Received: 7 January 2018 Revised: 7 August 2018 Accepted: 9 August 2018

DOI: 10.1002/bin.1646

RESEARCH ARTICLE

Treating obsessive compulsive behavior and

enhancing peer engagement in a preschooler with
intellectual disability
Emily L. Guertin1 | Tricia Vause2 | Heather Jaksic2 | Jan C. Frijters3 |

Maurice Feldman2

1
Department of Applied Disability Studies,
Brock University, St. Catharines, Ontario,
Canada
2
Department of Applied Disability Studies and
Department of Child and Youth Studies, Brock
University, St. Catharines, Ontario, Canada
3
Department of Child and Youth Studies,
Brock University, St. Catharines, Ontario,
Canada
Correspondence
Tricia Vause, Department of Applied Disability
Studies and Department of Child and Youth
Studies, Brock University, 1812 Sir Isaac Brock
Way, L2S 3A1 St. Catharines, Ontario, Canada.
Email: tvause@brocku.ca
Intellectual disability (ID) is a neurodevelopmental disorder
characterized by impairments in cognitive and adaptive func-
tioning in social, practical, or conceptual domains. Individuals
with ID present with higher‐order repetitive behaviors such
as a need for sameness, ritualistic, and compulsive behaviors.
Often referred to as obsessive compulsive behaviors (OCBs),
these behaviors increase in prevalence between 2 and 5 years
of age. The present study evaluated an exposure‐based behav-
ioral intervention for decreasing OCBs and concomitantly
increasing play skills in a 4‐year‐old boy with mild ID in an inclu-
sive preschool setting. Using a multiple baseline across behav-
iors design, the intervention was associated with a decrease in
target behaviors and an increase in the duration of peer social
engagement, with results maintained at 3‐week follow‐up.
The intervention consisted of exposure and response preven-
tion with function‐based components. Procedures including
prompting and reinforcement were generalized to parent and
teacher mediators. This study provides preliminary support
for the use of an exposure‐based behavioral intervention to
treat OCBs in children of preschool age with ID.

KEYWORDS

exposure and response prevention, functional behavioral

assessment, intellectual disability, obsessive compulsive behavior,
school‐based intervention

The researchers would like to thank the participating preschool, teachers, and family for their contribution to the project. This
research was supported by a graduate fellowship and Match of Minds scholarship from Brock University.

Behavioral Interventions. 2019;34:19–29. wileyonlinelibrary.com/journal/bin © 2018 John Wiley & Sons, Ltd. 19
20 GUERTIN ET AL.

1 | I N T RO DU CT I O N

Intellectual disability (ID) is a neurodevelopmental disorder characterized by impairments in intellectual and adaptive
functioning in domains of practical, social, and conceptual skills with an onset of symptoms during the developmental
period (American Psychiatric Association [APA], 2013). While not part of the diagnostic criteria for ID, unique
behavioral profiles of repetitive behaviors (RBs) are characteristic of populations with co‐occurring ID, including
people with autism spectrum disorder (ASD), genetic syndromes, and ID of heterogeneous causes (APA; Moss,
Oliver, Arron, Burbidge, & Berg, 2009). RBs can take the form of compulsions (e.g., checking or arranging), rituals
(e.g., bedtime routines), stereotypy (e.g., repetitive body movements), or preoccupations (e.g., restricted interests).
Factor analytic studies of RBs have identified at least two broad categories: lower‐order RBs, including motor stereo-
typy and self‐injurious behaviors, and higher‐order RBs, including insistence on sameness, ritualistic, and compulsive
behaviors (Mirenda et al., 2010).
There is a paucity of research on the impact of, and interventions for, higher‐order RBs in persons with ID. Most
research involves children with comorbid diagnoses of ASD, given the prevalence of ASD that is approximately 1 in
68 children (Centers for Disease Control, 2016) and approximately 65% of people with ASD meet criteria for ID
(Hall, 2013). Parent report indicates that children with ASD and ID display higher‐order RBs as early as 2 years of
age, and in children 1 to 4 years, 85% engage in these behaviors (Bishop, Richler, & Lord, 2006; Mooney, Gray, &
Tonge, 2006). Higher‐order RBs show a unique developmental trajectory, with levels increasing until stabilizing when
children are 5 years old (Richler, Huerta, Bishop, & Lord, 2010). There is evidence that engaging in RBs is associated
with negative developmental outcomes (Boyd, McDonough, & Bodfish, 2012). In addition, parent‐reported stress is
significantly related to RBs in preschool‐aged children with ASD (Harrop, McBee, & Boyd, 2016). Reduction of
RBs, especially with early intervention, may mitigate negative developmental and parental outcomes (Boyd et al.).
Topographies of higher‐order RBs can be similar to obsessions and compulsions characteristic of obsessive com-
pulsive disorder (OCD; APA, 2013; Wu, Rudy, & Storch, 2014). It is theorized that compulsions function to relieve
aversive internal states initiated by obsessions in OCD (i.e., automatic negative reinforcement; Miltenberger,
2005). In these cases, an aversive internal state (i.e., distress) would serve as an establishing operation for compulsive
behaviors, increasing the value and likelihood of engaging in the compulsion to lower it (Miltenberger). There is an
acknowledged difficulty with contriving and measuring the establishing operation required for assessing automatic
negative functions in a functional analysis due to its covert nature (Miltenberger). In ASD or ID, automatic positive
reinforcement or socially mediated functions may also influence higher‐order RBs, making it difficult to distinguish
between higher‐order RBs and compulsive behaviors in OCD (Vause, Hoekstra, & Feldman, 2014; Vause, Neil, Yates,
Jackiewicz, & Feldman, 2017). Given the often limited social‐communicative skills of children with ASD or ID, they
may not be able to communicate internal states associated with behaviors (Chok & Harper, 2016). Therefore, these
behaviors have been termed obsessive compulsive behaviors (OCBs; Chok & Harper; Vause et al., 2017).
Despite the negative consequences of higher‐order RBs, only a few behavior analytic studies using single subject
experimental designs have evaluated treatments for children and adolescents with ASD and ID (Kuhn, Hardesty, &
Sweeney, 2009; Rodriguez, Thompson, Schlichenmeyer, & Stocco, 2012; Sigafoos, Green, Payne, O'Reilly, & Lancioni,
2009). For instance, Sigafoos et al. treated a 15‐year‐old adolescent with ID and autistic disorder who frequently
rearranged classroom materials that interfered with his academic engagement. The intervention, consisting of
noncontingent social engagement and provision of incompatible preferred activities, was successful in reducing the
rearranging behavior to near‐zero occurrences per minute, and these effects were maintained at 6 weeks.
Recently, Chok and Harper (2016) treated arranging and ordering maintained by automatic positive reinforcement
in a 12‐year‐old girl with ASD. A discrimination training procedure utilizing a multiple schedule design was successful
at bringing the arranging behaviors under the control of schedule‐correlated stimuli.
Studies have also adapted exposure and response prevention (ERP) techniques (often used in cognitive behavior
therapy [CBT]) for children and adolescents with ASD and ID. ERP is the process by which an individual is exposed to
stimuli that trigger anxiety or distress and refrains from engaging in the compulsive behavior (March & Mulle, 1998).
GUERTIN ET AL. 21

Using an ERP procedure, Chok and Koesler (2014) treated a 14‐year‐old adolescent with ASD and ID who engaged in
repetitive cleaning behaviors. By prompting attention to the items on the table to extinguish the respondent behavior
(i.e., increased heart rate) and blocking attempts to clean to extinguish the operant behavior (i.e., repetitive cleaning),
rates of cleaning decreased to near‐zero levels. Boyd, Woodard, and Bodfish (2013) modified ERP techniques for
higher‐ and lower‐order RBs in children aged 5 to 11 years with ASD and ID. The authors reported mixed results
using trials of exposure and light redirection to other tasks, with some participants showing a marked change in
duration or latency to engage in OCBs. Overall, the emerging evidence suggests that ERP may be effective at
decreasing OCBs in children with ASD and ID, but more research is needed.

2 | PURPOSE

A preliminary randomized controlled trial has explored combining behavior analytic and CBT to treat OCBs in
school‐age children (n = 14) with high‐functioning ASD (Vause et al., 2017). On two standardized measures of OCBs,
participants who received the treatment showed significant reductions in OCBs relative to the treatment as usual
group. Daily parent ratings also showed a significant decrease of OCBs upon introduction of the intervention.
Preliminary results suggest that this manualized treatment package can reduce OCBs in school‐age children with
ASD. The present study extends this research by adapting this intervention for a younger child with mild ID in an
inclusive preschool classroom, with an emphasis on increasing peer engagement. A concurrent multiple baseline
design across two OCBs was used to determine if there was a functional relationship between the treatment,
decreases in the occurrence of OCBs, and gains in the duration of engagement with peers. Adaptations included
removing psychoeducation and significantly reducing the cognitive components, focusing treatment primarily on
function‐based interventions, antecedent strategies, and ERP components. It was hypothesized that treatment would
produce clinically significant reductions in occurrence and duration of OCBs and increases in duration of peer
engagement and the intervention would be considered effective by mediators.

3 | METHOD

3.1 | Participant and setting

The participant was a 4‐year‐old boy who met research criteria for a mild ID. Max (pseudonym) scored in the
extremely low range (IQ ≤ 69) on the Wechsler Preschool and Primary Scale of Intelligence–Fourth Edition
(Wechsler, 2012) and low (less than or equal to second percentile) and moderately low (3rd–16th percentile) ranges,
respectively, on the Communication and Socialization subdomains of the Vineland Adaptive Behavior Scales–Second
Edition (Sparrow, Cicchetti, & Balla, 2005). These assessments were conducted by a doctoral student under the
supervision of a doctoral‐level clinical psychologist with extensive experience. Max's expressive communication
consisted mainly of requests and repetitive questioning, with articulation difficulties. As a single parent with time
constraints in the home, Max's mother preferred preschool‐based treatment. Over the course of the study, Max
participated in speech and language therapy (not focusing on his OCBs); he was not taking medications or receiving
any other services.
The treatment took place in a preschool Casa Montessori classroom consisting of two teachers and 16 three‐ to
five‐year‐old children including Max. He attended the school each morning for 3 to 5 hr per day. Following the
Montessori method, work periods allowed students to select and terminate activities on their own (Standing,
1957). Activities included a variety of domains (e.g., functional skills, early literacy skills, and mathematics) and were
designed for either independent or small group work. Students also participated in scheduled activities including
lunch, recess, physical education, and music.
22 GUERTIN ET AL.

3.2 | Measures
Given that established informant assessments do not often differentiate between automatic positive and negative
reinforcement or distress as a motivating operation for OCBs, the Parent Interview for Assessing Function–OCB
(PIAF‐OCB; Guertin, Vause, & Feldman, 2016) is an interview specifically developed to elucidate hypothesized
function(s) of OCBs. It consists of 36 open‐ended questions for parents or caregivers and requires less than
20 min to complete. The interview addresses social positive (i.e., attention or tangible), social negative (i.e., escape),
automatic positive, and automatic negative reinforcement. A separate set of questions for each possible function
covers motivating operations, antecedents, and consequences of the OCB. This measure was modeled after ques-
tionnaires developed by Feldman, Condillac, Tough, Hunt, and Griffiths (2002) and a treatment package for trichotil-
lomania (Miltenberger, 2001). Published informant assessments were reviewed in order to ensure the measure
included key antecedents, motivating operations and consequences for assessing behavioral function.
A descriptive assessment was also included to observe the events correlated with the target behaviors. Using an
open‐ended chart format, the therapist recorded antecedent, behavior, and consequent events associated with each
occurrence of OCB in the school (Cooper, Heron, & Heward, 2007). Data were collected across 13 days for the target
behaviors by trained observers for 2 to 3 hr each day. The combination of narrative data and interview responses was
used to identify hypothesized functions of target behaviors.
On a daily basis, the therapist recorded narrative data in open‐ended case notes on target behaviors, related
behaviors, and unsolicited parent and teacher comments about the intervention.

3.2.1 | Target behaviors and measurement

Definitions and measurement of target behaviors are described in Table 1. Max's mother contacted the researchers
because of concern with several interfering OCBs at home and school; two of the most interfering behaviors were
selected for treatment. The first was a behavior chain involving Max walking or running to his classroom window
every morning instead of the school's doors. He then knocked on the window around 10 times until his peers and
teachers stopped their activities and waved to him. If his mother attempted to redirect him from this routine,

TABLE 1 Operational definitions of opportunities, behaviors, and duration data

Dimension of
Behavior measurement Definition

Morning routine Per‐opportunity Opportunity: Upon arrival to school with his mother; children and
occurrence teachers are present in the classroom.
Occurrence: Engaging in any part of the chain of behaviors, including
walking directly to the classroom window, repeatedly tapping on the
window, and waiting for attention from teachers or peers. Scored as
“1” if any part of the chain occurs during an opportunity.
Ritualistic completion Per‐opportunity Opportunity: When a peer approaches Max during a work activity and
of work tasks occurrence either asks to join him or begins to touch his materials. The start of
a new activity denotes a new opportunity.
Occurrence: An objection, either physical (e.g., pushing peer away and
leaving activity) or verbal (e.g., saying no, crying, whining, and yelling)
that occurs after an opportunity. Scored as “1” if any of the
behaviors
occur during an opportunity.
Peer Engagement Duration Duration starts when a peer sits at his activity, touches his materials, or
he agrees for the peer to join in. Duration ends when (1) the joint
activity stops: Max or at least one peer are not taking turns (i.e., not
actively completing task or waiting for peer to complete step), (2) one
of the children leaves the mat with the activity, or (3) the activity is
completed (i.e., all materials from the activity are put away in their
prescribed location). Visual engagement is not required for the full
duration of the activity, but as needed for Max to determine his turn
and complete his task.
GUERTIN ET AL. 23

teachers reported Max remained distressed for up to 40 min (i.e., crying, yelling, flopping to the ground, and pushing
past his mother). The second behavior was a ritualistic completion of work tasks alone, while Max worked, any peer
who approached him resulted in a verbal or physical protest, followed by a period of distress (e.g., crying, yelling, and
covering or grabbing his materials) for more than 30 min. As a result, Max did not engage in joint activities with peers
who learned to avoid him over time. Therefore, an additional goal was to increase the time Max spent in joint
engagement with peers. Due to the difference in applicable dimensions of measurement for each behavior, the
primary dependent variable was daily per‐opportunity percentage; peer engagement was measured as the daily
average duration per opportunity.

3.2.2 | Interobserver agreement

A second, trained observer with undergraduate coursework in applied behavior analysis collected interobserver
agreement (IOA) of the per‐opportunity occurrence data. IOA was calculated by dividing the daily occurrence of
the observed behaviors for the lower reported number by the higher reported number and multiplying by 100
(Cooper et al., 2007). For the morning routine, IOA was collected for 48% of opportunities and mean IOA was
100%. For the work routines, IOA was collected for 42% of opportunities and mean per‐opportunity occurrence
IOA was 100%. IOA for the duration of peer engagement was calculated on 36% of observations. Duration IOA
was calculated by dividing the lower reported duration value by the higher duration value and multiplying by 100.
The IOA for duration of peer engagement was 97% (range, 82–100%).
Interrater agreement was also conducted on the functional behavioral assessment by a second year MA student
in applied behavior analysis with 4 years of clinical experience blind to the hypothesized functions of the therapist.
Agreement on the hypothesized functions based on the ABC narrative data and PIAF‐OCB was 100%.

3.3 | Research design and procedures

The study followed a concurrent multiple baseline across behaviors design, treating the morning routine followed
by ritualistic completion of work tasks (Cooper et al., 2007). Time series per‐opportunity occurrence data were
collected for each of the behaviors. In addition, duration data for peer engagement in work tasks were collected as
a secondary measure.
All protocols and procedures received clearance from a University Research Ethics Board; participants provided
informed consent prior to participating in the project. The therapist was supervised weekly for at least 2 hr including
on‐site observations. The supervising researcher was a doctoral‐level clinical psychologist who was also a board
certified behavior analyst–doctoral. The therapist was present in the classroom for 12 hr across four mornings per
week for 10 weeks, for a total of approximately 115 hr.

3.3.1 | Baseline
In baseline, the therapist collected data on naturally occurring opportunities for both behaviors. At the recommenda-
tion of Max's teachers, the therapist or teacher also contrived scenarios for ritualistic work completion by asking a
peer to approach Max, touch his materials, or ask to join in his activity. In the event Max objected, peers were
instructed to follow his request to leave his activity. Approximately 1 week prior to treatment, the therapist
completed a PIAF‐OCB (Guertin et al., 2016) with Max's teacher who spent approximately 21 hr weekly in the
classroom with him.

3.3.2 | Treatment
Intervention for both behaviors consisted of (a) the completion of a functional behavioral assessment, (b) ERP for
treating respondent and operant components of automatic negative reinforcement, (c) behavioral strategies meant
to decrease physiological levels of distress during ERP, and (d) differential reinforcement of an alternative behavior
based on hypothesized social functions.
24 GUERTIN ET AL.

During baseline and treatment, Max was observed to display distress for over 30 min in both events prior to
engaging in OCBs (e.g., baseline) and in the early trials of the intervention when he was prevented from engaging
in the behavior. A hypothesized function of both OCBs was therefore automatic negative reinforcement including
both a respondent (conditioned distress responses) and operant (performance of a behavior to escape from distress
responses) component. A gradual ERP procedure (March & Mulle, 1998) was developed to both habituate Max to the
conditioned stimuli eliciting distress (respondent extinction) and prevent engagement in the OCB (operant
extinction). The researchers incorporated adapted behavioral strategies to lower the conditioned distress responses
during ERP, attempting to further expedite respondent extinction. First, a story guide or If/Then visual was used to
explain the contingencies of reinforcement for engaging in an exposure. A choice between a positive self‐statement
and blowing or counting strategy aimed at reducing conditioned distress responses was presented to Max prior to the
exposure; Max selected either singing/saying a positive self‐statement or taking deep breaths and blowing on a
pinwheel, adding visual feedback to taking deep breaths. The therapist had Max practice the selected strategy
in advance of performing the exposure step and prompted Max to use the strategy if he demonstrated
significant distress.
The ERP procedure was adapted to gradually disrupt the routine based on the relevant dimensions of the
behavior. For the morning routine, Max participated in an initially decreasing number of steps to the routine (e.g.,
walking to the window without tapping) for the first 2 days of the intervention until he walked directly into the
school. The treatment for ritualistic work completion gradually increased duration of disruption to his work routines
(i.e., peer play) from 10 s to the full time required to complete the activity according to Montessori method. While the
duration increased, peers took more turns touching and manipulating the items in the activity. For both behaviors,
physical response blocking or redirection was used to prevent Max from engaging in the OCBs. The therapist deliv-
ered competing reinforcers of small tangible items (e.g., toy cars) or high fives for the morning and ritualistic work
routines following successful completion of the exposure in order to increase motivation to engage in exposures.
According to combined assessment results, a possible additional maintaining variable of the morning window
routine was social positive reinforcement in the form of attention from teachers and peers. To address this maintain-
ing variable, the intervention consisted of providing attention (e.g., praise) by the therapist, Max's teacher, and
mother contingent on his direct entry to the school. If Max engaged in the routine, attention was withheld and he
was neutrally redirected to the front doors of the school. To provide an alternative response for receiving attention
from his peers, once inside the classroom, the therapist verbally prompted him to greet a peer whose name he
frequently called while outside tapping on the window.
An additional hypothesized maintaining variable of ritualistic work completion was social negative reinforcement
because peers left Max alone following a protest. After consideration of the results, this could have been due to
higher‐order conditioning of peers as conditioned stimuli for disruption of his routine. Therefore, as a secondary goal
during these exposures, the therapist provided verbal and gestural prompts as needed to promote turn taking,
commenting, and completion of the activity. The therapist provided behavior‐specific praise on a variable‐interval
10‐s schedule for engaging with peers on work tasks (Petscher, Rey, & Bailey, 2009).

3.3.3 | Intervention fading and mediator‐led maintenance

Following a minimum of six (range, 6 to 10) consecutive opportunities without Max engaging in the target behaviors,
a fading procedure was used to transfer maintenance of the behavior to more natural conditions. For the morning
routine, antecedent strategies (e.g., If/Then visual) were removed and tangible reinforcers were switched to verbal
praise from Max's mother. For ritualistic work completion, praise was adjusted to fit verbal attention provided to
students in a Montessori classroom (e.g., “Are you proud of what you did?”) instead of behavior‐specific praise
(e.g., “Great job working with your friends!”).
After four successful trials of intervention fading, the therapist conducted behavioral skills training with the
mother and teacher. They were asked to (a) set up the exposure and explain the expectation if required, (b) use
GUERTIN ET AL. 25

prompting to guide Max to complete the exposure, and (c) provide reinforcement. After the mediators observed the
intervention, the therapist reviewed the protocol and asked the mediator to complete the maintenance procedures
independently. The therapist provided feedback and problem solving in two instances; otherwise, Max's parent
and teacher were able to implement the protocol successfully. The therapist monitored mediator implementation
until they performed at least four exposures using the three components of the protocol and without Max engaging
in the target behaviors.

3.3.4 | Follow‐up
Three weeks following the last teacher‐led trial, the therapist conducted two to three follow‐up observations of
Max's performance with the mediator independently implementing the procedure.

3.3.5 | Treatment integrity

A secondary observer completed a treatment integrity checklist composed of antecedent, prompting, and reinforce-
ment strategies for 44% and 62% of the treatment sessions of the morning and work routines prior to treatment
fading, respectively. Average treatment integrity was 95% (range, 90–100%) for the morning routine and 93% (range,
83–100%) for ritualistic completion of tasks.

4 | RESULTS

The per‐opportunity occurrence and duration results are depicted in Figure 1. While treatment was introduced for
the morning routine, levels of ritualistic work completion showed a small decrease in level of responding, although
the behavior persisted in the majority of cases and the average duration of time Max was engaged with peers
remained below 20 s. It appears to reflect a functional relationship between the introduction of the behavioral
intervention and reductions in the targeted OCBs.

FIGURE 1 Daily per‐opportunity percentage (black data points) and average daily duration of peer engagement
(gray data points)
26 GUERTIN ET AL.

For the morning routine, during baseline, Max completed the behavior chain in all opportunities. Following inter-
vention, the routine decreased to zero levels by the third day of treatment in accordance with the exposure plan. The
behavior was maintained at zero levels throughout treatment fading and parent‐led maintenance for 1 month of data
collection. Results were maintained at a 3‐week follow‐up.
For the second behavior, protests to peers occurred at least once for 12 of 15 days in baseline on a variety of
two‐person Montessori work tasks. Duration data of time engaged with peers during work were collected on a
sample of baseline behaviors. In baseline, daily mean duration of peer engagement was 20 s or lower for all days
except one when Max was able to complete a short activity with a peer. Immediately upon introduction of treatment,
ritualistic work completion remained at zero levels except in one trial. In that trial, Max said “no” to a peer but com-
plied with the task per the function‐based protocol for the remainder of the activity. Treatment systematically
increased duration of peer engagement according to the exposure plan. By the fourth trial, Max was completing
the full duration of the activity based on Montessori expectations. Protests remained at zero levels and duration
of engagement maintained at similar levels (M = 455 s) during treatment fading. Duration of engagement remained
similar (M = 436 s) in teacher‐led maintenance. At a 3‐week follow‐up, Max did not protest and had a mean of
454 s of engagement with peers during work across three trials.
Teachers noted the positive change in Max's routine‐governed behaviors and levels of distress (e.g., crying or
yelling) when asked to refrain from targeted OCBs. The teachers also reported two occasions when Max spontane-
ously worked with peers in the classroom without their intervention. The therapist noted growing interest from both
Max and his peers to work together; peers spontaneously joined activities, requested to complete additional
activities, or asked the therapist to work with Max. On one occasion, Max asked his teacher to continue working
on an activity with peers after recess. Finally, evidence of teacher skill generalization was demonstrated with
ritualistic completion of activities in gym class. The therapist implemented similar procedures to the classroom
intervention, and a teacher performed the procedures independently for the remainder of the gym period. Teachers
also indicated that the therapist could contrive more opportunities in the classroom to work with peers. The therapist
was initially careful not to disrupt the classroom and maintain the Montessori method but adapted to this feedback
and initiated more daily sessions.

5 | DISCUSSION

The exposure‐based behavioral intervention was associated with a reduction in the occurrence of the repetitive
morning and work routines by the participant. Morning routine occurrence was reduced to zero levels. For ritualistic
completion of work tasks, the decrease in refusals to peers corresponded with increases in the duration spent
engaged in work tasks with his peers. Reductions in both behaviors were maintained at a 3‐week follow‐up. These
results extend the applicability of combined ERP and function‐based protocols (Vause et al., 2014; Vause et al.,
2017) to a child with ID and implementation in an inclusive preschool setting and contribute to a growing body of
literature about treatments for OCBs using function‐based intervention (Chok & Harper, 2016; Rodriguez et al.,
2012) or ERP (Boyd et al., 2013; Chok & Koesler, 2014).
This study provides preliminary support for modifications to the combined behavior analytic and CBT manualized
protocol (Vause et al., 2017) for a child with mild ID. Components such as psychoeducation and cognitive coping
strategies were removed due to Max's limited cognitive and verbal ability to participate in or benefit from them.
Instead, the treatment emphasized visual and verbal antecedent strategies such as deep breathing and positive
self‐statements prior to the exposure. Max often selected positive self‐statements, and following a successful expo-
sure, he often said, “I did it!” Additionally, collateral observations suggest that during treatment Max and his peers had
a growing interest in working together, including spontaneous joint engagement in the classroom. These potential
benefits of the treatment support Boyd et al.'s (2012) suggestion that OCBs may prevent social and developmental
opportunities if left untreated.
GUERTIN ET AL. 27

Limitations on Max's mother's and teachers' time required on‐site training of mediators to occur concurrently
with treatment delivery. This took greater therapist time and resources to complete than a mediator training and
implementation model but allowed for more rapport building and data collection opportunities. Within this context,
the therapist provided the full intervention, faded resource‐intensive treatment components (i.e., visuals and
continuous reinforcement schedules) to more natural conditions, and trained mediators to perform maintenance
procedures. Anecdotally, teachers started using modeled intervention procedures with OCBs not targeted in the
experimental design. Mediator‐led maintenance appeared effective as treatment gains were maintained at a 3‐week
follow‐up. Additionally at Max's mother's request, no treatment for OCBs occurred in the home. Following success
with the protocol at school, however, Max's mother reported using reinforcement strategies to reduce OCBs at
home; she had success with a sleeping routine and said he was now sleeping in his bed consistently.
Despite the promising results of the study, some limitations exist. The results of one participant limit generaliz-
ability, and only two behaviors were included in the multiple baseline, limiting the number of replications and level of
experimental control. Though average duration of peer engagement was 5 s or shorter with one daily average of 20 s
(indicating a limited ability for Max to disengage from ritualistic work routines), there was a small decrease in the level
of responding in the second behavior that co‐occurred with introduction of treatment of the first behavior. This could
be the result of overall variability of the classroom environment such as number of peers in the classroom or noise
level of the classroom. Replication of the results with greater control of extraneous variables will be necessary in
order to evaluate the treatment with greater internal validity. In order to determine the function of each OCB, an
experimental functional analysis could be conducted in future studies with technology aimed at determining the role
of physiological distress as a motivating operation for OCBs (Chok & Koesler, 2014). Further development of
informant assessments addressing the role of automatic negative reinforcement in maintaining OCBs will further
assist clinicians conducting functional behavioral assessments.
Out of consideration for rapport and mediator verbal or nonverbal preference not to have written evaluation of
their performance, treatment adherence data were not collected for the mediator‐led maintenance procedures.
Further replication of exposure‐based behavioral intervention data in schools and homes will explore the broader
applicability of the protocol to young children with ID. The additional measurement of observed collateral events
(e.g., approach from peers) as part of the experimental design will determine if a functional relationship exists
between the intervention and gains in these domains. Finally, exploration of the treatment through component
analysis will identify the efficacy of each intervention component, including the effectiveness of the piloted strategies
aimed at decreasing conditioned distress responses in the presence of the eliciting stimuli.
The exposure‐based behavioral intervention protocol was successful in reducing OCBs and increasing social
engagement in a preschooler with mild ID. Early intervention and prevention of future OCBs could help to mitigate
negative developmental consequences of OCBs. Ongoing research is required to evaluate treatment options for
children with ID, or comorbid ASD and ID, populations in which these behaviors are frequently occurring. Studies
of both home and school settings are crucial to target OCBs in the natural environment.

ORCID
Emily L. Guertin http://orcid.org/0000-0002-0854-8463

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How to cite this article: Guertin EL, Vause T, Jaksic H, Frijters JC, Feldman M. Treating obsessive compulsive
behavior and enhancing peer engagement in a preschooler with intellectual disability. Behavioral Interventions.
2019;34:19–29. https://doi.org/10.1002/bin.1646