CHRIS WILLIAMS, Senior Clinical Psychologist
MIKE PRICE, Charge Nurse
EARLY DAYS: first steps
t o a ward-based token system
!ti this paper we do not endeavour to prove,
demonstrate or applaud the token system us the ideal
solution to any and every ward problem of behaviour
management with retarded children. Neither are we
in any position to present it as a masterpiece o f
technical skill in implementing behaviour modification,
nor would we wish to do so. Our concerti is to share
some of the pi.obletns, difficulties, failures and successes
encountered during the early days of a pilot token
sclieme. If from this, you can app8,eciate some of the
structural and administrative manoeuvres necessary for
changing both your own and your children’s behaviour,
and, if we can also provide the germ o f an idea for
other projects, then we shall feel justified in our efforts.
Token Systems:
A token system parallels realistically the work-to-
pay relationship that is within the common experience
of the majority of people living in this country. All
of the staff of the hospital were, without exception,
already working under the control of a token payment
system, in that weekly or monthly pay packets were
regularly dispensed by the hospital treasurer’s depart-
ment. I t is essential to grasp this notion since it puts
into perspective any more structured token system,
insofar as it identifies it closely with the “normal”
living experiences that apply to all individuals whether
labelled patients or not.
There are essential differences between token
systems of normal living and the micro-economy of a
ward programme designed to socialise handicapped
children. The first is that the children must be paid
immediately whatever they are required to do and not
at the end of a week or month. The second important
feature is that earnings are directly related to
performance - no performance, no earnings - as
opposed to being paid as at present, irrespective of
performance. In this way the child is made to
assume responsibility for his behaviour as it now
begins to have a pay-off in an immediate and
meaningful manner.
Aims:
The first, and probably most important, aim is to
develop a powerful positive reinforcement agent that
can be used to shape appopriate skills, as opposed to
20
using the negative reinforcement procedure commonly
known as “nagging”. Children can quickly learn to
co-operate in order to avoid or escape from “nagging”
and such methods are often used where one staff
member has up to ten children to supervise during
eating, washing and dressing.
Such a method is demonstrably effective and
reinforcing for the staff in that it enables them to
keep control. Unfortunately such control must,
every now and then, be backed up by stronger
sanctions than mere voice alone and it is in this area
of behaviour control that abuses can sometimes arise.
The use of a positive reinforcer system entirely
circumvents this difficulty in that all secondary
reinforcers must be backed up by primary positive
reinforcement in order to be effective. Nagging,
scolding and shouting should then become redundant
as behaviour control methods.
The second important feature of an operant
approach is to determine the behaviour that is deemed
appropriate and to be reinforced. The corollary of
this is that the behaviour considered inappropriate
and to be extinguished has also to be determined.
This entails considering current short-term aims of the
ward to develop control and co-operation to facilitate
learning, and long-term aims of future placement and
development of the children presently under our care.
A third factor of importance to consider is the
setting in which children are expected to behave.
This covers the ground from such things as where to
store clothes to what behaviours are to be shown by
the staff in handling the children. The aim here is to
develop a stimulus situation that the child can
discriminate as one leading to positive reinforcement
as opposed to one in which he can escape from
negative reinforcement.
These three features can be summarised in a simple
model of behaviour modification which will help in
structuring the various theoretical aspects of operant
teaching through reinforcement. The model considers
each feature as being functionally related to the
others. Labelling them will make this clearer.
A-refers to the stimulus setting in which
behaviour occurs. It stands for antecedents in that
such stimuli come before any action is required.
B - refers to the behaviour that is being displayed
and
C - refers to the consequences available or pro-
duced by that behaviour.
The summary model is therefore known as the A-B-C Baselines and controls:
model and each feature can be considered in turn, The assessment data were all taken before any
with respect to its relationship to others in the token intervention procedures were implemented. More
system we are about to describe in outline. specific data were also collected in detail concerning
self-help skills. These data form the baseline assess-
ments against which -progress can be measured. With
The ward setting no formal control group each child must act as his
Nine of the most able children from a ward of 23 own control in that up to the time of the study each
were chosen for initial inclusion on the incentive child would have had a record of Vineland scale
system. Problems of space and staff shortage deter- assessments, the changes of which would give an
mined that this should initially be the case. The aim indication of his progress under standard ward and
is to develop the programme sufficiently to include school procedures. A more structured control group
further children as it becomes established routine for assessment would involve the withdrawal of token
the ward. Structural changes had to be kept to a reinforcement on some future date to note the effects.
minimum to be within a standard ward budget.
All children slept in one dormitory in standard Steps taken in establishing token system
3ft. 6in. divans 3ft. apart. They all ate together in The following steps were taken in the intial stages
groups of four, the food being taken to the tables on of developing a structured programme:
plates by the staff. Washing and dressing is done in (1) Records taken of current ward routine in
two groups. The ‘top’ group includes seven boys who detail by discussion between ward staff and
have the use of a room containing three lavatories, psychologist.
four washbasins, a few wall hooks and a table. This
bathroom is also used to store fresh laundry in boxes (2) Psychologist worked daily nursing shift to
and soiled linen in bags. The boys’ clothes are kept experience the practical problems involved in
in a room across the corridor from the bathroom. ward work with responsibility taken for
All of the remaining children are toileted, washed-and_ toileting, washing, dressing and feeding the
dressed in the second bathroom on the ward. This “top” group for a period of two weeks.
room contains one bath, five lavatory compartments, (3) Night staff informed of developments.
a pot rack, one washbasin and a shelf for clothing. (4) Medical staff consulting with the charge nurse
There are usually two staff members in this bathroom at ward meetings.
and one other for “top” boys’ bathroom. All but (5) Ward staff involved in group discussions of
three of the children have to be ready for school by aims and procedures.
about 9.45 a.m. It is under these conditions that the
staff have to work and the children have to learn (6) Tokens established as reinforcers by immedi-
social and self-help skills. ately exchanging them for sweets or pocket
money for spending on sweets in the hospital
This paper will concern itself from now on only with shop. (Pocket money was already a reinforcer
the “top” boys and the pilot programme designed to for these children in that they would take what
create a positive incentive system for social and they were given following each lunchtime and
self-help skill development. walk to the shop to spend it. They had no
appreciation of the value of individual coins).
The basic information on the token group are given It took only one day for tokens to become
in Table 1.
“valued” by the children as giving them access
to pocket money or sweets.
(7) Training was then given in using a lockable
TABLE 1 token savings-box where each child was shown
All the children included were classified “Severely how to insert his token into a box which could
Subnormal”. then be opened for him to recover it for
exchanging.
Age in
Residcnt Years Sex BQ SQ Clinical Features (8) The “top” group were seated together on one
long table. A rota drawn up for each child to
1 16.5 M 21 IS Left hemiplegia. Epilepsy
since 7 months of age. do the laying of places. Serving bowls provided
2 14.9 M 30 25 Unclassified. for self-service at the table.
3 14.9 M 23 22 Unclassified. (9) The savings-box was screwed to the wall
4 12.4 M 35 45 Down’s Syndrome. immediately behind the top group’s dining
Bilateral hare lip table.
(repaired). Palate defect
still present. (10) Details of procedure were changed by the staff
5 14.11 F 61 63 Epilepsy.
for eating, washing, toileting and dressing until
an agreed routine in keeping with the require-
6 11.0 M 20 22 Jaundice at 2 weeks of
age. Aggression. ments of a token system was established. Scope
Hyperkinesis. for change and improvement in the routine
I 11.4 M 42 64 Fibrocystic Disease. was considered to be essential.
8 13.0 F 35 50 Cretinism. Epilepsy. (11) The initial economy system was drawn up.
9 15.4 M 23 30 Down’s Syndrome. Tokens were to be given for co-operation at
meal-times and for washing and dressing
Table of basic data for token programme following breakfast and lunch. One token was
Key: BQ Fairview* Self-help scale behavioural quotient given to each child upon completion of each of
SQ = Vineland* Social quotient the two above gross behaviours. After lunch
*Further details of these scales can be obtained by writing to each day a token exchange period was estab-
the authors. lished when one new penny would be given for

21
 each token earned during the morning. The
children were then allowed to go to the shop to
spend their money. The shop lady was told
only to exchange goods to the correct value
and NOT to give sweets either when a child
did not have enough money or when he had no
money at all but had a temper tantrum in the
shop - this, we found, had sometimes been
the practice in the past.
(12) This initial programme ran so well during the
first two weeks of its inception that some
changes were made to increase the skills being
learned by the children.
(13) Individualised tokens were introduced. Each
child has a coloured token to himself - this
circumvents the problem of stealing from
others and permits the future development of
individualised programmes.
(14) A token trolley was acquired in which the staff
could store the tokens, the pay sheets and the
exchange records. Money and sweets were
also kept in this trolley. This would be wheeled
out with the drug trolley and would thereby
become associated with ward routine.
The token pay sheet includes the following list of
behaviours which achieve a pay-off for the children
of one token each:
Laying tables on rota
Eating appropriately
Cleaning table on rota
Toileting, washing and dressing
Help in bed making
Washing table tops
Washing table cloths weekly
The back-up reinforcers include:
pocket money
sweets
tickets for the cinema
(15)Each staff member was shown how the token
dispensing and exchange routine was to work
and the charge nurse and his deputy assumed
full responsibility for maintaining the pro-
gramme.
Ward changes necessary
Apart from the obvious changes in staff attitude
and behaviour a number of more subtle changes have
been and are to be made in order to cue in the staff
to the reinforcement system. Good behaviour must
be noticed in order for it to be reinforced. Hence
the signal for staff to dispense tokens at meal times
is a cleared table with everyone in his seat and quiet.
For washing, a timing clock is taken into the bath-
room on each occasion and set to ring half an hour
from starting. If a child is washed and dressed within
this period he receives a token. If not, then he
forfeits the opportunity. No coaxing, nagging or
bribing is necessary, merely a signal to both children
and staff that reinforcement is available for perform-
ance. The child is ‘free’ to choose not to dress on
time but he ‘pays’ for the privilege.
Data is recorded on the number of tokens given to
each child per day when the exchange takes place
after lunch. A chart is fixed inside the token t r o l l e ~
and the duty nurse merely notes down against eac!i
child’s name the number of tokens in his savings-box.
22
Since the rewarded behaviours are specified we have ;I
running record of success or failure. So far the
economy has moved from recession to inflation but
since it is still in its early days no reliable trend can
be determined.
Future Steps
The physical structure of the bathroom is to be
changed so that the problems of having the children
in one room and their clothes in another will be
circumvented. A series of lockable cupboards are to
be provided in the bathroom itself into which, each
evening, the children will put the clothes they have
chosen to wear on the following day. Access to
these clothes will be contingent on having washed and
dried, at which time the nurse in charge will open
the cupboard for the clothes. This minor change in
ward procedure again serves to cue in the staff to
reward appropriate behaviour. It also gets round the
problem of children and clothes becoming inextricably
combined on the bathroom floor.
The sleeping and eating arrangements are to be
modified with the aim of ‘normalising’ accommodation
using partitioned bedrooms and separate group-dining
rooms.
Additional skills are to be added to the token pay
sheets to include items of pre-academic and social
development and the school d l gradually be able to
take over some of the daily token programmes for
academic skills.
Summary and conclusions
The initial stages of setting up a pilot token system
and the steps taken so far have been described in
outline. As this is an on-going project it is hoped
that a future report can provide more precise details
of procedures and results, though one salient feature
of any ward based programme has impressed itself
upon us. Any programme, whether a token system
or not, to be successful must become part of the
established ward routine. If this does not happen
then it will be the first to be dropped whenever staff
are depleted by a shortage or through relieving on
other wards. Since our ward programme has never.
so far, expanded faster than the number of staff and
the routine would allow, it has been absorbed as a
routine every day activity as though it had always
been done.
To be continued .......
Further reading
A detailed list of relevant references can be obtained
by writing to the authors, but no token system should
be started without first reading:
Ayllon, T., and Azrin, N. H. The Token Economy:
a motivational system for therapy and rehabili-
tation. pbd. Appleton-Century-Crofts 1968.
and
Ball, T. S. (ed.) The establishment and adminis-
tration of operant conditioning programmes in a
state hospital for the retarded. State of California
Department of Mental Hygiene Research Sym-
posium No. 4 1969.