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BEHAVIORTHERAPY33, 65-86, 2002

The Development and Application of Individualized Levels Systems for the Treatment of Severe Problem Behavior Louis E HAGOPIAN KARENA S. R U S H DAVID M . RICHMAN PATRICIA E KURTZ STEPHANIE A . CONTRUCCI KIMBERLY CROSLAND

The Kennedy Krieger Institute and The Johns Hopkins University School of Medicine Behavioral levels systems are commonly used in a variety of settings and are usually applied at the group level to promote socially desirable behavior and compliance with institutional rules. Despite their widespread use, however, there is surprisingly little empirical data supporting the effectiveness of these interventions. In addition, some researchers have suggested that such group-based interventions may not be consistent with laws mandating individualized educational programming. The current investigation examined the effectiveness of individualized levels systems for decreasing severe problem behaviors exhibited by 4 individuals with developmental disabilities. An individualized multilevel system was developed for each participant based on functional analysis and preference assessment results. These interventions were highly effective in decreasing problem behaviors for each participant. For 2 participants, a component analysis was conducted to identify the necessary components of the levels system. Generalization and care provider training were conducted for all participants. The results suggest that levels systems based on functional analysis and preference assessment results can be effectively generalized and implemented by care providers with good treatment integrity. This approach is presented as a potential alternative to the group-based levels systems that are described in the literature and commonly applied in the community.

The authors would like to acknowledge Daniel Hendrickson, Alicia Perry, and Mary Augustin for their assistance with these clients. Address correspondence to Louis Hagopian, Ph.D., Department of Behavioral Psychology, Kennedy Krieger Institute, 707 N. Broadway, Baltimore, MD 21105; e-mail: Hagopian@ KennedyKrieger.org. 65 005-7894/02/0065~008651.00/0 Copyright2002 by Associationfor Advancementof BehaviorTherapy All rightsfor reproductionin any formreserved.

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Behavioral levels systems are commonly used in a variety of settings such as schools, psychiatric hospitals, correctional facilities, and residential programs. Levels systems typically involve altering the participant's level status contingent upon some behavioral criterion. Each "level" differs in terms of the type and the amount of reinforcement available. Thus, as the individual exhibits more desirable behaviors and less problem behavior, he or she is promoted to a higher level where there is increased access to materials and privileges that are thought to be preferred. Conversely, when the individual displays problem behaviors, he or she is demoted to a lower level where access to those putative reinforcers is restricted. Thus, levels systems can be conceptualized as multicomponent interventions involving differential reinforcement, response cost, and punishment. Typically, levels systems interventions are applied universally at the group level to promote socially desirable behavior and compliance with institutional rules (Barbetta, 1990; Jones, Downing, Latkowski, Ferre, & McMahon, 1992; Titus et al., 1990). With most levels systems, all participants ascend and descend within the levels system based on identical contingencies. In addition, the privileges earned are the same across all participants, including activities such as access to phone calls, TV, and outings. Likewise, reductive procedures (e.g., time-out and response cost) are uniformly applied across all participants. In many cases, participants begin the program in the lowest (and most restrictive) level and are required to remain at that level for extended periods of time prior to being eligible for promotion to a higher level (e.g., for one semester; Brennock, Zemitzsche, & Simon, 1989). After reviewing 10 published studies describing levels systems, Scheuermann, Webber, Partin, and Knies (1994) presented a number of legal concerns about levels systems as they are commonly applied and described in the literature. The fundamental issue underlying Scheuermann et al.'s concerns is the lack of individualization in the design and implementation of levels systems. As noted above, levels systems are commonly applied uniformly across participants within a group, often as a means to enforce institutional rules. In all the studies reviewed, levels systems were arranged such that placement in the least restrictive educational setting was available only after students were promoted from lower to higher levels. Additionally, promotion criteria to higher levels were either uniform across all participants, based on peer consensus, or based on arbitrary criteria. Scheuermann et al. contend that placement in a less restrictive setting contingent upon attaining a higher-level status, uniformly placing students in the lowest level upon entry in the levels system, and the use of universal criteria for promotion are in violation of the Individuals with Disabilities Education Act (IDEA). Based on their review of the levels system literature, Scheuermann et al. (1994) propose a model for designing levels systems using a three-phase, individualized decision-making process. Although their model is designed for the application of levels systems in educational settings targeting both educational and behavioral goals, the general principles are applicable to

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other settings and targets. Using this model, target behaviors, mastery criteria, and the composition of the levels are individually determined for each participant; problem behaviors are assessed by conducting a functional behavioral assessment; and behavior reduction interventions are designed based on an understanding of the function of the behavior (i.e., functional assessment). The authors suggest that the use of this model could facilitate the design of levels systems interventions that would be consistent with the laws mandating individualized educational programming. In addition to some of the legal concerns regarding the use and design of levels systems, some authors have commented on the lack of empirical data supporting the efficacy of levels systems (Smith & Farrell, 1993). Although a number of studies have reported favorable outcomes using levels systems (Bauer, Shea, & Keppler, 1986; Klotz, 1987; Mastropieri, Jenne, & Scruggs, 1988), the vast majority of published studies are descriptive in nature and lack adequate experimental control (Smith & Farrell). Based on a review of the literature, Smith and Farrell concluded that the design and use of levels systems is based largely on unsubstantiated assumptions. In addition to the need for empirical demonstrations of the effectiveness of levels systems, Smith and Farrell argue that researchers should examine (a) the extent to which combining multiple treatment components enhances the efficacy of levels systems; (b) whether providing students information about the consequences of their behavior within the framework of a levels system improves outcome; and (c) the extent to which the hierarchical structure of the levels system facilitates the development of self-management skills. Of the few studies that have attempted to systematically evaluate the efficacy of levels systems, only one study evaluated treatment efficacy using an experimental design that controlled for threats to internal validity (Grace, Thompson, & Fisher, 1996). In that study, Grace et al. evaluated an individualized levels system for an adult with developmental disabilities. The primary problem behavior was covert low-frequency, high-intensity self-injury (skin and nail picking; head banging; self-biting; inserting objects into the nose, ears, and eyes; and pulling eyelids). High-level status was associated with increased access to social and tangible reinforcers determined to be preferred based on preference assessment results, while low-level status was associated with decreased access to preferred items. Level status was contingent upon the presence of tissue damage due to self-injurious behavior and the occurrence of problem behavior (e.g., aggression). The results of the treatment evaluation suggested that the intervention was effective in decreasing problem behavior and resultant tissue damage. However, the generalizability of these results is limited in that only a single case was described and the treatment was not generalized to the community. The study by Grace et al. (1996) is also unique in that it described the application of a levels system as an individualized therapeutic intervention. The group-based levels systems described in the literature generally do not employ many behavioral procedures currently used to assess and treat indi-

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viduals. First, the activities and items that are made available as level status increases are informally selected and applied universally across participants, rather than empirically derived using a systematic preference assessment. Second, and perhaps more important, levels systems are rarely based on the results of a functional analysis of each participant's problem behavior. Rather, most levels systems described in the literature still rely on "default" technologies. That is, they involve the use of procedures designed to alter behavior by superimposing reinforcement and punishment contingencies on existing contingencies (Mace, 1994). A potential result of relying on default technologies is an overdependence on punishment procedures. The purpose of this study was to extend the existing literature on levels systems and address some of the legal and methodological issues raised by Scheuermann et al. (1994) and Smith and Farrell (1993), respectively. Specifically, we sought to systematically examine the effectiveness of individualized levels systems in decreasing severe problem behaviors displayed by four individuals with developmental disabilities. In the first phase, functional analyses were conducted to identity variables maintaining each participant's problem behavior. In the second phase, we systematically evaluated the effectiveness of individualized levels systems developed based on functional analysis and preference assessment results. In the third phase, the treatments were generalized and care providers were trained to implement the interventions.

General Method

Participants Four individuals with severe behavior problems participated in the current study. Three were admitted to an inpatient behavioral unit and one received treatment through an intensive outpatient program. All four participants communicated in complete sentences, ambulated without assistance, and followed complex instructions (e.g., completed 3-step commands such as, "Put your toys away, then get your swimming suit on and wait until it's time to go swimming"). Karl was a 14-year-old boy diagnosed with attention-deficit/hyperactivity disorder (ADHD), oppositional-defiant disorder (ODD), mild mental retardation, and depressive disorder. Karl exhibited a variety of problem behaviors including assaultive behavior and severe inappropriate social behaviors. On one occasion, he physically assaulted a woman in a public restroom, which led to his arrest. Kristi was a 12-year-old female diagnosed with mild mental retardation, ADHD, and ODD. Kristi exhibited aggression, socially offensive behaviors, and property destruction. On one occasion, Kristi physically assaulted her principal, which led to her permanent dismissal from school. Lori was a 16-year-old female diagnosed with moderate mental retardation, bipolar disorder, ODD, and a seizure disorder. She displayed a number of problem behaviors, including assaultive behavior, biting, and property


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destruction. She reportedly caused serious injury to others on a number of occasions prior to admission, including stabbing her sister with a knife. As a result of these incidents, Lori had four previous emergency admissions to inpatient psychiatric units. Mack was a 10-year-old male diagnosed with pervasive developmental disorder and borderline intelligence. He displayed aggression, disruption, and loud vocalizations. Mack's biting had resulted in injuries to students and staff. Additionally, he had destroyed furniture in the classroom, and cut his and others' hair with scissors. Mack had been suspended from school on multiple occasions following severe outbursts and was under consideration for residential services.

Data Collection and Response Definitions During functional analysis sessions, trained observers used laptop computers to record the frequency of problem behaviors for all participants. During all treatment and generalization sessions, paper-and-pencil data were collected (except for Lori's treatment sessions and Mack's treatment and generalization sessions, during which computer data collection was used). Operational definitions of each participant's problem behaviors are presented in Table 1.

Phase 1 : Functional Analysis Procedure and Design Functional analyses, using procedures similar to those described by Iwata, Dorsey, Slifer, Bauman, and Richman (1982/1994), were conducted for all participants to identify which, if any, environmental variables maintained target behaviors. The functional analysis consisted of analog conditions in which a specific environmental variable (e.g., access to attention or preferred item or escape from a task) was systematically presented contingent upon the occurrence of target behavior. Sessions were 10 min in duration. For Karl, Lori, and Mack, sessions were conducted in a padded room (3 m × 3 m) with a one-way observation mirror. For Kristi, sessions were conducted in a larger, nonpadded room (6 m X 4 m) with a one-way observation mirror. The conditions consisted of toy play, demand, social attention, and divided attention for Karl; toy play, demand, divided attention, and tangible for Lori; and toy play, demand, social attention, and tangible for Kristi and Mack. Divided attention sessions were conducted for Karl and Lori because descriptive data suggested that both participants were more likely to exhibit problem behaviors when two adults were interacting with one another. The tangible condition was not conducted during Karl's functional analysis because interview information provided by his parents did not suggest that his problem behaviors were sensitive to contingent access to preferred items. For all participants, the functional analysis was conducted using a multi-element design. During the toy play sessions, the therapist interacted with the participant, allowed access to preferred items, and provided praise every 30 s. This condi-

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TABLE 1 OPERATIONAL DEFINITIONS OF TARGEI" PROBLEM BEHAVIORS FOR EACH PARTICIPANT

Participant Karl

Kristi

Lori

Mack

Inappropriate Behaviors (Level 2)

Dangerous Behaviors (Level 1)

Aggression: hitting, pinching, scratching, kicking, grabbing, throwing objects at people, cursing, threatening language Inappropriate Touching: touching others except in areas specified as inappropriate social interaction Disruption: throwing objects, property destruction, kicking objects Elopement: going through doors without staff and running away from staff in an open area Inappropriate Sexual Behavior: exposing genitals and touching genital area under or over clothing Aggression: hitting, kicking, pushing, pinching, hair pulling Disruption: throwing or knocking over objects, hitting or kicking surfaces, property destruction Socially Offensive Behaviors: cursing, threatening others, insults, racial slurs, short high-pitched screams Biting: biting or attempting to bite others Verbal Aggression: threatening others Disruption: throwing objects, property destruction, knocking objects off surfaces or slamming objects on surfaces Cursing: swearing, profane language or gestures Disruption: throwing objects, property destruction, knocking over furniture Loud Vocalizations: yelling or talking over conversation level

Assaultive Behavior: biting, hair pulling, hitting others in the face, aggression toward children Inappropriate Social Interaction: touching others' buttocks, breasts, or genitalia; attempts to kiss others or blow in their ears

N/A

Assaultive Behavior: hitting, kicking, scratching, pinching, hair pulling, bending finger back, pushing, grabbing or elbowing others. throwing objects at others Biting: biting or attempting to bite others Assaultive Behavior: hitting, slapping, pushing, grabbing clothes, kicking, biting, throwing objects within 2 ft of a person, attempts to rush at students

tion served as a c o n t r o l c o n d i t i o n , a g a i n s t w h i c h other c o n d i t i o n s were c o m pared. D u r i n g the demand s e s s i o n s , the therapist u s e d s e q u e n t i a l v e r b a l , gestural, a n d p h y s i c a l p r o m p t s every 5 s u n t i l the p a r t i c i p a n t either c o m p l i e d or e n g a g e d in a p r o b l e m behavior. If the p a r t i c i p a n t c o m p l i e d f o l l o w i n g the verbal or gestural p r o m p t , he or she r e c e i v e d praise f r o m the therapist. If the par-


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ticipant displayed a problem behavior, the task was terminated and the therapist removed the materials for 30 s. All four individuals were prompted to complete academic tasks consistent with their individualized education plan. In addition, Karl's tasks included daily living tasks. The purpose of the demand condition was to determine if the participant engaged in problem behavior to escape from tasks. In the social attention condition, Karl, Kristi, and Mack were given toys and asked to play quietly while the therapist sat in the room reading a magazine. Attention in the form of a brief statement of concern (e.g., "Don't do that, you'll hurt me") was provided contingent upon each occurrence of a problem behavior. The divided attention condition (conducted with Karl and Lori) was similar to the attention condition described above, with the exception that two therapists were present in the room interacting with each other. A therapist provided a statement of concern contingent on problem behaviors. The purpose of the attention conditions was to determine if the participant engaged in problem behavior to gain access to attention. During tangible sessions (Loft, Kristi, and Mack), the participant was allowed to play with a preferred item (e.g., electronic game) for 2 min prior to the start of the session. The item was selected based on parental report that removal of that item resulted in problem behaviors. At the start of the session, the therapist removed the item. Following each occurrence of a problem behavior, the therapist returned the item to the participant for a 30-s period. The purpose of the tangible condition was to determine if the participant engaged in problem behaviors to gain access to tangible items. During initial functional analysis probes, Kristi displayed negative emotional responses to the contingencies in place and requested the opportunity to use appropriate communication to access reinforcement during the sessions. Thus, Kristi's functional analysis sessions were modified so that she could gain access to reinforcement for both problem behaviors and appropriate communication, defined as appropriately requesting attention, preferred materials, or escape from demands.

Interobserver Agreement Two independent observers scored the problem responses simultaneously but independently on laptop computers during 36%, 60%, 55%, and 93% of functional analysis sessions for Karl, Kristi, Loft, and Mack, respectively. Exact agreement for problem behavior was calculated by partitioning each session into 10-s intervals and dividing the number of exact agreements on the frequency of behavior by the sum of agreements plus disagreements and multiplying by 100. Mean exact agreement for combined problem behaviors during the functional analysis was 99.7%, 95.4%, 91.4%, and 98.1% for Karl, Kristi, Loft, and Mack, respectively. Results Results of the functional analyses for each participant appear in Figure 1. For Karl (top panel), problem behaviors were highest in the divided attention

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condition (M = 0.4 per min), followed by the social attention condition (M = 0.24), whereas problem behaviors rarely occurred in the demand or toy play conditions (M = 0.07, and M = 0.04, respectively). Although Karl exhibited low rates of problem behaviors in the functional analysis, the results were consistent with parental report suggesting that Karl engaged in problem behavior to gain access to attention. During Kristi's functional analysis (second panel), problem behaviors were high and variable in the tangible condition (M = 10.0 responses per min), high in the social attention condition (M = 19.3), and at moderate levels in the demand condition (M = 1.6). Problem behaviors were not observed in the toy play condition. In addition, appropriate communication remained low across all conditions (demand, M = 0; toy play, M = 0.55; social attention, M = 0.45; and tangible, M = 0.1). These results suggested that Kristi engaged in problem behavior to gain access to tangibles and attention, and to escape from demands. During Lori's functional analysis (third panel), problem behaviors were stable in the tangible condition (M = 2.2 responses per min) and high and variable in the divided attention condition (M = 23.7). Low rates of responding were observed in the demand condition (M = 0.26), and no problem behaviors were observed in the toy play condition. These results suggested that Lori engaged in problem behavior to gain access to tangibles and attention. For Mack (bottom panel), problem behaviors were highest in the tangible condition (M = 1.97 responses per min) and in the social attention condition (M = 2.8). Problem behaviors remained low in the demand and toy play conditions (M = 0.18, and M = 0.31, respectively). These results suggested that, similar to Loft, Mack's problem behaviors were maintained by positive reinforcement in the form of access to tangibles and attention.

Phase 2: Levels System Treatment Analysis Procedure and Design Preference assessments. Paired stimulus preference assessments were conducted with each participant using procedures described by Fisher et al. (1992). First, care providers were interviewed to identify several stimuli that appeared to be highly preferred for each participant. Next, stimuli were presented in pairs, and the participant was prompted to choose one of the stimuli. Observers recorded which stimulus was selected. After selecting a particular stimulus, the participant was permitted access to the chosen stimulus for 30 s. This procedure was repeated until all possible pairs of stimuli were presented (in a randomized order). A preference hierarchy for each participant was derived by calculating the percentage of trials that each particular stimulus was approached relative to the times it was presented. Items identified in the preference assessment as highly preferred for Karl included a Walkman, Beetle Borg, Mortal Combat game, and Nintendo Game Boy. Items identified as highly preferred for Kristi included nail polish, cas-

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settes, Barbie books, and Doritos. Items identified as highly preferred for Lori were potato salad, Uno card game, chips and dip, and nail polish. Highpreference items for Mack were Nintendo Game Boy, music, and Nintendo magazines. These items were used in the levels system treatment packages, and delivered using the schedules described below. Levels systems. Based on the results of the functional analyses (Phase 1) and preference assessments, individualized levels system packages were developed for each participant. Briefly, the levels system consisted of two to three levels. Level status was contingent upon problem behaviors. To address the attention and tangible functions, the levels varied with respect to the density of attention and access to preferred items and activities. To address Kristi's escape function, the levels also varied in terms of the density of reinforcement during work periods. Kristi's treatment also incorporated escape extinction, demand fading, and reinforcement for compliance during work situations. Generally, Level 3 consisted of dense schedules of attention and interaction, access to preferred items, frequent praise, and reinforcement during work periods. The specific activities or items present were individualized for each participant based on the results of the functional analysis and preference assessments. Level 2 was a nonexclusionary time-out, in which many of the preferred items available in Level 3 were removed. The preferred activities removed (i.e., attention, games, or toys) were specific to each participant, and some participants continued to have access to less preferred items. For some participants, verbal prompts were given to inform the participant of the time limits. In addition, some participants received praise during Level 2 for the absence of target behaviors. Such modifications were determined based on the function of behavior and the individual's current abilities. Level 1 consisted of an exclusionary room time-out. Problem behaviors were categorized as either inappropriate behaviors or as dangerous behaviors for three of the four participants (see Table 1 for a list of operational definitions specific to each participant). Dangerous behaviors included those behaviors for which even one occurrence was considered socially unacceptable and likely to produce injury. Therefore, Level 1 was only used for dangerous behaviors. Level 1 was not used if the participant engaged in problem behavior to escape demands, as a time-out procedure would be contraindicated. Detailed descriptions of the individualized interventions are provided below. Each participant's individualized levels system was reviewed and discussed with him or her after the initial baseline phase and at the start of each day during treatment. Each time a participant was moved to a particular level, he or she was informed of the change (i.e., "There is no hitting, you are now in Level 2"), and a 5 × 5 index card indicating the current level was displayed for the participant and other staff to see. All participants began every session (and every day during generalization) in Level 3. Karl. For Karl, treatment analysis sessions were 1.5 to 2 hours in duration and conducted in the living area of the inpatient unit. Baseline sessions


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were identical to the divided attention condition of the functional analysis in which two therapists were present, engaged in conversation, and only interacted with Karl contingent on problem behaviors. During treatment, Level 3 consisted of noncontingent reinforcement (NCR) involving the delivery of attention on a fixed-time (FT) schedule of 5 minutes, and differential reinforcement of appropriate requests (DRA) in which every appropriate request made by Karl was reinforced with compliance with the request (typically for attention). Contingent upon the occurrence of an inappropriate behavior (aggression, inappropriate touching, disruption, elopement, or inappropriate sexual behavior), Karl was placed in Level 2 (nonexclusionary time-out). While in Level 2, all preferred activities were terminated, materials were removed, and no attention was provided while the therapist remained in close proximity. If Karl tried to talk to the therapist during Level 2, he was given one verbal prompt: "Karl, you are in Level 2 so we can't talk?' All subsequent attempts to converse were ignored. Karl remained in Level 2 until he did not display any problem behaviors for 15 consecutive min (i.e., 15 min resetting timeout). In addition, if the timer had to be reset due to the occurrence of a problem behavior, no feedback was given to Karl; rather, the therapist reset the timer without any verbal interaction with Karl. During Level 2, Karl was told every 5 min (in the absence of inappropriate behavior), "Karl you are doing a nice job waiting, you have X minutes before you can move to Level 3?' Upon the occurrence of topographies of a dangerous behavior (assaultive behavior or inappropriate social interaction), Karl was placed in Level 1. He was led to his bedroom, using the minimum level of prompting necessary, and remained in Level 1 until he did not display any problem behaviors for 10 consecutive min (i.e., 10 min resetting time-out). Kristi. Kristi's treatment analysis sessions were 1.5 to 2 hours in duration and were conducted in the living area of the inpatient unit. Baseline sessions for Kristi included social attention contingencies in which Kristi was given attention contingent upon problem behaviors and escape contingencies during demand situations in which she received a 30-sec break from work contingent upon problem behaviors. Kristi's Level 3 included noncontingent attention on a FT 2-min schedule (later thinned to variable time [VT] 30 min), noncontingent access to preferred items, differential reinforcement of other behavior (DRO) using a token economy wherein she could earn one token on a 5-min resetting DRO schedule (later thinned to 10 min), and DRA for all appropriate requests. In addition, a response cost component was in place for which Kristi lost tokens for each occurrence of an inappropriate behavior (aggression, disruption, socially offensive behavior, or biting). Kristi could trade in her tokens multiple times a day (faded from every 40 min to 3 times per day) for preferred items not otherwise available (i.e., edibles, movies, nail polish). Kristi was moved to Level 2 contingent upon the loss of all of her tokens (due to the occurrence of inappropriate behaviors). While in Level 2, the therapist

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remained in close proximity; however~ all activities were terminated (except demands), preferred materials were removed, and no attention was provided. Less preferred materials continued to be available. Kristi could neither earn nor trade tokens while in Level 2. Kristi remained in Level 2 until she displayed no inappropriate behaviors for 15 consecutive min (i.e.~ 15 rain resetting time-out). In addition, to address the escape function of Kristi's problem behaviors, all of Kristi's treatment sessions included multiple 10-min work periods in which Kristi was given academic demands (later increased to 60 rain work periods during generalization). Demand fading, escape extinction, and differential reinforcement were used during work periods. Prior to treatment, a curriculum-based assessment was conducted to identify mastery and instructional level tasks to use in the context of demand fading. Initially, mastery level demands were used, Subsequently, instructional-level demands were presented. Finally, the duration of the academic period was increased. Throughout demand fading, escape extinction was in place in which problem behaviors did not result in escape from demands (consequently, her treatment package did not include Level 1). In addition, a DRA schedule was in place in which Kristi earned tokens for compliance with a set number of tasks and the absence of problem behaviors. Initially, she would earn one token after completing six tasks. Later, she earned one token at the end of the entire work period. The academic intervals were conducted in both Levels 3 and 2. However, if Kristi was in Level 2, she did not earn tokens for compliance. Lori. For Lori, treatment analysis sessions were 25 rain in length and were conducted on the living area of the inpatient unit. Baseline sessions were identical to the divided attention condition of the functional analysis as described above. During treatment, Level 3 consisted of noncontingent attention on a 5rain FT schedule (later thinned to FT 10 rain), continuous access to preferred activities (i.e., games), and reinforcement for appropriate requests for attention (DRA). Contingent on an inappropriate behavior (verbal aggression, disruption, or cursing), Lori was placed in Level 2 (nonexclusionary time-out). During Level 2, no attention was provided while the therapist remained in close proximity. In addition, all activities were terminated and any activityrelated materials were removed. Less preferred items that did not involve interactions with others continued to be available. Loft remained in Level 2 until she did not display any problem behaviors for 15 consecutive min (15 rain resetting time-out). Contingent upon a dangerous behavior (assaultive behavior or biting), Loft was placed in Level 1. She was led to a padded treatment room using the least amount of prompting necessary. Lori remained in Level 1 until she displayed no problem behaviors for 10 consecutive rain (10 rain resetting time-out). A separate component analysis of the levels system was conducted with Loft to determine which levels were necessary to effectively reduce problem behavior. The effects of Level 3 in isolation were examined to determine whether reinforcement alone, using NCR plus DRO, would reduce problem


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behaviors. In addition, because exclusionary time-out is restrictive, the omission of Level 1 from the treatment package was examined to determine whether Levels 3 and 2 could maintain low rates of problem behaviors. Sessions were conducted on the living unit and were 25 min in length. Frequency of problem behaviors was measured during the following four conditions using a multielement design: Levels 3, 2, and 1, which was the same as the complete levels system package previously described; Levels 3 and 2, which was identical to the complete levels package, except that Level 1 (exclusionary time-out) was not in place (i.e., Lori was moved to Level 2 for both inappropriate and dangerous behaviors); Level 3 only, during which Lori was in Level 3 continuously throughout the session, and problem behaviors were ignored; and baseline, which consisted of contingent attention for problem behaviors. After the treatment was generalized to the living unit across a 24-hour period, Lori's treatment was further faded to include a token economy with a response cost component. That is, rather than move immediately between levels contingent upon inappropriate behaviors, Lori earned and lost tokens contingent on her behavior, which eventually resulted in the promotion or demotion to a specific level. Lori started each day with five tokens and earned one token every 15 min in which there was no occurrence of a problem behavior (15 min resetting DRO, eventually faded to 20 min). If Lori engaged in an inappropriate behavior, the timer was reset and Lori lost two tokens. Thus, the occurrence of each inappropriate behavior no longer resulted in the immediate demotion to Level 2. When all of Lori's tokens were gone, she was moved to Level 2. However, the occurrence of dangerous behavior (assaultive behavior and biting) continued to result in the immediate placement into Level 1 (due to the risk of harm to others). In addition, Loft could trade in her tokens multiple times daily (faded from once every 2 hours to once every 3 hours) for additional preferred items not available during Level 3. Mack. Mack's treatment analysis sessions were 10 min in length and were conducted in an outpatient therapy room. Baseline sessions consisted of the first 10 sessions from the social attention and tangible conditions of the functional analysis, with additional sessions in both conditions conducted in accordance with a multiple baseline design. During Level 3, Mack initially received continuous noncontingent attention and noncontingent access to preferred items. In addition, a DRO was in place in which Mack gained access to highly preferred items at the end of the session if he had no problem behaviors throughout the session (10 min). Mack was moved to Level 2 on a 15-min resetting time-out schedule contingent upon the occurrence of inappropriate behaviors (disruptions or loud vocalizations). All preferred materials were removed and no attention was given during Level 2. Contingent upon the occurrence of dangerous behavior (assaultive behavior), Mack was moved to Level 1 and guided to a padded treatment room using the least level of prompting necessary. Contingent upon 10 consecutive min of no problem behaviors, Mack was moved to Level 2.

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H A G O P I A N ET A L .

Experimental design. The effects of the levels system treatment on problem behavior were evaluated using separate single-case experimental designs for each participant. An ABAB reversal design was used with Karl and Lori as all the components of the levels system were implemented simultaneously following baseline, briefly withdrawn, then reimplemented. A separate component analysis was conducted with Lori using a multielement or alternating treatments design in order to examine the relative contribution of some of the components of the levels systems. With Mack, a multiple baseline across conditions was used because the intervention effects could be replicated across conditions (social attention and tangible), thus avoiding a reversal to baseline. With Kristi, an ABABCBC reversal design was used. In her case, the more restrictive components of the levels system were implemented only after determining the lesser restrictive components were not adequately effective. hzterobserver Agreement Interobserver agreement was assessed during 81.7% of 5-rain intervals of the treatment sessions for Karl; 87.6% of 5-min intervals of the treatment sessions for Kristi; 100% of the levels system treatment analysis sessions for Lori; and during 36% of the treatment sessions for Mack. Agreement coefficients were calculated by partitioning each session into 5-rain intervals and dividing the number of exact agreements on the frequency of behavior by the sum of agreements plus disagreements and multiplying by 100. During the levels system treatment analysis, mean exact agreement for problem behavior was 95.4%, 97.8%, 96.4%, and 99.7% for Karl, Kristi, Lori, and Mack, respectively. For the component analysis with Lori, two observers scored problem behaviors simultaneously but independently during 68% of the sessions. Mean exact agreement for problem behaviors was 92%.

Results Levels systems. The results of the treatment analyses for each participant are depicted in Figures 2, 3, and 4. Open symbols represent sessions in which problem behaviors did not occur. All data reported below are in responses per rain. During baseline, Karl engaged in high rates of problem behaviors (M = 13.3; see Figure 2, top panel). When the levels system treatment package was implemented, problem behaviors were immediately reduced to near-zero levels (M = 0.02). Higher rates of problem behaviors were observed once treatment was withdrawn (M = 12.2). Problem behaviors were reduced to nearzero rates when the levels system intervention was reimplemented (M = 0.17). Throughout treatment, Karl's average percentage of time in each level was as follows: 89% of the time was spent in Level 3, 9% of time was spent in Level 2, and 2% of time was spent in Level 1. Kristi's treatment analysis is depicted in the bottom panel of Figure 2. Kristi engaged in an average of 2.1 problem behaviors per rain during baseline. When Level 3 alone was implemented, problem behaviors were immedi-

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FIG. 2. Levelssystems treatment analyses results during baseline (BL), treatment (L 3, 2, 1), and generalization for Karl (top panel); and during baseline, Level 3 only (L3), and Levels 3 and 2 (L 3, 2) for Kristi (bottom panel). Open symbols represent sessions in which problem behaviors were not emitted.

ately reduced to near-zero levels (M = 0.02). When treatment was withdrawn, problem behaviors increased beyond original baseline rates (M = 8.5). With the reintroduction of Level 3 alone, problem behaviors were once again reduced to near-zero rates (M = 0.11). The analysis was extended following an escalation observed in problem behaviors (M = 0.5) during demand fading (increasing the duration and number of tasks during the academic demand period) while treatment consisted of Level 3 alone. With the addition of the Level 2 component., Kristi's problem behaviors decreased to near-zero levels (M = 0.006). High rates of problem behaviors were recovered when Level 2 was withdrawn and Level 3 was again implemented in isolation (M = 1.14). Given the higher rate and the intensity of problem behaviors observed in the second reversal session, it was determined to be unsafe to continue implementing Level 3 alone. Levels 3 and 2 were reimplemented and problem behaviors were once again reduced to near-zero rates (M = 0.003). Kristi spent 97% of her time in Level 3, and 3% of her time in Level 2. Lori's treatment analysis is depicted in the top panel of Figure 3. During

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FIG. 3. Levels system treatment analysis results during baseline (BL), treatment (L 3, 2, 1), and generalization for Loft (top panel). Open symbols represent sessions in which problem behaviors were not emitted. The results of the component analysis are depicted in the bottom panel.

baseline, Lori engaged in high rates of problem behaviors (M = 9.6). When the levels system treatment package was implemented, problem behaviors were immediately reduced to near-zero levels (M = 0.01). When treatment was withdrawn, high rates of problem behaviors were observed (M = 14.2). Zero rates of problem behaviors were observed once the levels system intervention was reimplemented (M = 0). The results of the component analysis conducted with Lori are depicted in the bottom panel of Figure 3. The highest rates of responding were observed during the baseline condition (M = 5.1). The average rate per min of problem behaviors in the Levels 3 and 2 condition was 2.3, and a similar rate of responding was observed in the Level 3 only condition (M = 2.6). Thus, neither Level 3 alone or Level 3 in combination with Level 2 were effective in maintaining acceptably low levels of problem behaviors. Lori did not exhibit any problem behaviors in four of the five sessions in which the full levels system package (Levels 3, 2, and 1) was in place (M = 0.008). This demonstrated the necessity of the exclusionary time-out component (Level 1) for this particular participant.

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FIG. 4. Levels system treatment analyses results during baseline (BL) and treatment (L 3, 2, 1) obtained in the social attention condition (top panel) and in the tangible condition (bottom panel) for Mack. Open symbols represent sessions in which problem behaviors were not emitted.

The results of the multiple-baseline treatment analysis conducted with Mack are depicted in Figure 4. During the social attention baseline (top panel), Mack engaged in high rates of problem behaviors (M = 4.5). When the levels system treatment package was implemented in that condition, problem behaviors decreased (M = 1.0) while responding remained high in the baseline phase of the tangible condition (M = 1.91; bottom panel of Figure 4). Once treatment was implemented in the tangible condition, problem behaviors were reduced to near-zero rates (M = 0.09).

Phase 3: Generalization, Care Provider Training, and Follow-up Procedure Generalization. Following the demonstration of treatment effectiveness, the session length was increased to 6-hour sessions for Karl, Kristi, and Loft. Subsequently, the levels systems were implemented during the 24-hour day on the living unit prior to discharge. Direct care staff collected paper-andpencil data during 30-min intervals across the 24-hour day during all waking

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hours. For Mack, sessions were extended to 4 hours (see Figures 2, 3, and 4) and were conducted in the community. Data were collected as described in Phase 2. Care provider training. Prior to discharge, parents or care providers were trained in the implementation of each participant's levels system. Training was conducted on the unit for Karl and Lori, in the outpatient clinic for Mack, and at home for Kristi. Training consisted of (a) educating the care providers on the results of the functional analyses and the rationale for the individualized levels systems components; (b) modeling each component for the care providers; (c) rehearsal in which the care providers practiced implementing each treatment component with a therapist role-playing the child; and (d) the care provider implementing the treatment with the child while the therapist provided direct and immediate feedback. Karl's, Kristi's, and Lori's care providers were trained until they could implement the treatment independently with 90% accuracy across three consecutive sessions. For Mack, care providers were trained as described above, then generalization was conducted across care providers and in community settings identified by the parent as those in which problem behaviors were most likely to occur (e.g., waiting room, subway, and restaurant). Data were collected on problem behaviors for participants and on the care provider's implementation of each treatment component using paper and pencil for Karl, Lori, and Kristi (data were not collected on the accuracy with which Mack's care providers implemented the treatment). Each levels system was separated into major components (moving between levels, and implementing the procedures within each level). For example, for Kristi, the levels system treatment was separated into Level 3 components (NCR, enriched environment, DRO, DRA) and Level 2 components (transition to Level 2, minimal attention in Level 2, timer reset for the occurrence of problem behaviors, and retransition back to Level 3). Data were collected on correct implementation, incorrect implementation, and failure to implement each component (individualized definitions of these were developed for each care provider). Generically, correct implementation was defined as the care provider implementing the procedure as prescribed within a reasonable period of time. For example, correct implementation of the DRO component was defined as the care provider delivering praise within 20 s of the DRO timer signaling that reinforcement should be provided. Incorrect implementation was defined as the care provider deviating from the prescribed procedure. For example, incorrect implementation of Level 2 would include talking to the participant (other than presenting instructions) while in Level 2. Failure to implement was scored when a component of the intervention should have been implemented but the caregiver failed to attempt implementing it. For example, following the occurrence of a problem behavior, the participant should have been moved from Level 3 to Level 2. If the care provider did not move the participant to Level 2 within a specified period of time, the data collector scored this as a failure to implement. Per-


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cent accuracy was calculated by dividing the sum of correct implementation by the total number of opportunities to respond (sum of correct, incorrect, and failure to implement) and multiplying by 100. Follow-up. Follow-up data after discharge were collected for two of the three inpatients (Kristi and Loft). Follow-up data are not available for Karl, who moved out of state with his family prior to the 3-month follow-up visit. One session (approximately 1 hour in duration) was conducted at 3 months with Kristi, and at 3 and 6 months postdischarge with Lori. These sessions were conducted in the community, with care providers implementing the treatment while the therapist took data. Reliability data were not collected at follow-up.

Interobserver Agreement During generalization, a second observer collected data during 23%, 21%, and 11% of sessions for Karl, Kristi, and Loft, respectively. Reliability coefficients were 92%, 98.4%, and 98.5% for Karl, Kristi, and Loft, respectively. For Mack, reliability was collected during 33% of generalization sessions by staff accompanying Mack and his caregivers, and was 100%. During care provider training for Karl, Kristi, and Loft, reliability data were collected by a second observer during 100% of all 1-min intervals. Agreement coefficients were calculated by partitioning each session into 1-min intervals and dividing the number of exact agreements on correct, incorrect, and failure to implement by the sum of agreements plus disagreements and multiplying by 100. During care provider training, mean exact agreement was 100% for all three participants' analyses.

Results Generalization. Treatment generalization, consisting of increasing the session duration to 6 and then to 24 hours, was implemented for 31 days with Karl, 28 days with Kristi, and 94 days with Lori prior to discharge (see Figures 2 and 3). Rates of problem behaviors remained at near-zero levels for all three individuals (Karl, M = 0.05; Kristi, M = 0.04; and Lori, M = 0.02). Similar results were obtained with Mack during generalization sessions where the parent or instructional assistant implemented the levels systems in the community (M = 0.03; see Figure 4). Care provider training. Karl's mother and teacher, Loft's caregiver, and Kristi's grandmother all implemented the treatment with 100% accuracy across three consecutive sessions. Kristi's mother implemented the treatment with 97% accuracy across three consecutive sessions. Follow-up. Kristi engaged in zero problem behaviors during the 1-hour, 3-month follow-up session. Lori emitted 0.03 problem behaviors per min during the 1-hour, 3-month follow-up session, and zero problem behaviors during the 1-hour, 6-month follow-up session.

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General Discussion As noted previously, a review of the literature on behavioral levels systems reveals a number of limitations. First, the majority of published studies are descriptive and do not employ adequate experimental designs to evaluate treatment effects (Smith & Farrell, 1993). Second, the current use and design of levels systems in educational settings may be restrictive and universally applied to the extent that they may be in violation with legal mandates for individualized educational programming (Scheuermann et al., 1994). Finally, levels systems have been applied almost exclusively at the group level and rarely as an individualized therapeutic intervention. As such, levels systems described in the literature have not been developed based on functional analysis and preference assessment results. The current study attempts to address these limitations by demonstrating how behavioral levels systems can be individualized and applied therapeutically and by using single-case experimental designs to systematically evaluate the effectiveness of levels systems with four participants. In the current study, the stimuli and activities available within each level, the criteria for moving between levels, and the selection of problem behaviors were based on individual assessment findings. In contrast to many levels systems described in the literature, where participants start at the lowest level and must work their way up to higher levels, all participants in the current study started each day (or session) in the highest level (Level 3). Furthermore, participants remained in the lower levels for relatively brief periods of time (as little as 10 rain). The structure of the levels systems described in the current study is consistent with the recommendations described by Scheuermann et al. (19941) for designing levels systems in a manner that conforms to the principles underlying the IDEA. The current study may also contribute to the levels system literature in that it is one of the few empirical studies examining the effects of levels systems using an experimental design. Successful treatment outcomes were achieved with four individuals with mental retardation who displayed problem behavior. An 88% to 99.9% reduction in problem behaviors from baseline levels was observed across the four participants. Three of the four participants were treated in a highly controlled environment (an inpatient setting); however, none of the levels systems were designed to provide or restrict access to activities that were specific to that setting. Consequently, treatment was successfully generalized for all participants. Care provider training data demonstrate that care providers could implement the interventions with good integrity. It is interesting to note that dramatic reductions in behavior were observed immediately upon the introduction of treatment. For Lori and Kristi, problem behaviors were not emitted until the third and fourth treatment sessions, respectively. For Karl, problem behaviors did not occur in the first three treatment sessions following the reversal phase. This cessation of responding was also observed with Kristi when the time-out component (Level 2) was added to her treatment and with Mack when the levels system was first implemented in the tangible condition. Thus, there were several instances in which prob-

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lem behaviors were not emitted even though the participants had not contacted the consequences for their behavior. This suggests that the behavior of these participants was not only under the control of the consequences in effect, but also under antecedent control. The use of dense noncontingent reinforcement schedules to deliver reinforcers may have affected the rate of problem behavior as responding was allocated toward consumption of alternative reinforcement (Hagopian, Crockett, van Stone, DeLeon, & Bowman, 2000). In addition, problem behavior may have come under instructional control. This occurs when behaviors come under control of the stated "rules" or verbal stimuli that specify contingencies. Level status may facilitate instructional control by providing a simple and efficient means of indicating what schedules of reinforcement are in effect and what privileges the individual can and cannot access. It should be noted, however, that the results of the component analyses for Lori and Kristi suggest that the time-out contingencies were necessary to achieve acceptable and lasting reductions in behavior. In addition to enhancing instructional control, presenting these multicomponent interventions within the framework of a levels system may have facilitated the training of care providers. For some participants in this study, level status itself may have acquired some secondary reinforcing (or punishing) properties. That is, we observed that promotion to a higher level was typically associated with increases in participants' positive affect and pronouncements of level status to other patients and staff. It was also observed that high-level status was associated with increases in participants' initiation of positive social interactions with staff. It should be noted, however, that the design of the current study does not allow one to determine whether the presentation of these multicomponent interventions as levels systems had these salutary effects. Another limitation of this study is that it includes only four cases, all with similar characteristics. That is, all were mildly to moderately mentally retarded and all had socially maintained problem behaviors. The utility of the levels systems package across other participants with different characteristics and in other types of settings remains unclear. Finally, the design of the current study does not allow one to determine whether the use of functional analyses and systematic preference assessments increased the effectiveness of the levels system treatment package. However, the utility of this approach toward assessment and treatment development has been well documented with other types of treatments, and is regarded as a current best practice (see Neef, 1994). Although the results of the current study suggest the application of levels systems as individualized therapeutic interventions is promising, additional research is needed to confirm these preliminary findings

References Barbetta, P. M. (1990). GOALS: A group-oriented adapted levels system for children with behavior disorders. Academic Therapy, 25,645-656.

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Bauer, A. M., Shea, T. M., & Keppler, R. (1986). Levels systems: A framework for the individualization of behavior management. Behavior Disorders, 12, 28-35. Brennock, T. M., Zemitzsche, A., & Simon, D. J. (1989). A high school behavior disorder program focused on mainstreaming. The Pointer, 33, 27-31. Fisher, W. W., Piazza, C. C., Bowman, L. G., Hagopian, L. P., Owens, J. C., & Slevin, I. (1992). A comparison of two approaches for identifying reinforcers for persons with severe and profound disabilities. Journal of Applied Behavior Analysis, 25, 491-498. Grace, N. C., Thompson, R., & Fisher, W. W. (1996). The treatment of covert self-injury through contingencies on response products. Journal of Applied Behavior Analysis, 29, 239-242. Hagopian, L. P., Crockett, J. L., van Stone, M., DeLeon, I. G., & Bowman, L. G. (2000). Effects of noncontingent reinforcement on problem behavior and stimulus engagement: The role of satiation, extinction, and alternative reinforcement. Journal of Applied Behavior Analy-

sis, 33,433-450. Iwata, B. A., Dorsey, M. F., Slifer, K. J., Bauman, K. E., & Richman, G. S. (1982/1994). Toward a functional analysis of self-injury. Journal of Applied Behavior Analysis, 27, 197-209 (Reprinted from Analysis and Intervention in Developmental Disabilities, 2, 3-20, 1982). Jones, R. N., Downing, R. H., Latkowski, M. E., Ferre, R. C., & McMahon, W. M. (1992). Levels systems as shaping and fading procedures: Use in a child inpatient psychiatry setting. Child and Family Behavior Therapy, 14, 15-37. Klotz, M. E. (1987). Development of a behavior management level system: A comprehensive school-wide behavior management program for emotionally disturbed adolescents. The Pointel; 31, 5-11. Mace, F. C. (1994). The signilicance and future of functional analysis methodologies. Journal of Applied Behavior Analysis, 27, 385-392. Mastropieri, M. A., Jenne, T.. & Scruggs, T. E. (1988). A level system for managing problem behaviors in a high school resource program. Behavioral Disorders, 13,202-208. Neef, N. A. (Ed.). (1994). Functional analysis approaches to behavioral assessment and treatment [Special issue]. Journal of Applied Behavior Analysis, 27(2). Scheuermann, B., Webber, J., Partin, M., & Knies, W. (1994). Levels systems and the law: Are they compatible? Behavioral Disorders, 19,205-220. Smith, S. W., & Farrell, D. T. (1993). Level system use in special education: Classroom intervention with prima facie appeal. Behavioral Disorders, 18, 251-264. Titus, S., Savage, M., Krebs, F., Aquino, D., Simonet, M., & Sachs, J. (1990). The process of changing from a levels system to a token economy. Residential Treatmentfor Children and Youth, 7, 75-84. RECEIVED: February 14, 2001 ACCEPTED: July 24, 2001