Henry and His Family 14 to 16 hours
Olivia and Her Family 14 hours
Nathan and His Family 18 to 19 hours


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Also contributing to the efficiency and effectiveness of the process was the researchers ability to work on the development and organization of materials (e.g., visual schedules, detailed written instructions) that the families would use while they were implementing the BSPs during indirect (i.e., non-session) hours. The primary researchers schedule flexibility and use of indirect time reveal another implication for practice. That is, it is important to consider the number of families who home-visiting professionals work with at one time as it relates to the quality of the service that families receive. The efficiency of child behavior change might be impacted by a home-visitors inability to use indirect time, to reschedule during the same week, or to provide support and coaching for families during the actual routines as they occur in the family home.
Further, while the intent of the PTR-F manual is to guide home-visiting professionals and families through the family-centered PBS process, there may be circumstances that necessitate consultation with a professional who specializes in behavioral support in home settings. Even with the primary researchers specialization in applied behavior analysis, she met regularly with her dissertation advisor regarding varying, PTR-F process related issues that presented over the course of the research process. It would be beneficial for home visitors using the PTR-F model to have knowledge regarding who and what types of professionals are available for them to provide similar support and consultation hen needed.
Conclusion
This research study supports the literature indicating that family-centered PBS is an effective way to reduce the challenging behaviors and increase the desirable behaviors of young children in home settings. This study is one of only two current experimental analyses of PTR-F, a model of family-centered PBS. The PTR-F process resulted in families high


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fidelity implementation of the BSPs, and a functional relation existed between each familys implementation of their childs BSP and changes in his/her behaviors. Further, this study has shown that family-centered PBS, and specifically PTR-F, can improve familial routine satisfaction with target, difficult routines and increase familial confidence with implementing BSPs. Additionally, the findings of this study indicate that families favorably rate the PTR-F process and the comprehensive BSPs that are developed through their participation in the PTR-F process.
Research supporting the significance of family-centered PBS for young children with challenging behavior and their families continues to expand. To optimize outcomes for young children and their families, challenging behaviors should be targeted as early as possible and through efforts such as PTR-F that maximize the individualization of supports and also family involvement. PTR-F offers the structure for practitioners to be able to do this. Efforts should be taken to continue the research on and dissemination of the use of the model as a meaningful tool for practitioners and families that can impact immediate and long-term child and family outcomes.


Full Text

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AN EXPERIMENTAL ANALYSIS OF PREVENT TEACH REINFORC E FOR FAMILIES (PTR F): EFFECTS ON CHALLENGING BEHAVIORS, APPROPRIATE BEHAVIORS, AND SOCIAL VALIDITY by JACLYN D. JOSEPH B.A., Washington and Jefferson College, 2008 M.S.W., University of Pittsburgh, 2010 A thesis submitted to the Faculty of the Graduate School of the University of Colorado in partial fulfillment of the requirements for the degree of Doctor of Philosophy Education and Human Development 2016

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ii 2016 JACLYN JOSEPH ALL RIGHTS RESERVED

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iii This thesis for the Doctor of Philosophy degree by Jaclyn D. Joseph Has been approved for the Education and Human Development Program by Phillip S. Strain Adviso r Elizabeth Steed Chair Nancy Leech Glen Dunlap July 30, 2016

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iv Joseph, Jaclyn Danel (PhD, Education and Human Development) An Experimental Analysis of Prevent Teach Reinforce for Families (PTR F): Effects on Challenging Behaviors, Appropriate Behaviors, and Social Validity Thesis directed by Professor Phillip S. Str ain ABSTRACT The purpose of this study was to examine the effects of behavior support plans (BSPs) developed through the Prevent Teach Reinforce for Families (PTR F) process on changes in child behaviors. The level of fidelity at which families implemented BSPs was also considered in addition to family social validity ratings regarding the PTR F process and the BSPs that families developed and implemented during their partici pation in the PTR F process. A single case withdrawal research design was used across three families with children between the ages of 3 years 1 month and 3 years 9 months Results indicated that the families implemented BSPs with high levels of fidelity a nd that functional relation s existed across families between their implementation of the BSP s and changes in their child ren' s challenging and desirable behaviors. Results also indicated that familial routine satisfaction and familial confidence with implementing the BSP s improved throughout their participation in the PTR F process and with their implementation of the BSPs. S ocial validity findings indicated that f amilies favorably rate d the PTR F process and the BSPs that wer e developed and implemented A discussion of results, study limitations, recommendations for future research, and implications for practice are presented. The form and content of this abstract are approved. I recommend its publication. Approved: Phillip S. Strain

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v DEDICATION Th is is for you, Jace We'll all f loat on okay

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vi ACKNOWLEDGEMENTS This dissertation would not have been possible without the encouragement and support that I have been blessed to receive throughout the last few years from a number of individuals who deserve much more than the written thanks that follow. To my friends, I am better for having each and every one of you in my life, and I am forever thankful that you understood schedule conflicts and time demands To the individuals who directly contri buted to this study, you deserve so many thanks. To the three families who participated in this study thank you for o pening your homes to me, for your dedication to our partnerships, for the love that you have for your chil dren and families, and for making this dissertation process not only meaningful but also fun. To my independent observer thank you for watching and re watching so many videos, for completing tasks at the drop of a hat, and for your support. To my committ ee, I am so grateful and fortunate to have had your brilliance, practicality, down to earth styles, passion for what you do, and friendship s throughout my entire program and especially as I completed this dissertation work It is truly an honor to acknowledge you all here. To my advisor, Phil, thank you for always advocating on my behalf, for believing in me and pushing me to do more than what I think I am able to do, and especially thank you for sharing so many opportuniti es with me that continue to shape me for the better as a professional and also as a person M ost importantly, thank you for the laughs and for your continued friendship. To my parents, my biggest fans and supporters, not one minute goes by that I am not t hankful for you. I would not have accomplished half of what I have done if it weren't for your modeling of hard work, perseverance, and compassion for children with special needs and their families throughout much of my life. You are truly my best friends, and both of you in your individualized ways have made life so much better because we're in it together. And finally, t o Jace (even though I already dedicated this entire dissertation to you and I'm not sure what more you could want), thank you for working so hard to get us through these last few years and for never complaining when I get all of the credit for it You shine brighter than anyone I know, and it has been your steadfast, unwaver ing support and positivity (and also your humo r) that kept me going through the tough times

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vii TABLE OF CONTENTS CHAPTER I. INTRODUCTION AND LITERATURE REVIEW 1 Understanding Challenging Behaviors and Importance of PBS 1 Review of Literature 3 Social Emotional Development in Young Children 3 Programs to Support Families 5 Family Centered Positive Behavior Support 5 Conceptual Framework and Key Components 6 Theory of Change 14 The Efficacy of Family Centered Positive Behavior Support 15 Practical Sig nificance of Programs 17 Prevent Teach Reinforce for Families (PTR F) 18 Key Features of PTR F 18 Practical Significance of PTR F 21 Purpose and Research Questions 22 II. METHODOLOGY 24 Participants 24 Sampling Procedure 24 Henry and His Family 26 Olivia and Her Family 27 Nathan and His Family 28 Settings and Routines 29 Henry and His Family 29 Olivia and Her Family 30 Nathan and His Family 30

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viii Prevent Teach Reinfo rce for Families Process 31 Independ ent Variable: PTR F BSP 35 Henry and His Family 35 Olivia and Her Family 42 Nathan and His Family 49 Dependent Variables 56 Percentage of Fidelity of Intervention Chec klist Components Implemented 57 Measurement 57 Children's Challengin g and Desirable Behaviors 58 Percentage of Intervals 58 Family Beha vior Rating Scales (BRSs) 59 Eyberg Child Behavior Inventory (ECBI) 59 Family Perception of the PTR F Proce ss and BSP (Social Validity) 60 Family's I mplementation of the BSP 60 Experimental Design 61 III. RESULTS, DISCU SSION, AND RECOMMENDATIONS 64 I nterobserver Agreement 64 Results 66 Famil y's Implementatio n of the Comprehensive BSP 67 Children's Challengin g and Desirable Behaviors 67 Henry and His Family 68 Olivia and Her Family 70 Nathan and His Family 71 Family Behavior Rating Scales 72 Eyberg Child Behavior Inventory 73

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ix Family Perception of the PTR F Proce ss and BSP (Social Validity) 74 Discussion 77 Replication of Function Based Intervention and Prevent Teach Reinforce Model 78 Percentage of Fidelity of Intervention Checklis t Comp onents Implemented 79 Children's Challengin g and Desirable Behaviors 80 BRSs 81 ECBI 82 Family Perception o f the PTR F Process and BSP 83 Study Limitations 83 Recommendations 85 Implications for Practice 86 Conclusion 88 REFERENCES 90 APPENDIX A 96 B 107 C 118 D 127 E 128 F 130 G 13 2

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x LIST OF TABLES TABLE 1. Mean Fidelity Scores and Ranges Across Baseline, Intervention, and Withdrawal Phases 67 2. Mean BRS Scores Across Fa milies Across Study Phases 73 3. Social Validity Ratings Across Families Across Social Validi ty Questionnaire Items 76 4. Estimated Average Time Spen t with Each Family Across Study Phases 87

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xi LIST OF FIGURES FIGURE 1. PTR F theory of change diagram. 15 2. Percentage of desirable behavior for Henry across study phases. 130 3. Percentage of desirable behavior for Olivia across study phases. 130 4. Percentage of desirable behavior for Nathan across study phases 131 5. Percentage of challenging behavior for Henry across study phases. 68 6. Percentage of challenging behavior for Olivia across study phases. 69 7. Percentage of challenging behavior for Nathan across study phases. 71 8. Pre and post Eyberg Child Behavior Inventory Intensity scores across children. 74 9. Pre and post Eyberg Child Behavior Inventory Problem scores across children. 74 10. Family BRS ratings for Henry across study phases. 132 11. Family BRS ratings for Olivia across study phases. 132 12. Family BRS ratings for Nathan across study phases. 133

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CHAPTER I INTRODUCTION AND LITERATURE REVIEW During their early childhood years most young children (ages birth through five) experience and demonstrate behavioral difficulties as they advance through developmental stages (Dunlap et al., 2006). It is not uncommon for young children to intermittently exhibit behavior s such as tantrums, noncompliance, withdrawal, an d aggression, which often cause parents to question whether observed child behaviors are developmentally appropriate and momentary or whether they warrant more serious concern (Fox & Armstrong, 2004; Powell, Dunlap, & Fox, 2006). As young children grow older, and through facilitative and appropriate parenting and instruction, man y of them will become more capable of self regulating their emotions and behavior by the time they enter elementary school (Fox, Dunlap, & Cushing, 2002; Powell et al., 2006). For some young children and families, however, sustained behavioral difficulties that are more intense than what is considered developmentally appropriate might persist despite the best efforts of parents and early childhood professionals (Fox et al., 2002). There is a growing number of toddlers and young children who exhibit severe c hallenging behaviors that place strain on their families and that can limit instructional opportunities and optimal social emotional development (Buschbacher, Fox, & Clarke, 2004; Fox, Dunlap, & Powell, 2002; Powell et al., 2006). In addition to these more direct consequences for challenging behaviors, the likelihood of positive long term outcomes also declines if challenging behaviors are not ameliorated at an early age (Fox, Dunlap, & Philbrick, 1997; Fox et al., 2002). Furthermore, the earlier in life th at children and families receive support for reducing challenging

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2 behaviors, the greater is the likelihood that positive, long term outcomes will occur (Bailey, 2013; Campbell, 1995). One approach that has shown great promise in reducing the challenging be havior of young children is positive behavior support (PBS) (Fox, Dunlap, & Powell, 2002; Lucyshyn et al., 2007). PBS promotes the likelihood that successful future outcomes will occur by focusing on the provision of supports that lead to meaningful outcom es (Fox et al., 2002; Fox et al., 2002). When used with families during the early intervention and preschool years, PBS (referred to as family centered PBS herein ) assists families in the use of skills outlined in comprehensive behavior support plans (BSPs ; Fox & Armstrong, 2004). These plans are constructed to positively impact family quality of life by reducing challenging behaviors while simultaneously improving the social and communicative skill repertoires of young children (Fox & Armstrong, 2004; Dunl ap & Fox, n.d.). As noted by Fettig, Schultz, and Sreckovic (2015), the family centered PBS literature is limited in regard to the number of studies that consider the ability of practitioners and families to use the approach in an efficient and effective m anner. This scarcity of research is most likely due to the fact that the information surrounding the family centered PBS process requires a specific set of knowledge and skills that oftentimes only experts and researchers have. The skills associated with t his expertise (e.g., performing functional assessment, developing function based BSPs ) are difficult to transfer to practitioners and families due to limited available resources outlining the family centered PBS process in a simple, manualized way. In orde r to mitigate this issue, a manualized model of individualized family centered PBS (i.e., Prev ent Teach Reinforce for Families; PTR F ) has been developed for home visitors and practitioners to use with the families of young children with

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3 challenging behavior. This dissertation presents an experimental analysis of PTR F through a single case withdrawal research design replicated across three families of young children with challenging behaviors and their families. The following sections of this chapter will review the relevant literature Review of Literature The purpose of this section is to serve as a review of the literature surrounding family centered positive behavior support The following sections will review: (a) social emot ional development in young children and challenging behavior; (b) programs to support families in addressing young children's challenging behaviors; (c) a conceptual framework and key components of family centered PBS; (d) a theory of change for family cen tered PBS ; ( e ) the efficacy of family centered PBS ; ( f ) the practical significance of family and parent focused social emotional programs and family centered PBS; (g) a manualized model of family centered PBS (PTR F); and (h ) the purpose and research questions pertinent to this study. Social Emotional Development in Young Children It is typical and expected that most young children will demonstrate challenging behaviors (e.g., tantrums, noncompliance, aggression) during their early childhood y ears (Dionne, 2005; Dunlap et al., 2006; Fox & Armstrong, 2004; Lucyshyn et al., 2002; Powell et al., 2006; Seguin & Zelazo, 2005). As they develop skills for language, cognition, socialization, and self regulation, children's abilities to control their ow n behaviors increase, which generally associates with decreases in their challenging behaviors (Dionne, 2005; Fox et al., 2002; Lucyshyn et al., 2002; Seguin & Zelazo, 2005). When they are young, children are rapidly developing an ability to more independe ntly navigate their social worlds through

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4 their own biological development and also through the assistance of the adults in their lives (Lucyshyn et al., 2002; Seguin & Zelazo, 2005). Through maturation and developmentally appropriate parenting and caregiv ing, most children's challenging behaviors resolve; however, some families note challenging behaviors that are persistent and severe and that necessitate individualized intervention above and beyond what is typically provided for most children (Fox et al., 2002). In order for families and professionals to know what behaviors are considered typical and which ones warrant more individualized, intensive intervention, it is important to understand what behaviors constitute severe and persistent challenging beha viors. Challenging behavior has been defined as "any repeated pattern of behavior, or perception of behavior, that interferes with or is at risk of interfering with optimal learning or engagement in pro social interactions with peers and adul ts" (Smith & F ox, 2003, p. 6). Severe and persistent challenging behaviors tend to fall in the destruction, disruption, or "adaptive responding" categories, and can include a range of behaviors such as physical and verbal aggression, withdrawal, self injurious behavior, and sleeping problems (Powell, Dunlap, & Fox, 2006; Dunlap & Fox, n.d.; Smith & Fox, 2003). What is challenging for one family may not be for another. Therefore, in family centered PBS, the child's family members ultimately define the challenging behavio rs of young children based on the impact the behaviors have on familial relationships and experiences (Smith & Fox, 2003). Prevalence figures regarding the number of children who demonstrate challenging behaviors vary (Qi & Kaiser, 2003). In a review of r esearch Campbell (1995) concluded that 10 to 15% of children demonstrate challenging behaviors, and Qi and Kaiser (2003) noted that up to 30% of children from families with low incomes might demonstrate challenging

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5 behaviors. In a review of research focusi ng on behavioral and emotional disorders in young children, Egger and Angold (2006) concluded that the average prevalence rate of psychiatric disorders, most of which included the demonstration of challenging behavior, was 19.5%. Therefore, it can be concl uded that approximately 10 to 30% of young children exhibit challenging behaviors. Programs to Support Families in Addressing Young Children's Challenging Behaviors A variety of family and parent focused social emotional programs have been developed to promote the social emotional development of young children. In a recent analysis, Barton et al. (2004) reviewed eight parenting interventions that focus on the social emotional development of young children. Of the eight interventions that were reviewed, t wo programs (i.e., Child FIRST, Family Check Up) had a medium level of evidence and four programs (i.e., Incredible Years, Triple P Standard, Triple P Stepping Stones, Parent Child Interaction Therapy) had a high level of evidence according to the efficaci ous adoption criteria originally used by Joseph and Strain (2003). As noted by their medium to high levels of evidence, these models have proven to be effective in producing parent and family facilitated reductions in children's challenging behaviors. Howe ver despite their efficacy, there are noted limitations for each intervention, and each differs considerably from the model use d in this study (i.e., PTR F ) in regard to the implementation of family centered PBS to reduce severe and persistent challenging behaviors demonstrated by young children. The unique characteristics of family centered PBS are outlined below. Family C entered PB S PBS is a "collaborative, assessment based approach to developing effective, individualized interventions for people with problem behavior" (Lucyshyn et al., 2002. p. 7).

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6 Family centered PBS promotes the use of positive as opposed to aversive familial strat egies and consequences to change the behavior of children (Lucyshyn et al., 2002). The intent of family centered PBS is to improve the family's quality of life by reducing the challenging behaviors of young children in ways that are acceptable to the famil y and that lead to stable, long lasting outcomes (Fox et al., 1997). The key components of family centered PBS are discussed next. Conceptual Framework and Key Components of Family Centered PBS PBS draws on applied behavior analysis, the inclusion movement and person centeredness as its main foundational sources (Carr et al., 2002). While extending the foundations of PBS, family centered PBS also builds on the behavioral parent training literature (Buschbacher et al., 2004). In family centered PBS, person centeredness is expanded to include family centered practices, and families are provided with comprehensive supports that are individualized to their needs and strengths in order to encourage optimal functioning within the family system (Dunlap & Fox, n.d. ). Since each member of the family impacts the family system, family centered PBS focuses on the development of comprehensive and multicomponent intervention plans that consider the social context of the family and that promote the ability of family member s to support young children by resolving behavioral difficulties (Dunlap & Fox, n.d.). Family centered PBS also involves a multitude of key features that have been described in the literature and that further define its theoretical framework and delineate the practical implications of the approach (Lucyshyn, Horner, Dunlap, Albin, & Ben, 2002). These key features include: collaborative partnerships, family centeredness, meaningful lifestyle outcomes, functional assessment, multicomponent BSPs with systemic perspective, challenging behaviors as learning problems, foundation of

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7 communication, contextual fit, activity setting with routines as a unit of analysis and intervention, support for implementation, continuous evaluation, and sincerity and humility of pr ofessionals (Lucyshyn, et al., 2002). Each of these features will be discussed next in the order given. Collaborative partnerships. Different from expert or professional driven models, family centered PBS promotes the use of family professional partnerships in which parents actively participate in the development and implementation of interventions (Brookman Frazee & Koegel, 2004; Carr et al., 2002; McLaughlin, Denney, Snyder, & Welsh, 2011). Research has shown that when families ar e actively involved in the PBS process, the likelihood that interventions will be successful increases (Carr et al ., 1999; Powell et al., 2006). Both families and professionals are considered to have expertise that is both valuable and necessary for an eff ective family centered PBS process (Fettig, Schultz, Ostrosky, 2013; Lucyshyn et al., 2002). Collaborative partnerships involve a reciprocal exchange of information in a process that strives to empower families by not only equipping them with skills to pre vent or target future occurrences of challenging behavior, but also by giving them the ability to advocate for child and family supports that may be needed as the child continues to grow and develop (Buschbacher, 2002; Carr et al., 2002; Lucyshyn et al., 2 002; McLaughlin et al., 2011). By empowering families through partnerships, lifelong, durable support systems for children with special needs are generated, which include an optimistic and long term outlook of family quality of life (Bushbacher, 2002; McLa ughlin et al., 2011). Family centered. T he family system is frequently cited as the most influential and important learning context for young children (Barton & Fettig, 2013; Dunst, Trivette, &

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8 Hamby, 2008; Powell & Dunlap, 2010). Extending collaborative p artnerships, the family centered supports provided through family centered PBS are individualized and promote family strengths and capabilities (Fox, Dunlap, & Philbrick, 1997; Harrower, Fox, Dunlap, & Kincaid, 2000). Support is also provided through the u se of solution focused collaboration to problem solve any issues that may be blocking the family from achieving their goals (Harrower et al., 2000) Fox, Dunlap, and Powell (2002) note that family centered, individualization of intervention is concentrated around the incorporation of all relevant dimensions of the family system which can and should include aspects such as culture, beliefs, and child and family priorities. Meaningful lifestyle outcomes. By addressing the challenging behaviors of young childr en in family centered and collaborative ways, family centered PBS ultimately creates durable changes in the family syst em (Buschbacher et al., 2004). Skills are strategically transferred to members of the child's family so that they will eventually be able to problem solve difficulties without requiring the direct support of practiti oners (Harrower et al., 2000). Through this process, families are able to maintain lifestyle changes that work to prevent and target future occurrences of challenging behavior a nd that promote continued positive outcomes as children develop (Buschbacher, et al., 2004; Harrower et al., 2000 ). Carr et al. (2002) conclude d that such changes in lifestyle ultimately improve the quality of life for the entire family in addition to the lives of children with challenging behaviors. Functional assessment. A main difference between family centered PBS and common beliefs about behavioral difficulties is the understanding that challenging behaviors are the result of contextual variables present in the child's environment as opposed to the view that such behav iors are caused by inherent child issues (Carr et al., 2002; Fo x, Dunlap,

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9 & Philbrick, 1997). In regard to the direct support of young children, the process of family centered PBS starts when the team (i.e., practitioner, family, and other individuals who are invited to participate) completes a functional behavioral assessment to determine which variables in the environment correlate with the child's demonstration of challenging behaviors (Fox et al., 2002; Peck Peterson, Derby, Berg, & Horner, 2002). Some experts believe that formalized procedures (i.e., functional analysis) should be used to determine behavioral functions; however, others have argued that, particularly for toddlers and young children, such protocols are not necessary due to brief learning and intervention histories (Dunlap & Fox, 1996; Fox, Dunlap, & Philbrick, 1997; Harrower, Fox, Dunlap, & Kincaid, 2000). Once functional assessment information has been obtained, hypotheses, or summary statements, are created that describe what the team l earned about the challenging behavior in regard to antecedents and setting events and consequences (Harrower, Fox, Dunlap, Kincaid, 20 00; Marshall & Mirenda, 2002). The hypothesis statements are then used to develop multicomponent BSPs that are based on, a nd directly related to, the information obtained through the functional assessment process (Harrower, Fox, Dunlap, & Kincaid, 2000). Multicomponent BSPs and systemic perspective. Family centered PBS emphasizes a comprehensive approach to intervention that involves the development of a multicomponent BSP that addresses all challenging behaviors demonstrated by the child and that uses a variety of regularly and consistently implemented function based interventions (Carr et al., 2002; Harrower, Fox, Dunlap, Ki ncai d, 2000; Horner & Carr, 1997). This approach has proven to be more appropriate and functional for families given the dynamic and multi faceted nature of real life home and community settings (Carr et al., 2002).

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10 Moreover, it takes into consideration t he importance of changes in the family system that need to occur for long term and meaningful imp rovements (Carr et al., 2002). By including all relevant support plan components that create pervasive behavior changes for the young child, family centered PB S provides access to a new lifestyle for families that ultimately ensures continued use of learned strategies, supports, and interventions because family members experience improvements in their quality of life as challenging behaviors decrease, replacemen t skills increase, and as they begin to believe in their own self efficacy and ability to impact the behavior of the young child (Harrower et al., 2000; Marshal & Mirenda, 2002; McLaughlin et al., 2011). Challenging behaviors as learning problems. A corne rstone of family centered PBS, and PBS in general, is the understanding that challenging behaviors occur due to learning problems and problematic learning histories during which young children realize that their demonstration of challenging behavior result s in a want or need bein g met (Lucyshyn et al., 2002). In other words, young children see challenging behaviors as functional behaviors in that they result in responses from others that meet some want or need (e.g., getting attention when yelling, having shoes put on by a parent when crying; Fo x, Dunlap, & Philbrick, 1997). To target these learning problems, the family centered PBS process incorporates teaching strategies that increase the functional skill repertoires of young children by replacing challen ging behaviors with more socially appropriate behaviors that meet their wants and needs more efficiently and effectively (Lucyshyn et al., 2002). For example, children are taught to use communication skills to request desired items or to use self calming s trategies and to ask for help when upset as opposed to engaging in tantrum behavior (Fettig, Schultz, Ostrosky, 2013; Fox, Dunlap, & Philbrick, 1997).

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11 Foundation of communication. Just as practitioners and families work collaboratively through the use of positive communication, as previously alluded to, the child's team identifies ways that the BSP can incorporate opportunities for the child to learn and practice communication skills to replace challenging beh avior (Lucyshyn et al., 2002). Further such co mmunication skills are taught and practiced in natural environments and social contexts that promote the social competence of young children in addition to targeting their communicative abilities (Fo x, Dunlap, & Philbrick, 1997). The instruction of functio nal communication skills forms the basis of BSPs (Lucyshyn et al., 2002). Contextual fit. Through collaborative partnerships and family centered practices, practitioners can ensure that BSPs have good contextual fit with families (Harrower, Fox, Dunlap, & Kincaid, 2000; McLaughlin, Denney, Snyder, & We lsh, 2011; Moes & Frea, 2002). Contextual fit refers to the level of agreement the family experiences in regard to the BSP and its ability to effectively meet their needs (McLaughlin, Denney, Snyder, & We lsh, 2011; Moes & Frea, 2002). Contextual fit can be assessed in numerous ways (e.g., Lucyshyn & Albin, 1997) and incorporated in to all components of the BSP (e.g., Moes & Frea, 2002). BSPs that fit well into a family's ecology are more likely to be implement ed consistently with fidelity and to be generalized (McLaughlin, D enney, Snyder, & Welsh, 2011). Family ecology refers to concepts such as values, parenting practices, and resources, and it illuminates a significant concern of contextual fit, which is cult ural competence in the family centered PBS process (McLaughlin et al., 2011) The families of young children are diverse in regard to their ecological contexts, and practitioners need to consider the cultural competence of practices when assessin g the contextual fit of the family centered PBS approach. Cultural competency includes the

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12 process (i.e., how practitioners interact and communicate with families) in addition to the products (i.e., BSPs ) that comprise the family centered PBS approach. Che rmshynski, Lucyshyn, and Olson (2012) recommend the use of a cultural assessment or cultural guide to improve and promote cultural competence and contextu al fit (Lynch & Hanson, 2011). As described next, one of the ways to ensure contextual fit is through the use of family routines as contexts through which to understand challenging behavior and as settings and times during which interventions can be implemented. Activity setting and routines as a unit of analysis and intervention. In order for families to view interventions as useful ways to complete routines and tasks such as bathing, eating, and bedtime routines, practitioners work collaboratively with family members to determine supports that can be provided for children during daily routines that are pr actical and easily performed and that result in more successful routines (Marshall & M irenda, 2002). Lucyshyn et al. (2002) note, "activity settings represent a microco sm of family ecology" (p. 25). Therefore, practitioners implementing family centered PBS perform essential tasks (i.e., functional assessment, BSP implementation) with families at the time that the routine o ccurs (Harrower et al., 2000). By further supporting necessary and naturally occurring routines, the contextual fit of a support plan is enhanced, which increases the likelihood that families will consistently implement strategies across environ ments (Harrower et al., 2002). The consistent implementation of BSPs increases the likelihood of success and behavior reduction strategy generalizat ion because more learning opportunities are provided for the young child. Support for implementation. In order to ensure a family's success with family centered PBS and to promote their ability to generalize family centered PBS skills to

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13 untrained environ ments in the future, practitioners are committed to providing the level of support that is required for this to h appen (Lucyshyn et al., 2002). Lucyshyn and colleagues (2002) define phases of support that move from a strong reliance of the family on the sk ills and support of the practitioner to a period in which the family is able to primarily work through the family cente red PBS process independently. The practitioner performs multiple roles (i.e., teacher, resource coordinator, observer) and uses a variet y of techniques (i.e., modeling, specific feedback, encouragement) that are eventually faded as families exhibit more independent success with routines and challenging behaviors (Park, A lber Morgan, & Fleming, 2011). Levels and types of support are individ ualized based on a particular family's needs, and even when practitioners are no longer working intensively with families, it is recommended that continued follow up occur to ensure that families are maintaining their progress (Lucyshyn et al., 2002). Con tinuous evaluation. Once a sound BSP has been developed, it is important that teams continuously evaluate the young child's progress to ensure that the plan is being implemented as intended and that it is having the desired impact and enabling the family t o meet their goals (Harrower et al., 20 00; Marshall & Mirenda, 2002). Practitioners support families with continuous evaluation by transferring skills, strategies, and tools and by encouraging their independent use of progress monitoring skills surrounding the child's challenging behaviors and the implementation of the BSP (Marshall & Mirenda, 2002). Tasks that maintain the process of continuous evaluation such as using data to make decisions and communicating reg arding BSP adjustments are also collaborativ ely implemented (Harrower et al., 2000).

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14 Sincerity and humility of professionals. Although not largely discussed in the literature, Lucyshyn et al. (2002) highlight the importance of being sincere and having humility with families going through th e family centered PBS process. They recommend a number of qualities that are necessary in regard to this key com ponent of family centered PBS. These qualities and skills include listening, validation, responsiveness, valuing family input, changing BSPs based on ne eds and errors, and encouragement. The authors also note that family centered PBS outcomes are much likelier to be positive and in line with family goals when practitioners are able to demonstrate these qualities. Theory of Change The family centered PBS process is completed by families, initially with the support of a home visitor, to create change s in child behavior. More specifically, family centered PBS creates changes in family behavior that result in changes in the child's behavio r. Family centered PBS incorporates a number of elements described in the literature (and explained in the prior section) that lead to more positive outcomes for families such as family engagement and active involvement and the development of a comprehensi ve BSP that has contextual fit with the family ecology (Brookman Frazee & Koegel, 2004; Carr et al., 2002; Harrower, Fox, Dunlap & Kincaid, 2000; Horner & Carr, 1997; McLaughlin, Denney, Snyder, & Welsh, 2011; Moes & Frea, 2002). Figure 1 includes the Fami ly Centered PBS (i .e., PTR F ) Theory of Change Diagram.

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15 Figure 1. PTR F theory of change d iagram The Efficacy of Family Centered PBS Family centered PBS has been effective for a variety of populations of children and families with needs ranging from issues involving eating and food acceptance, to self regulatory skill difficulties, and to the significant needs of children and families who have experienced neglect and abuse (Binnendyk & Lucyshyn, 2009; Buschbacher, 2002; Hardaway, Wilson, Shaw, & Dishi on, 2012). A majority of the studies completed with young children and families have focused on children diagnosed with autism spectrum disorder (Boyd, Odom, Humphreys, & Sam, 2010; Conroy, Dunlap, Clarke, & Peter, 2005). Ample research exists for the abil ity of families to succeed in practitioner family partnerships. It has consistently been found that families are able to successfully implement BSPs and that greater treatment gains and generalization of such gains have been noted with

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16 participation of fam ilies in the PBS process (Barton & Fettig, 2013; Buschbacher, Fox, & Clarke, 2004; Koegel, Koegel, & Schreibman, 1991; Lucyshyn & Albin, 1997). Research has also shown that the maintenance of interventions increases when families are involved in the PBS pr ocess (Buschbacher et al., 2004). Studies have shown that f amily centered PBS creates positive immediate and long term parental and family outcomes (Brookman Frazee & Koegel, 2004; Buschbacher, Fox, & Clarke, 2004; Smith Bird & Turnbull, 2005). Family centered PBS has been shown to reduce stress levels and promote parental self efficacy (Brookman Frazee & Koegel, 2004). Additionally, anecdotal reports from studies have suggested that family perspectives and outlooks for their fu ture and for the future of their children improve with family centered PBS (Buschbacher et al., 2004). In a follow up study, Lucyshyn and colleagues (2007) found that positive outcomes associated with family centered PBS for the challenging behaviors of a young child endured seven years post implementation. Research also indicates that t he families of young children with challenging behavior need more support in regard to ways to effectively target their child's and family's needs, and they seek collaborat ive partnerships in order to learn how to do this (Fox, Vaughn, Wyatte, & Dunlap, 2012). Fox et al. (2002) suggest that the typical services provided to families for the challenging behaviors of young children are most likely not sufficient to support fami lies. Related to this need, multiple researchers have called for increased research involving the best way to support parents with young children with challenging behaviors in regard to participation in the intervention process, parent training and coachin g procedures, and increasing the contextual fit and individualization of interventions and supports (Boettcher,

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17 Koegel, McNerney, & Koegel, 2003; Brookman Frazee & Koegel, 2004; Buschbacher, Fettig & Barton, 2014; Buschbacher, Fox, & Clarke, 2004; Lundhal et al., 2006). Practical Significance of Family and Parent Focused Social Emotional Programs and Family Centered PBS Although effect size does not directly measure the practical significance of research findings, it can be used in conjunction with other fa ctors (e.g., cost, context) to determine the importance of research findings beyond a demonstration of statistical significance (Leech, Barrett, & Morgan, 2011). The family and parent focused social emotional programs previously mentioned (see Barton et al ., 2014) have established their practical effectiveness in reducing the challenging behaviors of young children with most efficacy studies demonstrating small to moderate effect sizes (Dishion et al., 2014; L. Fox & C. Vatland, personal communication, July 2015; Lowell, Carter, Godoy, Paulicin, & Briggs Gowan, 2011; Menting, Orobio de Castro, & Matthys, 2013; Sanders, 2008; Tellegen & Sanders, 2013; Thomas & Zimmer Gembeck, 2007). In a literature search for studies calculating an effect size for family cent ered PBS, no study was identified. This dearth of available literature is likely due to the fact that most of the empirical evidence for family centered PBS has been demonstrated through the use of single case research design s In order to establish an eff ect size for family centered PBS, as recommended by Parker (2011), a Percent of All Non Overlapping Data (PAND) analysis was completed for each of the 13 studies in Fettig and Barton's (2014) recent review of parent implemented function based interventions Effect sizes for these interventions ranged from .01 to 1.0 with a moderate mean effect size of .70 (P. Strain, personal communication, June 2015; Scruggs & Mastropieri, 1998).

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18 It is clear that a multitude of programs exist that can effectively reduce th e challenging behaviors of young children. As noted, however, to establish the practical significance of an intervention and/or program, additional factors must be considered (Leech et al., 2011). The factors that distinguish the model employed in this stu dy from the programs noted in this section are outlined below. These factors may lead to greater practical significance for this study's intervention, PTR F. Prevent Teach Reinforce for Families (PTR F): A Manualized Model of Family Positive Behavior Suppo rt Given a noted need for efficient, collaborative, specialized support for families of young children with challenging behavior, PTR F was designed as a manualized, family centered PBS process for home visiting professionals to use with the families of yo ung children with challenging behaviors. The PTR F manual outlines the five step PTR F process (each step outlined more thoroughly in the methods section) by dedicating a chapter to each step that provides in depth information in addition to all of the nec essary documentation that the step requires. The process is scripted as much as possible for home visitors and families, and each step includes a team and self check evaluation to ensure implementation fidelity. In addition to these efforts to descriptivel y outline and simplify the family centered PBS process, PTR F includes the key features that are summarized next. Key Features of PTR F. The PTR F model is comprised of a number of key features that differentiate it from other family and parent focused soc ial emotional programs and that, although PTR F incorporates all of the key features of family centered PBS, distinguish it from other studies that have implemented family centered PBS in clear ways. These key features and distinguishable factors are outli ned below.

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19 Manualized protocol. PTR F has manualized the family centered PBS process to promote the ability of home visitors and families to implement not only comprehensive BSPs but also the family centered PBS process with high levels of fidelity. In the ir review on parent implemented function based interventions, Fett ig and Barton (2014) found that although all of the studies produced child behavior change, they did not necessarily lead to high levels of intervention and implementation fidelity. In order to improve the efficiency and efficacy of family centered PBS, PTR F streamlines the family centered PBS process in an effort to increase intervention and implementation fidelity. Family teaming. As noted, two key features of family centered PBS are collaborative partnerships and family centeredness. To promote practices in line with these key features, the PTR F manual dedicates a chapter to the importance of family participation in the PTR F proc ess. Additionally considerations for family involvement in the PTR F process are described in order to encourage maximum family involvement. Individualized, function based intervention through PTR F Checklists. Another key feature of family centered PBS i s the use of functional assessment. There are varying ways of performing functional behavior al assessment ( FBA; e.g., functional analysis, descriptive FBA indirect FBA ) that require more or less skill and time depending on the method chosen (Cooper, Heron Heward, 2007). PTR F uses three PTR F checklists (i.e., Prevent Checklist, Teach Checklist, Reinforce Checklist) that teams complete together. In that PTR F streamlines the FBA process, the FBA can be completed during one meeting (compared to other proce sses that can take much longer) along with the summary of FBA inf ormation and the formation of hypothesis statement s regarding the perceived function of the child's behavior. With the hypothesis statement s in mind, practitioners and families use the

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20 interv ention menu (described below) to create a function based comprehensive BSP that outlines interventions that have been individualized for the child and that are based on the specific function of the child's behavior. Multi component, menu driven BSPs In order to increase the efficiency of the PTR F process and the likelihood that families implement BSPs with fidelity, PTR F provides a menu of intervention strategies that includes research supported interventions for reducing challenging behaviors and i ncreasing desirable behaviors in home and community settings. Through detailed instruction, practitioners and families develop BSPs that include at least one intervention from each of the Prevent, Teach, and Reinforce categories. Detail including factors t eams should consider when choosing interventions and information regarding the actual implementation of each intervention is also provided in the manual. PTR F coaching. PTR F emphasizes the importance of practitioner coaching for families to promote imple mentation and intervention fidelity. That is, coaching is provided for families to ensure that the steps of PTR F are followed as intended (i.e., implementation fidelity) and that the comprehensive BSP is implemented as designed (i.e., intervention fidelit y; Barton & Fettig, 2013). The coaching used in PTR F is consistent with the recommended and evidence based practices outlined in the literature for supporting families (McWilliam, 2010; Rush & Sheldon, 2011) and teachers (Fox, Hemmeter, Snyder, Binder, & Clarke, 2011) with their implementation of social emotional behavioral interventions (L. Fox & C. Vatland, personal communication, July 2015). In addition to team and self check evaluations to ensure implementation fidelity, the PTR F process also employs the use of PTR F Fidelity of Intervention Checklists that outline the comprehensive BSP and that can

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21 be used by families and coaches to ensure that the plan is being implemented as intended. Coaches can also use these checklists to structure coaching sessi ons with families. Practical significance of the prevent teach reinforce model when used with families. As previously noted, with the addition of these key features, it is likely that PTR F may have greater practical significance when compared to existing family and parent focused social emotional programs. Although the PTR F model has not been empirically studied to date, two studies (e.g., Bailey, 2013 ; Sears, Blair, Iovannone, Crossland, 2013) have extended a school based PTR model for young children wit h severe and persistent challenging behaviors (i.e., Prevent Teach Reinforce for Young Children) into home settings. Using single case research design, both studies concluded that the PTR model was efficacious in producing child behavior change and that pa rents were able to implement comprehensive BSPs with fidelity. Both studies found high levels of family and na•ve observer social validity. T he studies further demonstrated effect sizes of .84 (Bailey, 2013) and .91 (Sears et al., 2013) indicating that the PTR process and BSPs were acceptable to participants and observers and that meaningful outcomes occurred for all of the families who participated (P. Strain, personal communication, June 2015). A t the same time that this study was being implemented, the PTR F model was being used with one family across three routines. The primary researcher of this second PTR F study reported that desired changes in child behav ior occurred through the completion of the PTR F process and that the family favorably viewed the PTR F process and the BSP (C. Vatland, personal communication, April 2016).

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22 Purpose and Research Questions The purpose of this study was to conduct an expe rimental analysis of a manualized, family centered PBS process (i.e., PTR F) with three families of young children with challenging behavior. The aims of this study were to (a) examine the effect of the PTR F process on the family's level of fidelity in im plementing the comprehensive BSP ; (b) determine the effect of the BSP on child behavior; (c) determine the effect of the PTR F process and the family's implementation of the BSP on the family's ratings of their self confidence and of their satisfaction wit h the routine; and (d) determine how families perceive the PTR F process and the BSP developed through the PTR F process. The effect of PTR F, and specifically of a comprehensive BSP designed through the process, has not previously been empirically evaluated. Therefore, it was appropriate to perform a single case withdrawal design replicated across three families to investigate the following resear ch questions: (1) Does completing of the PTR F process result in families' high fidelity implementation of the BSP ? (2) Does a functional relation exist between the family's implementation of the comprehensive BSP and decreased child challenging behaviors and increased child desirable behaviors? (3) Do family ratings of their self confidence with implementing the BSP and of their satisfaction with the routine improve through the PTR F process and their implementation of the BSP ? (4) Is there a difference between pre test and post test Eyberg Child Behavior Inventory (ECBI) scores?

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23 (5) What is the average family social validity rating for the PTR F process and for the BSP ? (6) How do families rate the PTR F process and the BSP when provided t he opportunity to do so qualitatively?

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24 CHAPTER II METHODOLOGY The purpose of this chapter is to describe the methodology associated with this dissertation study. Participants, settings, and routines are discussed, and the PTR F process is explained. The independent variable and dependent variables are also described in addition to the measurement procedures associated with each variable. Finally, the study's experimental design is summarized. Participants Three young children (ages 3 years 1 month through 3 years 9 months ) with challenging behavior and their families participated in the study. Children and family participants were chosen using the following sampling procedure. Sampling Procedure The sampling process outlined by Gliner, Morgan, and Leech (2009) was used. Sampling was completed in two ordered s teps. The first step was to identify children and families from a larger selected sample. The second step was to select families with children who exhibit the most severe and persistent challenging behavior to participate in the study. Both sampling steps are described more fully in the sections that follow. Step 1. Preschool/child care center level: Pre screening assessment. Given the limited availability of resources for this study, the accessible population was comprised of young children with challenging behavior who attended (or who had a family member who attended) a child care center in a suburb of a large metropolitan city in the western United States. The selected sample was determined through this initial, convenience, pre screening sampling step of the sampling process. Teachers and staff members of the child care center

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25 recommended ch ildren and families to participate in the study based on the families' reporting the occurrence of challenging behavior in the home setting to child care and staff members. Following such reporting, these families were encouraged to contact the researcher. Initial contact was made by interested families through e mail. The researcher used an e mail recruitment script and scheduled a phone meeting during which the researcher briefly described the purpose of the research study and of the pre screening process The Eyberg Child Behavior Inventory (ECBI) was used for pre screening purposes (Eyberg & Pincus, 1999). Each family completed and returned an ECBI to indicate their interest to participate in the study. The ECBI has 36 Likert type scale questions that ar e rated by parents to indicate the intensity of their child's challenging behavior and to indicate whether or not the family considers the challenging behavior to be a problem (Eyberg & Pincus, 1999). Previous studies have found data from the ECBI to have adequate discriminant validity and convergent validity, and it has been shown to be sensitive to changes in challenging behaviors (Boggs, Eyberg, & Reynolds, 1990). Further, and directly related to its purpose in this study, the ECBI has been noted for its utility as a screening assessment tool given high concurrent validity with other established behavioral assessments (Boggs et al., 1990). The selected first step sample, then, was comprised of families who returned an ECBI to the researcher. After three w eeks the time period for receiving questionnaires was closed, and the questionnaires that were returned were scored to determine a range of intensity scores for the selected sample. ECBI raw intensity scores ranged from 111 to 163 and raw problem scores ra nged from 8 to 14 across participants. Step 2. Child with challenging behavior and family level. The purpose of the second step of the planned sampling process was to identify the actual sample to participate

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26 in the study (Gliner et al., 2009). That is, t his step was taken to narrow the selected sample down to the children and families who were invited to participate in the study. Only three families ret urned ECBIs to the researcher; consequently, all three families were invited to participate, and all accepted the invitation. Each family received a stipend of $100.00 f or participating in the study. Children and family participants are described next. Henry and His Family Henry was 3 years 8 months old when his family enrolled in the study. He was atten ding preschool at a non profit child care center two days per week in the morning for three hours. He was also attending outpatient play therapy one time per week for one hour for his tantrum behavior. His parents noted improvement in regard to a decrease in his tantrum behaviors during most routines other than the routine that the family chose to target through the PTR F process. That is, despite attending play therapy for five months, Henry's parents noted that leaving the house was "still challenging" fo r the family. Henry's parents discontinued his play therapy approximately two months into the family's participation in the study. Henry resided with his family in their family home in a suburban neighborhood approximately twenty miles from a large metro politan city in the western United States. All meetings and sessions took place in the family home. Henry's father, who was thirty six years old, worked outside of the home as a software engineer, and his mother, thirty seven years old, referred to herself as a stay at home parent. At the time of their entry into the study, Henry's parents were meeting two times per month with a family support person at the preschool. They had met this person while attending classes for parents to learn how to reduce challe nging behavior in the home setting. Henry's parents noted that they found the

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27 classes useful, but that the strategies did not seem to work for the routine that they chose to target through the PTR F process. They also reported that since the classes did no t reduce all of Henry's challenging behaviors, meeting with the family support person was more for their overall well being and ability to cope with Henry's challenging behavior than for gaining information about shaping Henry's behavior. In order to incre ase consistency and reduce the likelihood of confounding external advice, Henry's parents agreed that they would not discuss the routine that they chose to target during the PTR F process with any outside support individuals. Henry had two siblings residi ng in the home with him. His older sister was six years old and in the first grade at a local elementary school. His younger brother was 8 months old. Henry had positive relationships with his siblings and his parents. The family spent regular time togethe r, and they enjoyed playing together in their home and engaging in local activities outside the home as well. Olivia and H er Family Olivia was 3 years 9 months old when her family began participating in the study. She resided with her family in their suburban family home that was located approximately 15 miles from a large metropolitan city in the western United States. Also residing in the family home was Olivi a's sister (age six), Olivia's mother (age thirty seven), and Olivia's father (age forty six). Olivia's mother was employed full time in restaurant marketing, and her father was employed full time in restaurant operations. In addition to the caretaking tha t was provided by her parents, Olivia's family had a nanny who cared for Olivia and her sister five days per week while Olivia's parents were working. Olivia had positive relationships with all

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28 of her family members. In their spare time Olivia's family enj oyed traveling and taking weekend trips together. Olivia was also learning how to ski and to ride her scooter. Olivia was attending preschool three afternoons per week at a non profit child care center when the family enrolled in the study. Approximately two months into the study Olivia started attending preschool four afternoons per week. Olivia was diagnosed with childhood apraxia of speech for which she was receiving speech and language therapy at the child care center three times per week. She was als o diagnosed with developmental delays related to her motor skills, and she received occupational therapy one time per week at the child care center. Olivia's mother reported that Olivia's occupational therapist had informed the family that her motor skills placed her in the seventeenth percentile for coordination and the twenty fifth percentile for fine motor skills. Olivia's family had also enrolled her in a speech and movement class through the child care center. Her mother indicated that she attended app roximately 50% of these classes due to her involvement with a gym and swim class through a local recreational center that promoted gross motor development. When Olivia attended the gym and swim class, she did not attend the speech and movement class at the child care center. Nathan and H is Family Nathan was 3 years 1 month old when his family entered the study. He resided with his family in a suburban home located approximately 15 miles outside a large metropolitan city in the western United States. Nathan's parents and his sibling also resided in the home. Nathan's mother, a graphic designer who worked from h ome, was thirty six years old and his father was 45 years old and worked as a publisher. Nathan's older brother (age four) attended preschool three and a half days per week at which time Nathan and his mother spent

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29 one on one time with on e another. Nathan was not attending preschool or child care when his family entered the study, but he did attend a recreational swimming class and regular play groups with his mother while his brother was at school. Prior to entering the study Nathan's parents had previously attended classes provided by his brother's school for parents to learn how to reduce challenging behavior in the home setting. They noted that the strategies were useful for his brother but that they were not as useful for r educing Nathan's challenging behavior in the home setting. Settings and Routines The settings involving Henry, Olivia, and Nathan included the interior spaces of each of their families' homes. Each family chose a particular target routine (i.e., the most difficult routine of the family's day) on which to focus PTR F facilitation, and the spaces associated with the routine s (e.g., bathroom, bedroom) were the settings for all steps associated with the study and with PTR F. The settings and target routines fo r each family are described next. Henry and H is Family T he setting for Henry's family consisted of the upstairs, downstairs, and garage spaces of the family home. All PTR F meetings and planning occurred in the family's kitchen and living room. Henry's f amily indicated that the most difficult routine of their day was the one that occurred in the afternoon directly before Henry and his mother left to pick up his sister from school. The family indicated that leaving the house was always somewhat difficult f or Henry, but that this particular routine was the most difficult due to the time restrictions associated with his mother's need to leave the house within a certain timeframe to ensure a timely pick up for his sister. For most days this routine started ups tairs in Henry's play area and ended once he was buckled into his carseat in the family's minivan.

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30 Olivia and H er Family Olivia's bedroom and shared bathroom made up the setting for Olivia's family. PTR F meetings took place in the family's kitchen at their kitchen counter. The routine that Olivia's family chose to target through the PTR F process was their second most diffi cult routine, Olivia's morning routine. The family's most difficult routine was bedtime. Following a discussion of the family's upcoming schedule changes, and due to the research plan and the nature of a single case withdrawal design, the researcher and fa mily decided that targeting the family's second most difficult routine would create less stress for the family. It was determined that the anticipated difficulties associated with a changing schedule coupled with withdrawing a bedtime BSP and then re imple menting it could be avoided if the family focused on the second most difficult routine for the study. The researcher and family agreed that the researcher would provide support for the bedtime routine after the family had completed all of the experimental phases for the single case withdrawal design for the morning routine. Information regarding the bedtime support that was provided for Olivia can be found in the Monitoring Plan Implementation and Child Progress section specific to Olivia's PTR F process. N athan and His Family The setting for Nathan and his family consisted of the first floor and upstairs spaces of his family's home. The PTR F meetings and planning occurred in the family's dining room. Nathan's family reported that the most difficult routine of their day was Nathan's bedtime routine. Nathan's family indicated that if both his mother and father were home, Nathan would insist that his mother complete his bedtime routine with him. Nathan's family also reported that if Nathan's mother completed h is routine with him, she would have to lie

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31 down with him until he fell asleep. When Nathan's mother was not home and his father completed his routine with him, Nathan would fall asleep independently after his father left the room without having to lie down with Nathan When the family chose bedtime as their target routine, Nathan's mother indicated that if she wanted to work during the evening hours she would leave the family home at bedtime so that Nathan would not require her to lie next to him until he fell asleep. Prevent Teach Reinforce for Families Process This study is differentiated from other family PBS studies because it implements a manualized family PBS process, PTR F (Dun lap, Strain, Lee, Joseph, Vatland, Fox, in press) The PTR F intervention process is a revised version of Prevent Teach Reinforce (PTR), an evidence based, manualized form of PBS for school aged children (Dunlap et al., 2010; Iovannone et al., 2009) and Pr event Teach Reinforce for Young Children (PTR YC), a manualized form of PBS for young children in preschool and child care settings (Dunlap, Lee, Wilson, & Strain, 2013) that is currently being studied through a randomized controlled efficacy trial. As wit h PTR YC, PTR F does not add novel information to the field in regard to PBS; however, it provides a user friendly, comprehensive, five step model for practitioners to follow that can improve the fidelity with which BSPs are implemented by families (Dunlap Lee, Joseph & Strain, 2015). Home visiting professionals and PTR F facilitators (and, in the case of this study, the researcher) utilize the PTR F process with families to develop comprehen sive PTR F BSPs by following an intervention process that include s the following five steps: (1) Initiating the PTR F Process (2) PTR F Assessment (3) PTR F Intervention (4) Coaching and (5) Monitoring Plan Implementation and Child Progress Each step of the PTR F process is outlined in more detail below, and it is im plicit

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32 that during each step of the PTR F process the facilitator works collaboratively with the family in order to complete all tasks associated with each step as outlined in the PTR F manual. PTR F S tep 1: Initiating the PTR F Process Step 1 occurs during the initial meeting for PTR F in which the family and PTR F facilitator decide which members of the family will be involved in the PTR F process to develop and implement the BSP. This step also involves a discussion of the long term go als for the child. Additionally, a specific short term behavior goal is outlined for the child in regard to his/her challenging behavior that the family wants to target for decrease. Step 1 of PTR F also involves the development of a data collection method that is feasible for the family to implement on a regular basis. The PTR F process employs behavior rating scales (BRSs) that are individualized for the child's challenging and desirable behaviors. For the purpose of this study, two standardized BRSs were used by families to track changes in family satisfaction and confidence implementing the routine over time. The BRSs are described at more length in the dependent variable section. PTR F Step 2 : PTR F Assessment During step 2 the family completes a funct ional behavioral assessment by answering questions on the PTR F Functional Behavioral Assessment Checklists (i.e., Prevent Checklist, Teach Checklist, Reinforce Checklist). Following the completion of these checklists, the information is summarized and a h ypothesis statement is formulated regarding the family's perceived functi on of the challenging behavior (i.e., the family's belief about the child's purpose in exhibiting challenging behavior ) Once the family and PTR F facilitator have formulated a hypoth esis statement, the family sets a short term behavior goal for a

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33 target desirable behavior to increase. The desirable behavior short term goal is set after a hypothesis statement has been developed to ensure that the target desirable behavior is a function al replacement for the challenging behavior. An operational definition is then developed for the desirable behavior to increase. PTR F step 3 : Intervention In step 3 the family uses the hypothesis statement that was developed in step 2 to create a function based BSP using the menu of intervention strategies provided in the PTR F manual. This step requires that the family develop a detailed plan that targets the antecedents and consequences of challenging and desirable behaviors and that includes planning for the teaching of functional skills that can replace the child's challenging behaviors. During the final task of step 3 the BSP can be transferred to the PTR F Fidelity of Intervention Checklist that can be used for coaching the famil y to fidelity on the BSP For this, the team also decides on a feasible schedule of facilitator coaching. PTR F Step 4: Coaching Following the completion of Steps 1 through 3 of the PTR F process, the PTR F facilitator provides coaching for the family on the BSP until a sufficient level of fidelity ( a minimum of 80%) has been reached, and then until sufficient changes are noted in t he child's behavior (i.e., decreased challenging behavior and increased desirable behavior). Coaching sessions last for the duration of the routine. If necessary, the PTR F facilitator can use evidence based coaching strategies and document the use of part icular strategies during coaching sessions on a coaching log. The families in this study required very little coaching in order to implement the BSP T herefore, the PTR F Coach Planning and Reflection Log was not used with the families.

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34 PTR F s tep 5 : Moni toring Plan Implementation and Child Progress Like Step 4, Step 5 of PTR F commences when the family begins implementation of the BSP During this step, the data collection measure developed in step 1 and the PTR F Fidelity of Intervention Checklist are used to obtain ongoing data for data based decision making. The family uses these data in step 5 to determine whether any changes need to be made to the BSP and when supports might be faded if desirable trends are noted in the child's challenging behavior data. Steps 1 Through 3 Meetings For those following the PTR F process, Steps 1 through 3 occur during meetings that last for approximately 45 to 60 minutes at a time that is convenient for the family and PTR F facilitator. Families are permitted and encouraged to invite individuals who are able to provide meaningful input during these meetings. At these meetings, the PTR F facilitator supports each family in their completion of the sub steps associated with each primary step (i.e., steps 1 through 3 ) as outlined in the PTR F manual. Each primary PTR F step involves the completion of specific procedural elements and associated documentation to ensure that each step of the PTR F process is completed as ef ficiently and effectively as possible. PTR F meetings for steps 1 through 3 and subsequent step 4 facilitative coaching sessions are scheduled based on family need and on the family's and PTR F facilitator's mutual availability, with more frequent coaching sessions tending to occur at the start of the family's implementation of the BSP Additionally, t o ensure that the PTR F process occurs as planned (i.e., steps 1 through 5 are implemented as intended by the manual authors), the PTR F manual checklists associated with each step of the process are referred to during each step and completed by the PTR F facilitator and family after each step has been completed.

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35 Independent Variable: Prevent Teach Reinforce for Families BSP The independent variable in this study was the BSP developed during step 3 of the PTR F process and implemented by each family The PT R F process and details regarding the d evelopment and implementation for each child and family 's BSP are described next. Henry and His Family From the initial, in person meeting until the close out meeting, Henry's family participated in the study for 1 5 weeks. PTR F meetings occurred over the course of three weeks (one meeting per week) after which the family began implementing the BSP Over the course of the family's participation in the study, the family and primary researcher met one time per week other than one week during Henry's holiday break. Most often, only Henry's mother and the researcher met for meetings; however, on at least two occasions Henry's father was present. Henry's family's PTR F process is outline d next. PTR F Step 1: Initiating the PTR F Process For Henry's family, the PTR F Step 1 meeting lasted for approximately 30 minutes. During this meeting Henry's mother chose his refusal behavior as the target challenging behavior to decrease. Through a d iscussion with the researcher, refusal behavior was operationalized to include the following behaviors: making non compliant comments (e.g., never, no, I want to play ), yelling, throwing himself onto the floor, crying, screaming, whining (high pitche d, nasal sound without words), running away, and hiding. A number of desirable behaviors that Henry's mother would like to see him demonstrate during this routine were also discussed during this goal setting meeting. Henry's mother noted that most days whe n leaving the house she had to carry Henry into the car, which meant leaving his younger brother alone upstairs because she could not carry both of the children to the car at the same time. Therefore, her primary, initial goal

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36 was for Henry to exit the hom e and get into the car independently regardless of any whining or grumbling that might occur once he was told that it was time to leave the home. Henry's Goal Sheet can be found in Appendix A. In regard to family data collection, a s previously noted, fo r the purposes of this study, standard BRSs were used for family data collection. Therefore, individualized BRSs were not created during this step of the PTR F process for Henry. It was decided that the family would complete the standardized BRSs each time Henry left the family home and make any notes on the data collection form regarding unique circumstances that might be related to the routine. For example, Henry's family made notes on the BRSs if his sister helped him complete his routine, if he demonstr ated any particular challenging behaviors that were unusual (e.g., on one occasion Henry did not want his mother to talk to him while he completed his routine), and if the family did not leave the home for a day. The purpose of note tracking was to determi ne whether or not any patterns in antecedent variables, and specifically setting events, could be identified in regard to Henry's challenging behavior. PTR F Step 2: PTR F Assessment. During step 2 the researcher and Henry's mother met for approximately one hour to complete the PTR F assessment checklists and to develop a hypothesis statement regarding the perceived function of Henry's challenging behavior. Through the completion of the Prevent checklist, it was determined that activities when Henry's cha llenging behavior is very likely to occur include leaving the family home, arriving at the family home, toileting and diapering, and transitions. It was also determined that transitioning from preferred to less preferred activities was difficult for Henry. Generally, antecedent events tended to include a prompt to transition to something that is not

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37 preferred for Henry (e.g., toileting) or to terminate a preferred activity such as playing on the iPad or playing legos. The Teach checklist indicated that com munication skills that Henry could be taught were those related to expressing preferences when given a choice. It was also determined that it would be beneficial for Henry to develop his problem solving skill repertoire by learning how to control his anger control impulsive behavior, use strategies for calming down, follow directions, follow schedules and routines, choose appropriate solutions, make choices from appropriate options, and follow through with choices once made. Generally, Henry's mother indic ated that a primary skill for him to learn is to stop playing when a direction is given (even with warnings) and to begin following the direction. During this conversation Henry's mother indicated again that she would accept his complaining and expressing of his emotions as long as he did not demonstrate his refusal behavior. By completing the Reinforce checklist it was determined that common consequences for Henry's challenging behavior included a delay in the non preferred activity, termination of the dir ection, a verbal warning, verbal reprimanding, physical guidance, and, at times, access to a preferred or desired activity. Henry's mother was very honest in that she noted that approximately one time per week she responded to his challenging behavior by yelling and screaming." Henry's mother also noted that his challenging behavior was very likely to result in acknowledgement. She stated that she acknowledged and validated Henry's challenging behavior each time it occurred. She reported that she ignored h is challenging behavior in the past and that it would last for hours. Henry's mother also noted that he could not be left alone while demonstrating challenging behavior because he would "destroy his room," for example, by ripping items off of the wall. Pot ential reinforcing activities for

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38 Henry that were identified through the completion of the Reinforce checklist included verbal praise, physical interaction such as rough housing, social interaction with his sister, television time, time on the iPad, and fa mily outings. Henry's mother noted that he respond ed well to token economies such as the one the family was using for toilet training. With the checklists complete, Henry's mother and the researcher developed a hypothesis statement regarding the perceived function of Henry's challenging behavior. It was determined that the challenging behavior occurred when directions to terminate preferred activities or to transition to non preferred activities occurred and that the challenging behavior was likely to resu lt in delay or termination of the activity. Attention was also noted as a likely consequence for Henry's challenging behavior. Therefore, the hypothesis for Henry's challenging behavior was: when Henry is directed to terminate a preferred activity or to tr ansition to a non preferred activity, then he will demonstrate refusal behavior, and as a result, the transition or non preferred activity will be delayed or terminated and/or Henry will receive attention. Once the researcher and Henry's mother determined the perceived function of Henry's challenging behavior, a desirable behavior to increase was chosen that would serve as a functional replacement for the challenging behavior. The target desirable behavior the family chose was "following the routine." The operational definition for following the routine was "following the steps of the routine without being carried to the car by a parent." While the actual steps of the routine had not been identified yet, the team agreed that step identifi cation would occur during step 3 of the PTR F process and that it was acceptable to include the steps in the operational definition of the target desirable behavior. Henry's PTR F Assessment Checklists and PTR F Assessment Summary Table can be found in Appendix A.

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39 PTR F step 3 : Intervention. Henry's mother and the researcher met a third time for approximately an hour to develop the BSP The meeting started with a review of the function of Henry's challenging behavior. Then, they discussed the intervention strategy options from the PTR F menu of intervention strategies. Henry's mother and the researcher chose three Prevent strategies to include in the BSP : enhance predictability, use visual supports, and use a scripted social story. The Teach strategies that were chosen inc luded teach independence with visual schedules and calendars and teach self monitoring. Henry's mother and the researcher also followed the steps for designing a plan for reinforcement based on the recommendations from the PTR F menu of intervention strate gies. That is, a functional reinforcer was identified and a plan was designed to reinforce the desirable behavior and to remove reinforcement for Henry's challenging behavior. At this time, Henry's mother and the researcher had a discussion regarding atten tion as a function of Henry's challenging behavior. Henry's mother indicated that she did not feel comfortable removing attention for his challenging behavior, but that she would be able to ensure that the transition would not be delayed and/or that escape from the direction would not occur following his demonstration of challenging behavior. Given the family centered nature of the PTR F process, the researcher and Henry's mother worked together to develop a strategy for the Reinforce component of the PTR F process. She indicated that she felt comfortable with the strategy and would be capable of implementing it. The specifics of Henry's BSP were written on his PTR F BSP Summary f orm which can be found in Appendix A. PTR F Step 4: Coaching Due to the family's involvement, and primarily to his mother's involvement, in the PTR F process, minimal coaching was needed for the family to begin implementing the BSP During the BSP development meeting, Henry's mother and the

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40 researcher spoke extensiv ely about how the plan would be implemented and used problem solving to determine PTR F Reinforce intervention strategies Henry's mother would be most comfortable implementing. Following the BSP development meeting, the researcher and Henry's mother commun icated through e mail over the course of the next week. The researcher developed a number of supports for the family (i.e., soc ial story, visual schedule, typed BSP ) and e mailed all of these documents to Henry's mother for her feedback. Henry's mother ind icated that she would be most comfortable if the researcher was present the first time she implemented the BSP A date was chosen to begin plan implementation, and the researcher arrived approximately 45 minutes prior to the time that the routine would occ ur to review the plan and to allow the researcher to model the BSP for Henry's mother. Following the initial coaching session, the researcher visited the family home one time per week approximately 15 minutes to 30 minutes before the routine would begin to engage in problem solving discussions regarding the family's implementation of the plan during the week since the researcher's last visit. Following the pre routine meeting, the researcher would observe Henry's mother implement the BSP and provide side by side support most often in the form of prompts for Henry's mother to use verbal praise upon his completion of routine steps. Following the routine, the researcher spoke with Henry's mother briefly (for approximately three to five minutes) to indicate any additional noteworthy observations. In all, the researcher visited the home eight times for coaching sessions after the BSP was developed. A pre routine meeting did not occur for two of the coaching sessions. Additionally, during one coaching session, the researcher did not observe the routine. This session took place over a holiday break at which time the researcher met with Henry's

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41 mother and father to discuss a plan for the remaining sessions and to answer questions the family had about fading supports for Henry. PTR F step 5: Monitoring Plan Implementation and Child Progress Once the family had implemented the BSP a functional relation had been established between the BSP and changes in Henry's behavior, and the family noted overall increased confide nce and satisfaction with the routine, the researcher and family agreed that it would be acceptable to reduce the frequency of researcher visits to an as needed basis. A meeting was scheduled to plan for the steps that Henry's family would follow to increa se his independence with the routine and to fade reinforcement for his following the routine. At the meeting, a plan involving three phases was designed by Henry's mother and the researcher. The first phase was designed to decrease Henry's continued whinin g by providing a warning that if Henry continued to whine and did not use a "big strong voice" (the family's terminology for appropriate verbal behavior), then he would not earn his reinforcer (i.e., being allowed to watch a DVD in the car). The second pha se included a similar, preventative warning that Henry's family provided him with at the same time he received pre transition warnings. The difference in this second phase was that the warning was given before the routine started and if, during the routine Henry engaged in whining behavior, then he would not earn reinforcement. The third phase consisted of the development of a token economy system for Henry to earn reinforcement. The family and researcher knew that Henry understood token reinforcement and that he responded well to it, so it was decided that once he was consistently completing the routine without whining, the family would begin requiring that Henry complete more than one routine to earn the reinforcer. The plan stated that as Henry more succ essfully completed the routine, the family would slowly increase the number of

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42 tokens he would have to earn in order to earn his reinforcer. Henry's family indicated that they felt comfortable implementing these changes themselves, but it was agreed that t he researcher would be available for any follow up concerns or needs the family might have. Consequently, the meeting during which this plan for fading was developed was the last meeting the researcher had with Henry's family. Olivia and Her Family Olivia's family participated in the study for a total of 15 weeks from the initial meeting with the researcher until a close out meeting. That meeting occurred during week 15 to review the family's continued progress with Olivia's morning routine and to di scuss a second routine for which the researcher provided support to the family. The three meetings pertinent to the PTR F steps occurred over the course of three weeks. During each meeting both Olivia's father and mother were present. Once the family start ed implementing the BSP the researcher and family continued meeting one time per week for coaching purposes. On most days both of Olivia's parents were present for these meetings. However, on some occasions only her mother or her father was present for th e coaching meeting with the researcher due to work related travel. PTR F Step 1: Initiating the PTR F Process During Step 1 the researcher and Olivia's mother and father met for approximately 40 minutes to develop behavior goals and to review the BRS Ol ivia's family had a number of challenging behavior concerns that were brought up at this initial meeting in regard to Olivia's challenging behavior during her morning routine. The family reported that Olivia was "very needy" and "clingy" in that she touche d other people, "constantly" requested hugs and to sit on the laps of others, and frequently sought adult attention and reinforcement. The family also reported that Olivia

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43 would respond to directions by talking about her "boo boos" (i.e., scrapes or scratc hes), crying, or by making comments to engage in other activities such as "I have to go potty." Ultimately, the family determined that the challenging behavior that would be targeted during the morning routine was noncompliance. Noncompliance was operation ally defined as "when given a direction, Olivia will make comments (e.g., ask for a hug; ask to be held; ask for attention or reinforcement; saying "not ready," "no buttons," or "my boo boo") or engage in behaviors (e.g., cry, yell, scream, flop to the flo or, run away, jump on the bed) that are unrelated to the direction that was given." Olivia's mother and father indicated that in regard to desirable behaviors, they wanted her to follow the routine without demonstrating noncompliance. The family noted that eventually they hoped that Olivia would be able to follow the morning routine independently; however, they indicated that much improvement would have been made if the routine occurred without noncompliance each morning. As with Henry's family the PTR F process for developing challenging and desirable BRSs was not followed in step 1 with Olivia's family. At the end of the goal setting meeting, the researcher reviewed with the family how to collect data using the BRSs that were developed for the study. Oli via's mother and father agreed that they understood how to use the data collection system, and it was agreed that they would complete the BRSs each day after the occurrence of the morning routine. Olivia's PTR F Goal Sheet can be found in Appendix B. PTR F Step 2 : PTR F Assessment. Olivia's family and the researcher scheduled an initial meeting to complete the PTR F assessment; however, due to weather issues, the meeting had to be cancelled. In order to efficiently progress through the PTR F steps, the fami ly and rese archer agreed to complete step 2 during a phone meeting that occurred while

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44 the family was visiting Olivia's grandparents in Florida. The meeting occurred while Olivia's mother and father were in a car. The researcher was placed on speaker phone and read the items on each PTR F checklist to the family, who responded verbally. In regard to the Prevent checklist, Olivia's family indicated that the challenging behavior was most likely to occur while Olivia was alone or during transitions, and especi ally during clean up transitions. While completing this checklist, a discussion also occurred around Olivia's tendency to be what her parents described as a "time checker." They noted that she frequently and repeatedly asked questions such as "How many sle eps?" "How many times?" "What time?" and "When's mommy coming home?" They also noted that Olivia did not like surprises and that she needed "to understand what's coming next." The completed Teach checklist indicated that Olivia would benefit from learning how to express her preferences when given a choice. Further, the family noted multiple problem solving skills that could be taught to Olivia to reduce the likelihood that the challenging behavior would occur. These problem solving skills included using vis uals to support independence; following directions, schedules, and routines; choosing appropriate solutions; making choices from appropriate options; and following through with choices. Additional discussion that occurred while the family was completing th e checklists involved the family's observations that Olivia seemed to exhibit a low level of nervousness at all times regarding "not understanding what is going on around her" when her family was not present to interpret what Olivia was saying and to answe r her questions. The family reported that it was their belief that Olivia's nervousness corresponded to her historical and continued difficulties with expressive language. It was also noted, though, that even when the family was present Olivia's frequent q uestioning and seeking of adult attention continued.

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45 While completing the Reinforce checklist, the family noted that Olivia's challenging behavior was usually followed by a variety of consequences that included being sent to time out, being sent to a quiet spot or to a corner, a delay or change in the direction, provision of adult assistance, verbal warning or reprimanding from adults, physical guidance, and being provided with access to a desired activity. The family recalled that most often the challengin g behavior resulted in acknowledgement and attention from adults or a delay in a transition. It was also reported that Olivia's use of appropriate behavior was sometimes acknowledged but not as often as the challenging behavior was. The family completed th e Reinforce checklist and noted a number of reinforcing items and activities. Olivia's mother and father identified the following as reinforcers: social interaction and praise from adults and Olivia's sister, special activities (e.g., getting donuts with t he family, being a helper), small toys and prizes, and time on electronic devices. At the end of this meeting, the researcher reviewed the information that had been obtained, and it was decided that because the family was on the phone and almost at their d estination, a hypothesis statement regarding the perceived function of Olivia's challenging behavior would be developed by the team at the next meeting prior to developing a BSP When the team reconvened to develop a BSP the researcher and family summari zed the information from the PTR F assessment checklists and developed the following hypothesis statement: when Olivia does not receive adult attention and/or when she is directed to transition, she will demonstrate noncompliance, and as a result, she will receive adult attention and/or the direction to transition will be delayed or terminated. Next, the team agreed upon a desirable behavior short term goal for the morning routine. The family chose to focus on Olivia's ability to follow the routine, which w as operationally defined as "doing

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46 what parent/schedule tells Olivia to do (with adult prompting) without the demonstration of noncompliance (see definition of challenging behavior)." Olivia's PTR F Assessment Checklists and her PTR F Assessment Summary Ta ble can be found in Appendix B. PTR F Step 3 : Intervention. The meeting to develop Olivia's family's BSP lasted for approximately one hour including the time it took for the team to complete the step 2 activities previously discussed. During this meeting, the team chose three Prevent strategies from the PTR F Menu of Intervention Strategies for the BSP The team agreed to enhance predictability with calendars and schedules by developing a visual schedul e that was individualized for the steps of Olivia's morning routine, and the family decided to provide clothing choices for Olivia while she was getting dressed as opposed to requiring that she wear particular shirts or pants. The third Prevent strategy th e team chose was to provide a warning for Olivia during hair brushing so that she knew when this non preferred activity would end. The family agreed that this warning could be done by counting down from 10 while brushing Olivia's hair 10 times. Directly re lated to these Prevent strategies, the team agreed that teaching independence with visual schedules would be the best Teach strategy to focus on in the BSP Finally, the team followed the PTR F process for identifying a functional reinforcer for desirable behavior and for ensuring that reinforcement was removed for challenging behavior. Olivia's family agreed to use multiple forms of reinforcement for desirable behavior by providing verbal praise and attention during each step, physical attention following Olivia's completion of each step (e.g., hugs, high five) and a tangible reinforcer (i.e., a small prize from a snowman cookie jar) following her completion of the entire morning routine. Reinforcement for challenging behavior was removed by ignoring chall enging behavior. The family's BSP Summary form is included in Appendix B.

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47 Step 4: Coaching. The researcher and Olivia's family met twice to develop the morning routine BSP One meeting involved the previously discussed Step 3 activities, and the second meeting was held to ensure that the family was comfortable implementing the plan. Between the first and second meetings, the researcher developed supports for the visual schedule that was used during the routine and typed BSP fo r the family's reference Olivia's family purchased small prizes that she would be able to earn for completing her morning routine between the two meetings. At the second meeting the researcher reviewed the plan that the team had developed, and the team en gaged in problem solving around any questions or issues posed by the family regarding their implementation of the BSP It was agreed that the family would begin implementing the BSP on the morning of Olivia's next school day and that the researcher would m eet with the family after they had been implementing the plan for two days. After these planning meetings the researcher visited the family home one time per week directly before the morning routine was about to occur (i.e., at the same time the family w as waking up). The researcher observed the morning routine while making minimal comments due to the distraction this caused Olivia. At the end of the routine the researcher met with the family for approximately 30 minutes to review any observations that we re made and to engage in problem solving with the family regarding any issues that the family might have been experiencing. The researcher visited the home 10 times after the family began implementing the BSP Seven of these sessions were coaching sessio ns around the morning routine, two of these sessions pertained to the previously discussed follow up support provided by the researcher for the bedtime routine, and one of these sessions consisted of a close out meeting

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48 pertaining to both routines. The res earcher observed the morning routine during all seven coaching sessions. PTR F S tep 5: Monitoring Plan Implementation and Child Progress Once Olivia's family was implementing the BSP with confidence and noting satisfaction with the routine, and once a functional relation was established between the BSP and changes in Olivia's behaviors, the team agreed that it was acceptable to stop coaching sessions for the morning routine. The resear cher continued to meet with the family to develop a BSP and to provide any needed support around the family's most difficult routine, Olivia's bedtime routine. To plan for the bedtime routine, the researcher and family met and reviewed a manualized protoco l for improving sleep for young children with special needs (e.g., Durand, 2013). The team chose to use the Graduated Extinction strategy as outlined by Durand (2013) and to provide a reinforcer (i.e., a trip to Olivia's favorite donut store) for Olivia wh en she woke from sleeping in her own room. The family and researcher agreed that the researcher would visit the family home on the first night that the family implemented the bedtime BSP As recommended by Durand (2013), the family began implementing the b edtime BSP on a Friday night. The researcher arrived at the family home at approximately 8:15 pm, and left at approximately 10:30 pm when Olivia fell asleep. The family took anecdotal data that was sent to the researcher in the form of text messages for th e first week of bedtime BSP implementation. On the first two nights of plan implementation, Olivia continuously left her room, cried, screamed, and hit and bit her parents for over an hour each night, and on the second night, she threw up three times. Desp ite these noted challenging behaviors, Olivia's family indicated that they believed the plan was working and that, based on previous discussions with the researcher regarding the likelihood that an extinction burst would occur,

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49 they wanted to continue impl ementing the plan. Olivia's middle of the night waking ceased by the second night of plan implementation, and the family reported that she was sleeping in later than she had for the last few years by the second night as well. From the third night on, the f amily reported that Olivia would cry for approximately 10 to 15 minutes while staying in her room and that she would fall asleep and then remain asleep for the remainder of the night. After the family had been implementing the BSP at bedtime for 10 days, the researcher met with the family to review morning and bedtime routines and to gain team consensus around the fading of the researcher's support for the family. At this meeting, Olivia's family indicated that they were comfortable in discontinuing meetin gs and coaching with the researcher. The family reported that in the morning Olivia seemed "generally happier" and that the family had discontinued the use of the tangible reinforcer Olivia was receiving when she finished her morning routine. Also, the fam ily reported that they were no longer providing a reinforcer each morning Olivia woke from sleeping in her own bed. They indicated that they continue d to provide verbal praise and attention when Olivia woke but that they intermittently provide d other form s of reinforcement for Olivia (e.g., skiing alone with a parent for the morning, watching a cartoon). At the end of this close out meeting, the researcher and family engaged in a problem solving discussion regarding what the family would do should challeng ing behavior increase again (i.e., re establish reinforcement, implement the BSP strategies as originally planned), and the team also agreed that the researcher would remain available to the family should any other questions or concerns arise. Nathan and His Family Nathan's family participated in the study for a total of 20 weeks from the time that the initial meeting was held until a close out meeting that occurred during week 20. The

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50 researcher did not meet with the family each week during this 20 week timespan. During the first three weeks of the family's participation, the primary researcher met with Nathan's mother to complete steps 1 through 3 of the PTR F process. Once Nathan's family began implementing the BSP, the researcher and family met approx imately every week and a half for coaching sessions. Nathan's mother and father were both present during all coaching sessions. PTR F Step 1: Initiating the PTR F Process During step 1 of the PTR F process Nathan's mother and the researcher met to devel op Nathan's behavior goals and to ensure his family's understanding and level of comfort with the BRSs. Nathan's mother chose his tantrum behavior as his challenging behavior to reduce during the bedtime routine. The team then developed an operational defi nition for the challenging behavior that included the following behaviors: screaming, crying, yelling, hitting, kicking, lying on the floor, stomping feet, attempts to injure others, escaping the routine (e.g., running to other rooms, running to the bed), and refusing to engage in routine expectations (e.g., refusing to stand on the toilet to brush teeth). Nathan's mother also discussed desirable behaviors that she would like for Nathan to use during this routine. She stated that she would like Nathan "to let his dad do the bedtime routine" and to follow the routine expectations without engaging in tantrum b ehavior. At the end of the step 1 meeting, Nathan's mother and the researcher briefly reviewed the BRSs The team decided that Nathan's family would complete the BRSs each evening after the routine had occurred or in the morning as soon as the family wok e up in the case that Nathan's mother fell asleep with him in his bed prior to recording her satisfaction and/or

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51 BSP implementation confidence on the data collection sheet containing the BRSs Nathan's Goal Sheet is included in Appendix C. PTR F Step 2: P TR F Assessment During step 2, the researcher and Nathan's mother met for approximately 1 hour and 30 minutes to complete the PTR F assessment, to develop a hypothesis statement regarding the perceived function of Nathan's challenging behavior, and to choose and operationalize a desirable behavior to serve as a functional re placement for Nathan's tantrum behavior. Prior to the meeting Nathan's father completed the PTR F assessment checklists and the researcher and Nathan's mother incorporated this information into the assessment that was completed by his mother. The Prevent checklist indicated that his tantrum behavior was most likely to occur during meals and at bedtime. Nathan's mother stated that it most frequently occurred when both parents were home and that his yelling was often related to hi s wanting his mother to hold him or to do something for him. The Prevent checklist also led his mother to the conclusion that his challenging behavior tended to occur across activities when "he doesn't want to do something" and "if he wants something and it can't happen." Moreover, a discussion occurred around the fact that Nathan's challenging behavior did not occur at bedtime if his mother was not home. Furthermore, if Nathan's father completed the routine with him while his mother was not home, Nathan would fall asleep on his own w ithout his father in his room (something that did not happen if his mother was home). The team also discussed Prevent checklist data that revealed that his challenging behavior did not occur at naptime. Each day his mother would fall asleep in his bed with him during naptime. Nathan's Teach checklist indicated that he could learn to request wants and needs, express emotions and aversions, and express preferences when given a choice to reduce the

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52 likelihood of challenging behavior. His family also identifi ed social skills such as getting attention appropriately, sharing, taking turns, and waiting for acknowledgement or reinforcement that, if taught to Nathan, could reduce challenging behavior. Further, Nathan's mother and father identified a number of probl em solving skills that if learned, could reduce the likelihood of the challenging b ehavior occurring in the future These problem solving skills included controlling anger and impulsive behavior, strategies for calming down, following directions and routi nes, accepting "no," managing emotions, choosing appropriate solutions, and making choices from appropriate options. Upon completing the Prevent checklist, Nathan's family noted a number of consequences that usually followed his challenging behavior. It was reported that he was at times sent to time out or a quiet spot and that at other times the activity was ended or he was removed from the activity. It was also determined that Nathan received verbal attention in the form of calming, talking about what h appened, warnings, redirections, reprimands, and sibling reactions. He would also receive physical guidance and restraint when challenging behavior occurred. Additionally Nathan's family reported that there were occasions during which Nathan would receive desired items and/or access to desired activities following his demonstration of challenging behavior. The family also determined that the challenging behavior occurred more in the presence of his mother Reinforcing items and activities that were identified included: "all interaction" (e.g., physical, social), extra time in preferred activities, device time, and toy cars. Because he could not participate in the PTR F Ass essment meeting Nathan's father provided the following written comment regarding his frustration with Nathan's challenging behavior:

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53 Nathan has a severe case of the "mommy's." He refuses to let me do much of anything as long as his mom is around. Whet her I'm super sweet and praise him, love on him, or scold him, it really doesn't matter. When mom is gone, he's like a totally different kid. He does what I ask, we have fun and he even goes to bed and eats without issue most of the time. Once the c hecklists were complete the team summarized the PTR F assessment checklists and developed the following hypothesis statement: When Nathan is given a non preferred directive or told that an activity that he wants to happen will not occur, then he engages i n tantrum behavior, and as a result he gains access to what he wants, receives adult attention, and/or escapes having to complete the non preferred directive With this knowledge, the desirable replacement behavior that Nathan's mother chose to target was "following the bedtime routine," which was operationally defined as: using a quiet voice and following the steps of the bedtime routine (with prompting) without the demonstration of challenging behavior. The PTR F Assessment Checklists and the PTR F As sessment Summary table can be found in Appendix C. PTR F Step 3: Intervention Nathan's mother and the primary researcher met for approximately 1 hour and 30 minutes to develop the BSP. An initial BSP was developed during this meeting that the family implemented during one bedtime routine after which they determined that multiple aspects of the plan had to be changed. The primary issue with the original BSP was that the reinforcer that was chosen (earning access to highly preferred toy cars in the morn ing) for Nathan was not delivered immediately enough or at a dosage level that was strong enough to elicit the desirable behavior. Moreover, it became apparent to the team that the functional reinforcer that best fit the context of the routine would be for him to

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54 earn time with his mother at the end of the bedtime routine. Therefore, another meeting was scheduled that occurred for approximately 1 hour to develop a second BSP. This meeting and the second BSP th at was developed (and ultimately consistently implemented by Nathan's family) are described next. At his second BSP meeting the team reviewed chose, and planned for intervention strategies that would be used in Nathan's BSP Three Prevent strategies wer e chosen (i.e., enhance predictabili ty with calendars and schedules, reduce distractions or competing events or materials use scripted social stories to describe problematic situations and potential solutions ), one Teach strategy was chosen (i.e., teach i ndependence with visual schedules and calendars), and all of the Reinforce strategies were followed. Nathan's BSP Summary form is included in Appendix C. PTR F Step 4: Coaching After the BSP development meeting, the researcher communicated with the family through e mail about the details of the BSP and regarding varying materials that were developed by the primary researcher. Nathan's family implemented the BSP for the first time when the primary researcher was present. No meeting occurred p rior to this initial BSP implementation. Nathan's father did not use the visual schedule during this initial implementation of the BSP so a meeting was scheduled during which the team could meet to review how the BSP should be implemented. The meeting was scheduled at a time that would have minimal distractions and when Nathan's mother and father could be present and it lasted for approximately 75 minutes Problem solving and role playing were used during this meeting to ensure that both of Nathan's parent s reported feeling confident and able to implement the BSP. Following this meeting, Nathan's father implement ed the BSP with 100% fidelity. Nathan's family required minimal coaching to

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55 continue implementing the BSP at a high level of fidelity. Further co aching sessions occurred every one and one half weeks on average at which time the primary researcher would arrive at the family home approximately 30 minutes prior to the beginning of the bedtime routine. During these short meetings, problem solving discu ssions would occur. Then the researcher would observe Nathan's family implement ing the BSP and provide side by side support primarily in the form of verbal praise for BSP strategies the family used during the routine. In all, the researcher visited Nathan' s family's home 8 t imes for coaching sessions once BSP implementation began Each time the researcher met with the family to observe the bedtime routine, the team met for pre routine meetings that lasted for approximately 30 minutes. The researcher left th e family home immediately after the bedtime routine ended. PTR F Step 5: Monitoring Plan Implementation and Child Progress When Nathan's family was able to implement the BSP with fidelity, a functional relation was established between the BSP and changes in Nathan's behavior H is family reported that they were confident implementing the BSP and satisfied with the routine. Consequently, the researcher and family made a mutual decision that the researcher's support for the bedtime routine was no long er required It was agreed that the researcher would be available for any further support that the family felt was necessary. Two close out meetings were scheduled for Nathan's family. During one meeting Nathan's mother completed all post intervention stud y requirements (i.e., ECBI, social validity questionnaire) and simple, broad strategies were discussed regarding the family's future fading of his mother's reinforcement At the second meeting, the researcher and Nathan's mother met to discuss strategies for continued challenging behaviors that occurred during other routines of the day. A reinforcement system was developed for the afternoon and evening hours to encourage Na than's use of desired

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56 behavior (e.g., putting his plate in the sink when he was done eating). Also, the team reviewed strategies that Nathan's family had learned at the class provided by his brother's child care center to reduce challenging behavior in the home. Nathan's mother indicated that she would continue to review and practice implementing the se strategies throughout the family's daily routines and that she would contact the researcher if she had any further questions or if Nathan's challenging behav ior increased during the bedtime routine. Dependent Variables The dependent variables measured in this study included: (a ) children's challenging and desirable behaviors ; and (b ) Eyberg Child Behavior Inventory scores Social validity was also measured Each dependent variable is described below. Children's C hal lenging and Desirable Behaviors The study's dependent variables related to the children included the children's challenging and desirable behaviors. Families created operational definitions for ch allenging and desirable behaviors, and these individualized operational definitions were further defined by the primary researcher and used for data collection. Specifics regarding each operational definition can be found in the measurement section. Families also completed BRSs after each target routine that measured their satisfaction with the routine and their BSP implementation confidence over time. Further, families completed standardized pre and post test questionnaires (ECBI s ) to rate their chil d's overall challenging behavior and the amount of perceived problems that they experienced due to the ir child's challenging behavior (Eyberg & Pincus, 1999)

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57 Family's Perception of the PTR F P rocess and BSP Family perception of the PTR F process and of the BSP was indicated by their numerical ratings and written comments on the social validity questionnaire. Families completed the social validity questionnaire at the close out meeting after it was decided tha t the team should fade and/or terminate support provided by the researcher. Percentage of Fidelity of Intervention Checklist Components Implemented by the Family In order to ensure that the independent variable was implemented as it was designed to be, f amily BSP implementation was also evaluated. This measure included the average percentage of fidelity of intervention checklist components implemented by each family during each observation session. A PTR F Fidelity of Intervention Checklist that lists the steps of the BSP was developed and individualized for each family based on the PTR F strategies the family chose in their design of the individualized BSP. M easurement Videotaped observational data (i.e., percentage of intervals with challenging and desirable behaviors families' implementation of the BSP ) were collected with a digital video camera. Video data were obtained during the target routine on days th at the PTR F facilitator met with the family for meetings or to provide coaching. The family BRSs are family measures that were completed by the family each day. Each family completed an ECBI twice, once at pre test and again at post test.

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58 Children's Challenging and Desirable B ehaviors The percentage of intervals with chal lenging and desirable behaviors, family BRSs and ECBI scores were the measures used for collecting data for children's challenging and desirable behaviors. Percentage of intervals with challenging and desirable behaviors. To promote consistency with the family behavioral measure, videos were scored for occurrence of challenging behaviors by using modified, more explicitly defined operational definitions of the behaviors that were chosen by the family and researcher. A 10 second partial interval recording system was used to score video segments for challenging and desirable behaviors. A binary coding system with only two possibilities for intervals (i.e., challenging behav ior or appropriate routine behavior) was developed and used. That is, each interval was scored as a challenging behavior or desirable behavior interval. If challenging behavior occurred during the interval, it was scored as a challenging behavior interval. If challenging behavior did not occur during the interval, it was scored as a desirable behavior interval. The operational definitions used for video coding of challenging behaviors are as described next. The operational definition for Henry's challenging behavior included the following behaviors: refusal comments (e.g., never, no, I want to play), throwing self onto the floor, crying, whining, running away, and doing something other than what mother instructed to do. Olivia's challenging behavior operatio nal definition included the following behaviors: doing something other than what parent instructed, refusal comments (e.g., saying, "Olivia not ready," "No buttons," "I don't want that shirt"), making comments to distract adult (e.g., asking for hugs; sayi ng, "my boo boo"), flopping to the floor, and running away. The behaviors included in the operational definition for Nathan's challenging behavior were:

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59 crying, yelling, screaming, saying "no mommy," negotiating for mother to perform the routine, avoiding dad (e.g., hugging mom, grabbing for mom, running away from dad to other room), engaging in behaviors not related to the routine (e.g., running to brothe r's room, jumping on bed, hiding in closet), and being held by an adult to perform particular routine steps (e.g., parent holds for teeth brushing). Family BRS s The family BRSs are perceptual scales used by the family to track family confidence in their own implementation of the BSP and family satisfaction with the target routine. The collection of BRS data has been shown to be a promising, practical strategy for tracking changes in salient child behaviors (Iovannone, Greenbaum, Wang, Dunlap, & Kincaid, 2 013). Each family used the same two BRSs to track progress over time. After the occurrence of the routine s the families completed the BRSs by rating ( on a scale of 1 through 5) their satisfaction with the routine and their confidence with implementing the BSP. On the confidence BRS, families were provided with the following possible responses: (1) I can't do this; (2) I'm not sure of myself; (3) I am ok at this; (4) I'm good at this; (5) I got this and I can do this! Responses on the satisfaction BRS inclu ded: (1) extremely frustrated; (2) frustrated; (3) OK; (4) satisfied; and (5) extremely satisfied. The BRSs can be found in Appendix D. E yberg C hild B ehavior I nventory (ECBI) As previously noted, the ECBI is a questionnaire that is comprised of 36 Likert type scale questions (ranging from 1 to 7) that parents rate to indicate the intensity of their child's challenging behavior and whether or not they consider the challenging behavior to be a problem (Eyberg & Pincus, 1999). Each item corresponds wit h a particular behavior (e.g., "dawdles in getting dressed," "has temper tantrums," "yells or screams") that parents rate based on the frequency of the behavior from

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60 never (1) to always (7). They also rate whether or not the behavior is a problem by circli ng yes or no. Families completed the ECBI twice during study participation at pre and post assessment. The two ECBI scales (i.e., the Intensity scale, the Problem scale) were scored based on manual recommendations for each family (Eyberg & Pincus, 1999) Family P erception of the PTR F P rocess and BSP ( Social Validity) Families completed a modified version of the social validity measures that are currently in use by researchers conducting the randomized controlled trial of PTR YC. The first ten items were answered based on the family's agreement with a 5 point Likert type scale. For most items, a score of one indicated low social validity and a score of five indicated high social validity depending on the nature of the question. Some items were reverse scored (i.e., a score of one indicated high social validity with a score of five indicating low social validity). Items assessed areas such as the family's satisfaction with changes in their child's behavior, the family's perception of the amount of effort and time required to implement the BSP and whether the family believed that the BSP fit contextually with their familial norms. The eleventh item was open ended with a prompt inquiring whether the family had additional information to share that was not assessed on the social validity questionnaire. The social validity questionnaire can be found in Appendix E. Families' I mplementation of the C omprehensive BSP Once BSPs were created and Fidelity of Intervention Checklists were developed, all v ideos were scored using the checklists to note a "Yes" or "No" for each BSP step associated with the strategy fidelity (e.g., Prevent Implemented as intended, Teach Implemented as intended) comp onents. A fter scoring was completed for child behaviors, videos were scored on a later date a second time to obtain fidelity of intervention checklist scores. In order to

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61 reduce ambiguity in scoring, Fidelity of Intervention Checklists were made as simple as possible by including the minimal number of strategies each family had to implement in order to reach high fidelity implementation of the BSP. Only the Fidelity of Intervention Checklist components regarding the family's behavior (i.e., strategy impleme nted as intended, strategy implemented as frequently as intended) were scored due to the fact that observational data for child behavior s were collected and scored separately. An overall average fidelity of intervention checklist percentage score was obtai ned for each observation by dividing the total number of obtained "Yes" scores by the total number of possible "Yes" scores and multiplying the answer by 100. Experimental Design A single case research withdrawal (ABAB) design replicated across three fami lies was used to examine the effect that implementing a comprehensive BSP developed through the PTR F process had on child challenging behaviors and child desirable behaviors (Kennedy, 2005). The single case withdrawal research design has been established in the literature (e.g., Cheremskynski et al., 2012; Clarke, Dunlap, & Vaughn, 1999; Crozier & Tincani, 2005) as a feasible and efficient single case research design for use with similar populations of children and their famili es. Unlike other more temporally extended single case research designs that can delay intervention for prolonged periods of time, the withdrawal design was considered superior for use in this study because an experimental effect was demonstrated through a brief removal of the independent variable causing minimal disruption for children and families.

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62 Baseline A n uncontrolled baseline was employed in this study That is, during baseline, families were encouraged to engage in their typical, existing routine without being given any instruction. Baseline observation sessions were videoed using a digital video camera and lasted for 10 minutes. Each baseline observation session occurred during the family's target routine. All four planning steps in the PTR F proc ess involved in developing each BSP occurred during baseline but no intervention implementation occurred until the onset of the first intervention phase Intervention 1 Following the completion of steps 1 through 4, the PTR F facilitator met during the target routine chosen by each family. The PTR F facilitator engaged in coaching with the families to support their implementation of the BSP s and to establish fidelity of i ntervention. Withdrawal During the withdrawal phase, each family routine was briefly returned to baseline conditions. The researcher instructed the families not to implement the BSP during the withdrawal phase. As soon as a sufficient pattern of behavior (i.e., a return of child behavior to baseline [or close to baseline] rates) was noted, the intervention phase was re administered. A replication of baseline during the withdrawal phase was critical to determine that a functional relation existed between th e intervention and the child's behavior (Kennedy, 2005).

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63 Intervention 2 During this second intervention phase, the PTR F facilitator again met during the target routine chosen by each family. Coaching and feedback was provided on the family's implement ation of the BSP in order to re establish fidelity of intervention.

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64 CHAPTER III RESULTS, DISCUSSION, AND RECOMMENDATIONS The following sections outline study results, discussion, and recommendations. First, interobserver agreement for ea ch scored observational measure is discussed. Next, intervention fidelity and findings from all dependent variables are detailed. Then, a discussion that includes a summary of pertinent results and findings, study limitations, recommendations for future research an d implications for practice is provided. Interobserver Agreement A primary independent observer scored all observational measures. The primary independent observer's scores were used for all phase change decisions. The primary independent observer was a do ctoral student in the same program as the primary researcher. The researcher was the secondary observer. The secondary observer was trained using the process outlined by Kennedy (2005) that includes the following steps: (a) memorization of observational codes and operational definitions for behaviors; (b) discussion of occurrence and non occurrence behavioral examples; (c) practice scoring using observational codes; (d) independent scoring of video examples; and (e) calculation of interobserver agreement with the primary observer's coding. Once a minimum interobserver agreement (IOA) of 85% was reached, both o bservers were permitted to score observational measures. The secondary observer scored an aver age of two videos per family to establish sufficient IOA. In order to ensure tha t observations were independent each observer scored all sessions at different ti mes and t he secondary observer was trained using videos that were not used for calculating interobserver agreeme nt The primary observer noted on each scoring sheet the exact moment (i.e., the time stamp including the hundredths of the second) of the

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65 video when coding began. If the secondary researcher noted any issues in IOA once video scoring had occurred, the primary and secondary observer s would discuss such issues after the video scoring was complete O nce it was determined that a video would be s cored for calculating IOA for the study, no changes in scoring were made. That is, discussions between the primary and secondary observer that occurred over time did not influence previously scored videos that were designated as study IOA videos. IOA was c alculated and reported for a minimum of 33% of the observational measures for all participants and families distributed evenly across all study phases. Occurrence /nonoccurrence IOA was calculated using the following recommendations outlined by Kennedy (200 5, pp. 116 117): (1) a check is made each time the secondary observer agrees with the primary observer regarding whether or not an occurrence of the behavior occurred ; (2) the number of agreements are tallied; (3) the number of possible agreements are tall ied; (4) the number of agreements is divided by the number of possible agreements and multi plied by 100. In regard to the family's fidelity of intervention checklist scores, the mean occurrence interobserver agreement for Henry across all study phases was 96.5 % (range 82 100 %), and the mean nonoccurrence interobserver agreement across all study phases was 100 % For challenging behavior, the mean occurrence interobserver agreement for Henry across all study phases was 95.2 % (range 87 100%), and the mean nonoccurrence interobserver agreement across all stu dy phases was 94.7 % (range 82 100%). The mean occurrence i nterobserver agreement for Henry's desirable behavior across all study phases was 94.7 % (range 82 100 %), and the mean nonoccurrence interobserve r agreement across all study phases was 95.2 % (range 87 100 %).

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66 In regard to Olivia's family's fidelity of intervention checklist scores, the mean occurrence interobserver agreement across all study phases was 98.3 % (range 90 100 %), and the mean nonoccurrence interobserver agreement across all study phases was 91.3 % (range 57 100 %). For challenging behavior, the mean occurrence interobserver agreement for Olivia across all study phases was 85.6% ( range 78% 97%), and the mean nonoccurrence interobserver agreement across all study phases was 92.6% (range 67% 100%). The mean occurrence interobserver agreement for Olivia's desirable behavior across all study phases was 92.6 % (range 67 100 %), and the mean nonoccurrence interobser ver agreement across all study phases was 85.6% % (range 78 97 %). The mean occurrence interobserver agreement for fidelity of intervention checklist scores across all study phases for Nathan was 100% and the mean nonoccurrence interobserver agreement acros s all study phases was 96 % (range 80 100 %). For challenging behavior, the mean occurrence interobserver agreement for Nathan across all study phases was 98.9 % (range 94% 100%), and the mean nonoccurrence interobserver agreement across all study phases w as 100% The mean occurrence interobserver agreement for Nathan's desirable behavior across all study phases was 100% and the mean nonoccurrence interobserver agreement across all study phases was 98.9 % (range 94 100 %). Results The purpose of this section is to discuss study results across children and families. First a discussion of BSP implementation across families is provided. The remaining sections describe the results for all dependent variables including: (a) percentage o f challenging and desirable behaviors per routine; ( b ) BRS scores; ( c ) ECBI scores; and ( d ) social validity.

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67 Family Implementation of the Comprehensive BSP Each family was able to achieve a pre established criterion (i.e., 80% or more) level of fidelity of BSP implementation score during intervention phases through their participation in the PTR F process. Across families, elements of the BSP s were implemented during the baseline phases indicating that the families were already using some of the strategies that were chosen as PTR F strategies to include in the BSPs prior to their developing the BSPs Some of the strategies were also used during the withdrawal phase indicating t hat a complete withdra wal of the BSPs did not occur during the withdrawal phases Table 1 shows the mean fidelity scores and ranges for each family across baseline, intervention, and withdrawal phases. Table 1 Mean Fidelity Scores and Ranges Across Baseline, Intervention, and Withdrawal Phases Baseline Intervention 1 Withdrawal Intervention 2 Mean Range Mean Range Mean Range Mean Range Henry and His Family 66% 39 81 % 100% N/A 65% 59 71% 100% N/A Olivia and Her Family 51 % 43 59 % 86% 63 100% 70% 70 71%) 86% 62 95% Nathan and His Family 56% 54 58% 95% 92 100% 50% N/A 100% N/A Children's Challenging and Desirable Behaviors A functional relation was noted for all child participants in regard to the reduction of child challenging behavior that occurred once each family began implementing the BSP When the BSPs were withdrawn, all three participants demonstrated increases in challenging behavior that subsequently decreased with the re implementation of their families' BSPs

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68 Desirable behavior intervals were score d as the inverse of challenging behavior intervals. Therefore, a functional relation was identified for all children and their families for desirable behavior as well. Across all families, the introduction of the BSPs resulted in an increase in desirable behavior for all child participants. During the withdrawal phase, desirable behavior decreased for all participants. Once the BSPs were re implemented, desirable behavior again increased for all participants. Appendix F contains Figures 2 through 4, which illustrate the percentage of intervals with desirable behavior across study phases and participants. Figures 5 through 7 show the percentage of intervals with challenging behavior for each participant across sessions. Challenging behavior results for each participant and his/her family are described next. Figure 5 Percentage of challenging behavior for Henry across study phases. Henry and His Family During the initial baseline phase, Henry's mean challenging behavior was 60.4% of intervals (range 11 84%). On one occasion, Henry engaged in 11% challenging behavior,

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69 which was well below his other challenging behavior scores (52.7% lower than his next lo west challenging behavior score). The team had no explanation for the occurrence of this low score. Excluding this outlier, Henry's percentage of challenging behavior during baseline was stable and demonstrated a low, upward trend. During intervention, Hen ry's challenging behavior rapidly decreased to a mean score of 1 4.75% (range 0 33 %). Intervention data showed low to medium variability with a low, downward trend. When the intervention was withdrawn, Henry's challenging behavior scores increased rapidly a gain to a mean of 70% (range 68 72%). Withdrawal challenging behavior data showed low variability with a low decreasing trend. This downward slope was not concerning given the stability of the withdrawal data and the shortened duration of the withdrawal ph ase to minimize familial stress. When the BSP was re implemented again, Henry's challenging behavior decreased rapidly to a mean of 12.3% (range 0 25%). Intervention data demonstrated low to medium variability and a low to medium, decreasing trend. Figure 6 Percentage of challenging behavior for Olivia across study phases.

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70 Olivia and Her Family During basel ine, Olivia's mean challenging behavior was 70.5% of intervals (range 50 78%). Her baseline percentage of challenging behavior data had medium va riability and a moderate to high increasing trend. Once the intervention was implemented, Olivia's challenging behavior rapidly decreased to a mean of 30.1% (range 13 45%). Intervention data showed medium variability due to a break that occurred between th e third and fourth intervention data point. The family went on a 5 day trip to visit Olivia's grandparents, at which time the BSP was not implemented. The family began implementing the B SP upon their return home, and a brief increase in Olivia's percentage of challenging behavior scores occurred. With this increase in challenging behavior, Olivia's intervention data demonstrated a medium upward trend. However, eventually, Olivia's challenging behavior reached pre trip levels, and the last three data points in the intervention phase had a medium to high downward trend. Olivia's withdrawal challenging behavior data indicate a rapid increase to a mean of 66% (range 67 65%). Withdrawal data were stable with a low decreasing trend. The downward slope was not conc erning given the low variability of Olivia's withdrawal data and the shortened duration of this phase to prevent unnecessary stress on the fam ily. With the re introduction of the BSP, Olivia's percentage of challenging behavior rapidly decreased to a mean challenging behavior score of 35% (range 27 54%). On one occasion during intervention, Olivia exhibited 54% challenging behavior, which was 23% hig her than her next highest challenging behavior score. There were a number of changes occurring at this time for Olivia (e.g., her school schedule changed, her mother was out of town for work), but no particular explanation for this increase in challenging behavior was identified. Olivia's percentage of challenging behavior during intervention was otherwise stable and

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71 demonstrated a low, upward trend through the third to last data point. Then a decrease in challenging behavior was noted between the second to last and last data point indicating a rapid downward trend. Figure 7 Percentage of challenging behavior for Nathan across study phases. Nathan and His Family Throughout the baseline phases Nathan's mean percentage of challenging behavior was 96.1%. Du ring the last two baseline sessions, Nathan demonstrated challenging behavior for the entire duration of each videotaped observation period. His percentage of challenging behavior scores, therefore, demonstrated high rates of challenging behavior with a low, increasing tren d. Once his family began implementing the BSP, Nathan's mean percentage of challenging behavior immediately decreased by 25% between the last two baseline data points and the first intervention data point, and then by 75% between the first and second inter vention observation period. A meeting occurred between the primary researcher and Nathan's family between the first and second videotaped intervention observation period during which the team thoroughly discussed the BSP and broke the steps of the BSP down

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72 into even more concrete tasks for Nathan's father. Following this meeting Nathan's challenging behavior decreased to 0% and his percentage of challenging behavior remained low and stable throughout the remaining duration of the intervention phase with a m ean score of 3.3% (range 0 10%) not including his 75% score mentioned above. Nathan's mean challenging behavior score for intervention across all scores was 21.3% (range 0 75%). When the intervention was withdrawn, Nathan's percentage of challenging behavi or rapidly increased to a mean of 85% (range 75 95%), and his withdrawal data showed a medium upward trend. The withdrawal data appear to have medium variability; however, this is difficult to determine based on the limited number of videotaped observation s that occurred during the withdrawal phase in order to reduce familial stress. Once the BSP was re implemented, Nathan's percentage of challenging behavior immediately decreased to 0% and remained stable at 0% across all four videotaped intervention obser vations. Family BRSs Appendix G contains graphs illustrating data from the BRSs completed by each family throughout their study participation. Each family reported different issues in regard to their completing the BRSs. Olivia and Nathan's family consist ently had difficulties in completing the BRSs over time, and Henry's family lost approximately three weeks of data when they misplaced their BRSs and could not find them. I mproved routine satisfaction was reported across all families from the baseline to t he second intervention phase. Both families who reported their BSP implementation confidence during the first intervention phase reported an increase in their confidence during the second intervention phase. A ll families reported high rates of BSP implementation confidence by the second intervention phase. Table 2 shows each family's mean BRS scores across study phases.

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73 Table 2 Mean BRS Scores Across Families Across Study Phases Baseline Intervention 1 Withdrawal Intervention 2 Satisfaction Confidence Satisfaction Confidence Satisfaction Confidence Satisfaction Confidence Henry 2.9 N/A 3.2 3.2 3.9 4.2 Olivia 3.4 N/A 4.6 2 5 4.5 5 Nathan 2.4 N/A 4.3 4.3 2 5 4.8 5 Eyberg Child Behavior Inventory Figure s 8 and 9 provide the pre and post raw intensity and problem scores for all three child participants as rated by their families during pre assessment and post assessment. During pre assessment, only the intensity of Nathan's challenging behavior fell in the clinical range. Henry and Olivia's challenging behaviors were within a typical range of challenging behavior according to the ECBI. No families reported perceived challenging behavior problems in the clinical range during pre or post assessment. During post assessment, Olivia and Nathan's families both reported decreased challenging behavior intensity and problem scores. During post assessment, Henry's family rated his challenging behaviors to be slightly more intense and slightly more problematic than during baseline. However, at post assessment, a ll families rated child challenging behaviors and perceived problems to be within a typical range.

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74 Figure 8 Pre and p ost Eyberg Child Behavior Inventory Intensity scores across children. Figure 9 Pre and p ost Eyberg Child Behavior Inventory Problem scores across children. Family Perception of the PTR F Process and BSP (Social Validity) All three families favorably rated both the PTR F process and the BSPs that were developed and implemented. On questionnaire items with a rating of 5 indicating the most

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75 favorable score, average social validity ratings for Henry and his family, Olivia and her family, and Nathan and his family were 4.83, 4.83, and 5, respectively. On questionnaire items with a rating of 1 representing the most favorable score and a rating of 5 the least favorable score, average social validity ratings for the families included a score of 2 for Henry and his family, a score of 2.25 for Olivia and her family, and a score of 1 for Nathan and his family. The most highly rated questionnaire items indicated that families found the BSPs acceptable, the BSPs fit we ll into the ir existing routines, the children learned desirable behaviors through the families' implementation of the BSPs, and the BSPs were congruent with each family's goals for their child. Items related to the family's willingness to carry out the BSP s and the amount that families liked the BSPs were also highly rated. Families rated items regarding BSP disadvantages, side effects and child discomfort more variably. Henry's family reported that they rated the questionnaire item addressing undesirable side effects a 3 out of 5 because their children now watched a DVD in the car (Henry's reinforcing activity for completing his routine), which prevented their ability to listen to music while driving. Olivia's family noted that they rated the questionnaire item addressing child discomfort that might occur through their BSP implementation a 3 out of 5 because the "first time [implementing the BSP] was rough." The last item on the social validity questionnaire offered families the opportunity to write in any additional comments about the PTR F process or the BSP that were not addressed by questionnaire items. No families made additional comments. Table 3 shows the social validity ratings for each family across all items on the social validity questionnaire.

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76 Table 3 Social Validity Ratings Across Families Across Social Validity Questionnaire Items Henry and His Family Olivia and Her Family Nathan and His Family Question 1: Acceptability of the PTR Plan 5 5 5 Question 2: Family's Willingness to Carry Out Plan 5 4 5 *Question 3: Disadvantages in Following the Behavior Plan 2 3 1 *Question 4: How Disruptive is it to Carry Out the Plan 2 2 1 Question 5: How Much Do You Like the Proposed Plan Procedures 4 5 5 *Question 6: Extent that Undesirable Side Effects Result from the Behavior Plan 3 1 1 *Question 7: How Much Discomfort is Your Child Likely to Experience During the Behavior Plan 1 3 1

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77 Table 3 (cont.) Question 8: How Well Does The Behavior Plan Fit Into Existing Routine 5 5 5 Question 9: Effectiveness of Plan In Teaching Child Appropriate Behavior 5 5 5 Question 10: Fit of Plan With Family's Goals to Improve Child's Behavior 5 5 5 Note: Questions marked with an asterisk were rated inversely with a score of 1 indicating the most favorable rating and a score of 5 indicating the least favorable rating. Discussion The purpose of this study was to experimentally analyze the PTR F process wit h three families having young children with challenging behavior. A single case research withdrawal design across three young children and their families was implemented to examine the effect of the PTR F process on the level of fidelity at which each fami ly implemented the BSP, the effect of the BSP on child challenging and desirable behaviors, and the effect of the PTR F process and the family's implementation of the BSP on family ratings of self confidence and satisfaction with the routine. H ow families perceived the PTR F process and the BSP s that were developed and implemented was also considered Through the use of the PTR F process, all families achieved a satisfactory level of fidelity in regard to their implementation of the BSPs that were develope d, and functional relations were established between each family's implementation of the BSP and positive changes in their child's behavior s Familie s also reported increased satisfaction with their

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78 target routines, increased self confidence regarding thei r ability to implement the BSPs, and positive perceptions of the PTR F process and the BSPs. This section summarizes results and noteworthy findings as they relate to family centered PBS. A limitations section will follow this summary in addition to sectio ns outlining recommendations, implications for practice, and concluding remarks. Replication of Function Based Intervention and the Prevent Teach Reinforce Model This study support s existing studies that have demonstrated that families are able to implement function based BSPs with their young children with challenging behavior in ways that produce desired outcomes (Fettig & Barton, 2014). The results of this study are consistent with an ever increasing literature base (e.g., B uschbacher et al., 2004; Clark et al., 1999; Fettig & Barton, 2014; Fettig, Schultz, & Sreckovic, 2015; Fox & Clarke, 2004; Koegel et al ., 1991; Lucyshyn & Albin, 1997) that provides support for the use of family centered PBS to effectively decrease child challenging behavi ors and improve the quality of life of young children and t heir families in home settings. The findings of this study also add support for the efficacy of the PTR model when used with families of young children with challenging behavior in home settings ( Bailey, 2013; Sears et al., 2013). Currently, only two studies have been conducted using the PTR F model with families. In addition to the efficacy of the PTR F model demonstrated in this study across three families with a focus on one routine per family, the model has also proven effective in reducing challenging behavior for one fami ly across three routines (C. Vatland, personal communication, April 2016). Thus, the results from this study extend current research by providing evidence of the effectiveness of the PTR F model when used with families of young children with challenging behavior.

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79 Percentage of Fidelity of Intervention Checklist Components Implemented by the Family The current study replicates findings that families can and do implement BSPs with high levels of fidelity when using the individualized support an d coaching provided through family centered PBS ( Cheremshynski et al., 2013; Fettig et al., 2015). Furthermore, it adds support for existing studies in dicating that families' high fidelity implementation of BSPs leads to desired changes in child behavior (Barton & Fettig, 2013) All of the families who participated in this study reached a satisfactory level of intervention fidelity. Interestingly, no fam ilies had to be coached to use BSP strategies that are considered to be general positive parenting practices (e.g., Dunlap et al., in press) such as providing praise for a child's desirable behavior and reducing excessive demands and negative comments throughout the routine. In regard to the families' fidelity of intervention scores across phases, as previously noted, each family used some of the strategies that were inclu ded in the BSPs during baseline and withdrawal phases. The inclusion of these strategies in the BSP was important for the family centered nature of the PTR F process because it ensured that the plan built on the strengths of the family and on practices tha t were already in place in the home setting Further, all families indicated that including specific strategies in the BSP served as a reminder for them to use the strategies during the routine. For example, while Henry's mother was using verbal praise dur ing baseline, her use of this strategy increased during the intervention phase, and she used it more regularly across varying steps of the routine. It co uld be concluded that even without large changes in fidelity of intervention scores, behavior change wa s observed across families It is more likely, though, that the comprehensive nature

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80 of the BSPs led to the inclusion of some strategies that were not necessarily critical for child behavior change to occur. No experimental manipulation occurred to determi ne which strategies from the BSPs led to changes in child behavior. However, overall, the strategies that were used across families during baseline and withdrawal phases were related to the families' use of verbal praise and positive attention during the r outine s and to the families' following of the individual routine steps in a specific order. None of the families used visual schedules at baseline or during the withdrawal phase, and access to functional, individualized tangible reinforcers (e.g., Henry's DVD, Olivia's prize jar, Nathan's mother's lying with him in bed when the routine was finished) did not occur the during baseline or withdrawal phases. In regard to each family's ability to reach high fidelity implemen tation of the BSP, a cross all videotaped observation sessions, only Olivia's family did not reach 100% fidelity of intervention at least once Her family's inability to reach 100% fidelity might have been related to Olivia's continued demonstration of chal lenging behavior during each morning routine across baseline, withdrawal, and intervention phases. That is, Olivia's percentage of challenging behavior did not reduce to 0% at any time during the study like the challenging behavior of the young children fr om the other two families did. Nonetheless, the PTR F process effectively led to each family's high fidelity use of the BSP, which in turn led to observed and reported desired changes in the young children's behaviors. Children's Chal lenging and Desirable Behaviors The findings of this study are consistent with other studies examining the impact of family centered PBS on changes in child behavior. Like other studies with family centered PBS as their focus (e.g., Clarke et al ., 1999; Dunlap et al., 2006; F ettig et al., 2015), this

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81 study showed that the family's implementation of the BSP led to decreased percentage s of child challenging behaviors and increased percentage s of child desirable behaviors across families. As previously noted, two of the families (i.e., Henry's family, Nathan's family) had multiple sessions during which their child demonstrated 0% challenging behavior. Olivia's family had no sessions during which she demon strated 0% challenging behavior, which might be associated with the family's fidelity of intervention scores. Additionally, Olivia's family indicated that she had been diagnosed with fine and gross motor delays in addition to motor planning issues that could have also led to her continued demonstrat ion of challenging behavior. Fine motor tasks such as undressing and dressing, which took up a large portion of the target routine, were extremely difficult for Olivia. Overall, functional relations were noted across families between the family's implement ation of the BSP and resulting changes in child behaviors BRS All families reported increased satisfaction with the target routine and increased self confidence regarding their ability to implement the BSP during the PTR F process. This finding is consis tent with findings from other studies that have shown that parent training is correlated with increased familial satisfaction and self confidence (Boettcher Minjarez, Mercier, Williams, & Hardan, 2012; Durand et al., 2013; Graf, Grumm, Hein, Fingerle, 2014 ). Changing perspectives over time was noted for Henry's family. That is, Henry's mother indicated that throughout her family's participation in the PTR F process, increased expectations developed based on their learning that Henry was capable of exhibitin g high levels of desirable behavior. Durand ( 2011 ) has noted this phenomenon (i.e., changing f amilial perspectives) as well.

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82 As previously noted, overall, each family experienced difficulties with their consistent tracking of BRS data. Along w ith these difficulties, each family also noted their own frustration with themselves in regard to the difficulties that they were experiencing. Problem solving discussions did occur around solutions to difficulties that were reported by families (e.g., los t BRSs, forgetting to complete the BRSs); however, these discussions did not seem to impact the families' actual data collection. Further, despite families indicating their willingness to receive reminders to collect BRS data, the researcher was unaware of any impact constant, or even regular reminders had on the families difficulties In a personal communication (C. Vatland, 2016) with the researcher responsible for the other experimental analysis of the PTR F model, family data collection issues were al so reported. ECBI Two of three families had decreased ECB I scores from pre to post test. Henry's family noted an increase in his challenging behavior from pre to post test and an increase in the perceived problems that his challenging behaviors cause for the family. These score increases might be in some part re lated to the previously discussed changes in Henry's family's perceptions about his challenging behavior. Additionally, based on further review of the ECBIs that were completed by Henry's family, one of his scores increased around a routine that was not ta rgeted (e.g., bedtime). Henry's family reported that o nly three additional behaviors (i.e., argues about rules, gets angry when doesn't get own way, yells or screams) increased and were problems for the family. It is hypothesized, although unable to be con firm ed, that these challenging behaviors result in attention from Henry's family It follows that if the function of these behaviors is attention, given Henry's family's previously discussed preference to attend to his behaviors rather than ignore them, th e behaviors may continue due to the reinforcement that Henry receives for his using the behaviors.

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83 The decreased ECBI scores for the other two families are somewhat surprising The ECBI measures a wide variety of challenging behaviors that are not specific to the target challenging behavior chosen by each family to reduce for study purposes. Additionally the ECBI measures challenging behaviors across many routines as opposed to main taining a focus on each family's target routine. Consequently a lack of change in ECBI scores from pre to post intervention would not necessarily indicate that the intervention did not reduce a specific challenging behavior in a particular, target routine However, the decreased scores noted by these two families indicate that some more generalized changes in their children's challenging behaviors may have occurred following their participation in the PTR F process and implementation of the BSP Family's Perception of the PTR F Process and BSP The social validity find ings of this study substantiate similar findings from previous research that suggest that families favorably rate family centered PBS ( Binnendyk & Lucyshyn, 2009; Buschbacher et al., 2004; Fettig et al., 2015 ). Overall, positive ratings were noted for the PTR F process and for the BSPs that were developed by each team. It is noteworthy that no family chose to provide additional written comments while completing the social validity questionna ire. Perhaps families perceived their discussions with the researcher over time and during the close out meeting to be sufficient. Or, families may have thought that the items on the social validity questionnaire sufficiently assessed all of their thoughts and concerns regarding their participation in the study. Study Limitations There are several limitations to this research study. First, the generalizability of study findings is limited give n the small sample size and limited participant diversity. Second, this

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84 single case withdrawal design implemented only two withdrawal data points per family. Although clear and immediate level changes were observed for each child's percentage of challenging beh avior between intervention and withdrawal phases, results should be interpreted with caution due to the limited number of data points that were used to establish the functional relation between the withdrawal and re implementation of the BSP. Third, the BR S measure was inconsistently used across families, and, therefore, the conclusions that were made from these data should be interpreted with caution. Fourth due to family data collection issues, it is not possible to calculate the actual number of session s that occurred between videotaped observations. Therefore, there is no ability to determine the exact number of times that the BSP was implemented between videotaped observations in order to confirm the actual dosage of intervention that each child receiv ed throughout his/her family's participation in the study. Fifth, although it might be extremely difficult to have a blind coder score the videos for these particular families given the number of changes to the routine s that were made from baseline to inte rvention, the primary video observation scorer was not blind to study conditions. Therefore, the video observation scorer may have had some knowledge of the phase changes that occurred. It is unknown whether or not this impacted scoring. However, IOA betwe en observers was sufficient, which adds support for scoring validity Sixth no generalization, maintenance, or follow up data were collected after the primary researcher's final close out meeting with the families. Therefore, no information is available regarding the families' use of BSP strategies during other routines or the fa milies' continue d implementation of the BSP once their regular visits with the primary researcher stopped Lastly, the primary research and PTR F facilitator has expertise in the PTR F model and in working with families around severe and persistent challen ging behavior in the home setting.

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85 The intent of PTR F is to be used by home visiting professionals and families who may not have such expertise. While the findings of this study provide support for the model, they do so for the implementation of the model with a highly skilled team. This study's findings do not, however, provide information about the effectiveness of the PTR F model when used by typical home visiting professionals working with families in the field. Recommendations Given the findings and also the limitations of this study, a number of recommendations can be made for future research studies. It is important that the efficacy of the PTR F model continue to be studied with young children and families. Future studies should, for example, focu s on the implementation of the model across child ren with a variety of disabilities and special needs across families from varying culturally and linguistically diverse backgrounds, and with families of different socioeconomic statuses. Future stud ies sho uld also consider how family data collection issues might be mitigated Although the use of a pre post measure would likely eliminate these issues, the intent of SCRD is to track changes over time, and, therefore, some regular measurement of the family's perceptions of the routine, satisfaction, or the child's challenging and desirable behaviors throughout their engagement in the PTR F process is necessary if SCRD is used Perhaps reducing the number of times the family is expected to complete the BRSs wou ld increase their consistent collection of these data over time Or, for families who may experience more data collection issues than others, it might be useful for the PTR F facilitator and family to complete the BRSs one time per week during coaching ses sions. Further, it would be interesting to determine what type of reminders (e.g., texts from facilitator, e mails from facilitator, smart phone alerts) lead to the most consistent completion of the BRSs by families. Along these

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86 lines, as Iovannone et al. (2013) did for the use of the BRS in school settings, future research should consider the effectiveness of the use of the BRS s with families in home settings to track changes in child behavior over time. While all families noted relatively rapid changes in their children's behaviors, future research should consider the average number of sessions that are required for families to report changes in child behaviors in practice based settings in which home visitors and families are using the PTR F model. It is likely that the PTR F process might be even more efficient in these practice based settings without the research study requirements that were dictated by the single case research withdrawal design that was emp loyed in this study. Additionally, it is recommended that future studies consider the generalization of the families' learned skills to other routines and settings and also the changes in child challenging and desirable behaviors that might occur in routin es that are not directly targeted through the PTR F process. Finally, BSP implementation maintenance and follow up data should also be collected in future studies. Implications for Practice The results of this study indicate that families can successfully participate in the PBS process when used in home settings and that their participation and implementation of BSPs can lead to desired changes in child behavior and increased family satisfaction and confidence implementing BSP s All three families successfully participated in all steps (including PTR F Assessment) of the PTR F process implemented in this study The results also indicate that family centered PBS, and specifically the PTR F model, may be an efficient and effectiv e way to reduce challenging behavior in the home setting s of families of young children with challenging behavior

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87 A primary implication for practice emerging from this study wa s the need for flexibility and availability from the researcher in order to support the families who participated in the most efficient and effective way possible. For example, the researcher was present for each family during the time that the actual routine occurred. This meant that the researc her arrived at the fami lies' homes during very early (e.g., 6:30 a.m.) and somewhat late (e.g., 8:30 p.m.) hours Meeting times tended to fluctuate throughout the research process Further, f amilies were not a lways available on the same day every week, so the primary researcher met with families when they were available as opposed to meeting with each family on the same day and at the same time each week. Additionally, there were multiple occasions during which the researcher was en route to a fami ly's home when the family had to cancel the session at the last minute The researcher's ability to reschedule with families during the same week that sessions were canceled contributed greatly to the efficiency of the process. Table 4 shows the estimated average amount of the primary re searcher's time that was spent with each family across study phases. The averages in Table 4 include estimations of the number of indirect hours the researcher spent with each family but they do not include estimations of the researcher's travel time. Tabl e 4 Estimated Average Time Spent with Each Family Across Study Phases Child and Family Estimated Average Time Spent With Each Family Across Study Phases Henry and His Family 14 to 16 hours Olivia and Her Family 14 hours Nathan and His Family 18 to 19 hours

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88 Also contributing to the efficiency and effectiveness of the process was the researcher's ability to work on the development and organization of materials (e.g., visual schedules, detailed written instructions) that the families would use whil e they were implementing the BSPs during indirect (i.e., non session) hours The primary researcher's schedule flexibility and use of indirect time reveal another implication for practice That is, it is important to consider the number of families who hom e visiting professionals work with at one time as it relates to the quality of the service that families receive. The efficiency of child behavior change might be impacted by a home visitors inability to use indirect time, to re schedule during the same we ek, or to provide support and coaching for families during the actual routines as they occur in the family home. Further, w hile the intent of the PTR F manual is to guide home visiting professionals and families through the family centered PBS process, there may be circumstances that necessitate consultation with a professional who specializes in behavioral support in home settings. Even with the primary researcher's specialization in applied behavior analysis, she met regularly with her dissertation adv isor regarding varying, PTR F process related issues that presented over the course of the research process. It would be beneficial for home visitors using the PTR F model to have knowledge regarding who and what types of professionals are available for th em to provide similar support and consultation hen needed. Conclusion This research study supports the literature indicating that family centered PBS is an effective way to reduce the challenging behaviors and increase the desirable behaviors of young chi ldren in home settings This study is one of only two current experime ntal analyses of PTR F, a model of family centered PBS The PTR F process resulted in families' high

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89 fidelity implementation of the BSPs, and a functional relation existed between each f amily's implementation of their child's BSP and changes in his/her behaviors. Further, this study has shown that family centered PBS and specifically PTR F, can improve familial routine satisfaction with target, difficult routine s and increase familial confid ence with implementing BSP s. Additionally, the findings of this study indicate that families favorably rate the PTR F process and the comprehensive BSPs that are developed through their participation in the PTR F process. Research supporting the sig nificance of family centered PBS for young children with challenging behavior and their families continues to expand To optimize outcomes for young children and their families, challenging behaviors should be targeted as early as possible and through effo rts such as PTR F that maximize the individualization of supports and also family involvement. PTR F offers the structure for practitioners to be able to do this. Efforts should be taken to continue the research on and dissemination of the use of the model as a meaningful tool for practitioners and families that can impact immediate and long term child and family outcomes.

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90 REFERENCES Bailey, K. (2013). An evaluation of the family centered prevent teach reinforce model with families of young children with developmental disabilities (Unpublished master thesis). University of South Florida, Tampa. Barton, E. E., & Fettig, A. (2013). Parent implemented interventions for young children with disabilities: A review of fidelity f eatures. Journal of Early Intervention, 35, 194 219. doi: 10.1177/1053815113504625 Barton, E. E., Steed, E. A., Strain, P., Dunlap, G., Powell D., & Payne, C. J. (2014). An analysis of classroom based and parent focused social emotional programs for young children. Infants and Young Children, 27, 3 29. doi: 10.1097/iyc.0000000000000001 Binnendyk, L., Lucyshyn, J. (2009). A family centered positive behavior support approach to the amelioration of food refusal behavior. Journal of Positive Behavior Interventions, 11, 47 62. doi: 10.1177/1098300708318965 Boettcher, M., Koegel, R. L., McNerney, E. K., & Koegel, L. K. (2003). A family centered prevention approach to PBS in a time of crisis. Journal of Positive Behavior Interventions, 5, 55 59. doi: 10.1177/10983007030050010901 Boggs, S. R., Eyberg, S., & Reynolds, L. A. (1990). Concurrent validity of the Eyberg child behavior inventory. Journ al of Clinical Child Psychology, 19, 75 78. doi: 10.1207/s15374424jccp1901_9 Boyd, B. A., Odom, S. L., Humphreys, B. P., & Sam, A. M. (2010). Infants and toddlers with autism spectrum disorder: Early identification and early intervention. Journal of Ea rly Intervention, 32, 75 98. doi: 10.1177/1053815110362690 Brookman Frazee, L., & Koegel, R. L. (2004). Using parent/clinician partnerships in parent education programs for children with autism. Journal of Positive Behavior Interventions, 6, 195 213. doi: 10.1177/10983007040060040201 Buschbacher, P. W. (2002). Positive behavior support for a young child who has experienced neglect and abuse: Testimonials of a family member with professionals. Journal of Positive Behavior Interventions, 4, 242 248. doi: 10.1177/10983007020040040701 Buschbacher, P., Fox, L., & Clarke, S. (2004). Recapturing desired family routines: A parent professional behavioral collaboration. Research and Practice for Persons with Severe Disabilities, 29, 25 39. doi: 10.2511/rps d.29.1.25 Campbell, S. B. (1995). Behavior problems in prescho ol children: A review of recent research. Journal of Child Psychology and Psychiatry, 36, 113 149. doi: 10.1111/j.1469 7610.1995.tb01657.x

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93 transition to school. Journal of Emotional and Behavioral Disorders, 10 149 157. doi: 10.1177/10634266020100030301 Fox, L., Dunlap, G., & Philbrick, L. A. (1997). Providing individual supports to yo ung children with autism and their families. Journal of Early Intervention, 21, 1 14. doi: 10.1177/105381519702100101 Fox, L., Dunlap, G., & Powell, D. (2002). Young children with challenging behavior: Issues and considerations for behavior support. Journal of Positive Behavior Interventions, 4 208 217. doi: 10.1177/10983007020040040401 Fox, L., Vaughn, B. J., Wyatte, M. L., & Dunlap, G. (2002) "We can't expect other people to understand": Family perspecti ves on problem behavior. Exceptional Children, 68, 437 450. doi: 10.1177/001440290206800402 Gliner, J. A., Morgan, G. A., & Leech, N. L. (2009). Resear ch methods in applied settings: An integrated approach to design and analysis. New York, NY: Routledge Graf F. A. Grumm M. Hein S. Fingerle, M. (2014). I mproving parental competencies: Subjectively perceived usefulness of a parent training matters. Journal of Child and Family Studies, 23 20 28. doi: 10.1007/s10826 012 9682 1 Hardaway, C. R., Wilson, M. N., Shaw, D. S., & Dishion, T J. (2012). Family functioning and externalizing behavior among low income children: Self regulation as a mediator. Infant and Child Development, 21, 67 84. doi: 10.1002/icd.765 Harrower, J. K., Fox, L., Dunlap, G., & Kincaid, D. (2000). Functional assessment and comprehensive early intervention. Exceptionality: A Special Education Journal, 8:3, 189 204. doi: 10.1207/s15327035ex0803_5 Horner, R. H., & Carr, E. G. (1997). Behavioral support for students with severe disabilities: Functional assessment and comprehensive intervention. Journal of Special education, 31, 84 104. doi: 10.1177/002246699703100108 Iovannone R., Greenbaum, P. E., Wang, W., Kincaid, D., Dunlap, G., & Strain, P. (2009). Randomized con trolled trial of the Prevent teach reinforce (PTR) tertiary intervention for students with problem behavior preliminary outcomes. Journal of Emotional and Behavioral Disorders, 17, 213 225. doi: 10.1177/1063426609337389 Joseph, G. E., & Stra in, P. S. (2003). Comprehensive evidence b ased social emotional curricula for young children: An analysis of efficacious adoption potential. Topics in Early Childhood Special Education, 23 62 73. doi: 10.1177/02711214030230020201 Kennedy, C. H. (2005) Single case designs for educational research. Boston, MA: Pearson. Koegel, R. L., Koegel, L. K., & Schreibman, L. (1991). Assessing and training parents in

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94 teaching pivotal behaviors. In R. J. Prinz (Ed.), Advances in beahvoral assessment of children and families: A research annual, Vol 5 ( pp. 65 82). Bristol, PA: Jessica Kingsley. Leech, N. L., Barrett, K. C., & Morgan, G. A. (2011). IBM SPSS for intermediate statistics (4 th ed.). New York, NY: Routledge. Lowell, D. I., Carter, A. S., Godoy, L., Paulicin, B., & Briggs Gowan, M. J. (2011). A randomized controlled trial of Child FIRST: A comprehensive home based intervention translating research into early childhood practice. Child Development, 82, 193 208. doi: 10.1111/j.1467 8624.2010.01550.x Lucyshyn, J. M., & Albin, R. W. (1997). Embedding comprehensive behavioral support in family ecology: An experimental, single case analysis. Journal of Consulting and Clinical Psychology, 65, 241 251. doi: 10.1037/0022 006x.65.2.241 Lucyshyn, J. M., Al bin, R. W., Horner, R. H., Mann, J. C., Mann, J. A., & Wadsworth, G. (2007). Family implementation of positive behavior support for a child with autism: Longitudinal, single case experimental, and descriptive replication and extension. Journal of Positi ve Behavior Interventions, 9 131 150. doi: 10.1177/10983007070090030201 Lucyshyn, J. M., Horner, R. H., Dunlap, G., Albin, R. W., & Ben, K. R. (2002). Positive behavior support with families. In G. H. S. Singer, A. P. Turnbull, H. R. Turnbull, L. K. Irvin, & L. E. Powers (Eds.), Families and positive behavior support (pp. 3 43). Baltimore, MD: Paul H. Brookes Publishing Co. Lundahl, B., Risser, H. J., & Lovejoy, C. (2006). A meta analysis of parent training: Moderators and follow up effects. Cl inical Psychology Review, 26, 86 104. doi: 10.1016/j.cpr.2005.07.004 Marshall, J. K., & Mirenda, P. (2002). Parent professional collaboration for positive behavior support in the home. Focus on Autism and Other Developmental Disabilities, 17, 216 228. doi: 10.1177/10883576020170040401 McLaughlin, T. W., Denney, M. K., Snyder, P. A., Welsh, J. L. (2011). Behavior support intervention implemented by families of young children: Examination of contextual fit. Journal of Positive Behavior Interventions, 14, 87 97. doi: 10.1177/1098300711411305 Menting, A. T., de Castro, B. O., & Matthys, W. (2013). Effect iveness of the Incredible Years parent training to modify disruptive and prosocial child behavior: A meta analytic review. Clinical Psychology Review 33 901 913. doi: 10.1016/j.cpr.2013.07.006 Minjarez M. B. Mercier E. M. Williams S. E. Hardan A. Y. (2012). Impact of Pivotal

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95 Response Training group therapy on stress and empowerment in parents of children with autism. Journal of Positive Behavior Interventions, 15, 71 78. doi: 10.1177/1098300712449055 Moes, D. R., & Frea, W. (2002). Contextualized behavioral support in early intervention for children with autism and their families. Journal of Autism and Developmental Disorders, 32, 519 533. doi: 10.1023/A:1021298729297 Onwuegbuzie, A. J., & Collins, K. M. T. (2007). A typology of mixed methods sampling designs in social science research. The Qualitative Report, 12 281 316. doi: 10.1177/1558689807299526 Powell, D., Dunlap, G., & Fox, L. (2006). Prevention and intervention for the challenging behaviors of toddlers and preschoolers. Infants & Young Children, 19, 25 35. doi: 10.1097/00001163 200601000 00004 Qi, C. H., & Kaiser, A. P. (2003). Behavior problems of pre school children from low income families: Review of the literature. Topics in Early Childhood Special Education, 23, 188 216. doi: 10.1177/02711214030230040201 Sanders, M. R. (2008). Triple P Positive Parenting Program a s a public health approach to strengthening parenting. Journal of Family Psychology, 28, 506 517. doi: 10.1037/0893 3200.22.3.506 Sears, K. M., Kwang Sun Cho, B., Iovannone, R., & Croslan d, K. (2013). Using the prevent teach reinforce model of families of young children with ASD. Journal of Autism and Developmental Disorders, 43, 1005 1016. doi: 10.1007/s10803 012 1646 1 Seguin, J. R., & Zelazo, P. D. (2005) Exec utive function in ear ly physical aggression. In R. E Tremblay, W. W. Hartup, & J. Archer (Eds.), Developmental origins of aggression (pp. 307 329 ) New York, NY: The Guilford Press. Smith Bird, E., & Turnbull, A. P. (2005). Linking positive behavior support to family quality of life outcomes. Journal of Positive Behavior Interventions, 7, 174 180. doi: 10.1177/10983007050070030601 Tellegen, C. L., & Sanders, M. R. (2013). Stepping Stones Tri ple P Positive Parenting Program for children with disabi lity: A systematic review and meta analysis. Research in D evelopmental D isabilities 34 1556 1571. doi: 10.1016/j.ridd.2013.01.022 Thomas, R., & Zimmer Gembeck, M. J. (2007). Beha vioral outcomes of parent child interaction therapy and Triple P Positive Parenting Program: A review and meta analysis. Journal of A bnormal C hild P sychology 35 475 495. doi: 10.1007/s10802 007 9104 9

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96 APPENDIX A PTR F Procedural Documents : Henry and his Family Forms have been adapted from Dunlap, G., Wilson, K., Strain, P., & Lee, J.K. (2013). Prevent Teach Reinforce for Young Children: The Early Childhood Model of Individualized Positive Behavior Support. Baltimore: Paul H. Brookes Publishing Co., Inc. Forms have been modifie d from Dunlap, G., Strain, P. S., Lee, J., K., Joseph, J. D., Vatland, C., & Fox, L. (in press). Prevent teach reinforce for families of young children with challenging behavior: The home based model of individualized positive behavior support. Baltimore, MD: Brookes. PTR F Goal Sheet Instructions: 1. Identify and write out the child 's challenging behaviors to decrease and the contexts or routines where these behaviors need to improve. 2. Select ONE challenging behavior to target within family conte xts or routines 3. Operationally define this target behavior observable (seen or heard), and measurable (counted or timed) 4. Identify and write out the child 's desired behaviors to increase 5. Select target desirable behavior (to be completed following PTR F Assessment) 6. Operationally define desirable behavior (to be completed following PTR F Assessment) Child: Henry Date: Fall 2015 Goals: Challenging Behaviors Behaviors Context/Routines Challenging Behaviors to Decrease Leaving the home prior to picking up sister from school. Target Behavior Refusal Behavior Leaving the home prior to picking up sister from school. Operational Definition Making non compliant comments (e.g., never, no, I want to play), yelling, throwing himself onto the floor, crying, screaming, whining (high pitched, nasal sound without words), running away, hiding

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97 Goals: Desirable Behaviors Desirable Behaviors to Increase Shorter routine Less whining and complaining Exit the home and get into the car independently without whining or grumbling Target Behavior (to be completed following PTR F Assessment) Following the routine Operational Definition (to be completed following PTR F Assessment) Following the steps of the routine without being carried to the car by a parent

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98 PTR F Assessment: Prevent Checklist Challenging behavior: Refusals Person Responding: Mother Child: Henry 1. Are there times of the day when challenging behavior is most likely to occur? If yes, what are they? ___ Waking up ___ Morning ___ Before meals ___ Afternoon ___ During meals ___ Nap time ___ After meals ___ Evening ___ Prepare meals ___ Bedtime Other: __________________________________________________ ___________________ 2. Are there specific activities when challenging behavior is very likely to occur? If yes, what are they? X Leaving home X Arriving home ___ Family celebrations ___ Church/reli gious activities ___ Looking at books ___ Watching television/device ___ Special event (specify): ________________ ___ Nap time X Toileting/diapering ___ Bathing ___ Toothbrushing ___ Play group/classes ___ Eating out ___ Visiting others ___ Snack ___ Interactions with sibling/child ___ Indoor play ___ Outdoor play ___ Meals ___ In the car/bus ___ At a store ___ Park/playground ___ Taking Medicine ___ Medical procedure ___ At doctor or therapist ___ At dentist ___ Children's attractions (e.g., zoo) X Transitions (specify): Leave the House Other: When iPad time is over. At times will refuse to put jacket on and to take shoes off. 3. Are there other children or adults whose proximity is associated with a high likelihood of challenging behavior? If so, who are they? ___ Siblings ___ Family member(s) ___ Care provider(s) ___ Other adults Specify:______________ Specify: ________________ Specify: ____ ____________ Specify: ___ ____________ ___ Parent ___ Other children (Specify) ____ _______ Other: _____________________________________________ ________________________ 4. Are there times of the day when challenging behavior is least likely to occur? If yes, what are they? ___ Waking up ___ Morning ___ Before meals ___ Afternoon ___ During meals ___ Nap time ___ After meals ___ Evening ___ Prepare meals ___ Bedtime Other: __________________________________________________ __________________ 5. Are there specific activities when challenging behavior is least likely to occur? What are

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99 they? ___ Leaving home ___ Arriving home ___ Family celebrations ___ Church/religious activities ___ Looking at books ___ Watching television/device ___ Special event (specify): ________________ ___ Nap time ___Toileting/diapering ___ Bathing ___ Toothbrushing ___ Play group/classes ___ Eating out ___ Visiting others ___ Snack ___ Interactions with sibling/child ___ Indoor play ___ Outdoor pla y ___ Meals ___ In the car/bus ___ At a store ___ Park/playground ___ Taking Medicine ___ Medical procedure ___ At doctor or therapist ___ At dentist ___ Children's attractions (e.g., zoo) ___ Transitions (specify): ______________ Other: The more fun that he is having with an adult (and especially mom before leaving to go pick up sister), the more difficult of a time he has when transitioning.

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100 PTR F Assessment: Teach C hecklist Challenging behavior: Refusals Person Responding: Mother Child: Henry 1. What communication skill(s) (using words, pictures, signs, augmentative systems) could the child learn in order to reduce the likelihood of the challenging behavior occurring in the future? ___ Asking for a break ___ Asking for help ___ Requesting wants and needs ___ Expressing emotions (e.g., frustration, anger, hurt) ___ Expressing aversions (e.g., "No," "Stop") _X__ Expressi ng preference when given a choice (e.g., "Yes, I like that," "I wa nt the _____ one." Other: ____________________________________________________________ ______ 2. What social skill(s) could the child learn in order to reduce the likelihood of the challenging behavior occurring in the future? ___ Getting attention appropriately ___ Sharing giving a toy ___ Sharing asking for a toy ___ Taking turns ___ Beginning interactions with peers and adults ___ Responding or answering peers and adults ___ Staying on topic with peers and adults in a back and forth exchange ___ O ffering a play idea ("You be the mommy") ___ Playing appropriately with toys and materials with peers ___ Accepting positive comments and praise ___ Making positive comments ___ Giving praise to peers ___ Waiting for acknowledgment or r einforcement ___ Skills to develop friendships Other: ____________________________________________________________ _____ 3. What problem solving skill(s) could the child learn in order to reduce the likelihood of the challenging behavior occurring in the future? X __ Contr olling anger X __ Controlling impulsive behavior X __ Strategies for calming down ___ Asking for help ___ Using visuals to support independent play ___ Self management ___ Playing independently ___ Playing cooperatively X __ Following directions X __ Following schedules and routines ___ Accepting "no" ___ Managing emotions ___ Getting engaged in an activity ___ Staying engaged in activities X __ Choosing appropriate solutions (child independently generates solution) X __ Making choices from appropri ate options (family presents child with limited reasonable options and child chooses one) X __ Following through with choices Other: ________________________________________________ _______________ Additional comments not addressed:

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101 If he stopped playin g would be acceptable "he could even complain and express his emotions" as long as he goes downstairs, puts shoes on, gets in the car without tantrum behavior Usually play at sister's school with a group of children once he gets out the door, he en joys playing with her friends and her friends' younger siblings (but this is not always possible either due to weather

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102 PTR F Assessment: Reinforce Checklist Challenging behavior: Refusals Person Responding: Mother Child: Henry 1. What consequence(s) usually follow your child's challenging behavior ? ___ Sent to time out ___ Sent to bedroom ___ Sent to quiet spot/corner ___ Gave personal space _X_ Delay in activity ___ Activity changed _X Activity ended ___ Removed from activity Delays include giving one more minute, doing something else first like changing brother's diaper and then starting the routine Occasionally mother will just try again later to go to the gr ocery store or somewhere like that ___ Calming/soothing ___ Talk about what just happened ___ Spanking ___ Assistance Given _X Verbal Warning ___ Verbal redirect _X_ Verbal reprimand/scolding ___ Review house rules _X Physical guidance ___ Sibling/peer reaction ___ Physical restraint Verbal warnings include statements like, "If you don't _____, I'll do it for you" ___ Gets desired item/toy/food ___ Gets access to desired activity Might get access to a certain activity/item/food ("I'm sure he does, but I can't think of anything specific right now") Other: Parent will yell and scream (about 1 time per week this happens) 2. What is the likelihood that privileges or preferred items/activities are removed from your child following your child's challenging behavior? _____ Ve ry Likely _____ Sometimes __X___Seldom _____Never (e.g., had a tantrum at Starbucks (was told to choose between A and B, but he wanted something else) 3. What is the likelihood of yo ur child's challenging behavior resulting in acknowledgment (e.g., reprimands, corrections, restating house rules) from adults and children? ___X__ Ve ry Likely _____ Sometimes _____Seldom _____Never ("I acknowledge and validate every time" ignoring tantrum in the past led to tantrums that were hours and hours long we can't leave him alone when he's tantruming because he destroys his room (e.g., will rip things off the wall, etc.) 4. Does the cha llenging behavior seem to occur in order to gain attention from other children (e.g., siblings, peers)? ___ Yes List specific children _______ __________________________________________ ___ No

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103 5. Does the challenging behavior seem to occur in order to gai n attention from adults? ___ Yes List specific adults __________________ ________________________________ ___ No 6. Does the challenging behavior seem to occur in order to obtain objects (e.g., toys, games, materials, food) from other children or adults? ___ Yes List specific objects _________ ________________________________________ ___ No 7. Does the challenging behavior seem to occur in order to delay a transition from a preferred activity to a nonpreferred activity? _X_ Yes List specific transitions Leaving the house ___ No 8. Does the challenging behavior seem to occur in order to terminate or delay a nonpreferred (e.g., difficult, boring, repetitive) task or activity? ___ Yes List specific tasks or activities _____________ __ _______________________ ___ No 9. Does the challenging behavior seem to occur in order to get away from a nonpreferred child or adult? ___ Yes List specific children or adults ____________ __________________________ ___ No 10. What is the likelihood of your child's appropriate behavior (e.g., participating appropriately; cooperation; following directions) resulting in acknowledgment or praise from adults or children? _____ Ve ry Likely ___ __ Sometimes _____Seldom _____Never Leaving is not likely (not likely to occur at all to be acknowledged), sometimes good with diaper changes and we try to compliment him on that (i.e., give adult attention) 11. Does your child enjoy praise from adults and children? Does your child enjoy praise from some people more than others? __X_ Yes List specific people ________ _________________________________ ___ No 12. What items and activities are most enjoyable to the child? What items or activities could serve as special rewards? __X_ Social interaction with adults __X Physical interaction with adults (rough housing, tickle, cuddle) __X_ Social inter action with siblings/peers ___ High fives __X_ Praise from adults ___ Praise from siblings/other kids ___ Music ___ Puzzles ___ Books ___ Small toys, prizes (such as stickers, or stamps) _X__ Device time (e.g. tablet, electronic game system) ___ Art activities (such as drawing pictures, painting, etc.) ___ Objects/Toys:

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104 ___ Playing a game ___ Parent helper ___ Extra time outside _X _Extra praise and attention from adults ___ Ex tra time in preferred activity ___ Special activity ___ Special helper ___ Computer time __X_ Television time (specify ) _______________ ___ Food: (specify)____ _____________ Other(s): prize box for potty training (5 stickers and gets to pick a prize) get one about every other day, going to the playground, going to the indoor play area at the mall, build a bear, Disney store Additional comments not addressed above in the Reinforce Component:

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105 PTR F Assessment Summary Table Child: Henry Date: Fall 2015

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106

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107 APPENDIX B PTR F Procedural Documents : Olivia and her Family Forms have been adapted from Dunlap, G., Wilson, K., Strain, P., & Lee, J.K. (2013). Prevent Teach Reinforce for Young Children: The Early Childhood Model of Individualized Positive Behavior Support. Baltimore: Paul H. Brookes Publishing Co., Inc. Forms have been modifie d from Dunlap, G., Strain, P. S., Lee, J., K., Joseph, J. D., Vatland, C., & Fox, L. (in press). Prevent teach reinforce for families of young children with challenging behavior: The home based model of individualized positive behavior support. Baltimore, MD: Brookes. PTR F Goal Sheet Instructions: 1. Identify and write out the child 's challenging behaviors to decrease and the contexts or routines where these behaviors need to improve. 2. Select ONE challenging behavior to target within family contexts or routines 3. Operationally define this target behavior observable (seen or heard), and measurable (counted or timed) 4. Identify and write out the child 's desired behaviors to increase 5. Select target desirable behavior (to be completed following PTR F Assessment) 6. Operationally define desirable behavior (to be completed following PTR F Assessment) Child: Olivia Date: Fall 2015 Goals: Challenging Behaviors Behaviors Context/Routines Challenging Behaviors to Decrease Needy, clingy, touching other people, requesting attention and hugs, requesting to sit on others' laps, talking about "boo boos," crying, making excuse comments (e.g., "I have to go potty") Morning routine Target Behavior Noncompliance Morning routine

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108 Operational Definition When given a direction, Olivia will make comments (e.g., ask for a hug; ask to be held; ask for attention or reinforcement; saying "not ready," "no buttons," or "my boo boo") or engage in behaviors (e.g., cry, yell, scream, flop to the floor, run away, jump on the bed) that are unrelated to the direction that was given. Goals: Desirable Behaviors Desirable Behaviors to Increase Follow the routine without noncompliance Follow the morning routine independently Target Behavior (to be completed following PTR F Assessment) Follow the routine Operational Definition (to be completed following PTR F Assessment) Doing what parent/schedule tells Olivia to do (with adult prompting) without the demonstration of noncompliance (see definition of challenging behavior)

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109 PTR F Assessment: Prevent Checklist Challenging behavior: Noncompliance Person responding: Mother and Father Child: Olivia 1. Are there times of the day when challenging behavior is most likely to occur? If yes, what are they? ___ Waking up ___ Morning ___ Before meals ___ Afternoon ___ During meals ___ Nap time ___ After meals ___ Evening ___ Prepare meals ___ Bedtime Other: ____________________________________________________ 2. Are there specific activities when challenging behavior is very likely to occur? If yes, what are they? ___ Leaving home ___ Arriving home ___ Family c elebrations ___ Church/religious act ivities ___ Looking at books X Watching television/device ___ Special event (specify): _________ _____ X Nap time ___Toileting/diapering ___ Bathing ___ Toothbrushing ___ Play group/classes ___ Eating out ___ Visiting others ___ Snack ___ Interactions with sibling/child ___ Indoor play ___ Outdoor play ___ Meals ___ In the car/bus ___ At a store ___ Park/playground ___ Taking Medicine ___ Medical procedure ___ At doctor or therapist ___ At dentist ___ Children's attractions (e.g., zoo) __ X Transition (specify): at times/ certainly from play to bath time (more during clean up cleaning up toys to get ready for dinner) Other: ___________________________________________________ 3. Are ther e other children or adults whose proximity is associated with a high likelihood of challenging behavior? If so, who are they? ___ Siblings ___ Family member(s) ___ Care provider(s) ___ Other adults Specify:______________________ Specify: ______________________ Specify: ______________________ Specify: ______________________ ___ Parent ___ Other children (Specify) _____________ Other: _______________________________________________ 4. Are there times of the day when challenging behavior is least likely to occur? If yes, what

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110 are they? ___ Waking up ___ Morning ___ Before meals ___ Afternoon ___ During meals ___ Nap time ___ After meals ___ Evening ___ Prepare meals ___ Bedtime Other: ____________________________________________________ 5. Are there specific activities when challenging behavior is least likely to occur? What are they? ___ Leaving home ___ Arriving home ___ Family celebrations ___ Church/religious activities ___ Looki ng at books ___ Watching television/device ___ Special event (specify): __ __ ___ ___ Nap time ___Toileting/diapering ___ Bathing ___ Toothbrushing ___ Play group/classes ___ Eating out ___ Visiting others ___ Snack ___ Interactions with sibling/child ___ Indoor play ___ Outdoor play ___ Meals ___ In the car/bus ___ At a store ___ Park/playground ___ Taking Medicine ___ Medical procedure ___ At doctor or therapist ___ At dentist ___ Children's attractions (e.g., zoo) ___ Transiti ons (specify) ____ _______ Other: _______________________________________________________

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111 PTR F Assessment: Teach C hecklist Challenging behavior: Noncompliance Person responding: Mother and Father Child: Olivia 1. What communication skill(s) (using words, pictures, signs, augmentative systems) could the child learn in order to reduce the likelihood of the challenging behavior occurring in the future? ___ Asking for a break ___ Asking for help ___ Requesting wants and needs ___ Expressing emotions (e.g., frustration, anger, hurt) ___ Expressing aversions (e.g., "No," "Stop") _X__ Expressi ng preference when given a choice (e.g., "Yes, I like that," "I want the _____ one." Other: _________________________________________________________ 2. What social skill(s) could the child learn in order to reduce the likelihood of the challenging behavior occurring in the future? ___ Getting attention appropriately ___ Sharing giving a toy ___ S haring asking for a toy ___ Taking turns ___ Beginning interactions with peers and adults ___ Responding or answering peers and adults ___ Staying on topic with peers and adults in a back and forth exchange ___ Offering a play idea ("You be the mommy") ___ Playing appropriately with toys and materials with peers ___ Accepting positive comments and praise ___ Making positive comments ___ Giving praise to peers ___ Waiting for acknowledgment or r einforcement ___ Skills to develop friendships Other: _________________________________________________ ________________ 3. What problem solving skill(s) could the child learn in order to reduce the likelihood of the challenging behavior occurring in the future? ___ Controlling anger ___ Controlling impulsive behavior ___ Strategies for calming down ___ Asking for help __ X Using visuals to support independent play ___ Self management ___ Playing independently ___ Playing cooperatively _X Following directions X __ Following schedules and routines ___ Accepting "no" ___ Managing emotions ___ Getting engaged in an activity ___ Staying engaged in activities X __ Choosing appropriate solutions (child independently generates solution) X __ Making choices from appropriate options (family presents child with limited r easonable options and child chooses one) X __ Following through with choices Other: Comply with less reminders

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112 Additional comments not addressed: Calming a level of anxiety. Babysitter (we wouldn't tell her unless it was happening) will warn 3 to 4 times during the day and there seems to be less issue when the babysitter is coming (low level anxiety of not understanding what is going on around her) directly related to the communication (not always comfortable asking questions to others, so if we're not around she can't get the answers she wants)

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113 PTR F Assessment: Reinforce Checklist Challenging behav ior: Noncompliance Person responding: Mo ther and Father Child: Olivia 1. What consequence(s) usually follow your child's challenging behavior ? __X_ Sent to time out ___ Sent to bedroom _X__ Sent to quiet spot/corner ___ Gave personal space _X__ Delay in activity _X__ Activity changed ___ Activity ended ___ Removed from activity ___ Calming/soothing ___ Talk about what just happened ___ Spanking __X_ Assistance Given __X_ Verbal Warning ___ Verbal redirect __X_ Verbal reprimand/scolding ___ Review house rules __X_ Physical guidance ___ Sibling/peer reaction ___ Physical restraint ___ Gets desired item/toy/food _X__ Gets access to desired activity (acknowledge and move on, sometimes give hugs) Other: 2. What is the likelihood that privileges or preferred items/activities are removed from your child following your child's challenging behavior? _____ Ver y Likely _____ Sometimes __X___Seldom _____Never The step before yelling if you do not get into the bath, I am taking away (after asked, warned, I'm serious) then she'll do it (if we could do the 4 steps before all chaos, we'd all be much happier compliant before having to do this) 3. What is the likelihood of your child's challenging behavior resulting in acknowledgment (e.g., reprimands, corrections, restating house rules) from adults and children? __X_ __ Very Likely _____ S ometimes ___ __Seldom _____Never 4. Does the challenging behavior seem to occur i n order to gain attention from other children (e.g., siblings, peers)? ___ Yes List specific children _______ _______________ _________________________ ___ No 5. Does the challenging behavior seem to occur in order to gain attention from adults? __X_ Yes List specific adults _____ _______________ ___________________________ ___ No 6. Does the challenging behavior seem to occur in order to obtain objects (e.g., toys, games, materials, food) from other children or adults? ___ Yes List specific objects _____ ___________ _______________________________ ___ No

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114 7. Does the challenging behavior seem to occur in order to delay a transition from a preferred activity to a nonpreferred activity? _X__ Yes List specific transitions ______________________________________ ___ No 8. Does the challenging behavior seem to occur in order to terminate or delay a nonpreferred (e.g., difficult, boring, repetitive) task or activity? _X Yes List specific tasks or activities _____________ ____ ___ __________________ ___ No 9. Does the challenging behavior seem to occur in order to get away from a nonpreferred child or adult? ___ Yes List specific children or adults __________________ _____________________ ___ No 10. What is the likelihood of your child's appropriate behavior (e.g., participating appropriately; cooperation; following directions) resulting in acknowledgment or praise from adults or children? ___ __ Very Likely _X___ Sometimes _____Seldom _____Never 11. Does your child enjoy praise from adults and children? Does your child enjoy praise from some people more than others? _X__ Yes List specific people _______________ _______________________________ ___ No 12. What items and activities are most enjoyable to the child? What items or activities could serve as special rewards? _X_ Social interaction with adults _X_ Physical interaction with adults (rough housing, tickle, cuddle) __X_ Social interaction with siblings/peers ___ Playing a game _X Parent helper ___ Extra time outside _X_Extra praise and attention from adults ___ Extra time in preferred activity __X_ High fives __X_ Praise from adults _X Praise from siblings/other kids ___ Music ___ Puzzles ___ Books ___ Special activity _X_ Special helper ___ Computer time ___ Television time _X_ Small toys, prizes (such as stickers, or stamps) _X_ Device time (e.g. tablet, electronic game system) ___ Art activities (such as drawing pictures, painting, etc.) ___ Objects/Toys: (specify ) _______________ ___ Food: (specify)_________________ Other(s): ice cream (going out for ice cream), running special errands, doing things all by herself, helping out/doing chores

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115 Having some type of chart # of good things she has to do to get a reward/ time checker (how many more ) Additional comments not addressed above in the Reinforce Component: Time checker, how many sleeps, how many times, what time, when's mommy coming home surprises aren't good for her she likes to understand what's coming next We make a lot of amends, (e.g., helping/doing it for her) can put on her tank top/dress and put on her jammies, we help her do everything (to move the activity forward) certain things we will need to do, but others we don't but we end up doing them because it helps getting dressed Verbal warning not as effective as it is in my brain "you're pushing it" I do think part of the challenging behavior occurs because we are not as disciplined with Olivia as we have been with her sister (soft spot given Olivia's sensitivity and language) "boo boo" you forgot that I have this, so we can't do this

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116 PTR F Assessment Summary Table Child: Olivia Date : Fall 2015

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117

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118 APPENDIX C PTR F Procedural Documents : Nathan and his Family Forms have been adapted from Dunlap, G., Wilson, K., Strain, P., & Lee, J.K. (2013). Prevent Teach Reinforce for Young Children: The Early Childhood Model of Individualized Positive Behavior Support. Baltimore: Paul H. Brookes Publishing Co., Inc. Forms have been modified from Dunlap, G., Strain, P. S., Lee, J., K., Joseph, J. D., Vatland, C., & Fox, L. (in press). Prevent teach reinforce for families of young children with challenging behavior: The home based model of individualized positive behavior support. Baltimore, MD: Brookes. PTR F Goal Sheet Instructions: 1. Identify and write out the child 's challenging behaviors to decrease and the contexts or routines where these behaviors need to impro ve. 2. Select ONE challenging behavior to target within family contexts or routines 3. Operationally define this target behavior observable (seen or heard), and measurable (counted or timed) 4. Identify and write out the child 's desired behaviors to increase 5. Select target desirable behavior (to be completed following PTR F Assessment) 6. Operationally define desirable behavior (to be completed following PTR F Assessment) Child: Nathan Date: Fall 2015 Goals: Challenging Behaviors Behaviors Context/Routines Challenging Behaviors to Decrease Refusals, tantrum behavior Bedtime Target Behavior Tantrum behavior Bedtime Operational Definition Screaming, crying, yelling, hitting, kicking, lying on the floor, stomping feet, attempts to injure others, escaping the routine (e.g., running to other rooms, running to the bed), and refusing to engage in routine expectations (e.g., refusing to stand on the toilet to brush teeth)

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119 Goals: Desirable Behaviors Desirable Behaviors to Increase Let dad do the bedtime routine Follow expectations of routine without tantrum behavior Target Behavior (to be completed following PTR F Assessment) Following the bedtime routine Operational Definition (to be completed following PTR F Assessment) using a quiet voice and following the steps of the bedtime routine (with prompting) without the demonstration of challenging behavior

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120 PTR F Assessment: Prevent Checklist Challenging behavior: Noncompliance Person Responding: Mom and Dad Child: Nathan 1. Are there times of the day when challenging behavior is most likely to occur? If yes, what are they? ___ Waking up ___ Morning ___ Before meals ___ Afternoon X __ During meals ___ Nap time ___ After meals X __ Evening ___ Prepare meals X __ Bedtime Other: Seem to occur at any time. Often associated with "mommy behavior" asking mom to hold him, when he's tired, when he's hungry, (when dad's home) 2. Are there specific activities when challenging behavior is very likely to occur? If yes, what are they? ___ Leaving home ___ Arriving home X __ Family celebrations X __ Church/religious activities ___ Looking at books ___ Watching television/device ___ Special event (specify): ____ _______ ___ Nap time ___Toileting/diapering X __ Bathing X __ Toothbrushing ___ Play group/classes X __ Eating out ___ Visiting others ___ Snack X __ Interactions with sibling/child ___ Indoor play ___ Outdoor play X __ Meals ___ In the car/bus ___ At a store ___ Park/playground __ X Taking Medicine ___ Medical procedure ___ At doctor or therapist ___ At dentist ___ Children's attractions (e.g., zoo) ___ Transitions (specify): ______ _______ Other: When he does not want to do something, if he wants something and it can't happen tests boundaries 3. Are there other children or adults whose proximity is associated with a high likelihood of challenging behavior? If so, who are they? X Siblings X Family member(s) ___ Care provider(s) ___ Other adults Specify:______ _________ Specify: Dad Specify: __________ ____ Specify: _______ _______ __ X Parent ___ Other children (Specify) _____ _____ Other: With mom at bedtime, Mom says, "If I'm not home, he's fine 4. Are there times of the day when challenging behavior is least likely to occur? If yes, what are they? X Waking ___ Before meals ___ During X After Prepare

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121 up X __ Morning ___ Afternoon meals ___ Nap time meals ___ Evening meals ___ Bedtime Other: @ least 30 minutes 5. Are there specific activities when challenging behavior is least likely to occur? What are they? ___ Leaving home X __ Arriving home ___ Family celebrations ___ Church/religious activities ___ Looking at books X __ Watching television/device ___ Special event (specify): _______ ___ __ X Nap time ___Toileting/diapering ___ Bathing ___ Toothbrushing ___ Play group/classes ___ Eating out ___ Visiting others ___ Snack ___ Interactions with sibling/child ___ Indoor play __ X Outdoor play ___ Meals ___ In the car/bus ___ At a store __ X Park/playground ___ Taking Medicine ___ Medical procedure ___ At doctor or therapist ___ At dentist __ Children's attractions (e.g., zoo) ___ Transitions (specify): ________ ____ Other: keep tablets away and only give occasionally (1 time / week); watches PBS Kids in the morning, plays with VReader about 3 times per week; watches a movie 3 4 times / week

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122 PTR F Assessment: Teach C hecklist Challenging behavior: Noncompliance Person Responding: Mom and Dad Child: Nathan 1. What communication skill(s) (using words, pictures, signs, augmentative systems) could the child learn in order to reduce the likelihood of the challenging behavior occurring in the future? ___ Asking for a break ___ Asking for help X __ Requesting wants and needs X __ Expressing emotions (e.g., frustration, anger, hurt) __ X E xpressing av ersions (e.g.,"No," "Stop") __X_ Expressi ng preference when given a choice (e.g., "Yes, I like that," "I want the _____ one." Other: "I need a break," asking brother to stop 2. What social skill(s) could the child learn in order to reduce the likelihood of the challenging behavior occurring in the future? X __ Getting attention appropriately X __ Sharing giving a toy X __ Sharing asking for a toy X __ Taking turns ___ Beginning interactions with peers and adults ___ Responding or answering peers and adults ___ Staying on topic with peers and adults in a back and forth exchange ___ Offering a play idea ("You be the mommy") ___ Playing appropriately with toys and materials with peers ___ Accepting positive comments and praise ___ Making positive comments ___ Giving praise to peers X__ Waiting for acknowledgment or r einforcement ___ Skills to develop friendships Other: ___________________________________________________________ 3. What problem solving skill(s) could the child learn in order to reduce the likelihood of the challenging behavior occurring in the future? X __ Controlling anger X __ Controlling impulsive behavior X __ Strategies for calming down ___ Asking for help ___ Using visuals to support independent play ___ Self management ___ P laying independently ___ Playing cooperatively X __ Following directions X__ Following schedules and routines X __ Accepting "no" X __ Managing emotions ___ Getting engaged in an activity ___ Staying engaged in activities X __ Choosing appropriate solutions (child independently generates solution) __ X_ Making choices from appropriate options (family presents child with limited reasonable options and child chooses one) ___ Following through with choices Other: __________________ Additional comments not addressed:

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123 PTR F Assessment: Reinforce Checklist Challenging behavior: Noncompliance Person R esponding: Mom and Dad Child: Nathan 1. What consequence(s) usually follow your child's challenging behavior ? _X__ Sent to time out ___ Sent to bedroom _X__ Sent to quiet spot/corner ___ Gave personal space ___ Delay in activity ___ Activity changed __X_ Activity ended _X__ Removed from activity _X__ Calming/soothing _X__ Talk about what just happened _X__ Spanking _X__ Assistance Given __X_ Verbal Warning _X__ Verbal redirect _X__ Verbal reprimand/scolding _X__ Review house rules _X__ Physical guidance __X_ Sibling/peer reaction _X__ Physical restraint _X__ Gets desired item/toy/food _X__ Gets access to desired activity Other: 2. What is the likelihood that privileges or preferred items/activities are removed from your child following your child's challenging behavior? _____ Ve ry Likely __X___ Sometimes __X _Seldom _____Never 3. What is the likelihood of your child's challenging behavior resulting in acknowledgment (e.g., reprimands, corrections, restating house rules) from adults and children? __X___ Very Likely _____ Sometimes ____ _Seldom _____Never 4. Does the challenging behavior seem to occur in order to gain attention from other children (e.g., siblings, peers)? __X_ Yes List specific children ___ No 5. Does the challenging behavior seem to occur in order to gain attention from adults? _X__ Yes List specific adults Mom ___ No 6. Does the challenging behavior seem to occur in order to obtain objects (e.g., toys, games, materials, food) from other children or adults? _X__ Yes List specific objects mom's phone, tablet, "anything he wants that he's not getting" ___ No 7. Does the challenging behavior seem to occur in order to delay a transition from a preferred activity to a nonpreferred activity? ___ Yes List specific transitions _X__ No

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124 8. Does the challenging behavior seem t o occur in order to terminate or delay a nonpreferred (e.g., difficult, boring, repetitive) task or activity? _X__ Yes List specific tasks or activities bedtime, meals ___ No 9. Does the challenging behavior seem to occur in order to get away from a nonp referred child or adult? __X_ Yes List specific children or adults Does not want dad to do anything, just mom (when mom's home) ___ No 10. What is the likelihood of your child's appropriate behavior (e.g., participating appropriately; cooperation; follo wing directions) resulting in acknowledgment or praise from adults or children? _____ Very Likely __X___ Sometimes __X___Seldom _____Never 11. Does your child enjoy praise from adults and children? Does your child enjoy praise from some people more than others? ___ Yes List specific people __X_ No 12. What items and activities are most enjoyable to the child? What items or activities could serve as special rewards? ___ Social interaction with adults _X_ Physical interaction with adults (rough housing, tickle, cuddle) ___ Social interaction with siblings/peers ___ Playing a game ___ Parent helper ___ Extra time outside ___Extra praise and attention from adults _X__ Extra time in preferred activity __X_ High fives ___ Praise from adults ___ Praise from siblings/other kids ___ Music ___ Puzzles ___ Books ___ Special activity ___ Special helper ___ Computer time ___ Television time ___ Small toys, prizes (such as stickers, or stamps) __X_ Device time (e.g. tablet, electronic game system) __X_ Art activities (such as drawing pictures, painting, etc.) _X__ Objects/Toys: (specify ) cars, animals, play doh, sand ___ Food: (specify) ___ ____ Other(s): flash cards, electronics Additional comments not addressed above in the Reinforce Component:

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125 PTR F Assessment Summary Table Child: Nathan Date: Fall 2015

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126

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127 APPENDIX D Family Behavior Rating Scales C hild: _____________ Rater: _____ _________ Routine : _________ _____ Complete this each day following the occurrence of the routine.

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128 APPENDIX E Social Validity Questionnaire Parental Self Evaluation: Evaluation, Monitoring, and Maintenance Social Validity Please score each item by circling the number that best indicates how you feel about the PTR intervention(s). 1. Given your child's challenging behavior, how acceptable do you find the PTR behavior plan? 1 2 3 4 5 Not at all Neutral Very acceptable Acceptable 2. How willing are you to carry out this behavior plan? 1 2 3 4 5 Not at all Neutral Very willing Willing 3. To what extent do you think there might be disadvantages i n following this behavior plan? 1 2 3 4 5 None Neutral Many likely Likely 4. How disruptive is it to carry out this behavior intervention plan? 1 2 3 4 5 Not at all Neutral Very D isruptiv e Disruptive 5. How much do you like the procedures used in the proposed behavior plan? 1 2 3 4 5 Do not like Neu tral Like them T hem at all V ery much

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129 6. To what extent are undesirable side effects likely to result from this behavior plan? 1 2 3 4 5 No side Neutral Many side Effects likely effects likely 7. How much discomfort is your child likely to experience duri ng this behavior plan? 1 2 3 4 5 No discomfort Neutral Very much A t all D iscomfort 8. How well does this behavior plan fit into the existing routine? 1 2 3 4 5 Not at all Neutral Very well Well 9. How effective is the intervention in teaching your child appropriate behavior? 1 2 3 4 5 Not at all Neutral Very effective effective 10. How well does the goal of the intervention fit with your family's goals to improve your child's behavior? 1 2 3 4 5 Not at all Neutral Very much ----------------------------------------------------------------------------------------------------------------------------------------------------Do you have any additional comments to make about the in tervention and its effect on your child and/or family ? For example, does your child seem to do better in other routines not targeted for the intervention? (Adapted from the TREATMENT ACCEPTABILITY RATING FORM R EVISED; TARF R, Reimers & Wacker, 1988; PTR YC Teacher Social Validity Evaluation)

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130 APPENDIX F Figure 2 Percentage of desirable behavior for Henry across study phases. Figure 3 Percentage of desirable behavior for Olivia across study phases.

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131 Figure 4 Percentage of desirable behavior for Nathan across study phases.

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132 APPENDIX G Figure 10 Family BRS ratings for Henry across study phases. Figure 11 Family BRS ratings for Olivia across study phases.

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133 Figure 12 Family BRS ratings for Nathan across study phases.