Behavior Analysis in Practice

https://doi.org/10.1007/s40617-020-00490-3

RESEARCH ARTICLE

An Evaluation of “Balance”: a Home-Based, Parent-Implemented

Program Addressing Emerging Problem Behavior
Kelsey W. Ruppel 1,2 & Gregory P. Hanley 1,2 & Robin K. Landa 1,3 & Adithyan Rajaraman 1,4

# Association for Behavior Analysis International 2020

Abstract
Programs that prevent the development of severe problem behavior in young children with autism spectrum disorder (ASD) are
critically needed. We describe a program designed to do this, and we report on a preliminary evaluation of its effects with four 3-
and 4-year-old children with ASD. Parents served as the primary implementers, with twice-weekly coaching from a Board
Certified Behavior Analyst. Direct measures and Aberrant Behavior Checklist scores reflected decreases in emerging problem
behavior. Direct measures also reflected increases in child communication, social, and cooperation skills, and parents rated the
process as highly acceptable. A randomized controlled trial will be required to evaluate the extent to which the program prevents
the development of problem behavior in young children with ASD.

Keywords autism . early intervention . parent training . prevention . problem behavior

The average age at an autism spectrum disorder (ASD) diagnosis
in the United States is 4 years 4 months (Centers for Disease
Control and Prevention, 2019), and research focuses on ever-
earlier identification (e.g., English, Tenenbaum, Levine, Lester,
& Sheinkopf, 2019; Franchini et al., 2018). The American
Academy of Pediatrics recommends early intervention services
as soon as ASD is suspected (American Academy of Pediatrics,
2014; Myers & Plauché Johnson, 2007). A critical function of
Research Highlights
• Parents served as the primary implementers of a skill-building package,
resulting in child cooperation with multistep tasks following denial of a
functional communication response.
• Rates of problem behavior decreased among all participants.
• Behavior analyst support occurred for 2 hr per week, making this package
potentially useful where service availability is limited.
• Evaluation of the preventive effects of this package on the development of
severe problem behavior in children with autism seems warranted.
* Kelsey W. Ruppel
kruppel@ftfbc.com
1
Psychology Department, Western New England University,
Springfield, MA, USA
2
Present address: FTF Behavioral Consulting, 40 Southbridge St.,
Suite 202, Worcester, MA 01608, USA
3
Present address: May Institute, Worcester, MA, USA
4 Ingvarsson, 2020). No published studies have evaluated its pre-
Present address: Psychology Department, University of Maryland,
Baltimore County, Baltimore, MD, USA
these services would seem to be preventing the development of
severe problem behavior, given that it is more common in chil-
dren with ASD than in typically developing children and children
with other disabilities (American Psychiatric Association, 2013;
Bodfish, Symons, Parker, & Lewis, 2000; Farmer & Aman,
2011; Mayes et al., 2012). However, most early intensive behav-
ioral intervention outcome studies report little or no data on prob-
lem behavior (Smith & Iadarola, 2015). To our knowledge, no
programs from any discipline have empirically demonstrated the
prevention of severe problem behavior in children with ASD.
However, there is research suggesting the potential utility of
certain procedures. The Preschool Life Skills Program (Hanley,
Heal, Tiger, & Ingvarsson, 2007) focuses on systematically and
explicitly teaching children how to respond to challenging situa-
tions they are likely to encounter in daily life. Target skills in-
clude responding to name calls, functional communication,
responding calmly to delays and denials, following instructions,
and interacting with peers. It has been demonstrated to prevent
the development of problem behavior in typically developing
children (Luczynski & Hanley, 2013). The Preschool Life
Skills Program also reduces existing problem behavior and
strengthens social skills in typically developing preschoolers
and children with developmental disabilities (Fahmie &
Luczynski, 2018; Gunning, Holloway, & Healy, 2019;
Gunning, Holloway, & Grealish, 2020; Robison, Mann, &
ventive effects for children with developmental disabilities.

However, given the program’s preventive effects for typically
developing children and its intervention effects for children with
developmental disabilities, this seems a logical next step for
researchers.
Recent research outside of that investigating the Preschool
Life Skills Program suggests some additional components that
might enhance its effects for children with ASD. Comparative
research suggests that synthesized reinforcers (e.g., escape from
work to tangibles, attention, and sensory reinforcement) produce
stronger treatment effects than isolated reinforcers (e.g., escape
only or praise only; Slaton & Hanley, 2018; Slaton, Hanley, &
Raftery, 2017).1 Indeed, research has shown that synthesized
reinforcers delivered continuously at first, then intermittently
and unpredictably, establish social skills to the exclusion of prob-
lem behavior in individuals with ASD (e.g., Beaulieu, Van
Nostrand, Williams, & Herscovitch, 2018; Falcomata, Roane,
Muething, Stephenson, & Ing, 2012; Falcomata, Muething,
Gainey, Hoffman, & Fragale, 2013; Greer, Fisher, Saini,
Owen, & Jones, 2016; Hanley, Jin, Vanselow, & Hanratty,
2014; Herman, Healy, & Lydon, 2018; Jessel, Ingvarsson,
Metras, Kirk, & Whipple, 2018; Rose & Beaulieu, 2019;
Santiago, Hanley, Moore, & Jin, 2016; Strand & Eldevik,
2017; Taylor, Phillips, & Gertzog, 2018). Therefore, the effects
of the Preschool Life Skills Program might be enhanced by in-
corporating synthesized, personalized reinforcers to shape skills.
This synthesized, personalized reinforcement interval could
be thought of as a child-led playtime (see also Luckett, Bundy,
& Roberts, 2007). A prevention program might begin by
targeting adult–child interaction during child-led play to create
the most reinforcing context possible for the child. Access to this
context could then be delivered contingent on the demonstration
of target skills during the remainder of the program.
The Preschool Life Skills Program might also be enhanced by
the addition of an emphasis on developing a balance between
child- and adult-led activities. The National Association for the
Education of Young Children (NAEYC) recommends both
child- and adult-led experiences (NAEYC, 2009), and yet access
to both types of experiences might be limited for children with
ASD. Research suggests that adults avoid adult-led activities with
children with a history of uncooperative behavior (Carr, Taylor,
& Robinson, 1991). At the same time, the quality of child-led
experiences might be routinely compromised due to common
treatment recommendations. For example, caregivers are often
encouraged to embed teaching into play activities for children
with ASD, but research suggests that children may not prefer this,
and that embedded teaching can even punish some children’s
play (Heal & Hanley, 2011; Heal, Hanley, & Layer, 2009).
Therefore, separating child- and adult-led activities and striking
1
Studies calling synthesized reinforcers into question have not included compar-
ative treatment phases (Fisher, Greer, Romani, Zangrillo, & Owen, 2016; Greer,
Mitteer, Briggs, Fisher, & Sodawasser, 2019), permitting the conclusion that iso-
lated and synthesized functional analyses may produce different results but pre-
cluding conclusions about the comparative treatment utility of those results.
Behav Analysis Practice
a balance between the two might improve the quality of both and
ensure that children access important learning opportunities.
This general framework of child-led time and adult-led time is
used in other programs, such as parent–child interaction therapy
(Masse, McNeil, Wagner, & Chorney, 2007). Parent–child inter-
action therapy is a treatment program typically used with children
with significant, existing behavior problems. Although re-
searchers have begun to experimentally evaluate its use with
children with ASD (e.g., Ginn, Clionsky, Eyberg, Warner-
Metzger, & Abner, 2017; Scudder et al., 2019; Solomon, Ono,
Timmer, & Goodlin-Jones, 2008), no prevention studies have
been published. In fact, we suspect that there may be components
important to preventing the development of problem behavior in
children with ASD that are not included in parent–child interac-
tion therapy, such as the explicit teaching of functional commu-
nication and tolerance for request denials (Ala’i-Rosales et al.,
2019; Fahmie, Iwata, & Mead, 2016). We also suspect that some
components that are included may not be optimal for children
with ASD, such as the recommendation that parents model, ex-
pand, describe, and imitate during child-led time (Ginn et al.,
2017; Masse et al., 2007; Scudder et al., 2019). These could
present as demands to children with ASD, decreasing the quality
of the child-led time and potentially evoking problem behavior.
Therefore, we developed a program that is the subject of the
current study—a home-based, parent-implemented program spe-
cifically designed to prevent the development of severe problem
behavior in children with ASD. It is based on the Preschool Life
Skills Program, with modifications based on recent research (i.e.,
synthesized reinforcement, a focus on balance between child-
and adult-led activity). Given this emphasis, we call it the
“Balance Program.” It also contains modifications to make it
accessible to children not receiving intensive early intervention
services: The primary interventionists are parents, with 2 hr of
Board Certified Behavior Analyst (BCBA) support per week,
and teaching occurs in the home.
In this preliminary investigation, we evaluated the effects of
the Balance Program using a single-subject experimental design,
and we report on direct and indirect measures of emerging prob-
lem behavior and direct measures of communication, social, and
cooperation skills. We also report on procedural integrity, the
amount and distribution of teaching and support required to
achieve the observed outcomes, and the social validity of the
goals, procedures, and outcomes. Evaluating the preventive ef-
fects of the Balance Program will necessitate a randomized con-
trolled trial, and the present study is a precursor to such an effort.
Method
Participants
Participants were four young children and their primary care-
givers (see Tables 1 and 2). Child inclusion criteria were are
Behav Analysis Practice

Table 1 Child characteristics

Name Age Sex Diagnosis Race/ethnicity Language EPB Tasks

(yr:mo) levela

Walt 4:3 M ASD White 3 Whining, yelling, hitting Cleaning up, putting on outerwear, sharing with
brother, listening to story
Jaden 4:7 M ASD White 4 Yelling, throwing,b kicking air, Cleaning up, handwriting, putting on outerwear,
stomping, squeezing parent’s face making bed, brushing teeth
Max 4:1 M ASD White 4 Whining, yelling, throwing,b Cleaning up, putting on particular clothes,
flopping, verbal attacks playing parent-selected game, playing alone
Kelly 3:3 F ASD Black/African 1 Whining, kicking air, pushing Cleaning up, listening to story, early VB tasks,
American items/people away, flopping playing alone

Tasks include those used in baseline and Steps 6 and thereafter; yr, years; mo, months; ASD, autism spectrum disorder; EPB, emerging problem behavior;
VB, verbal behavior
a
1 = nonverbal; 2 = one-word utterances; 3 = short disfluent sentences; 4 = full fluency
b
This included small/lightweight items, such as socks or game pieces, not in the direction of another person

follows: (a) between 3 and 6 years old, (b) diagnosed with
ASD by an outside evaluator within the last year, (c) living
at home, and (d) reported by parents to engage in frequent
uncooperative behavior or nondangerous problem behavior
that appeared to be socially mediated.
We recruited participants by distributing flyers to local ser-
vice providers, with the request that they offer them to families
of young children recently diagnosed with ASD. The first au-
thor screened respondents using the inclusion criteria. For the
fourth criterion, the researcher asked the parent whether the
child exhibited any uncooperative or problematic behaviors,
and if so, to describe the topographies, frequency, intensity,
and situations in which they tended to occur. Children were
included when parent report suggested “emerging” socially me-
diated behavior problems. An “emerging” behavior problem
was defined as the parent-reported daily occurrence of uncoop-
erative behavior or nondangerous problem behavior. If parents
reported the occurrence of severe problem behavior (i.e., self-
injury, pica, elopement, aggression resulting in injury to others,
or behavior that resulted in observable damage to property),2 or
if parent report suggested automatic reinforcement, we referred
the child to other programs within our clinic.
Although our participants were not referred for dangerous
problem behavior, their parents nevertheless reported that the
emerging problem behavior had adverse effects on the family.
Parents had difficulty running errands, completing household
tasks, and caring for siblings, and some reported persistent
family conflict and/or mental health concerns related to par-
enting issues.
2 We conducted assessments during the first and second
Severe problem behavior is sometimes observed in children under 5. For
example, Kurtz et al. (2003) reported on 30 children’s self-injury. The mean
age was 2 years 9 months, and all produced tissue damage; 83% engaged in
head banging (see also Kurtz, Chin, Huete, & Cataldo, 2012). Children who
engaged in such behaviors were not eligible for the current study, given the
preventive focus of the program.
Three master’s-level BCBAs participated, all of whom
were enrolled in a behavior-analytic doctoral program at the
time of the study and were supervised by the second author, a
doctoral-level behavior analyst. One BCBA completed all
visits for a family.
Overview
The Balance Program was designed to fit within existing ser-
vice systems for children with ASD. Practice guidelines for
the behavior-analytic treatment of ASD include at least 2 hr
per week of case supervision by a BCBA (The Council of
Autism Service Providers, 2020). Therefore, the Balance
Program involves two 1-hr visits by a BCBA per week, with
the recommendation that parents practice at least five trials
with their child twice daily between visits. To promote child
skill acquisition and provide parents with immediate rein-
forcement for their teaching efforts, we asked parents to teach
in short, circumscribed practice sessions with short intertrial
intervals (Francisco & Hanley, 2012) early in the program.
We specifically suggested that they not attempt to teach all
day or embed the trials in typical routines until Step 10. To
minimize demands on parents, we did not ask them to collect
data on practice sessions. We anticipated that it would be
apparent from the child’s responding at the start of the next
visit whether high-quality practice had occurred between
visits, and we planned to continue practicing with the parent
and child at the current level until performance criteria were
met (see Appendix D).
visits. During subsequent visits, the BCBA taught the parent
to teach the child a skill (see Tables 3 and 4). Following
mastery of all skills, there was a break of at least 1 month,
after which follow-up was conducted.
 Behav Analysis Practice

Table 2 Parent characteristics

Child Participating Race/ethnicity Primary Highest education Employment Other Training/professional

name caregivers language children experience—early childhood

Walt Mother, mother White English College degree, Full time outside 1 No
postgraduate degree home
Jaden Mother, father White English College degree, high Full time outside 0, 1 Yes (general), no
school degree home
Max Mother White English Some college Not employed 1 No
outside home
Kelly Mother Black/African English College degree Full time outside 2 Yes (general)
American home

For Walt and Jaden, when a column contains one response, it applies to both parents. When a column contains two responses separated by a comma, one
response pertains to each parent

Setting and Materials
BCBA visits were conducted in one room in the partic-
ipants’ homes until Step 10, at which point skills were
practiced throughout the home. All materials originated
in the participants’ homes, except for video equipment,
program-related written materials, and empty bins, which
the BCBA provided. Items related to child- and adult-led
activities were identified via interview and sorted into
two bins of the same size (approximately 30 cm3 or
60 cm × 40 cm × 30 cm). Parents were not asked to
obtain any new items for the program.

Table 3 Objectives by teaching steps

Parent objective Child objective Selected references

Teaching 1 Present no EOs for Play in the absence of EPB. Ghaemmaghami, Hanley, Jin, & Vanselow, 2016; Hanley et al., 2014 &
process EPB. repl.; Heal et al., 2009; Heal & Hanley, 2011; McLaughlin & Carr, 2005;
NAEYC, 2009
2 Shape responding to Stop, look, say “yes” to Beaulieu, Hanley, & Roberson, 2012, 2013; Beaulieu & Hanley, 2014;
name. name call. Everett et al., 2005; Hamlet, Axelrod, & Kuerschner, 1984; Hanley et al.,
2007 & repl.; Kraus, Hanley, Cesana, Eisenberg, & Jarvie, 2012; Miller
et al., 2017
3 Shape functional Emit part of request. Carr & Durand, 1985; Ghaemmaghami, Hanley, Jin, & Vanselow, 2016;
communication. Hanley et al., 2007 & repl.; Hanley et al., 2014 & repl.; Horner & Day,
1991; Reeve & Carr, 2000
4 Teach complete Emit complete request. Ghaemmaghami, Hanley, Jessel, & Landa, 2018; Hanley et al., 2007 & repl.;
request. Hanley et al., 2014 & repl.; Hernandez, Hanley, Ingvarsson, & Tiger, 2007
5 Shape tolerance. Respond to denials calmly. Carr & Carlson, 1993; Fagen & Hill, 1987; Hanley et al., 2007 & repl.;
Hanley et al., 2014 & repl.; Skinner, 1953
6 Shape cooperation. Follow 1–3 instructions. Ghaemmaghami, Hanley, & Jessel, 2016; Hanley et al., 2007 & repl.; Hanley
et al., 2014 & repl.; Lalli & Casey, 1996; Piazza et al., 1996;
Tarbox et al., 2007
Post 7 Shape persistence. Complete all steps of an Hanley et al., 2007 & repl.; Hanley et al., 2014 & repl.
activity.
Generality 8 Practice with new Complete new activities. Stokes & Baer, 1977
instructions.
9 Practice without bins. Demonstrate all skills without
bins.
10 Practice during typical Demonstrate all skills during
routines around typical routines around
house. house.

EO, establishing operation; EPB, emerging problem behavior; repl., replications

Behav Analysis Practice
Table 4 Teaching procedures
Content
BCBA teaches How to:
parent Initiate trials
Prompt desired child responses & fade prompts
Differentially reinforce child responding
Parent teaches child How to:
Respond to name calls
Emit FCR
Emit TR
Cooperate with adult-led activities of
increasing length, diversity
BCBA, Board Certified Behavior Analyst; FCR, functional communication response; TR, tolerance response. See Appendix A for BCBA and parent
implementation integrity checklists
Data Collection and Response Definitions
Data Collection
The primary dependent variables were emerging problem
behavior, child-led play, responding to name, functional
communication, tolerance responding, and cooperation.
Responses per minute were used to analyze emerging prob-
lem behavior; percentage of opportunities correct was used
for responding to name, functional communication, and
tolerance responding; and percentage of 20-s whole inter-
vals was used to analyze play and cooperation. Data were
also collected on parent integrity of the teaching proce-
dures (see Appendix A), which are reported as a percentage
of 20-s intervals in which no errors were made. A checklist
was used to measure each BCBA’s fidelity to the support
procedures (see Appendix A). In baseline, all direct mea-
sures were collected in 5-min sessions. In the teaching pro-
cess, data were collected from one 5-min or 5-trial session
at the start of each visit. In follow-up, data were collected
from one or two 5-trial sessions at the start of the visit. All
sessions were video-recorded and scored later.
Indirect measures included a semistructured parent inter-
view called the Individualized Features of Reinforcement
Meeting (InFORM; see Appendix B); the Aberrant
Behavior Checklist, Second Edition (ABC-2; Aman &
Singh, 2017); and social validity assessments (see
Appendix C). The purpose of the InFORM, administered
during the first visit, was to identify the materials and ac-
tivities to be used during teaching. The ABC-2 is a 58-item
rating scale completed by parents/caregivers and often used
in evaluations of interventions for children with ASD out-
side of behavior analysis (Kaat, Lecavalier, & Aman,
2014). The ABC-2 was completed by each participant’s
primary caregiver at baseline and again after Step 10.
Parents completed versions of the social validity assess-
ment at baseline, after Step 10, and at follow-up.
Process Dosage
Written, vocal description and rationale Two 1-hr visits/week
Modeling
Prompting, feedback as parent
practices with child
Adult-initiated trials Two 1-hr visits/week with BCBA
Prompting: and
Three step or wait out Two 5-trial sessions/day
Differential reinforcement: independently
Synthesized reinforcers
Intermittent, unpredictable schedule
Response Definitions
The definition of emerging problem behavior was individual-
ized per child (see Table 1). Hitting was rarely observed and of
low intensity—that is, distinct from “severe problem
behavior.”
Child-led play was defined as the child manipulating toy(s)
and/or engaging in activity-related conversation with the care-
giver in the absence of problem behavior. Responding to name
definitions were individualized per participant but generally
involved stopping, looking toward the parent, and/or saying
“yes.” Functional communication was defined as any instance
of a request for access to items or to play the child’s way, to
escape or avoid items or parental instruction, or any combina-
tion thereof, emitted in the absence of emerging problem be-
havior. The topography of the functional communication re-
sponse (FCR) taught was individualized for each child based
on the child’s language level. A tolerance response was defined
as any instance of an explicit and calm response to a delay or
denial imposed by the parent (e.g., “OK”). Cooperation was
defined as behaving in accordance with the adult instruction or
expectation in place at the time. For example, if the adult asked
the child to color and left the area, the expectation that the child
color would be considered in place until the adult returned. See
Table 1 for participant-specific tasks.
Interobserver Agreement
Interobserver agreement was evaluated by having a sec-
ond independent observer review the video recordings
and collect data on all target behaviors at a separate
time from the primary data collector. Each session was
divided into 20-s intervals. Interobserver agreement for
emerging problem behavior was calculated by dividing
the smaller total number of occurrences by the larger
total number of occurrences in each interval, adding
up the proportions, dividing by the number of intervals,

and multiplying by 100. Interobserver agreement for all
other measures was calculated by dividing the number
of agreements (intervals marked with the same symbol
by both data collectors) by the number of agreements
plus disagreements, and then multiplying by 100.
Interobserver agreement data were collected for at least
20% of sessions across all conditions and participants
and averaged at least 86% (range 67%–100%) for all
participants and all measures.
Design
Functional control by the independent variable over child
emerging problem behavior and over parent teaching behavior
was demonstrated using a nonconcurrent multiple-baseline
across-participants design. Functional control over child skills
(responding to name, FCR, tolerance responding, and cooper-
ation) was demonstrated via repeated measures and replication
of the effects of the independent variable on multiple depen-
dent variables across points in time. The effects of the package
on the balance between child- and adult-led time were inferred
rather than demonstrated.
Procedures
Natural Baseline
The BCBA distributed the materials identified in the parent
interview and directed the parent to engage with the child as
they normally would. Two or three 5-min sessions were con-
ducted. These data were used to assess the balance between
time spent on child-led and adult-led activities, prior to any
instruction to the parent in this regard.
Prompted Baseline
The BCBA instructed the parent to allow the child to play for
about half of the time and try to have the child complete tasks
for the other half of the time. No further prompts were given.
Three to five 5-min sessions were conducted. These data were
used to evaluate the parent’s ability to create balance between
child-led and parent-led activities when specifically asked to
do so, as well as to evaluate child behavior under these
conditions.
Teaching (Steps 1–10)
Following baseline, participants moved into the teaching pro-
cess. Beginning with Step 1, the BCBA taught the parent to
teach each skill outlined in Table 3. At least one visit was
dedicated to each step, with progression to the next step based
on parent and child performance (see Appendices for details).
Behav Analysis Practice
Teaching Procedures The procedures by which BCBAs
taught parents and parents taught children are outlined in
Table 4. Before teaching began, the BCBA described two
prompting approaches—three-step prompting (verbal,
model, physical prompt; e.g., Tarbox, Wallace, Penrod,
& Tarbox, 2007) and a “wait-out” (parent delivers a
verbal instruction, removes tangibles unrelated to the
instruction, and waits for the child to follow the
instruction; Piazza, Moes, & Fisher, 1996). Parents were
asked to select the approach they preferred. Jaden’s,
Max’s, and Kelly’s parents opted to use three-step
prompting. Walt’s parents opted to use a wait-out.
Each teaching step built on the previous ones such that the
child continued to practice and, intermittently, contact imme-
diate reinforcement for all previously learned skills. The order
of trial types varied across sessions such that the response that
would result in immediate reinforcement on each trial was
unpredictable (see Appendix D).
Posttest The data from Step 7 were considered the posttest. At
this time, all the skills had been taught and the same contextual
features as in the baseline were present.
Generality Steps 8, 9, and 10 were considered generality steps,
as they extended the process beyond that which was assessed
in baseline. Step 8 involved introducing new activities, Step 9
involved items kept in their regular locations (rather than
bins), and Step 10 involved practice in new areas of the home
and during natural routines.
Performance Criteria The teaching process was considered
complete following two consecutive sessions at Step 10 in
which the child displayed (a) near-zero rates of emerging
problem behavior, (b) independent skills (responding to
name, functional communication, and tolerance
responding) in most opportunities, (c) cooperation and
play in most applicable intervals, and when parent- and
child-led times each composed roughly half of the
session.
Booster and Follow-Up
The BCBA conducted a booster session between 4 and 10
weeks after the last Step 10 visit, depending on the family’s
availability. The BCBA observed the parent and child practice
Step 10 and provided feedback as needed. The BCBA then
returned later the same week to record a five-trial session of
Step 10. If the child’s performance met the criteria noted pre-
viously, a second session was recorded during that visit. If not,
the BCBA provided feedback, asked the parent to practice
with the child, and returned to record another session when
the family’s schedule allowed.
Behav Analysis Practice
Table 5 Modifications for Max and Kelly
Child Modifications
Max (1) Moved to clinic-based practice:
(i) BCBA practiced Steps 8, 9 with child
Parent collected treatment integrity data
Parent & BCBA discussed scores
(ii) Parent practiced Step 9 with child & BCBA,
then child alone
(2) Returned to home-based practice:
(i) BCBA practiced Steps 9, 10 with child before
parent did
(3) BCBA conducted parent education modules
Kelly (1) Added BCBA practice with child in home
(2) Eliminated response to name and tolerance
response trials
Note. BCBA, Board Certified Behavior Analyst. All BCBA-run sessions were conducted using the same procedures parents had used. Parent education
modules consisted of didactic instruction and discussion only, without the child present, and are detailed in Appendix E
Modifications
Based on Max’s and Kelly’s performance and on feedback
from their parents, we made modifications for these partici-
pants. These are detailed in Table 5. The reasons for the mod-
ifications were different for the two children, leading us to
make different changes for each.
For Kelly, we attempted a set of modifications (marked as
“Modif.” phase on Figure 5) that were unsuccessful, prior to
the successful modifications detailed in Table 5 and marked as
“Express” on the figure. The unsuccessful modifications
consisted of adding BCBA practice with Kelly in the home,
returning to Step 2, and reinforcing only independent re-
sponses. When these modifications did not yield the desired
rates of independent FCRs over six visits, we consulted with
Kelly’s mother to determine which skills she most wanted
Kelly to learn. She indicated the FCR and cooperation.
Therefore, we developed a shortened version of the program
called “Balance Express,” which omitted responding to a
name call and tolerance responding.
Results
Summary
Figure 1 summarizes data for all participants. Black sym-
bols represent performance given the standard program,
and gray symbols represent Max’s and Kelly’s perfor-
mance with their parents, in the home, following modifi-
cations. For all participants, emerging problem behavior
(top-left panel) decreased from the prompted baseline to
postprogram (posttest, generality, and follow-up), even
given balance between child- and adult-led times (top-
right panel) and given that social skills and cooperation
Rationale Timing
- Low child skill emission suggests need for more practice After first follow-up
- Low parent-reported confidence suggests need for: phase
More modeling by BCBA
Practice under more controlled conditions
-Parent questions suggest need for additional education
- Low child skill emission suggests need for more practice After Step 9 visits
- Decrease in parent time for practice for family/personal
reasons
were required (third and fourth panels on the left). All
participants played in the absence of emerging problem
behavior for most child-led intervals in all conditions (sec-
ond panel on the left), although an increase in play was
observed with Jaden after teaching. Parental integrity to
the teaching procedures improved from the prompted base-
line to postprogram for all participants, with more substan-
tial improvements observed for Max’s mother following
modifications to the program (bottom-right panel).
Emerging Problem Behavior
Individual participant data are displayed in Figures 2, 3, 4 and
5. Figure 6 displays emerging problem behavior data from the
prompted baseline and the first three steps of teaching for all
participants, to highlight the multiple-baseline across-partici-
pants design.
During the natural baseline, all participants except Walt
emitted some emerging problem behavior. Jaden and Max
emitted it following certain parent actions during play (e.g.,
when parents did not follow their instructions), and Kelly
emitted it during her mother’s attempts to implement adult-
led time. During the prompted baseline, all parents imposed
some adult-led activities, and all participants engaged in in-
creasing (Walt, Jaden, Max) or stable (Kelly) rates of emerg-
ing problem behavior. With the introduction of Teaching Step
1, rates of emerging problem behavior decreased to zero or
near zero and remained below the baseline average throughout
the teaching process and follow-up for all participants, except
for a few isolated spikes for Max and Kelly.
Play
Walt and Kelly engaged in play in the absence of emerging
problem behavior for 100% of the child-led time in baseline

Figure 1 Summary Data for All Participants. Note. The baseline mean
was calculated from all sessions of the prompted baseline for all measures
except for “Balance,” which was calculated from all sessions of the
natural baseline. The posttest mean was calculated from all sessions of
Step 7. The generality test mean was calculated from all sessions of Steps
(Figures 2 and 5, second panels). Jaden and Max engaged in
play for the entire child-led time, but their play was sometimes
accompanied by emerging problem behavior (Figures 3 and 4,
second panels; black portions of the bars reflect play in the
absence of emerging problem behavior; gray portions reflect
Behav Analysis Practice
8, 9, and 10. The follow-up mean was calculated from all sessions of
follow-up. Gray symbols (Max, Kelly) represent performance in the
home, with the parent as implementer, following modifications to the
package
the time in which play was permitted, but the child either did
not play or played while emitting emerging problem
behavior). In Step 1, Jaden’s and Max’s play in the absence
of emerging problem behavior increased to 100%. All partic-
ipants engaged in play for all or most of the allotted time
Behav Analysis Practice

Figure 2 Individual Data for

Walt. Note. Numbers in brackets
refer to teaching steps. Nat. =
natural baseline; Prompt. =
prompted baseline; Teach. Integ.
= teaching integrity

across all teaching sessions and follow-up. Because there was
little change in the quality of play from baseline to teaching,
we characterize our participants as having had initially strong
child-led play skills.
Responding to Name
2. Across subsequent teaching steps and follow-up,
responding generally remained high for Walt, Jaden, and
Max. Kelly’s responding was more variable. Following the
first set of modifications to Kelly’s program, responding im-
mediately increased and became more stable; however, it be-
came variable again following the reintroduction of Step 3.

Walt’s and Max’s parents did not call their names during Functional Communication
baseline, and Jaden’s and Kelly’s did so infrequently.
Neither Jaden nor Kelly responded to these name calls. All caregivers attempted to restrict access to tangibles and/or
Responding emerged only following the introduction of Step place demands during the prompted baseline, creating
 Behav Analysis Practice

Figure 3 Individual Data for

Jaden. Note. Numbers in brackets
refer to teaching steps. Nat. =
natural baseline; Prompt. =
prompted baseline; Teach. Integ.
= teaching integrity

opportunities for children to emit requests to retain the tangi-
bles and escape the demands. However, only Max did so in
the absence of problem behavior, and he only did so on one
out of four opportunities. Responding emerged for all partic-
ipants in Steps 3 and 4. Walt and Jaden emitted FCRs in most
or all opportunities across subsequent steps. Max’s and
Kelly’s responding was variable until modifications were
made, at which time responding for both became high and
stable and remained so across subsequent phases.
Tolerance Responses
Because participants emitted few or no requests using
words in baseline, there were few explicit request denials
by parents and therefore few opportunities to emit a tol-
erance response. Tolerance responding emerged follow-
ing the introduction of Step 5 for Walt, Jaden, and Max
and in the third visit at Step 5 for Kelly. Responding
maintained in most opportunities across subsequent steps
Behav Analysis Practice

Figure 4 Individual Data for

Max. Note. Numbers in brackets
refer to teaching steps. At parent
request, Step 4 (gain attention)
was terminated prior to mastery.
Nat. = natural baseline; Prompt. =
prompted baseline; Teach. Integ.
= teaching integrity; BCBA =
Board Certified Behavior Analyst

for Walt and Jaden. Max’s responding was variable until
modifications were made, at which time it became high
and stable and remained so across subsequent phases.
Kelly’s responding decreased following Step 7, and the
tolerance response was not included in her modified
program.
Cooperation
All participants engaged in some cooperation during baseline;
however, it averaged less than 50% of requested intervals for
all participants. Cooperation was targeted beginning in Step 6,
and it increased for Walt, Jaden, and Kelly. Max’s cooperation
was variable but increased to consistently high levels follow-
ing modifications.
At follow-up, Walt and Max emitted cooperation in all
requested intervals, and Kelly emitted cooperation in 95% of
requested intervals. Jaden emitted cooperation in 100% of
requested intervals with his father but only in 29% of intervals
with his mother.
Balance
During the natural baseline, most of the time was spent in
child-led activity for all participants. During most prompted
baseline sessions, time was either allocated disproportionately
to child- or adult-led activity. During Step 1, time was again
allocated exclusively to child-led activity by design, but this
decreased gradually across teaching steps for all participants
until follow-up, at which point child- and adult-led time were
allocated more equally.
Parent Integrity to Teaching Procedures
Parent integrity to the teaching procedures increased up-
on the introduction of the teaching process for all
 Behav Analysis Practice

Figure 5 Individual Data for

Kelly. Note. Numbers in brackets
refer to teaching steps. At parent
request, Step 4 (gain attention)
was terminated prior to mastery.
Nat. = natural baseline; Pr. =
prompted baseline; Teach. Integ.
= teaching integrity; BCBA =
Board Certified Behavior
Analyst; Modif. = modification

participants. It remained high for Walt’s, Jaden’s, and Time Requirement

Kelly’s parents across teaching and follow-up. For
Max’s mother, it decreased upon the introduction of The entire process, from the InFORM through follow-up, re-
Step 2 and remained variable across teaching, although quired 15 one-hour BCBA visits for Walt, 20 for Jaden, 59 for
it was generally higher than in baseline. Following mod- Max, and 56 for Kelly.
ifications to the program, the level of teaching integrity
increased and variability decreased.
Aberrant Behavior Checklist–2

The results for each subsection of the ABC-2 are summarized

BCBA Integrity to Support Procedures
BCBA integrity to the support procedures was scored for
an average of 17% of sessions (range 14%–22%) across
all three conditions (baseline, teaching process, and
follow-up) for all participants and averaged at least
93% (range 86%–100%).
in Table 6, with raw scores appearing first and percentile
ranks3 in parentheses. According to the ABC-2’s authors, a
score in the 75th percentile or above suggests the need for
intervention (Aman & Singh, 2017). At baseline, both of
3
Based on 1,036 parent ratings of children under the age of 6 with an ASD
diagnosis (Aman & Singh, 2017).
Behav Analysis Practice
Figure 6 Emerging problem
behavior multiple baseline across
participants
Walt’s parents rated his behaviors at or above the 75th per-
centile for Hyperactivity/Noncompliance and Inappropriate
Speech. Max’s mother rated his behavior at the 75th percentile
for Irritability. All participants’ parents rated behaviors in all
the other categories below the 75th percentile, supporting our
designation of the participants’ behaviors as “emerging” (rath-
er than “severe”) problems.
The ABC-2’s authors state that generally, a reduction of
one standard deviation or more might be considered clinically
significant (Aman & Singh, 2017). Walt’s Parent A’s ratings
met this criterion in the areas of Hyperactivity/Noncompliance
and Inappropriate Speech, and his Parent B’s ratings met this
criterion in all areas except Stereotypic Behavior. Max’s
mother’s ratings met this criterion in the areas of Irritability
and Stereotypic Behavior.4 By contrast, Jaden and Kelly did
not meet this criterion in any area. However, their baseline
ratings were lower (at or below the 50th percentile), making
this outcome unsurprising. All participants’ raw scores im-
proved by at least three points in at least one category, and
none worsened by the same amount.
Social Validity
All parents rated the goals of the program as very important
(M = 6.9 on a 7-point Likert-type scale), the procedures as
4
All participants displayed some restricted/repetitive behavior or interests,
consistent with the diagnostic criteria for ASD. The Stereotypic Behavior
section of the ABC-2 focuses on motor stereotypy specifically. For our par-
ticipants, vocal stereotypy and restricted interests were more common.
highly acceptable (M = 7), and their comfort implementing
the procedures as high (M = 6.7). At Step 10 and follow-up,
parent ratings of their satisfaction with the effects outside of
BCBA visits varied across participants (M = 5.6, range 3–7).
Generally, Walt’s and Jaden’s parents rated themselves as
more satisfied than Max’s and Kelly’s. Walt’s, Jaden’s, and
Kelly’s parents provided only positive responses to open-
ended questions, and Max’s mother did not respond to any
open-ended questions. (See Appendix C for participant-
specific scores and comments.)
Discussion
Direct measures suggest that the Balance Program reduced
emerging problem behavior, improved social and cooperation
skills, and was associated with the development of balance
between child- and adult-led activities for all participants.
These outcomes were demonstrated in the home, with parents
providing all or most of the teaching. Parents socially validat-
ed the goals and procedures, and an indirect, standardized
measure of problem behavior detected general improvements.
In other words, the Balance Program produced important child
behavior outcomes relevant to children with an ASD
diagnosis.
Our evaluation also revealed some areas for improvement
and important directions for future research. First, two out of
four children acquired all the targeted skills given the “stan-
dard” package. Modifications to the program were associated
 Behav Analysis Practice

Table 6 Aberrant behavior checklist (ABC-2) scores (with percentiles)

Name Irritability Social Withdrawal Stereotypic Behavior Hyperactivity/ Noncompliance Inappropriate Speech

Max. 45 Max. 48 Max. 21 Max. 48 Max. 12

Clin. Sig. 20 Clin. Sig. 15 Clin. Sig. 8 Clin. Sig. 29 Clin. Sig. 6

Pre Post Pre Post Pre Post Pre Post Pre Post

Walt
Parent A 9 (37th) 1 (<16th) 4 (25th) 0 (<16th) 0 (16th) 1 (25th) 35 (84th) 9 (16th) 6 (75th) 0 (16th)
Parent B 18 (70th) 3 (<16th) 13 (70th) 4 (25th) 1 (25th) 1 (25th) 32 (75th) 13 (32nd) 6 (75th) 1 (32nd)
Jaden 6 (25th) 6 (25th) 9 (50th) 6 (37th) 1 (25th) 1 (25th) 19 (50th) 21.4 (50th) 2 (37th) 2 (37th)
Max 21 (75th) 12 (50th) 1 (<16th) 0 (<16th) 4 (50th) 0 (16th) 28 (70th) 19 (50th) 3 (50th) 4 (63rd)
Kelly 7 (32nd) 2 (<16th) 7 (37th) 3 (16th) 1 (25th) 2 (25th) 12 (32nd) 12 (32nd) 1 (45th) 1 (45th)

Clin. Sig. = clinically significant score per ABC-2 authors. Boldface denotes a clinically significant reduction according to criteria provided in the ABC-2
manual. Post measures reported for Max were collected following Session 58. Mean scores for a sample of children with autism spectrum disorder, as
rated by their parents, are as follows: Irritability = 12.8 (50th percentile); Social Withdrawal = 10 (50th percentile); Stereotypic Behavior = 5 (50th
percentile); Hyperactivity/Noncompliance = 18.7 (50th percentile); and Inappropriate Speech = 3.7 (63rd percentile; Aman & Singh, 2017)

with more robust performance for the other two children, and
some of these modifications might be incorporated from the
beginning for future participants. In addition, on the social
validity assessment, some parents provided equivocal ratings
for the outcomes of the program outside of BCBA visits;
therefore, steps might be taken to improve outcome generality.
Once these areas have been addressed, future researchers
might consider a randomized controlled trial to evaluate the
program’s preventive effects on problem behavior in children
with ASD.
All children in the present study acquired at least a simple
FCR, and three out of four acquired responding to their name
and tolerance to denial responses. It is likely that initial lan-
guage skills are a moderator of outcomes in this program. The
three participants who acquired responding to their name and
tolerance response communicated in short, disfluent sentences
or with full vocal-verbal fluency at the start of the program,
whereas the participant who did not acquire these responses
(Kelly) was nonverbal at the start of the program. Kelly’s
individual data suggest that these responses were attainable
for her in isolation; in several sessions, she emitted high levels
of responding to her name, but she never emitted criterion
levels of responding to her name and the FCR in the same
session, suggesting that the desired conditional discrimination
was not established. Future researchers should evaluate the
program with additional participants who have little verbal
behavior in baseline. If similar outcomes are observed, the
program might prescribe a modified approach (e.g., Balance
Express) for children with little initial language and/or parents
who foresee having limited time to dedicate to practice.
Max’s modifications also suggest revisions to the program.
Max’s performance improved substantially in sessions imple-
mented by the BCBA in the clinic with higher teaching integ-
rity than his mother had exhibited. When his mother returned
to teaching, she demonstrated improved teaching integrity.
Although the current data do not allow for conclusions about
which changes were responsible for either Max’s or his
mother’s improvements, his mother may have benefited from
the higher dose of modeling from the BCBA and from the
experience of scoring teaching integrity until she did so with
no errors. In future in-home applications, the BCBA could
model implementation or show video models and teach the
parent to accurately evaluate teaching integrity.
The in-home, parent-implemented Balance Program could
also be considered a Tier 1 intervention in a response-to-
intervention model. That is, most or all children admitted to
early intervention services could receive the Balance Program,
implemented by parents in the home. If the Balance Program
does not produce the desired outcomes for a child, a Tier 2
intervention would be indicated and considered. A Tier 2 in-
tervention might consist of professionally implemented ses-
sions a few times per week, either in the home or in a clinic. A
Tier 3 intervention, should it be required, might consist of
intensive outpatient or inpatient services. Therefore, under this
conceptualization, given that the Tier 1 intervention did not
yield a general-enough change in Max’s behavior, Max expe-
rienced a Tier 2 version of the program.
Walt’s, Jaden’s, and Max’s performances suggest a possi-
ble relation between teaching integrity averaging at least 80%
and robust child outcomes—child performance reached
criteria in phases in which teaching integrity averaged 80%
or higher and did not otherwise. Future implementers might
consider adding a role-play component to the program and
coaching parents until they demonstrate at least 80% correct
implementation before beginning to teach their children a giv-
en step. In other words, in future iterations, the parent-training
procedures might include all the steps of behavioral skills
training (BST; e.g., Drifke, Tiger, & Wierzba, 2017;
Behav Analysis Practice
Sawyer, Crosland, Miltenberger, & Rone, 2015). We did not
initially incorporate role-play because of expected time con-
straints in practice and because we hoped the program might
be useful in telehealth settings, in which role-play is more
difficult. However, future researchers might consider adding
opportunities for parents to demonstrate robust teaching skills
prior to practicing with their children.
Parents’ ratings of the goals and procedures of the program
were overwhelmingly positive, and parents reported that the
BCBA support was enough to make them feel comfortable
teaching the skills. However, parents’ ratings of the outcomes
of the program outside of BCBA visits were mixed, with
Walt’s and Jaden’s parents rating the outcomes more highly
than Max’s and Kelly’s. Walt and Jaden progressed through
the program more quickly than Max and Kelly, with no mod-
ifications. Some variables that might have influenced both the
child’s progress and parents’ satisfaction with outcomes out-
side of visits include the amount and/or procedural integrity of
practice outside of visits throughout the program. In the future,
researchers might collect data on between-visit practice and
evaluate the effects of procedural modifications on the fre-
quency and quality of practice, as well as the generality of
outcomes. Interestingly, Kelly’s mother’s open-ended com-
ments on the effects of the program seem to contrast with
her rankings, suggesting that future researchers might find
multiple types of social validity measures informative.
Future researchers implementing the program using a
single-subject design might also consider design modifica-
tions to enhance the demonstration of functional control over
all child skills by the program. In the present study, there were
no baseline opportunities for children to demonstrate some of
the skills. Future researchers could ask parents to provide op-
portunities for specific skills during the prompted baseline or
afterward, as its own baseline condition, if no opportunities
are observed in the prompted baseline.
However, even when parents did not present opportunities
in baseline, we have several reasons to infer that children
lacked these skills and acquired them as a function of the
program. First, it is unlikely that a child has had
opportunities to acquire a skill if, over repeated
observations, the parent does not provide opportunities for
the child to emit that skill. Skill acquisition requires practice;
Luczynski and Hanley (2013) demonstrated that, in the ab-
sence of explicit teaching, typically developing preschoolers
did not develop similar skills. The fact that the parents did not
provide baseline opportunities for commonplace parent–child
interactions suggests that parental attempts had been
extinguished by persistent child noncooperation or punished
by emerging problem behavior, as suggested by Carr et al.
(1991). Finally, all parents rated the goals of the program as
very important. It seems unlikely they would have done so if
children had a history of reliably emitting these skills in rele-
vant opportunities.
We inferred, rather than demonstrated, control by the pro-
gram over the balance between adult- and child-led activities.
In early teaching steps, child-led play was delivered contin-
gent on relatively short responses, and a great deal of the
session was spent in child-led play by design; balance was
achieved gradually, emerging around Step 6 or later. We
deemed it undesirable to extend participants’ baselines for
the time that would be required to demonstrate stability until
after balance emerged for earlier participants. However, given
the demographic and geographic differences among the fam-
ilies, and the varying amounts of time between baseline and
demonstration of balance, it seems implausible that balance
would have emerged as a function of some factor other than
the program.
There is precedent for teaching each of the skills in the
Balance Program (e.g., Durand & Moskowitz, 2015; Everett,
Olmi, Edwards, & Tingstrom, 2005; Hanley et al., 2014;
Luczynski & Hanley, 2013); nevertheless, whittling down
the program to the behaviors that are essential for preventing
the development of severe problem behavior is an important
task for researchers. Such an evaluation might be most pro-
ductive after a demonstration of the preventive effects of the
program via a randomized controlled trial; the question will
then be which components of the program are necessary to
produce those preventive effects. It is possible, for example,
that differentially reinforcing various durations of cooperation
with personalized and synthesized reinforcers may be enough.
Future researchers, before or after a randomized controlled
trial, might also investigate the moderating role of initial play
skills. All children engaged with the materials their parents
had nominated as preferred for most of the child-led time in
baseline, and no parents prompted their children to do so.
Despite these robust child performances in baseline, all
BCBAs conducted instruction in Step 1 to address parent
behavior—such as interfering with child toy manipulation or
attempting to teach—that might have made access to the play
materials a less potent reinforcing context. It is unclear what
the effects of the program would have been had the partici-
pants not demonstrated robust child-led play in baseline. It
seems probable that baseline play behavior moderates the ef-
fects of the program; whether this is the case and how to
address it are important research questions.
Despite the many remaining questions, the promising ef-
fects of the Balance Program shown in the current study—and
the studies showing positive effects of similar skill-based
teaching programs in different service models (e.g., Hanley
et al., 2007; Hanley et al., 2014; Jessel et al., 2018; Robison
et al., 2020)—suggest that Balance may be a useful program
for professionals supporting parents of young children with
ASD in the home.
Supplementary Information The online version contains supplementary
material available at https://doi.org/10.1007/s40617-020-00490-3.

Author Note This manuscript was prepared in partial fulfillment of the
doctoral program requirements of the Psychology Department at Western
New England University. We thank Amy J. Henley, Rachel H.
Thompson, and Jonathan W. Pinkston for their comments on earlier ver-
sions of this manuscript.
Compliance with Ethical Standards
Conflict of interest During the peer review and publication process for
this manuscript, Kelsey Ruppel and Gregory Hanley received salaries
from FTF Behavioral Consulting, an organization that offers training on
the Balance Program among other services. Neither were employed by
FTF Behavioral Consulting before or during the conduct of the study.
Robin Landa and Adithyan Rajaraman declare no conflict of interest.
Ethical approval All procedures performed in studies involving human
participants were in accordance with the ethical standards of the institu-
tional review board of the university and with the 1964 Helsinki declara-
tion and its later amendments.
Informed consent Informed consent was obtained from all individual
participants included in the study.
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