1983; Upshur, 1982; Webb et al., 1984).. Con- tributing to this problem is a lack of competency- based, experimentally validated respite care training programs ...
JOURNAL OF APPLIED BEHAVIOR ANALYSIS
1991,24,473-486
NUMBER
3 (FAU 199 1)
VIDEO-BASED TRAINING OF RESPITE CARE PROVIDERS: AN INTERACTIONAL ANALYSIS OF PRESENTATION FORMAT
NANCY A. NEEF DEVEREUX INSTITUTE OF CLINICAL TRAINING AND RESEARCH AND CHILDREN S SEASHORE HOUSE
AND
SYMME TRACHTENBERG, JUDITH LOEB,
AND
KIMBERLY STERNER
CHILDREN S SEASHORE HOUSE
We conducted two studies to evaluate a video-based instructional package for training respite care providers and the role of presentation format (viewing the videotapes alone, with a partner, and with structured group training) as a contextual variable. In Study 1, the results of a within-subjects Latin square design nested within a multiple baseline showed that performance during simulated (role-played) respite care situations improved in five of the six skill areas for the 12 trainees following presentation of the videotape, with no differences between presentation formats. Correct responding generalized to respite care situations involving a developmentally disabled child, and in most cases, acquired skills were maintained for up to 6 months. In Study 2, we conducted a clinical replication of Study 1 under conditions more dosely approximating those in which the training program would be implemented by respite care agencies. Results of the between-groups analysis were consistent with the findings of Study 1. DESCRIPTORS: respite care, video-based training, contextual variables, experimental design, staff training
The day-to-day care of children with severe disabilities can be inordinately stressful for families because of the extended duration, intensity, and unchanging pattern of responsibilities (Cohen & Warren, 1985). There is some evidence to suggest that the provision of respite care can attenuate the risks of family dysfunction, social isolation, negative attitudes toward the family member with disabilities, and, ultimately, placement of the family member with disabilities outside the home (Apolloni & Trieste, 1983; German & Maisto, 1982; Joyce, This research was supported in part by USDE/OSERS Grant G00873006 1. However, the opinions expressed herein do not necessarily reflect the position or policy of that agency, and no official endorsement by the U.S. Department of Education should be inferred. We gratefully acknowledge the assistance of our advisory board members in the design of the curriculum, of Lenore Stem in conducting assessments, of Doran Shade in constructing the graphs, and of Gregg Macmann and Fran Mues in the preparation of this manuscript. Requests for reprints can be sent to Nancy A. Neef, The Devereux Foundation, Institute of Clinical Training and Research, 19 South Waterloo Rd., Devon, Pennsylvania 193330400.
Singer, & Israelowitz, 1983; Lawson, Connolly, Leaver, & Englisch, 1979; Pagel & Whitling, 1978; Webb, Shaw, & Hawes, 1984; Wilker, 1981). One of the most serious and commonly reported problems related to both the availability and use of respite care services is the lack of adequately trained personnel (Cohen & Warren, 1985; Cutler, 1986; Neef & Parrish, 1989; Salisbury & Griggs, 1983; Upshur, 1982; Webb et al., 1984).. Contributing to this problem is a lack of competencybased, experimentally validated respite care training programs and materials (Salisbury & Griggs, 1983). Neef, Parrish, Egel, and Sloan (1986), in a series of four experiments, evaluated a curriculum based on a self-directed instructional manual for training respite care providers. Although the self-instruction manual was an effective means of training, reading can be a relatively time-consuming and effortfil means of acquiring information, making it difficult to attract and retain recruits. The design of training products responsive to the habits and preferences of consumers may have greater appeal for potential program adopters. The popularity of television and
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NANCY A. NEEF et al.
video media relative to books, for example, suggests that many people prefer watching and listening than the more effortful activity of reading (e.g., Salomon, 1984). Thus, one promising means of training respite care providers is through the use of videotapes. Instructional videotapes are easily duplicated and exported and, properly packaged, may be useful to agencies with limited financial resources and technical expertise. Although videotapes, usually in the context of modeling, have been shown to produce behavior change (e.g., Winett, Kramer, Walker, Malone, & Lane, 1988), a number of factors may influence their effectiveness. There has been increasing recognition that the effects of procedures inevitably are subject to multiple sources of control that must be identified for a procedure to be optimally applied (Baer, Wolf, & Risley, 1987; Hains & Baer, 1989; Haring & Kennedy, 1990; Johnston, 1988; Van Houten, 1987). Winett et al. (1988), for example, using a between-subjects design, found that videotaped modeling was more effective than a videotaped lecture, particularly when combined with feedback and goal setting, in modifying consumer food purchases. Presentation format represents another potentially important contextual factor. Alternative formats emphasize different learning processes. For example, viewing a videotape alone permits selfpacing (reviewing selected material when and as often as desired); viewing a videotape with a partner provides an opportunity for private discussion and practice of the skills presented; and presentation of the videotape material in a structured group format affords supervised control of the process. Information on the extent to which presentation format differentially modulates the effectiveness of the videotape program is important in determining the optimal conditions and flexibility with which the program can be used by agencies. Therefore, we conducted two studies to determine the effectiveness of a video-based instructional package for training respite care providers and to analyze the role of presentation format (viewing the videotapes alone, with a partner, and in the context of a structured group training format) as a contex-
tual variable in influencing the effectiveness of the videotape in facilitating skill acquisition.
STUDY 1 MFXHOD
Participants
Respite care trainees were recruited and referred by three human service agencies. Participants were selected based on the following criteria: (a) granting of informed consent, (b) age 18 years or older, and (c) availability for and interest in providing respite care. The group of trainees from the first agency consisted of 4 females, 21 to 52 years old (M = 34). The education level ofthe trainees ranged from 11 to 14 years (M = 12), and they had from 1 to 10 years (M = 7) of experience with developmentally disabled children, either as family members or in a paraprofessional capacity. The group of trainees from the second agency consisted of 3 females and 1 male, 30 to 50 years old (M = 39), with 12 to 13 years of education and 0 to 15 years of experience with developmentally disabled children (M = 6.5) as either a parent or a paraprofessional. The third group of trainees consisted of 2 males and 2 females, 25 to 32 years old (M = 29), with 12 to 14 years of education (M = 12.5) and 0 to 7 years of experience (M = 2.3) working in paraprofessional positions with developmentally disabled children. Trainees were awarded a certificate and paid $75 (for probe sessions) contingent upon successful completion of the program.
Target Behaviors Target respite care behaviors, which previously had been validated (Neef et al., 1986), were updated and reviewed by 10 respite care agency coordinators and a representative from the American Red Cross. These skills were then recategorized into six areas: (a) preparation (e.g., soliciting key information from caretakers, recognition and use of basic manual communication signs), (b) daily routines (maximizing educational opportunities, managing bedtime, toileting, and mealtime routines, induding feeding children with oral-motor difficulties), (c) behavior management (preventing and
VIDEO-BASED TRAINING managing behavior problems, use of safety main cases of physical aggression), (d) physical/medical management (positioning and handling, transfers, and medication), (e) emergencies (seizures, choking, poisoning, and other medical emergencies), and (f) parent return (reporting information). Task analyses of each ofthe target skills yielded 48, 26, 21, 36, 39, and 5 behaviors in the respective areas. To meet mastery criteria, trainees were required to perform 100% of the behaviors rated as crucial by the advisory board and at least 90% of the remaining behaviors. (Target behaviors and their ratings are available from the first author.) neuvers
Self-Instructional Videotape An instructional videotape was developed for each of the six skill modules of the validated curriculum (Neef & Parrish, in press). The format for each module consisted of behavioral objectives, introduction, management strategies, examples of and rationale for the strategies, a quiz (consisting of freeze-framing vignettes, asking for the appropriate response, pausing, providing or illustrating the correct response, and continuing the process for each subsequent question), and a review. Accompanying guidelines for presenting and viewing the videotapes consisted of one to three pages per module, suggesting points at which to stop the videotape for review and specific exercises to practice the target skills alone or with a partner to enhance mastery. (Revised versions of the assessment materials and video guidelines used in this study can be obtained from Research Press.) Setting and Stimuli The study was conducted in a room of the service agency from which the groups of trainees were referred. The room was furnished at minimum with a table and chairs, a cot (bed), and adjacent bathroom facilities. It was equipped with various portable stimuli commonly found in a home setting that were necessary for target responses to occur (e.g., a telephone, snack items of various textures, dishes and utensils, play materials, and medication bottles with simulated contents). For situations involving a physically disabled child, stimuli included
475
a wheelchair, a medically related or therapeutic piece of equipment, and a large doll with moveable limbs.
Probes Simulation probes. Performance of target skills was assessed via simulated respite care probes, during which one of the experimenters (a social worker) alternately role-played the part of a parent, a child with disabilities (the doll was substituted where appropriate), and other miscellaneous persons (e.g., emergency personnel). Simulations were guided by one of four scripts, which varied according to the characteristics of the child (e.g., the age, handicapping conditions, functioning level, communication system, adaptive devices used), topography of behavior problems, routines, and sequence of events represented. The different scripts were used in an arbitrary order across probe sessions for each participant. At the end of each script, behaviors that could not be represented "in character" (e.g., manual communication signs in a script involving a vocal child) were probed in isolation so that all target skills could be assessed. Each probe session lasted 30 to 60 min, depending on how many of the target behaviors the trainee performed, and simulated approximately 4 hr of respite care. Probes were otherwise conducted in the same manner as described by Neef et al. (1986). After the experimenter described the general characteristics and requirements of the role-play situation, a probe was begun with the initiation of a "respite care assignment" at the "home" of a new "client." The "parent" provided scripted answers to questions but did not initially volunteer essential information; this allowed determination of whether the trainee would solicit it. Following the parent's departure, scripted events were presented to permit observation of responses to the child's routine (e.g., play, mealtime, medication, toileting, bedtime) as well as to unpredictable occurrences (e.g., medical emergencies). After the occurrence of all scripted events, the parent returned "home," providing an opportunity for key information to be reported. Upon "exit" of the care provider, remaining target behaviors (i.e., for which there was no natural context in the script
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NANCY A. NEEF et al.
for that character) were assessed as indicated above. At the completion of the probe, the trainee was praised for his or her efforts without reference to performance of specific target responses. Generalization probe. Generalization probes were conducted following the completion of training to assess trainee performance in an actual respite care situation. Probes occurred during the first hour of a respite care assignment involving a developmentally disabled child registered with the referral agency (the assigned family differed for each trainee). Applicable target behaviors (i.e., those occasioned by naturally occurring stimulus conditions) were scored by one or two of the experimenters who accompanied the trainee during this period. The experimenter(s) remained as unobtrusive as possible and, except for minimal social conversation to put them at ease, refrained from interacting with the child or the trainee. Maintenance probe. Maintenance probes were conducted 1 to 6 months after the completion of training to assess the durability of acquired skills, particularly those not likely to be frequently required in natural situations (e.g., emergency procedures). A modified script was used to sample the target behaviors in each skill area. Otherwise, procedures were the same as for pre- and posttraining simulation probes. Two of the 12 trainees (TiC and T2B) were not available at the time maintenance probes were scheduled. Data Collection and Reliability During probes, the experimenter recorded each of the applicable target behaviors as correct or incorrect. Behaviors not performed when required or not performed properly as defined in the task analysis were scored as incorrect. Interobserver agreement was assessed during 50% of the probe sessions, for each participant and in each condition, by having two persons independently observe and record the trainee's performance. Primary and reliability observers' records were compared on a per-response basis, and reliability scores were computed by dividing the number of agreements by agreements plus disagreements and mul-
tiplying by 100%. Interobserver agreement averaged 93.6% (range, 82% to 100%). Trainee Satisfaction Measures of trainee satisfaction with the training program were obtained via a questionnaire, adapted from one developed by Larsen, Attkisson, Hargreaves, and Nguyen (1979). Participants were asked to rate anonymously their satisfaction with the training on a Likert-type scale (1 to 4). The questions included ratings of (a) the quality of training, (b) the kind of training, (c) the extent to which training met the respondent's needs, (d) whether the respondent would recommend the program to a friend with similar needs, (e) the amount of training, (f) the effectiveness of training, (g) overall satisfaction with the training, and (h) whether the respondent would choose the training program again if seeking assistance. The participants were also asked to comment on various aspects of the training program and to indicate the preferred presentation format. Questionnaires were returned by all participants. Training Procedures For training purposes, the six skill modules were paired into three sets, with each pair containing a similar number of target behaviors. Following stable performance on baseline probes, each trainee was given the videotapes for the first set of two skill modules (preparation and parent interaction) in one of three different presentation formats. With the individual format, the trainee was given the videotapes and viewer guidelines for the respective skill modules and was shown how to operate the VCR. He or she was instructed to view the videotape alone at whatever pace and as many times as desired, using the viewer guidelines, until he or she had mastered the skills specified in the behavioral objectives at the beginning of the videotape. With the partner presentation format, the procedure was the same except that trainees were paired and instructed to view the videotape and practice the skills together according to the guidelines. With the group presentation format, all trainees attended
VIDEO-BASED TRAINING
477
Table 1 a structured training session ranging from 2 to 3 Ordinal Position of Treatment Across Response Sets hr (depending on the skill modules presented), during which the experimenter followed the format 1 2 3 specified in the accompanying guidelines for viewT x I Tx 2 Tx 3 Group I ing and presenting the videotape. At indicated points 2 Tx 3 Group T x I Tx 2 she stopped the videotape, supervised practice exTx 2 Tx 3 T x I Group 3 ercises (e.g., in which each member alternately dem- Note. T X I = individual format; T X 2 = partner format; onstrated the target procedure on a doll or group and T X 3 = group format. member and constructively critiqued another member's performance), and led a discussion of the key and orders of treatment within a 3 X 3 X 3 points. square), as shown in Table 1. Each square represents If the trainee did not meet mastery criteria during a unique configuration of the three elements (varisubsequent probes for the skill areas trained, re- ables) to permit efficient sampling of the combimedial training was provided. The experimenter nations of conditions. modeled the appropriate target behaviors and then REsuLrS AND DISCUSSION provided contingent praise and corrective feedback Figures 1 through 3 show the results of the for trainee performance. This process was repeated until correct performance was demonstrated. multiple baseline across behaviors and subjects for Videotaped training using another of the three each of the three groups of trainees, respectively. presentation formats was then conducted for the These data represent the percentage of correct renext set of skills (daily routines and behavior man- sponses on simulation, generalization, and mainagement), followed by a posttraining probe and tenance probe sessions across pairs of skill modules remedial training as necessary. The process was then for each of the 4 trainees (TA, TB, TC, and TD) repeated, using the remaining presentation format, within each group (1, 2, and 3). Results show that, for the final two skills areas (physical/medical man- in most cases, performance increased upon presenagement and emergencies). Training was initially tation of the videotape training program. The perterminated when the performance criteria were met centage of total correct responses averaged across in all skill areas on a simulation probe. However, trainees increased from a mean of 40.6% during remedial training (as described above) was subse- baseline to 80.8% following video-based training quently provided for skills not performed correctly (before remedial training). The exceptions were in on maintenance probes. the area of parent interaction (see T3A, T3B, and T3D in Figure 3), and may have been an artifact Experimental Design of the probe procedure (i.e., because so many events This study used a within-subjects Latin square were consolidated in the simulated respite care design nested within a multiple baseline (across probes, it may have been difficult to remember behaviors and subjects). Specifically, video-based which occurred "in character" or had already been instruction was implemented successively across the reported to the "parents"). In addition, the five three pairs of skill modules, each presented with a target behaviors in this skill module by necessity different presentation format (individual, partner, occurred at the end of the probe when the trainee and group); the instructional format used for a was most likely to be fatigued. The magnitude of particular pair ofskill modules was counterbalanced the increases varied across skill modules and was across the three groups of trainees. Thus, the Latin not associated with any one type of presentation square aspect of the design involved the arrange- format, with the possible exception of TIA (see ment of three levels of each of three experimentally Figure 1); she improved the least on skills trained relevant variables (groups, treatment conditions, with the partner format.
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NANCY A. NEEF et al.
Although videotape training alone resulted in performance increases (as reflected by the first posttraining probe), remedial training was almost always necessary. In some cases involving the first two pairs of skill modules, however, performance increases following videotape training were not maintained or did not improve with remedial training during the next probe session (e.g., behavior management for T1A). This might be attributable to the fact that the next probe was conducted 1 to 2 weeks after remedial training in the previous skill modules (if criteria had not been met following videotape training) and after new skills (in the subsequent pair of modules) had been introduced. Continued remedial training, however, appeared to enhance the durability of acquired skills, as evidenced by subsequent improvements in performance on probes. The mean percentage of correct responses on skills for which remedial training was provided was 88.4%, 94.9%, and 98.3% across consecutive posttraining probes. Effects were generally maintained for up to 6 months, as indicated by performance on maintenance probes, although there were exceptions (most notably in the areas of parent interaction and physical/medical management for TiA, parent interaction for TIB, and parent interaction and physical/medical management for T3C). The mean percentage of correct responses on maintenance probes (for all skill areas across trainees) was 90.1% and ranged from 76.2% (T1B) to 97.7% (T2A and T2C). In addition, the generalization probe data show a high percentage of correct responses for target skills performed during observations of an actual respite care situation (M = 98.7%). These data suggest that skills demonstrated during simulation probes following videotape and remedial training generalized to criterion situations. The results of the contextual analysis are summarized in Figure 4. These data show the difference between the mean percentage of correct responses during baseline and the first probe following videotape training, with the three presentation formats counterbalanced across skill modules for the participants in each group. No consistent differences
associated with either the presentation format or skill module are apparent. Furthermore, with the exception of parent interaction, there was no consistent pattern of errors across participants to suggest modification of specific aspects of the program as an alternative to individualized remedial training. The results of the social validation assessment indicate that the trainees were quite satisfied with the training program. On a scale of 1 to 4 (with 4 being most favorable), all trainees rated each of the eight dimensions at 3 or above (M = 3.7), with the exception of one rating of 2 to the question regarding satisfaction with the amount of training received. Of the 10 trainees who responded to the question regarding their preference for type of presentation format, 4 indicated that they had no preference (e.g., that each format presented different advantages). Individual, partner, and group formats were rated as most preferred by 2, 3, and 1 of the trainees, respectively. All participants commented favorably on the content, format, and usefulness of the videotape as a training tool (e.g., the demonstration and practice opportunities made the information easy to understand). Two additional comments were that too much information was presented to digest easily, and that the children portrayed were not sufficiently representative of the range of clients likely to be served. All trainees indicated that the hands-on remedial exercises were an important part of training (e.g., it helped to "reinforce information" and "refine skills learned" from the videotape, and that "personal interaction with the trainer" was helpful). The most frequent comments regarding the most- and least-liked aspects of the program, respectively, centered upon the usefulness of the training and the repetitive role-play assessments with no feedback. STUDY 2 The purpose of Study 2 was to conduct a clinical replication of Study 1 (i.e., under conditions more closely approximating those in which the training program would be implemented by respite care agencies).
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VIDEO-BASED TRAINING
Reliability
METHOD
Participants and Setting The participants were 10 females and 2 males, referred by three human service agencies serving clients with developmental disabilities. Participants were selected according to the same criteria described for Study 1. The 4 trainees in one group (individual format) ranged in age from 29 to 35 years (M = 32.5) and had 12 to 18 years of education (M = 15.5). One trainee had no prior experience with developmentally disabled children, and the others had at least 3 years of experience providing direct care (e.g., as a foster parent). The 4 trainees in the second group (partner format) ranged in age from 19 to 51 years (M = 33.3) and had 10 to 12 years of education (M = 11.5). Three of the trainees in this group had no prior experience with developmentally disabled individuals, and the other was the parent of a developmentally disabled child. The 4 trainees in the third group (group format) ranged in age from 26 to 58 (M = 38), had completed at least 4 years of college, and had at least 3 years of experience in caring for children with disabilities. The study was conducted in settings similar to those described in Study 1. Procedures and Experimental Design Groups of participants were randomly assigned to one of the three training presentation conditions as described in Study 1. Following the administration of a baseline simulation probe, videotape training was conducted sequentially in each of the skill areas using the assigned presentation format. After videotape training had occurred for the final skill area,
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Interobserver agreement was assessed for 25% of the probe sessions, in the same manner as described in Study 1. Agreement scores ranged from 85.1% to 100%, with a mean of 94.7%. REsuLS AND DISCUSSION Figure 5 shows the percentage of correct responses on probes for each trainee, across experimental conditions (pre- and posttraining, remedial training, and generalization). The results are consistent with those of Study 1. For each of the three presentation formats, performance improved substantially following videotape training, with the only exceptions occurring in the skill area of parent interaction (TIA, T1B, T2A, and T3B). The mean increase in the percentage of total correct responses following videotape training was 35.5% for the individual format group (range, 28.9% to 45.3%), 47.6% for the partner format group (range, 45.3% to 51.2%), and 43.6% for the group format trainees (range, 32.4% to 52.3%). Even though the mean percentage increase in the individual format condition was approximately 10 points lower than that obtained for the other two groups, an analysis of variance (ANOVA) indicated that the three groups did not differ significantly in terms of total change, F = 3.14, df = 2, p > .05. Moreover, follow-up ANOVAs revealed that the 10-point difference in total change was attributable almost exciusively to the behavior management skill module, F = 6.01, df = 2, p < .05, with no consistent pattern of between-group differences evident across the other five dependent measures. Remedial training, which was usually required for mastery (the exceptions were in the skill areas of preparation for T3C, parent interaction for T2D and T3C, and in physical/medical management for T3D), resulted in 100% correct responding in most cases. For all trainees, acquired skills also occurred when performed in an actual respite care situation; the percentage of total correct responses on generalization probes ranged from 98.4% to 100%.
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PROBES: LI GENERALIZATION PRE POST REMEDIAL Figure 5. The percentage of correct responses across skill modules on baseline, posttraining, remedial training, and generalization probes for each trainee in the individual, partner, and group presentation format groups.
GENERAL DISCUSSION The two studies reported here systematically extended the findings of Neef et al. (1986). The results demonstrated that an instructional videotape (when combined with individualized remedial training) can be an effective alternative to the use of printed training materials in the acquisition of respite care skills. The uniformly positive ratings obtained with the assessment of trainee satisfaction supports the appeal of the videotape training to consumers. Despite their conveniences, however, videotape materials cannot be modified as easily as printed instructional materials (e.g., on the basis of evaluation data). The necessity for remedial training (guided by idiographic error patterns) substantiates the importance of performance-based assessment and cor-
rective feedback as a component of effective care provider training programs (e.g., Alavosius & Sulzer-Azaroff, 1990). The savings in trainer time and cost that accrue through the use of packaged videotape instructional programs could be used to provide remedial training in individualized areas of need. Only 15 to 45 min of remedial training were required for any of the participants to reach criteria. (This does not include, however, the 30- to 60min simulation probes used to assess performance.) Although acquired skills were generally maintained for up to 6 months, the occurrence of some performance decrements indicates that periodic booster sessions may be important. On the other hand, consistently high levels of generalization were attained in actual respite care situations, which were undoubtedly less demanding than the simulations. Although the reactivity of the assessment method
VIDEO-BASED TRAINING
limits inferences regarding routine performance, Alavosius and Sulzer-Azaroff (1990) pointed out that natural contingencies associated with caregiver tasks may help to maintain acquired skills in those environments.
The results also suggest that presentation format did not differentially influence the effectiveness of videotape training and, therefore, that there is considerable flexibility for its use within either a selfdirected (individual and partner formats) or trainerdirected (structured group format) instructional context. Although the integrity of implementation (e.g., the extent to which the video guidelines were followed in viewing the videotapes) was not assessed, the results suggest that the instructional videotape may be effective even when implemented under conditions in which there is little experimenter control over the trainee's behavior (i.e., when viewing it privately or with a partner). Future research is needed to examine the generality of these findings, given that the effects of presentation format may differ with variations in the instructional aspects of videotape programs (e.g., didactic instruction vs. guided participatory viewing). Finally, this study demonstrated a useful and efficient methodology for exploratory analyses of interaction effects (cf. Neef, Lensbower, Hockersmith, Gray, & DePalma, 1990). The within-subjects Latin square design nested within a multiple baseline extends the analytic power of single-subject designs to the analysis of multiple independent variables. Further research is needed to evaluate the generality of inferences about interaction effects in relation to fulfl factorial single-subject designs (e.g., Hains & Baer, 1989). Although the relative sensitivity of the present design has not been demonstrated, the relative efficiency is dear. REFERENCES Alavosius, M. P., & SuLzer-Azaroff, B. (1990). Acquisition and maintenance of health-care routines as a function of feedback density.Journal ofApplied Behavior Analysis, 23, 151-162. Apolloni, A., & Trieste, G. (1983). Respite services in California: Status and recommendations for improvement. Mental Retardation, 21, 240-243. Baer, D. M., Wolf, M. M., & Risley, T. F. (1987). Some
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