Journal of Applied Behavior Analysis 2020, 9999, 1–9 NUMBER 9999 ()

Teaching students with autism spectrum disorder to tolerate

haircutting
Jessica Buckley, James K. Luiselli, Jill M. Harper and Andrew Shlesinger
Melmark New, England

We describe intervention with 2 adolescent male students who had autism spectrum disorder
(ASD) and resisted haircutting performed by care providers at a residential school. The students
were exposed to a graduated hierarchy of steps including the presence of hair clippers, and
increased duration of hair clippers against their scalp and hair. Edible reinforcement was pres-
ented contingent on completion of a step without interfering behavior. Both students learned to
tolerate all of the steps in the graduated hierarchy and a full haircut with maintenance at 2-, 4-,
and 6-month follow-up. The study supports previous tolerance-training research with children
and youth who have intellectual and developmental disabilities and resist personal care and
hygiene routines.
Key words: autism spectrum disorder, compliance training, graduated exposure, haircutting
tolerance, personal hygiene

Many children and youth who have intellec-
tual and developmental disabilities (IDD) do
not comply with basic healthcare routines,
necessitating intervention that teaches them to
tolerate dental treatment (Conyers et al.,
2004), physical examination (Cavalari et al.,
2013; Cuvo et al., 2010), blood draws (Grider
et al., 2012), and needle injections (Davit
et al., 2011). Compliance problems are also fre-
quently encountered in the area of personal
hygiene, such as brushing teeth (Carter et al.,
2019), washing hands (Walmsley et al., 2013),
and applying lotion (Ellis et al., 2006). There
are many untoward consequences from poor
health and hygiene care, including illnesses,
untreated conditions, functional impairments,
unappealing appearance, and stigmatization. Of
note, several effective behavioral methods to
improve compliance and toleration have been
researched, namely graduated exposure, model-
ing, positive reinforcement, and response
Address correspondence to: James K. Luiselli, Director
of Clinical Development and Research, Melmark New
England, 461 River Road, Andover, MA 01810.
Email: jluiselli@melmarkne.org
doi: 10.1002/jaba.713
© 2020 Society for the Experimental Analysis of Behavior
1
prompting (Kupzyk & Allen, 2019; Mattson
et al., 2016).
Care providers at schools, residential homes,
and similar service settings are often responsible
for maintaining the hygiene and appearance of
persons with IDD. In illustration, Dowdy et al.
(2018) evaluated a program that care providers
could use to cut the fingernails and toenails of
12-year old and 16-year old male students who
had autism spectrum disorder (ASD) and force-
fully resisted nail-cutting. During intervention
sessions, a therapist delivered preferred food to
the students each time they tolerated a nail cut,
paused 5 s contingent on interfering (escape)
behavior, then re-presented the nail clippers for
another cutting trial. This combination of pro-
cedures successfully increased compliance with
nail-cutting by both students, from 0-30%
baseline levels to 90-100% with intervention.
Similarly, Bishop et al. (2013) evaluated a pro-
gram to increase compliance with therapist
implemented tooth brushing among three chil-
dren with ASD. Using a 30-step stimulus fad-
ing hierarchy, the children were gradually
exposed to a toothbrush at closer proximity to
their mouths, then increased duration of teeth-
to-toothbrush contact, and finally actual tooth
2 Jessica Buckley et al.
brushing. The therapist also presented a pre-
ferred edible item to the children when they
successfully tolerated the target stimulus fading
step. Interfering behaviors did not result in ses-
sion termination. During intervention, the chil-
dren demonstrated increased compliance with
tooth brushing for up to 60s and positive find-
ings generalized to other care providers.
Getting a haircut is a conventional personal
care routine, but often difficult to complete
with some children who have ASD. Challenges
are commonly attributed to a sensory
processing disorder, hypersensitivity, and stim-
ulus novelty (e.g., www.calmingclipper.com).
Compliance problems include physically strug-
gling against the person trying to cut hair, pos-
ing an injury risk in the presence of cutting
implements, and causing disruption in public
settings such as a barbershop. In the only study
addressing haircutting, Schumacher and Rapp
(2011) implemented home-based intervention
with a 5-year old boy who had ASD by having
his mother present a preferred edible item
when he tolerated having his hair cut during
trials starting at 5 s in duration, and gradually
increased to 160 s. A 30-s break from haircut-
ting was also provided following successful tri-
als. This compliance training program enabled
the mother to cut the boy’s hair absent interfer-
ing behaviors and these positive effects
maintained through 10-week follow-up.
In summary, the hygiene tolerance interven-
tions evaluated by Dowdy et al. (2018), Bishop
et al. (2013), and Schumacher and Rapp
(2011) included compliant-contingent positive
reinforcement but instead of escape extinction,
allowed brief pauses during sessions when the
children displayed interfering behavior or fol-
lowing successful trials. Notably, escape extinc-
tion is an effective intervention for escape-
maintained problem behavior (Vollmer et al.,
2015) although implementation through
response blocking and physical redirection can
be difficult, may occasion extinction-induced
resistance (Lerman & Iwata, 1995), and poses
risk of injury when sharp instruments are
required for personal-care routines. Given that
additional research is needed to replicate and
extend compliance with haircutting programs
applied by care providers (Schumacher &
Rapp, 2011), the present study evaluated the
effects of graduated exposure and compliance-
contingent reinforcement without escape
extinction for teaching students with ASD to
tolerate haircutting.
Method
Participants and Setting
The participants were two students at a pri-
vate residential school serving children and
youth with neurodevelopmental disabilities.
Josh was 16 years old and diagnosed with ASD.
He did not speak and communicated through
vocal approximations to words, gestures, facial
expression, and a picture exchange modality.
The focus of his educational program was
self-care, daily living, vocational, and domes-
tic skills as well as intervention to reduce
noncompliance and aggressive behavior. Stan-
dardized testing placed him in the very low
range of nonverbal cognitive functioning on
the Leiter International Performance Scale-
Third Edition (Roid et al., 2013) and with
significantly underdeveloped adaptive skills on
the Vineland Adaptive Behavior Rating Scales-
Third Edition (Sparrow et al., 2005).
Aiden was 17 years old and diagnosed with
ASD. He communicated vocally in full sen-
tences, followed simple directions, and com-
pleted most self-care and daily living skills with
supervision from a care provider. His educa-
tional program focused on several academic and
functional community objectives. During
instructional activities, he sometimes demon-
strated aggression, self-injury, and property
destruction. Standardized testing placed him in
the very low range of nonverbal cognitive func-
tioning on the Leiter International Performance
Scale-Third Edition (Roid et al., 2013) and
 Haircutting Tolerance
with significantly underdeveloped adaptive
skills on the Vineland Adaptive Behavior Rat-
ing Scales-Third Edition (Sparrow et al., 2005).
Josh and Aiden did not tolerate haircuts pre-
ceding intervention despite parent and care
provider efforts to quickly trim their hair.
Direct observations revealed that the partici-
pants resisted haircutting by engaging in envi-
ronmental disruption, motor agitation, self-
injury, and aggression. File documents included
written entries such as “he engages in challeng-
ing behaviors when an adult completes an
activity for him like cutting hair” and “his lim-
ited tolerance may affect his hygiene and overall
quality of life.” With parent approval, the
school educational team wrote compliance-
Table 1
Graduated Exposure Hierarchy for Josh
Steps Description
1 Hair clippers (turned on) with “long guard” in contact
with hair-scalp: 1 s
2 Hair clippers (turned on) with “long guard” in contact
with hair-scalp: 2 s
3 Hair clippers (turned on) with “long guard” in contact
with hair-scalp: 3 s
4 Hair clippers (turned on) with “long guard” in contact
with hair-scalp: 4 s
5 Hair clippers (turned on) with “long guard” in contact
with hair-scalp: 5 s
6 Hair clippers (turned on) with “long guard” in contact
with hair-scalp: 7 s
7 Hair clippers (turned on) with “long guard” in contact
with hair-scalp: 9 s
8 Hair clippers (turned on) with “long guard” in contact
with hair-scalp: 12 s
9 Hair clippers (turned on) with “long guard” in contact
with hair-scalp: 15 s
10 Hair clippers (turned on) with “long guard” in contact
with hair-scalp: 20s
11 Hair clippers (turned on) with “long guard” in contact
with hair-scalp: 25 s
12 Hair clippers (turned on) with “long guard” in contact
with hair-scalp: 30s
13 Hair clippers (turned on) with “long guard” in contact
with hair-scalp: 40s
14 Hair clippers (turned on) with “long guard” in contact
with hair-scalp: 50s
15 Hair clippers (turned on) with “long guard” in contact
with hair-scalp: 60s
16 Hair clippers (turned on) with “long guard” in contact
with hair-scalp: 60s (no edible reinforcement)
3
with-haircutting as a formal personal-care learn-
ing objective into Josh’s and Aiden’s Individu-
alized Education Program (IEP).
At the residential school, the participants
attended classrooms with four to five other stu-
dents for 6 hr on weekdays. A senior teacher
and several teaching assistants conducted
instruction with students during individual and
small group activities throughout the day. Out-
side of the classroom, the participants lived in a
community group home with six other students
and six to seven residential care providers who
were present during morning, afternoon, and
evening hours. The classroom teachers, teacher
assistants, and group home care providers
instructed the participants and other students
according to lesson plans in the areas of aca-
demic, self-care, daily living, communication,
social, and leisure skills.
Measurement
The dependent measure in the study was the
duration (seconds) of time the participants tol-
erated steps comprising individualized gradu-
ated exposure hierarchies. Toleration was
defined as the participants completing hierarchy
steps without demonstrating the following
behaviors: (a) self-injury, (b) aggression,
(c) removing or attempting to remove mate-
rials, (d) getting out of their seat, and (e) using
their hands to push against or pull away from
the care provider implementing steps. For Josh,
the hierarchy steps (N = 16) were defined by
the duration of time hair clippers contacted his
hair and scalp, beginning at 1 s and terminating
at 60 s (Table 1). For Aiden, the hierarchy
steps (N = 11) were defined by (a) the proxim-
ity of hair clippers to his hair and scalp begin-
ning with hair clippers on a counter top, and
(b) the duration of time hair clippers contacted
his hair and scalp beginning at 60 s and termi-
nating at 300 s (Table 2). Steps 1 and 2 were
arranged with Aiden because he demonstrated
more distress and interfering behavior than Josh
4 Jessica Buckley et al.
Table 2
Graduated Exposure Hierarchy for Aiden
Steps Description
1 Hair clippers (turned off) on counter top in front of
participant: 60s
2 Hair clippers (turned on) on counter top in front of
participant: 60s
3 Participant kneeling on floor, head on mat, hair clippers
(turned on) 1 inch from hair-scalp: 60s
4 Participant kneeling on floor, head on mat, hair clippers
(turned on) with “long guard” touching head-scalp:
60s
5 Participant kneeling on floor, head on mat, hair clippers
(turned on) with “correct guard” clipping hair: 60s
6 Participant in chair, hair clippers (turned on) with
“correct guard” clipping hair: 60s
7 Participant in chair, hair clippers (turned on) with
“correct guard” clipping hair: 120 s
8 Participant in chair, hair clippers (turned on) with
“correct guard” clipping hair:180 s
9 Participant in chair, hair clippers (turned on) with
“correct guard” clipping hair: 240 s
10 Participant in chair, hair clippers (turned on) with
“correct guard” clipping hair: 300 s
11 Participant in chair, hair clippers (turned on) with
“correct guard” clipping hair: 300 s (no edible
reinforcement)
when care providers attempted to place hair
clippers in contact with his hair and scalp prior
to the study. Additionally, Aiden independently
put himself in a kneeling position starting at
step 3 and was provided a small floor mat com-
posed of vinyl-covered 1-inch foam on which
he placed his forehead. By step 6, he trans-
itioned to sitting in a chair.
Baseline and intervention sessions were
scheduled daily in a designated location at the
group home. During sessions, one of several
familiar care providers interacted with the par-
ticipants. Upon initiating each step in the grad-
uated exposure hierarchies, the care provider
activated a count-down timer that was set at
the specified duration and produced an audible
signal. The care provider then (a) recorded
whether the participant tolerated the full dura-
tion of the step or (b) recorded the duration
indicated if the timer had been stopped because
the participant demonstrated interfering behav-
ior and the session was terminated.
Interobserver Agreement and Procedural
Integrity
During 20% of sessions with Josh and 19%
of sessions with Aiden across baseline and inter-
vention phases, another individual conducted
measurement with a second timer simulta-
neously but independently with the care pro-
vider. Interobserver agreement (IOA) was
derived by comparing the two duration record-
ings and dividing the smaller duration by the
larger duration and multiplying by 100. IOA
was 100% for both participants.
During 12.4% of intervention sessions with
Josh and 10.6% of intervention sessions with
Aiden, an independent observer assessed proce-
dural integrity of care provider implementation.
Referencing a behavior-specific checklist, the
observer recorded whether the care providers
(a) displayed the selected food item to the partic-
ipants, (b) implemented the correct step in the
graduated exposure hierarchy, (c) set and acti-
vated the count-down timer to the specified
duration, (d) completed the step correctly or ter-
minated the session contingent upon interfering
behaviors, if displayed, and (e) accurately
recorded session data on the designated form. A
procedural integrity percentage was computed
by dividing the number of steps implemented
correctly by the total steps (correct + incorrect)
and multiplying by 100. Procedural integrity
averaged 93.3% (range, 80-100%) for Josh and
99% (range, 80-100%) for Aiden.
Procedures and Experimental Design
Procedures were evaluated in a multiple
baseline across participants design (Kazdin,
2011) with intermittent probe assessments (full
haircuts) performed during intervention phases
and at 2-, 4-, and 6-months postintervention
follow-up.
Baseline
After the participants were seated in a chair,
the care provider initiated the first step of their
 Haircutting Tolerance
graduated exposure hierarchy. Contingent on
completion of the step, the next step was
implemented without feedback or reinforcement
from the care provider. If the participants dis-
played interfering behavior, the care provider ter-
minated the session. Thus, under baseline
conditions, the care provider continued with as
many steps in the graduated exposure hierarchy
that the participants tolerated during sessions.
To illustrate, if a participant had tolerated step
6 in the graduated exposure hierarchy, the care
provider would have continued to step 7 and if
successful, step 8, and so on until he demon-
strated interfering behavior. For that session, tol-
erance would be recorded as the duration at the
step preceding the failed step.
Intervention
Sessions began with the care provider dis-
playing several edible items to the participants.
The edible items were identified through
paired-stimulus preference assessment (Fisher
et al., 1992) conducted with each participant
and included cookies, potato chips, pretzels,
and similar snack foods. From the available edi-
ble items displayed, the participants chose one
for that session.
After allowing the participants to choose an
edible item, the care provider initiated steps
according to the duration and proximity criteria
specified in the graduated exposure hierarchies.
Contingent on the participant completing the
current step without interfering behavior, the
care provider delivered praise, allowed him to
consume the edible item, and terminated the
session. Identical to baseline conditions, the
care provider also terminated sessions immedi-
ately following the first occurrence of interfer-
ing behavior. The next steps in the graduated
exposure hierarchies were targeted when the
participant had successfully tolerated the imme-
diately preceding step during several consecu-
tive intervention sessions.
The care provider implemented steps in the
graduated exposure hierarchies using a cordless
5
hair clipper fitted with two blade covers (Wahl
Professional Cordless Magic Clip™). Hair clip-
ping was performed by having the care provider
turn on the hair clippers for several seconds
before placing them in contact with the hair
and scalp of participants while simulating the
motions of cutting hair. The “long guard”
cover placed on the clippers did not allow hair
to pass through the actual clipping mechanism,
but the participants could feel the clippers
against their hair and scalp. The second cover,
the “correct guard,” permitted full hair cutting
and was used during some of the graduated
exposure hierarchy steps with Aiden and during
probe assessment sessions with both Josh and
Aiden. The “correct guard” was not used with
Josh during intervention sessions because the
low-duration graduated exposure steps made it
difficult to thoroughly clip his hair.
Probe Assessments and Follow-Up
Probe assessments consisted of the first
author cutting the participants’ hair in the
same group home location. Sessions were
scheduled intermittently during the interven-
tion phase when participants’ hair was judged
long enough to warrant a haircut. The first
author used the same clippers as in interven-
tion, with the “correct guard” attached. Edible
items delivered during intervention sessions
were also presented to the participants with
accompanying verbal praise (e.g., “You’re
doing great, keep going!”) every 60-120 s
while having their hair cut. Any edible items
the participants did not consume during a
probe assessment were made available to them
when the session concluded. Hair cutting con-
tinued for as much time required to comple-
tion and similar to baseline and intervention
conditions, probe sessions terminated contin-
gent on interfering behavior. At 2, 4, and
6 months following intervention, the partici-
pants received a hair cut from the senior
author under conditions identical to the probe
assessments.
6 Jessica Buckley et al.

Figure 1
Duration (Seconds) that Aiden and Josh Tolerated Hair Clipping During Consecutive Sessions (Closed Circles).

Note. Open squares indicate duration (minutes) of probe assessment haircuts. Follow-up measures occurred 2, 4, and
6 months postintervention. Numbers above intervention phases represent steps in the graduated exposure hierarchies.

Results seven occasions (3.5%). He completed every

Results are presented in Figure 1. In base-
line, Aiden (top panel) tolerated between 0-55 s
of step 1 in the graduated exposure hierarchy.
During intervention, he consistently tolerated
the closer proximity and increased duration at
each step in the graduated exposure hierarchy
and successfully achieved the terminal criterion
of 300 s without edible reinforcement. Over
the course of 199 intervention sessions, Aiden
demonstrated interfering behavior on only
probe assessment haircut without interfering
behaviors during and following intervention
(M haircut duration = 15 min).
Josh (bottom panel) only occasionally com-
pleted step 1 (1 s) of the graduated exposure
hierarchy in baseline. During intervention, he
consistently tolerated the increased duration
required at each step of the graduated exposure
hierarchy and successfully achieved the terminal
criterion of 60 s without edible reinforcement.
 Haircutting Tolerance
Over the course of 215 intervention sessions,
Josh demonstrated interfering behavior on only
nine occasions (4.1%). He completed every
probe assessment haircut without interfering
behaviors during and following intervention
(M haircut duration = 25 min).
Discussion
The present study taught two adolescent stu-
dents with ASD to tolerate hair clipping by
exposing them to the presence, contact, sound,
and movement of hair clippers against their
hair and scalp for increasingly longer durations,
combined with compliance-contingent positive
reinforcement. Similar to other research on tol-
erance of personal care routines, the study did
not include escape extinction as a component
of intervention (Bishop et al., 2013; Dowdy
et al., 2018; Schumacher & Rapp, 2011).
Notably, intervention sessions were terminated
when the participants demonstrated interfering
behavior but compliance with hair clipping
steps increased and interfering behavior
occurred less frequently when edible items were
delivered. One explanation for these findings is
that access to edible items may have functioned
as an abolishing operation by reducing the aver-
sive features of receiving a haircut
(Schumacher & Rapp, 2011).
Probe assessment sessions revealed that both
participants tolerated a full haircut at intermit-
tent points during intervention. These assess-
ments were scheduled largely based on
participants’ hair growth from week to week.
Rather than stop intervention following their
first successful probe assessment, we chose to
continue sessions with the graduated exposure
hierarchies and subsequent probes to confirm
that haircutting success was not a one-time
event. Also, intervention sessions continued
through mastery of the final hierarchy step to
meet the personal-care learning objective speci-
fied in each participant’s IEP. However, these
factors make it unclear whether all of the
7
intervention sessions were required for Josh and
Aiden to consistently tolerate a full haircut dur-
ing and following the study. Interpretation of
the probe assessment data is limited further
because (a) full haircuts were not conducted
during baseline, (b) positive reinforcement with
edible items and praise was presented in probe
sessions, and (c) probe assessment procedures
did not match the terminal step criteria in the
graduated exposure hierarchies. Of note, the
first author who conducted probe assessments
had also performed instruction with the partici-
pants for several years, and this history may
have contributed to their tolerance during these
sessions.
The procedures of graduated exposure and
positive reinforcement in this study were rela-
tively easy to implement and may have been
responsible for the high percentage of proce-
dural integrity. In particular, the graduated
exposure hierarchies were prepared based on
unique participant characteristics. For example,
Josh was observed to tolerate the presence of
hair clippers but not their contact against his
hair and scalp. This presentation suggested
that he should start intervention with very
brief and gradually increasing durations of
clipper contact without actual hair cutting.
Aiden, on the other hand, had to first tolerate
presence and proximity of the hair clippers
while he kneeled on the floor instead of sitting
in a chair. He then moved to a chair and
accepted gradually increasing durations of hair
clipping. For many children and youth similar
to our participants, it should be expected that
the steps comprising graduated exposure hier-
archies will have to be individualized in
tolerance-training programs and modified
depending on a participant’s response to inter-
vention (e.g., changing the criteria for advancing
and decreasing steps). It is also likely that
tolerance-training programs will need to be
implemented across many sessions before com-
plete compliance is achieved. The present study
lasted several months in order to accommodate a
8 Jessica Buckley et al.
schedule of one brief-duration session with the
participants each day, for example.
In this study, session termination criteria
eliminated the need for care providers to strug-
gle with physical prompting or response block-
ing as required in escape extinction (Vollmer
et al., 2015). Furthermore, the very small
advancement of steps in the graduated exposure
hierarchies was intended to be so minimally
demanding as not to evoke interfering behavior
but instead promote compliance and contact
with reinforcement. Thus, our findings support
previous personal hygiene compliance training
programs in which escape extinction was not
implemented during intervention (Bishop
et al., 2013; Dowdy et al., 2018; Schumacher &
Rapp, 2011). Of course, the combination of
graduated exposure, positive reinforcement, and
negative reinforcement represented an interven-
tion package that cannot confirm the separate
influence of these procedures. Accordingly,
component analyses of multiprocedure pro-
grams would be a fruitful area of future
inquiry.
One limitation of the study is that we did
not directly measure interfering behavior dem-
onstrated within baseline and intervention ses-
sions. However, as compared to baseline
phases, the session termination data revealed
that the participants engaged infrequently in
interfering behavior during intervention. A
related concern is that a functional analysis was
not conducted with the participants to isolate
the consequences maintaining their interfering
behavior (Chok et al., 2019). Finally, the study
did not assess procedural fidelity during base-
line and probe sessions or evaluate generaliza-
tion to other settings such as a barbershop.
Despite these shortcomings, the current study
adds to the literature on compliance training to
promote completion of health and personal care
routines among persons with IDD (Kupzyk &
Allen, 2019; Mattson et al., 2016) and supports
the limited research among children and youth
with ASD who refuse haircuts (Schumacher &
Rapp, 2011). Similar interventions for addressing
haircutting tolerance, assessment of generalization
and maintenance, and extension to other areas of
grooming and appearance are warranted.
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Received November 6, 2019
Final acceptance February 27, 2020
Action Editor, Timothy Vollmer.