Revisiting the social validity of services rendered through a university‐based practicum addressing challenging behavior

Abstract

This paper represents the third in a three‐part series intended to challenge the social validity of the services provided by a university‐based practicum for addressing the challenging behavior of individuals with disabilities. In this paper, we surveyed referring stakeholders (e.g., parents, teachers) of past service recipients to explore the acceptability of the service model's goals, methods, and outcomes. We probed for tensions resultant from the model's threefold mission (service, training, and research) and explored how conflicts between these goals affected the quality of our services. Generally, results were favorable and appeared to support continued model implementation, but not without qualification. Emergent themes, areas for improvement, and future directions for intervention research are all discussed.

Full text

Revisiting the Social Validity of Services Rendered Through a University-Based Practicum
Addressing Challenging Behavior
Joseph M. Lambert, Amanda L. Sandstrom, Robert M. Hodapp, Bailey A. Copeland, Jessica L.
Paranczak, Margaret J. Macdonald, & Nealetta J. Houchins-Juarez
Department of Special Education, Vanderbilt University
Author Note
We would like to thank Dr. Jennifer Ledford for the feedback she provided during the
writing of this paper. We also thank Kathryn Bailey, Ipshita Bannerjee, Cassandra Standish,
Esther Kwan, and Eugenia Perry for their assistance in project development.
Correspondence concerning this article should be addressed to Joseph M. Lambert,
Department of Special Education, Vanderbilt University, Nashville, TN 37203.
Email: joseph.m.lambert@vanderbilt.edu.

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Abstract
This paper represents the third in a three-part series intended to challenge the social
validity of a critical aspect of one graduate training program intended to expose its scholars to a
valid process of intensive intervention for addressing the challenging behavior of individuals
with disabilities. In this paper, we surveyed referring stakeholders (e.g., parents, teachers) of past
service recipients to explore the acceptability of the service model’s goals, methods, and
outcomes. In particular, we probed for tensions resultant from the model’s threefold mission
(service, training, and research) and explored the degree to which conflicts between these goals
manifested themselves in the quality of services provided to clients. Generally, results were
favorable and appeared to support continued model implementation. However, not without
qualification. Emergent themes, areas for improvement, and future directions for intervention
research are all discussed.
Keywords: Applied behavior analysis, practitioner training, problem behavior, special
education, social validity

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Revisiting the Social Validity of Services Rendered Through a University-Based Practicum
Addressing Challenging Behavior
Stakeholder reports of the acceptability and impact of a service program’s goals,
methods, and outcomes are critical variables which qualify and substantiate objectively measured
empirical demonstrations of effect (Kazdin, 1977), protect said programs from rejection and
sabotage (Schwartz & Baer, 1991), and represent a feature of behavior analysis which
distinguishes applied from basic science (Baer et al., 1968). As a result, applied researchers have
long encouraged practitioners to assess the ongoing viability and validity of their programming
by recruiting subjective feedback (i.e., reports of acceptability and impact) from key
stakeholders, to consider obtained data in relation to objective demonstrations of effect, and to
react to this feedback with programmatic evolutions (Wolf, 1978).
As a case in point, the BAC (not an acronym, pronounced B-A-C) was a university-based
intensive practicum designed to imbue in masters- and doctoral-level scholars critical
competencies associated with the assessment and treatment of challenging behavior (see
Lambert, Paranczak et al., 2022 [here]). Its mission was threefold (i.e., service, training,
research) and entailed providing community members with no-cost access to intensive
intervention for challenging behavior during three-month consultations which entailed 48 hours
of direct client contact distributed across 12-weeks.
Standard goals for this service entailed conceptual clarity (i.e., identification of all
function[s] of challenging behavior), (2), response elimination (i.e., reductions in challenging
behavior in historically evocative contexts), (3) tolerance of establishing operations, or “EO
tolerance” (i.e., maintenance of reductions in challenging behavior during periods of time in

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which functional reinforcers were unavailable), and (4) generalization (i.e., reductions in
challenging behavior in therapy sessions contrived to match typical environments).
Through this service, faculty created a context in which scholars could accumulate
applied experiences with gold-standard assessments (e.g., functional analysis; FA) and
interventions (e.g., functional communication training; FCT) using a practitioner-training model
intended to build fluency with a process of case conceptualization, data-based individualization,
and problem solving apparently effective at addressing pervasive challenging behavior (i.e.,
Lambert, Copeland et al., 2022 [here]).
Because the BAC used valid and reliable measurement systems to establish experimental
control over assessment and treatment outcomes, it was often possible to publish data from
successfully discharged BAC cases—thus satisfying a third mission of the BAC to contribute to
the field’s generalizable knowledge through peer-reviewed publication.
This paper represents the third of a three-part series and is intended to assess the social
validity of the BAC treatment model. Specifically, Lambert, Paranczak et al. (2022 [here])
described a retrospective consecutive case series spanning six years (i.e., 2014-2019), focusing
on data from past scholars (i.e., direct beneficiaries of the BAC’s training mission and indirect
beneficiaries of its research mission). Similarly, Lambert, Copeland et al. (2022 [here])
described a retrospective controlled consecutive case series (Hagopian, 2020) focusing on client
outcome data and the extent to which these data reflected achievement of the BAC’s service
mission (i.e., conceptual clarity, response elimination, EO tolerance, and generalization).
Importantly, the threefold mission introduced complexity to assessments of social
validity because the identity of direct service recipients changed depending on which mission
was considered (i.e., scholars were direct recipients of training, individuals affected by pervasive

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challenging behavior were direct recipients of service). This complexity introduced potential
conflicts of interest for all cases because the priorities were split across multiple stakeholders and
objectives. Any decrement to the quality of service due to conflicts introduced by training or
research missions immediately challenges the validity of all three, and of the BAC experience.
Given this reality, a notable omission from Lambert, Paranczak et al. (2022 [here]) and
Lambert, Copeland et al. (2022 [here]) was a comprehensive accounting of perspectives and
opinions of stakeholders involved in the original referrals of BAC clients. This omission is
noteworthy because the meaningfulness of the results of Lambert, Paranczak et al. and
Lambert, Copeland et al. cannot be established without feedback from the individuals who
initially sought help. Said differently, because it was their complaint which defined the problem
to be resolved, it was their satisfaction which served to justify and validate the BAC’s goals,
methods, and outcomes (Barton et al., 2018; Wolf, 1978; Kazdin, 1977).
Thus, the purpose of this data-informed discussion paper was (1) to describe stakeholder
knowledge of the BAC’s goals, methods, and outcomes, (2) to use stakeholder perspectives to
contextualize and frame the method and outcomes of Lambert, Paranczak et al. (2022 [here])
and Lambert, Copeland et al. (2022 [here]), and (3) to identify, expose, and shore up the BAC
model’s weaknesses (cf. Schwartz & Baer, 1991; Halle, 2019).
Method
Participants
Of the 53 eligible respondents (i.e., caregivers and teachers who had been the primary
points of contact during BAC consultations described by Lambert, Copeland et al. (2022 [here]),
29 (54.7%) consented to participate and completed the survey (described below). Two
additional respondents were consented but never completed the survey.

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Measurement
The survey was delivered to respondents electronically and all records were distributed,
managed, and stored through Research Electronic Data Capture (REDCap; Patridge & Bardyn,
2018). The full survey entailed Likert scales and open-ended questions, included 176 total items,
incorporated branching logic (i.e., certain questions were conditional and depended on specific
responses to previous questions), and took approximately 20-30 min to complete.
Procedures
Survey Development
One BCBA-D, three BCBAs, and four masters students with BAC experience converged
in a series of focus-group meetings to develop this survey. After coming to consensus about
general themes and specific items to be addressed by the survey, the focus group consulted an
expert on survey design to develop an instrument which adhered to psychometrically valid test
construction, and basic rules of statistics (cf. Kazdin, 1977; Schwartz & Baer, 1991). To protect
against bias (Barton et al., 2018; Garfinkle & Schwartz, 2002; D’Agostino et al., 2019), the
focus-group coordinator and primary point of contact for all participants was a masters student
who had no history with survey respondents and who was instructed to develop an instrument
capable of exploring and exposing potential weaknesses of the BAC model (cf. Halle, 2019), and
of qualifying positive appraisals reflected by data reported in Lambert, Paranczak et al. (2022
[here]), and Lambert, Copeland et al. (2022 [here]).
Survey Content & Structure
The survey’s content and structure were modeled after that of previously published
instruments and was divided into five distinct sections: Demographics, Before Services, During
Services, After Services (up to the present moment), Final Thoughts. Generally, questions

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explored the identity and motivation of respondents, as well as their awareness and approval of
the BAC’s goals, methods, and outcomes. Because this mission introduced a potential conflict of
interest to all cases served, the survey explicitly probed for tensions that missions unrelated to
therapy (i.e., training, research) imposed onto respondents’ therapeutic experiences.
Similarly, we probed the acceptability of treatment techniques common to BAC practice.
Specifically, because the BAC employed an easily misapplied and potentially difficult-to-
understand technique (i.e., massed-trial instruction in a single-operant paradigm; referred to in
the survey as “high-stakes roleplaying”), we probed stakeholder awareness of the rationale for its
use, the extent to which they believed it had been effective, and the extent to which they believed
observed effects were valid. We also probed the acceptability of the specific dosage, and
concentration of dosage, of therapy offered through the BAC and recruited information about
how these parameters might have been optimally adjusted to meet individual respondents’ needs
(e.g., longer or shorter appointments, more or fewer appointments, appointments distributed
across a longer or shorter period of time).
We also probed respondents’ perceptions of the bedside manner (e.g., respect for family
culture, responsiveness to feedback) of BAC teams, and the extent to which the training that
respondents received reflected adherence to a Behavior Skills Training framework (i.e.,
instructions with rationale, model, data-informed practice with feedback; Schaefer & Andzik,
2021). In this vein, we also asked respondents whether the amount of training they received was
adequate, whether they believed it had been effective, and whether associated training materials
(i.e., discharge summary, training video) were valued.
Respondents also reported the extent to which treatment effects maintained, and the
extent to which the intervention continued to be used, after BAC discharge. To explore the extent

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to which treatment effects established at the BAC promoted desirable outcomes in both proximal
and distal domains (i.e., the frequency, intensity, and location of challenging behavior, access to
inclusive contexts), we asked participants to complete the Problem Behavior subscale of the
Scales of Independent Behavior – Revised (SIB-R; Bruininks et al., 1996), as well as questions
drafted by this study’s survey designer.
Survey Distribution
Following IRB approval, the survey designer emailed eligible survey respondents an
invitation to participate. Eligible respondents who expressed interest were consented and those
who did not were not contacted again. If eligible respondents did not respond to initial contact
attempts, the survey designer asked a BAC-affiliated contact with a previous relationship (e.g., a
case manager or supervisor) to attempt a contact (this occurred for 27.6% [8 of 29] participants).
If contact was made and interest expressed, the known contact informed participants that the
survey designer would soon be in touch. In total, 29 of 53 (54.7%) eligible participants
completed the survey. Mean latency from the calendar year in which services were rendered to
survey respondents to the year in which surveys were distributed was 3.6 years (range 1-6 years),
with a median and mode of 3 years.
Once consented (Supplemental Materials [SM]-C1, here), respondents were provided
with access to content intended to occasion memories of their experiences with challenging
behavior and the BAC (SM-C2 [here]; SM-C3 [here]). Specifically, 79.3% (23 of 29)
respondents were provided a secure link to a 5-15 min discharge video which was produced for
their case at the time services were provided (see Lambert, Paranczak et al. (2022 [here]). For
cases for whom discharge videos were not produced (6 respondents), we provided a summary of
the methods and outcomes of their BAC services and thumbnail pictures of members of their

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BAC team. Respondents then completed a brief caregiver (SM-C4a [here]) or teacher (SM-C4b
[here]) demographic survey, and advanced to the main survey (SM-C5 [here]).
Data Analysis
We considered descriptive statistics of rating-scale items individually and in relation to
categorical themes (e.g., goals, methods, outcomes). When considering changes in the
prevalence, intensity, and locations of challenging behavior, and access to inclusive
environments, we first assigned points to specific options relevant to each scale (Table 1). Then,
we summed within-scale scores to produce a single composite score for the prevalence, intensity,
& location of challenging behavior (low scores valued) and access to inclusive environments
(high scores valued) at two distinct time periods (i.e., before, after) and conducted paired-
samples t-tests to test the statistical significance of noted pre/post changes.
When considering responses to open-ended questions, we used an inductive (ground up)
approach whereby we derived codes based on participant responses using open coding followed
by thematic analysis coding (cf. Creswell & Clark, 2017; Patton, 2014).
Results & Discussion
Demographic data are displayed in SM-C6 (here) and survey results are displayed in
Table 2, Figure 1, SM-C7a (here), and SM-C7b (here). Most (79%) participants indicated that
the BAC was not their child’s first experience with related services. Related, 58.6% reported
receiving previous training from service providers on strategies to decrease challenging behavior.
Most respondents reported learning about the BAC via professional recommendation (48%; e.g.,
teacher, doctor) or informal recommendation (34.5%; e.g., friend or colleague). All respondents
reported they had personally experienced the child’s challenging behavior and 58.6% reported
that several people had been exposed to it. Despite experience with apparently ineffective

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strategies, 86.2% reported some expectation that the BAC would result in permanent
improvements in challenging behavior.
BAC Goals
All respondents reported knowing their case was supervised by a qualified BCBA, that
the team assigned to them consisted of practitioners-in-training, and that their experiences might
have contributed to research. All reported enjoying their contributions to training and research.
Notwithstanding, some reported that practitioner-training efforts (20.7%) and imbedded research
initiatives (10.3%), decreased the quality of service provided. Seventy-two percent indicated they
could not have paid for the BAC but only 6.9% indicated they would not have paid for it. The
majority (93.1%) indicated that having to pay for services would not have motivated them more
than they already were to attend appointments or learn the intervention.
BAC Method
All respondents indicated they understood both assessment and intervention processes.
Seventeen percent indicated they wished they had asked, and 24.1% indicated they wished they
had been asked, additional questions prior to initiating services.
When considering massed-trial instruction (described as “high stakes” roleplaying),
96.6% of respondents indicated their team explained its rationale before attempting it. Although
96.6% indicated they understood the rationale, 10.3% did not believe the approach helped their
child develop new skills and 10.3% indicated they did not believe that skills learned through this
method generalized to their everyday lives. When asked to consider how they would modify
appointment structure, 48.3% indicated they believed the child would have benefitted from more
appointments (e.g., 3-5 days/week [as opposed to 1-2 days/week]) and 72.4% indicated the child
would have benefited from more time with therapy (e.g., 4-6 months instead of 3 months).

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Most respondents (96.6%) indicated they enjoyed being included in the intervention
process. Ninety three percent confirmed the way they were trained aligned with the Behavior
Skills Training framework, 96.6% indicated they enjoyed this training, and 86.2% indicated the
training they received allowed them to support their child in academics, recreation, and family
life. However, roughly half (i.e., 44.8%) wished they had been involved sooner than they were
(typically, parent training began a few weeks prior to discharge) and 58.6% wished they had
received more training. With respect to permanent products of the training process, most
respondents reported reading their discharge summary (75.9%) and watching their training video
(87%, when one was made). Fewer reported allowing someone else to read summaries (13.8%)
or watch videos (39.1%). Most valued discharge summaries (79.3%) and videos (91.3%) as
instructional tools and some valued them as mementos (summaries, 44.8%; videos, 65.2%).
Eighty-six percent of respondents indicated they made sacrifices while the child was in
the BAC and 41.4% reported working with the therapeutic team disrupted their daily life and
routines. Fifty nine percent of participants reported that the benefits of involvement in the BAC
outweighed the sacrifices. All reported that the team was respectful of their cultural needs and
preferences and 96.6% reported that the team addressed all problems promptly.
BAC Outcomes
After being discharged from the BAC, 51.7% of respondents reported that challenging
behavior returned and 20.7% reported that, after discharge, they had both stopped using the
intervention and that they later began to use it again.
At the time they completed this survey, most (86.2%) indicated that either they, or
someone else, still used the intervention. Of the 25 who indicated the intervention was still being

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used, 24 specified that it was used in the child’s home, nine in school, four in therapy, eight in
the community, and one during doctor appointments.
When asked why the intervention was still used, 56.6% indicated it worked and was still
needed, 48.3% indicated the child liked it, 51.7% indicated they liked it, and 13.8% indicated
they used the intervention for “other” reasons. When asked why the intervention was not used,
13.8% indicated it had worked and was no longer needed, 3.4% indicated it was not useful,
10.3% indicated it was too difficult, 13.8% indicated it was too time consuming, and 17.2%
indicated they stopped using the intervention for “other” reasons.
Seventy-nine percent of respondents reported that working with the BAC team decreased
the child's challenging behavior, 86.2% reported it increased the child's appropriate behavior
(e.g., asking for a break, complying with requests), and 100% reported their team’s efforts had a
positive impact on the child. Likewise, 100% reported having an overall positive reaction to their
experience with the BAC, 86.2% reported this experience increased their desire for additional
related services, and 93.1% indicated they were very satisfied with the overall BAC experience.
SM-C7a (here) displays summaries of reports of the prevalence (left column) and
intensities (right column) of challenging behavior prior to and following participation in the
BAC. SM-C7b (here) displays aggregate summaries of respondent reports specifying the
prevalence of challenging behavior by location (left column), as well as reports of access to
various inclusive contexts (right column). Across cases, categorical changes in prevalence (t [28]
= 5.44, p < .001), intensity (t [28] = 5.03, p < .001), and location (t [28] = 5.23, p < .001) of
challenging behavior were statistically significant. However, changes in access to inclusive
contexts were not (t [28] = -0.60, ns; see Figure 1).
Open Ended Feedback

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Twenty-three respondents provided insight to one, or more, of four optional and open-
ended questions at the end of the survey. Brief summaries of common themes are described
below and verbatim transcriptions are reported in SM-C8 (here).
Prompt 1: Before initiating services, I wish we had discussed…
Five respondents answered this question. One indicated she wished she had learned the
details of her son’s challenging behavior before working with the BAC so should could have
made different choices with respect to how she spoke to and interacted with him. Another
indicated she wished the team had been more explicit about their expectations, as well as on how
to implement prescribed therapies. Two challenged the social and ecological validity of both the
BAC’s method and outcomes and indicated they wished they had better understood the contrived
nature of the therapy at the onset of the experience.
Prompt 2: Describe your overall experience
Twenty-two respondents answered this question. Fifteen indicated their experience was
positive, effective, and/or life changing. Three indicated it helped them learn about their child,
one said they learned how to adapt in response to tough situations and to celebrate small
successes, and one described how effective their team was at connecting procedures to valued
outcomes. Four indicated their teams were compassionate, responsive, well-trained, respectful,
and/or professional.
One respondent indicated their son had been non-responsive to all treatments and that the
BAC was one more “empty therapy”. Three suggested treatments were effective but not
comprehensive and that effects did not generalize. Three expressed a desire for more time in
therapy, more training, or both. One indicated the therapy was “hard to watch” but that it was
also worth it. One respondent with limited English proficiency suggested she had difficulty

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communicating but wished to help other parents of children with special needs. Finally, one
indicated they held negative feelings toward the field of ABA, generally.
Prompt 3: What advice would you give to a parent in the BAC?
Twenty respondents answered this question. Common responses were explicitly
endorsing and/or encouragement to try the experience (n = 11), advising to be open-minded
about the BAC approach (n = 4), acknowledging that the experience was hard but worth it (n =
3), and suggesting that parents should be active participants in therapy (n = 2). A single
respondent each indicated: that the BAC was a great option when they were out of options, that
parents should embrace the extra help, that progress was not linear, that parents be honest about
problems they faced, that parents be proactive and recruit help when needed, that parents should
provide their team with feedback, that parents be realistic about expectations, that parents should
insist teams do a better job both with training, and with programming for generalization, and that
it was important to have clear goals to avoid wasted time.
Prompt 4: Is there anything else you would like to share about your experience?
Sixteen respondents answered this question. Nine explicitly expressed gratitude, one
indicated the experience was informative and useful, one indicated their son enjoyed the
experience, and one indicated the team was responsive and adapted to their needs. Another
indicated the BAC was a great introduction to ABA which had inspired them to pursue more
intensive supports for their child. One loved that the experience facilitated practitioner-training
and another indicated the BAC helped them learn how to work in a team.
Two participants indicated they believed the source of their child’s challenging behavior
was either medical or developmental; thus, extending beyond the variables assessed and treated
at the BAC. However, they also emphasized that contingency-management ameliorated the

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intensity of the problems caused by these other perceived sources. One participant expressed
incredulity at the intensity of her child’s need; however also affirmed her commitment to
advocacy and therapy. Four participants indicated they wished they’d been given more time with
the BAC, as well as ongoing refreshers and consultations after formal discharge.
Survey Limitations
Prior to interpreting results, discussion of limitations is warranted. First, only 54.7% (i.e.,
29 of 53) of eligible participants completed the survey. Thus, it is likely that our results are not
fully reflective of the opinions and experiences of all BAC service recipients and results should
therefore be interpreted with caution. Related, the most prevalent respondent demographic
entailed white, college educated, female mothers who were either married or in a domestic
partnership. Thus, the generality of survey results is likely most representative of the opinions
and perspectives of that specific population (cf. BAC 52’s narrative feedback in response to
Prompt 1 in SM-C8 [here]).
Another limitation is that we asked respondents to rely on recall of events which occurred
anywhere from 1-6 years (M=3.6) prior to survey completion, and not all participants were
provided with the same stimuli to prompt recall of their BAC experience (i.e., some were
provided with videos with voiceover narrations, while others were provided with thumbnail
pictures and written text). Importantly, recall is notoriously unreliable and is subject to a slew of
confounding influences (e.g., Capitani et al., 1992; Kelly & Risko, 2021; Mechner & Jones,
2011; Skinner, 1957). Although previous research suggests that recall-based reports of program
efficacy can remain fairly consistent across time (e.g., Dillenburger et al., 2004; Hood &
Eyeberg, 2003; Johnson & Christensen, 1975), it is unclear the extent to which reports would

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have changed if we had asked parents to report their perspectives at the times imagined by
survey prompts (i.e., before, during, after BAC).
It is plausible; however, that the lapse in time between services rendered and survey
completion (i.e., 1-6 years) served to mitigate tendencies to acquiesce unearned favorable reports
(e.g., Ware, 1978). In this case, the extended time could have been a benefit to an accurate
accounting of stakeholders’ perspectives. Although survey items differed substantially, rendering
direct comparisons invalid, there is some evidence to suggest this may have been the case, as
social validity instruments administered immediately following discharge reflected unanimous
and near-perfects reports of satisfaction (see Table 6 in Lambert, Copeland et al. (2022 [here]).
This was not reflected in the current study and although a general message of gratitude remained,
that message was dampened by sobering (and far more useful) accounts of aspects of the
experience which went wrong.
A fourth limitation of this survey was that only interventionists (i.e., BCBAs and
graduate students) were represented during focus-group meetings. Although the survey was
drafted with an intention to invite critical feedback about the BAC experience, the absence of
other key stakeholders’ perspectives during survey design (e.g., caregivers, individuals with
disabilities) likely rendered the final product insufficient for its intended purpose.
Finally, with the exception of one subscale of the SIB-R, we did not use a previously
published instrument to assess social validity. Rather, we drafted questions unique to the BAC
experience. Although standardized instruments can facilitate interpretation and extrapolation of
principle (Kazdin, 1977), their lack of detail and program specificity appears to encourage non-
critical “ho hum” appraisals of acceptability which are neither reflective of reality (Halle, 2019),
nor protective against eventual program rejection (Schwartz & Baer, 1991).

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By contrast, individualized assessments of social validity are both valued (e.g., Mash &
Terdal, 1981) and prevalent (D’Agostino et al., 2019). Notwithstanding, individualized
instruments tend to produce uninterpretable data (Kazdin, 1977). Thus, we took steps to ensure
our survey possessed certain properties associated with psychometric rigor. For example, we
isolated specific periods of time during which respondent experiences should be considered (i.e.,
before, during, and after BAC), questions were specific and direct, employed scales of a wide
enough range to invite variation in responses, and required differential responding such that
stakeholders were required to use the entire range of the scale to complete the survey (i.e.,
specific scale values depicted both positive and negative reflections of experience, depending on
the question [cf. Schwartz & Baer, 1991]). Despite these efforts, our non-standardized approach
limits this project’s ability to serve as a metric of external validity for previous and subsequent
work, thus limiting its contribution.
Contextualizing the Findings of Papers 1 & 2
Pervasive challenging behavior has the potential to adversely impact social, emotional,
psychological, and academic landscapes of those afflicted by it (Edwards et al., 2020;
Eisenhower et al., 2005; Horner et al., 2002; Kurth, 2015; Lauderdale-Littin et al., 2013). There
is consensus amongst scientists and practitioners that FA-informed and function-based intensive
interventions are the most likely to ethically and effectively address chronic and severe
challenging behavior (Jeong & Copeland, 2020; Lloyd et al., 2020). Despite this, and the fact
that the assessment and treatment of challenging behavior falls within the scope of practice of
both Board Certified Behavior Analysts (BCBA; Behavior Analyst Certification Board, 2017)
and Special Education (SPED) teachers (Council for Exceptional Children, 2015), practitioners
from both fields report difficulties in dealing with challenging behavior and feel inadequately

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prepared to address it, often employing suboptimal methods when they attempt to do so
(Colombo et al., 2020; Freeman et al., 2014; Knight et al., 2019; Moore et al., 2017). Scientists
from both fields have thus encouraged personnel-preparation programs to coordinate experiences
that develop in scholars competence with validated methods for addressing challenging behavior
(e.g., Barnhill et al., 2014; Hemmeter et al. 2008; Wacker et al., 2018). The BAC was designed
for this purpose and has facilitated training of hundreds of practicing SPED teachers and
BCBAs.
Lambert, Paranczak et al. (2022 [here]) and Lambert, Copeland et al. (2022 [here]) each
reported data from a retrospective consecutive case series of services provided through the BAC
over a six-year timeframe (i.e., 2014-2019) and presented both objective and subjective data
which spoke to the validity of the BAC construct from the perspectives of direct service
recipients (i.e., scholars, clients) and distal community members (i.e., professional credentialing
boards, scientific peer review). However, neither paper presented a comprehensive report
reflecting the perspectives of the stakeholders who initially requested help. Without reference to
the experiences and satisfaction of these “original complainers,” social validity cannot be
established (Wolf, 1978; Schwartz & Baer, 1991).
Thus, in this study, we asked stakeholders to reflect on their experiences with challenging
behavior at three points of time (i.e., before, during, & after BAC), and solicited perceptions of
the acceptability and impact of the goals, methods, and outcomes of the BAC’s model. The
primary purpose was to recruit critical feedback intended (1) to describe stakeholder knowledge
of the BAC’s goals, methods, and outcomes, (2) to use stakeholder perspectives to contextualize
and frame the method and outcomes of Lambert, Paranczak et al. (2022 [here]) and Lambert,

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Copeland et al. (2022 [here]), and (3) to identify, expose, and shore up the BAC’s weaknesses
(cf. Schwartz & Baer, 1991; Halle, 2019).
With respect to these objectives, it is encouraging to note that the vast majority of
respondents provided favorable reflections of the BAC. For example, to consider the extent to
which therapeutic gains achieved during formal therapy were restricted to the direct targets of
therapy, at the times and in the locations in which therapy was provided (i.e., to assess the
boundedness of treatment outcomes; Sandbank et al., 2021), we asked participants to recall the
frequency and intensity of challenging behavior prior to and following their time at the BAC and
found statistically significant reports of improvement across both categories. Further, those
improvements were enjoyed across home, school, community, and therapeutic environments.
Notwithstanding, effects were fairly proximal in that they were limited to reductions in
the prevalence and intensity of challenging behavior. More distal outcomes (i.e., improved
access to grade-level academics, inclusive classroom settings, recreational activities, friendships
& community life, family life & traditions) were not reported. On the one hand, this is not
surprising because those outcomes were not targeted for therapy. On the other, the finding is
important because it suggests that the simple reduction or elimination of pervasive challenging
behavior does not automatically entail improved access to valued environments or a higher life
quality. As such, this finding serves as a call to action for BAC interventionists (and practitioners
who employ similar models) to more meaningfully incorporate instructional programming that
promotes skill acquisition across a variety of domains (e.g., social, academic, self-help).
Related, effects also appeared to be time constrained, as 52% of respondents reported that
challenging behavior returned after BAC discharge. Perhaps for this reason, 72% of respondents
indicated they would have benefited from services across a larger period of time (e.g., 4-6

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months) and 48% reported they would have benefitted from services occurring more often (e.g.,
3-5 days per week). Thus, in addition to model considerations stipulated in Lambert, Copeland et
al. (2022 [here]), future practitioners might also consider introducing more flexibility to both the
concentration, and duration, of service provision. In so doing, care should be taken to maximize
impact while minimizing less-desirable aspects of the model (e.g., 58% of participants reported
working with the BAC disrupted daily life and routines).
Model Limitations
Despite generally favorable reflections of the BAC, there were few domains for which
respondent appraisals were unanimous. Given that assessments of social validity may
overestimate consumer satisfaction (Bornstein & Rychtarik, 1983; Fuqua & Schwade, 1986;
Lebow, 1982; McMahon & Forehand, 1983; Ware et al., 1978), and the fact that almost 50% of
eligible survey respondents did not participate in this study, it is reasonable to assume that our
data underestimated the prevalence of dissatisfaction with key features of the BAC experience.
Importantly, discontented consumers are not members of a homogenous group and
reasons for dissatisfaction are likely to vary substantially from one case to the next (Schwartz &
Baer, 1991). This is likely especially true within the context of the practitioner-training model
employed by the BAC, in which the baseline skillsets, dispositions, and bedside manners of
interns varied considerably across cases, and in light of the fact that the impact of focused
professional development on interns’ performances could not (by nature of the training model)
carryover to new cases (i.e., new interns were rotated into the BAC for every case).
In reflection of this point, some respondent reports of dissatisfaction implicated clear
lapses in practitioner training and oversight (e.g., not involving key stakeholders in the
intervention process soon enough, not offering sufficient rationale for a prescribed course of

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action, not reacting to stakeholder concerns). Although suboptimal, these weaknesses can be
(and often have been) corrected by improving the quality and focus of our training protocols.
We found more disturbing the fact that objective and reliable accounts of improvement
(i.e., those reported by Lambert, Copeland et al. (2022 [here]) did not perfectly predict
stakeholder accounts of improvement and satisfaction (i.e., those reflected in this study). To
establish the gravity of this point, we highlight the case of BAC 4, below.
Case-Study Examples of Lessons Learned Through Data Triangulation
In this section, we use parent reports to contextualize and frame data reported in Lambert,
Copeland et al. (2022 [here]) through a series of case studies (Table 3). In all cases, parents
provided ongoing and honest informal feedback about their perceptions of impact throughout
their BAC consultation. The first case presented (i.e., BAC 4) represents an empirically
verifiable demonstration of treatment effect, ultimately deemed by us to be socially invalid. The
next two (BAC 7, BAC 22) represent cases with empirically verifiable and socially valid
demonstrations of effect. In all cases, child performance during formal therapy did not fully
reflect parent reports of performance outside of formal therapy and the evidence used to inform
important programmatic decisions extended beyond established measurement systems. Below,
we highlight emergent themes which appear worthy of future investigation.
Measurement Validity. BAC teams 4 and 7 both served cases in the same year, in which
similarly aged clients shared relatively similar diagnoses, and who shared relatively similar
formal and functional profiles for challenging behavior (although communication skills were
disparate across cases; see Table 3). Further, treatments in both cases achieved better than 90%
reductions in challenging behavior; a commonly invoked standard of effective practice (cf.
Hagopian et al. 1998; Rooker et al., 2013; Wacker et al., 2017). Notwithstanding these

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22
similarities, Likert-scale and narrative (open ended) stakeholder reports of efficacy between
these two cases were strongly divergent; with recollections of therapy being “marginally
impactful” and otherwise “empty” for one (BAC 4), and life changing for the other (BAC 7).
Particularly in the case of BAC 4, the extent of the disparity between objective (i.e.,
greater than 90% reductions in challenging behavior) and subjective (“marginally impactful”,
“empty”) accounts of the BAC’s impact merit scrutiny. The findings of Lambert, Copeland et al.
(2022 [here]) benefitted from reliable, valid, and objective measurement systems and it is thus
tempting to prioritize their interpretation in resolving the apparent discrepancy. However, those
data were obtained under fairly contrived circumstances (e.g., precise schedule enforcement by
external agents) and are vulnerable to measurement artifacts associated with observer reactivity
and similarity between treatment and generalization contexts. Thus, what was gained in precision
and reliability of the report from Lambert, Copeland et al. may have been offset by the
boundedness of that assessment (Sandbank et al., 2021; Yoder et al., 2018; see also Halle, 2019;
Lucshyn et al., 2007). Importantly, this issue is not unique to the BAC and represents a pervasive
problem in intervention research (cf. Kazdin 1979; Kennedy, 2002; Halle, 2019) for which there
are few realistic solutions (although see Akemoglu et al., 2019; Barton et al., 2018; Halle, 2019).
On the other hand, despite our field’s general skepticism of subjective reports of impact
(e.g., Halle, 2019; Schwartz & Baer, 1991; Skinner, 1957), such reports can corroborate the
occurrence of empirically verifiable events in some circumstances (e.g., Kent & O’Leary, 1976;
Maloney & Hopkins, 1973) and are unconstrained to contexts which happen to be convenient to
rigorous measurement (e.g., at times and in locations in which availability aligns). Further,
despite their subjective quality, recall, emotions, and verbal appraisals of value and impact are all
intimate sources of stimulation which, when occasioned, are capable of transforming the

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functions of lived experience on listener behavior (e.g., Han et al., 2021; Hayes et al., 1989;
Snyder et al., 2011; Powers et al., 2009). Thus, stakeholder report is a critical source of data.
Further, to the extent to which social validity is a feature which distinguishes basic from
applied science (cf. Baer et al., 1968), the content and construct validity of purportedly objective
measures of efficacy reported in Lambert, Copeland et al. (2022 [here]) must be challenged
whenever conclusions drawn from them differ from conclusions drawn by stakeholders. For
BAC 4, then, what we found was an example in which an empirically rigorous demonstration of
effect lacked social validity; with no clear explanation for the discrepancy.
However, circumstantial evidence may shed some light. For example, while services
were rendered, this caregiver indicated she did not understand why we continued to provide
practice opportunities for the same skill (i.e., manding for functional reinforcers during massed-
trial FCT), and that patterns of challenging behavior remained unaffected in the home context.
However, in-session data supported the then-current course of action and this team persisted in
its original approach for months.
Eventually, the team transitioned services from a clinical setting to the caregiver’s home
and imbedded both massed and distributed FCT trials into a function-informed activity schedule
which systematically rotated through experiences designed both to provide a context for
instruction during FCT, and to abolish the reinforcers for challenging behavior (i.e., tangible,
escape). Notwithstanding, the fixed-duration of the consult (i.e., 3 months) precluded
achievement of socially significant outcomes. To date, it remains unclear whether our team’s
lack of socially significant impact was the result of a disability-specific characteristic (as
suspected by this caregiver), or if a more intensive treatment dosage (i.e., more therapeutic trials
concentrated into a larger percentage of the child’s days and weeks), a longer duration of

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services (i.e., more than 3 months), more creative programming (e.g., instruction on
complementary skills in domains other than manding), or some combination of these variables,
could have moderated improvement.
The Potential Value of Circumstantial Evidence. For contrast we highlight BAC 7,
who was served the semester after BAC 4. At the time they were enrolled for BAC services,
BAC 4’s caregiver reported that neither she nor her child had left their home for three
consecutive months, due to the severity of aggression that the act occasioned. Like BAC 4, BAC
7’s out-of-session reports of the persistence in both frequency and severity of aggression were
not reflected by in-session treatment data. Notwithstanding, experiences with BAC 4 imbued in
leadership the flexibility needed to adapt to a rapidly deteriorating scenario (see Guiding
Principle 14 in SM-B1 [here]). Specifically, Team 7 introduced arbitrary sources of
reinforcement (Guiding Principle 13 [here]) into an individualized-levels system (Hagopian et al.
2002), which included a function-based punishment component (Guiding Principles 10-13
[here]).
To protect against threats to generality associated with behavioral contrast (Boyle et al.,
2018), resurgence (Perrin et al., 2021), and counter-control (Delprato, 2002), we first validated
our treatment approach within the highly controlled contexts described by Lambert, Copeland et
al. (2022 [here]). However, we only considered those validated efforts a “proof of concept” of
what might be possible for the child’s life. Afterward, we took steps to ensure treatment fidelity
at highly problematic times (e.g., morning routines, transitions), and to troubleshoot
unanticipated life circumstances in real time, by coordinating schedules to ensure ongoing home-
based coaching and implementation support from at least one BAC-7 team member for 8-10
hours a day, across an entire week (a strategy informally referred to as a “treatment blitz”).

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During this “blitz,” the caregiver became fluent not only with the methods we prescribed, but
also with their logic and rationale and became increasingly less prompt dependent. Eventually,
the caregiver adapted to novel scenarios independently, correctly, and in conceptually systematic
ways. At the same time, the intensity and severity of the child’s aggression dissipated and she
became more compliant with her mother’s requests. After the blitz, we continued to accompany
progress during typically scheduled appointments (twice a week for two hours) and began to
systematically introduce elements of generalization (e.g., adherence to standards of hygiene,
transition, and instructional methods) which facilitated the child’s eventual reintegration into
school.
Importantly, scheduling conflicts and resource constraints precluded valid measurement
of the outcomes of the blitz (which occurred after the treatment package had been formally
validated through experimentally rigorous methods). Thus, the impact of two critical decisions
(i.e., the introduction of an individualized levels system which incorporated function-based
punishment, and an intensification in treatment dosage) was not demonstrated. However,
circumstantial evidence (including video samples which reflected drastic improvements to the
child’s affect, demeanor, hygiene, and environmental access) appeared to suggest each played a
role in the outcomes reported by the parent who participated in this study.
Levels of Analysis. Importantly, and in contrast to procedures described for BAC 7,
circumstantial evidence did not always justify treatment intensification. In the case of BAC 22,
suspected moderating medical variables (see prompts 2 & 4 in SM-C8 [here]), and parent reports
of increasingly intense and persistent out-of-session escalations in dangerous behavior, led us to
conclude that a treatment plan which incorporated precise suppressive contingencies (see BAC’s
precision hierarchy in SM-B4 [here]) had become both untenable and socially invalid.

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Specifically, although our massed-trial FCT and discrimination training protocol technically
conformed to a reinforcement-only paradigm, and in-session behavior reflected a desirable
therapeutic trajectory (i.e., high rates of manding, no challenging behavior), this child became
unwilling to enter the room in which therapy was provided. Further, parents reported that the
child also began engaging in self-injurious behavior prior to appointments, the moment he saw
the BAC team park in his driveway. It thus became apparent that our method had conditioned the
entire therapeutic context as an aversive experience in a way that our measurement system was
insensitive to (cf. Hineline, 1984; Perone, 2003; Staats, 2006).
This observation (in conjunction with the fact that the child was language proficient) led
us to pivot away from massed-trial FCT as the primary element of our treatment plan (i.e., he
only had to “practice asking” when he was aggressive or self-injurious) and toward function-
informed noncontingent reinforcement and environmental enrichment (Guiding Principles 10, 14
[here]). Specifically, across all hours of the day, 30-min of high-quality structured activities (to
abolish attention functions), followed by 30 min of “down time” during which the child could
read books and access his iPad (to abolish escape and tangible functions), was imbedded into a
daily schedule which programmed powerful but arbitrary reinforcers (e.g., restaurants,
swimming) into a 6-hr DRO schedule conceptualized through a self-monitoring token board.
The pivot was intended to address a perceived interaction between the establishing
operations of multiple functions of challenging behavior, as well as a general degradation in
within-session reinforcer quality relative to what was available under typical circumstances,
which can result from strict adherence to poorly conceptualized differential reinforcement
systems (Guiding Principles 9, 11[here]). Anecdotally, the nature and cadence of appointments
improved immediately, as well as parent reports of quality of life outside of appointments. Thus,

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as was the case for BAC 7, the impact of a programmatic decision based on circumstantial
evidence (in this case, to abandon precise contingencies in favor of guaranteeing frequent contact
with high quality stimulation at all times of the day) cannot be confirmed through empirically
rigorous methods. However, the data which exist (i.e., Table 3; SM-C8 [here]) suggests it may
have been important.
Implications and Future Directions
There is evidence to suggest that the field of ABA, as a whole, does not consistently or
meaningfully incorporate comprehensive assessments of social validity into models of
intervention (Carr et al., 1999; Conroy et al., 2005; D’Agostino et al., 2019; Ghaemmaghami et
al., 2021; Hurley, 2012; Ledford et al.; 2016; Park & Blair, 2019; Snodgrass et al., 2018).
From those who have contributed to the conceptualization of the construct, assessments
of social validity are considered a defensive technique which help service-providers anticipate
and circumvent program rejection and sabotage by sampling the acceptability and sustainability
of programs implemented at scale and in real-world circumstances (Kazdin, 1977; Snodgrass et
al., 2018; Wolf, 1978). Despite this purpose, social validity assessments often appear engineered
to endorse whatever program they were intended to critique and the result has been a mirage of
unanimous and enthusiastic support for behavior analytic programming reflected within the
annals of ABA journals, but not necessarily elsewhere. As complaints against behavior analysis
from those harmed by its misapplication grow louder and more uniform (e.g., Kupferstein., 2018;
Milton, 2018; Shyman, 2016; Wilkenfield & McCarthy, 2020), the repercussions of poorly
selected programmatic goals and methods are both dire, and increasingly apparent.
Given the merit of objective empirical markers of social validity (e.g., Kennedy, 1992),
BAC 4’s outcome served as a call to action to improve our standards of valid measurement and

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interpretation; a process which is both ongoing and incomplete. Even still, as a preservice-
practitioner training program, our commission has been to train professionals whose practice is
guided (not constrained) by objective data. Our experiences with the BCBAs and SPED teachers
we have trained suggest that this population is eager to be influenced by data, logic, and
compassion. We have also noticed that their behavior tends to be rule governed and can be fairly
insensitive to natural contingencies which operate in opposition to expectation (cf. Hayes et al.,
1989).
Because problems associated with the rule governance of typically developing adults are
unlikely to be easily resolved outside of therapies developed for that population (cf. Dixon et al.
2020), the most straightforward solution to their manifestation appears to be the development
and presentation of sufficiently dynamic rules (e.g., Guiding Principles); as well as a willingness
to modify such rules as evidence of their impact emerges. As a result, BAC leadership has placed
substantially more value on function-informed and mechanisms-based problem solving
(Lambert, Copeland et al., 2022 [here]) which accounts for both measured (e.g., Table 2, SM-
C7a [here]; SM-C7b [here]; SM-C8, here) and unmeasured (see case-study anecdotes)
contextualizing factors that guide interpretation of objective empirical outputs (Guiding
Principles 2, 3, & 14 [here]). Our hope is that these factors embolden practitioners to think more
critically about the data they obtain, and to more readily accept reports of the lived experiences
of the people they intend to serve.
Notwithstanding, our programming has sometimes been socially invalid (e.g., BAC 4)
and has at times been marred by conflicts of interest imposed by practitioner training and/or
research initiatives (Table 2). Further, despite operationalization efforts (i.e., Lambert, Copeland
et al., 2022 [here]), decision-making pathways which have led to treatment selection remain

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under-studied and possibly irreplicable. Thus, socially validity (and the clinical judgments which
make it possible) has been more art than science for us. Recent commentary from other labs
(e.g., Ghaemmaghami et al., 2021) suggests we are not alone. To the extent to which this is true,
we assert that a behavior-change technology which consistently leads to socially valid
programming has yet to be developed. We thus call for researchers who specialize in the
assessment and treatment of challenging behavior to prioritize its development.

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30
References
Akemoglu, Y., Garcia-Grau, P., & Meadan, H. (2019). Using masked raters to evaluate social
validity of a parent-implemented communication intervention. Topics in Early Childhood
Special Education, 39(3), 144-155. https://doi.org/10.1177/0271121419865945
Baer, D. M., Wolf, M. M., & Risley, T. R. (1968). Some current dimensions of applied behavior
analysis. Journal of Applied Behavior Analysis, 1, 91–97.
https://doi.org/10.1901/jaba.1968.1-91
Barnhill, G. P., Sumutka, B., Polloway, E. A., & Lee, E. (2014). Personnel preparation practices
in ASD: A follow-up analysis of contemporary practices. Focus on Autism and Other
Developmental Disabilities, 29, 39-49. https://doi.org/10.1177/1088357612475294
Barton, E. E., Meadan, H., & Ledford, J. R. (2018). Independent variables, fidelity, and social
validity. In J. R. Ledford & D. L. Gast (Eds.), Single case research methodology:
Applications in special education and behavioral sciences (3rd ed., pp. 133–156). New
York, NY: Routledge.
Bornstein, P. H., & Rychtarik, R. G. (1983). Consumer satisfaction in adult behavior therapy:
Procedures, problems, and future perspectives. Behavior Therapy, 14, 191-208.
https://doi.org/10.1016/s0005-7894(83)80110-5
Boyle, M. A., Hoffmann, A. N., & Lambert, J. M. (2018). Behavioral contrast: Research and
areas for investigation. Journal of Applied Behavior Analysis, 51(3), 702-718.
Bruininks, R., Woodcock, R. W., Weatherman, R. F., & Hill, B. K. (1996). Scales of
Independent Behavior–Revised (SIB-R). Chicago: Riverside.
Capitani, E., Della Sala, S., Logie, R. H., & Spinnler, H. (1992). Recency, primacy, and memory:
Reappraising and standardising the serial position curve. Cortex, 28(3), 315-342.

VALIDITY OF SERVICES RENDERED
31
https://doi.org/10.1016/s0010-9452(13)80143-8
Carr, J. E., Austin, J. L., Britton, L. N., Kellum, K. K., & Bailey, J. S. (1999). An assessment of
social validity trends in applied behavior analysis. Behavioral Interventions, 14, 223–231.
https://doi.org/10.1002/(sici)1099-078x(199910/12)14:4<223::aid-bin37>3.0.co;2-y
Colombo, R. A., Taylor, R. S., & Hammond, J. L. (2020). State of current training for severe
problem behavior: A survey. Behavior Analysis in Practice, 1-9.
https://doi.org/10.1007/s40617-020-00424-z
Conroy, M. A., Dunlap, G., Clarke, S., & Alter, P. J. (2005). A descriptive analysis of positive
behavioral intervention research with young children with challenging behavior. Topics
in Early Childhood Special Education, 25, 157–166.
https://doi.org/10.1177/02711214050250030301
Council for Exceptional Children. (2015). What every special educator must know: Professional
ethics and standards. Arlington, VA: CEC.
https://exceptionalchildren.org/sites/default/files/2020-
07/Standards%20for%20Professional%20Practice.pdf
Creswell, J. W., & Plano Clark, V. L. (2017). Designing and conducting mixed methods research
(3rd ed.). SAGE Publications.
D’Agostino, S. R., Douglas, S. N., & Duenas, A. D. (2019). Practitioner-implemented
naturalistic developmental behavioral interventions: Systematic review of social validity
practices. Topics in Early Childhood Special Education, 39(3), 170-182.
https://doi.org/10.1177/0271121419854803
Delprato, D. J. (2002). Countercontrol in behavior analysis. The Behavior Analyst, 25(2), 191-
200. https://doi.org/10.1007/BF03392057

VALIDITY OF SERVICES RENDERED
32
Dillenburger, K., Keenan, M., Gallagher, S., & Mcelhinney, M. (2004). Parent education and
home-based behaviour analytic intervention: An examination of parents' perceptions of
outcome. Journal of Intellectual and Developmental Disability, 29 (2), 119-130.
https://doi.org/10.1080/13668250410001709476
Dixon, M. R., Hayes, S. C., Stanley, C., Law, S., & al-Nasser, T. (2020). Is acceptance and
commitment training or therapy (ACT) a method that applied behavior analysts can and
should use?. The Psychological Record, 70(4), 559-579. https://doi.org/10.1007/s40732-
020-00436-9
Edwards, N., King, J., Williams, K., & Hair, S. (2020). Chemical restraint of adults with
intellectual disability and challenging behaviour in Queensland, Australia: Views of
statutory decision makers. Journal of Intellectual Disabilities, 24(2), 194-211.
https://doi.org/10.1177/1744629518782064
Eisenhower, A. S., Baker, B. L., & Blacher, J. (2005). Preschool children with intellectual
disability: Syndrome specificity, behaviour problems, and maternal well-being. Journal
of Intellectual Disability Research, 49(9), 657-671. https://doi.org/10.1111/j.1365-
2788.2005.00699.x
Freeman, J., Simonsen, B., Briere, D. E., MacSuga-Gage, A. S. (2014). Pre-service teacher
training in classroom management: A review of state accreditation policy and teacher
preparation programs. Teacher Education and Special Education, 37(2), 106-120.
https://doi.org/10.1177/0888406413507002
Fuqua, R. W., & Schwade, J. (1986). Social validation of applied behavioral research: A
selective review and critique. In A. Poling & R. W. Fuqua (Eds.), Research methods in
applied behavior analysis: Issues and advances (pp. 265-292). New York: Plenum.

VALIDITY OF SERVICES RENDERED
33
Garfinkle, A. N., & Schwartz, I. S. (2002). Peer imitation: Increasing social interactions in
children with autism and other developmental disabilities in inclusive preschool
classrooms. Topics in Early Childhood Special Education, 22(1), 26–39.
https://doi.org/10.1177/027112140202200103
Ghaemmaghami, M., Hanley, G. P., & Jessel, J. (2021). Functional communication training:
From efficacy to effectiveness. Journal of Applied Behavior Analysis, 54(1), 122-143.
https://doi.org/10.1002/jaba.762
Hagopian, L. P. (2020). The consecutive controlled case series: Design, data‐analytics, and
reporting methods supporting the study of generality. Journal of Applied Behavior
Analysis, 53(2), 596-619. https://doi.org/10.1002/jaba.691
Hagopian, L. P., Fisher, W. W., Sullivan, M. T., Acquisto, J., & LeBlanc, L. A. (1998).
Effectiveness of functional communication training with and without extinction and
punishment: A summary of 21 inpatient cases. Journal of Applied Behavior
Analysis, 31(2), 211-235. https://doi.org/10.1901/jaba.1998.31-211
Hagopian, L. P., Rush, K. S., Richman, D. M., Kurtz, P. F., Contrucci, S. A., & Crosland, K.
(2002). The development and application of individualized levels systems for the
treatment of severe problem behavior. Behavior Therapy, 33(1), 65-86.
https://doi.org/10.1016/S0005-7894(02)80006-5
Halle, J. (2019). Avoiding the humdrum: Recommendations for improving how we
conceptualize and assess social validity in ECSE. Topics in Early Childhood Special
Education, 39(3), 139–143. https://doi.org/10.1177/0271121419873525

VALIDITY OF SERVICES RENDERED
34
Han, A., Yuen, H. K., & Jenkins, J. (2021). Acceptance and commitment therapy for family
caregivers: A systematic review and meta-analysis. Journal of Health Psychology, 26(1),
82-102. https://doi.org/10.1177/1359105320941217
Hayes, S. C., Zettle, R. D., & Rosenfarb, I. (1989). Rule-following. In Rule-governed
behavior (pp. 191-220). Springer, Boston, MA.
Hemmeter, M. L., Santos, R. M., Ostrosky, M. M. (2008). Preparing early childhood educators to
address young children’s social-emotional development and challenging behavior: A
survey of higher education programs in nine states. Journal of Early Intervention, 30(4),
321-340. https://doi.org/10.1177/1053815108320900
Hineline, P.N. (1984). Aversive control: A separate domain? Journal of the Experimental
Analysis of Behavior, 42(3), 495-509. https://doi.org/10.1901/jeab.1984.42-495
Hood, K., & Eyberg, S. (2003). Outcomes of parent-child interaction therapy: Mothers' reports of
maintenance three to six years after treatment. Journal of Clinical Child & Adolescent
Psychology, 32(3), 419-429. https://doi.org/10.1207/S15374424JCCP3203_10
Horner, R. H., Carr, E. G., Strain, P. S., Todd, A. W., & Reed, H. K. (2002). Problem behavior
interventions for young children with autism: A research synthesis. Journal of Autism
and Developmental Disorders, 32(5), 423-446. https://doi.org/10.1023/a:1020593922901
Hurley, J. J. (2012). Social validity assessment in social competence interventions for preschool
children: A review. Topics in Early Childhood Special Education, 32(3), 164–174.
https://doi.org/10.1177/0271121412440186
Jeong, Y. & Copeland, S. R. (2020). Comparing functional behavior assessment-based
interventions and non-functional behavior assessment-based interventions: A systematic

VALIDITY OF SERVICES RENDERED
35
review of outcomes and methodological quality of studies. Journal of Behavioral
Education, 29(1), 1–41. https://doi.org/10.1007/s10864-019-09355-4
Johnson, S.M. & Christensen, A. (1975). Multiple criteria follow-up of behavior modification
with families. Journal of Abnormal Child Psychology, 3(1), 135-154.
https://doi.org/10.1007/BF00919807
Kazdin, A. E. (1977). Assessing the clinical or applied importance of behavior change through
social validation. Behavior Modification, 1(4), 427-452.
https://doi.org/10.1177/014544557714001
Kazdin, A. E. (1979). Unobtrusive measures in behavioral assessment. Journal of Applied
Behavior Analysis, 12(4), 713-724. https://doi.org/10.1901/jaba.1979.12-713
Kelly, M. O., & Risko, E. F. (2021). Revisiting the influence of offloading memory on free
recall. Memory & Cognition, 1-12. https://doi.org/10.3758/s13421-021-01237-3
Kennedy, C. H. (1992). Trends in the measurement of social validity. The Behavior Analyst,
15(2), 147–156. https://doi.org/10.1007/BF03392597
Kennedy, C. H. (2002). The maintenance of behavior change as an indicator of social
validity. Behavior Modification, 26(5), 594-60.
https://doi.org/10.1177/014544502236652
Kent, R. N., & O'Leary, K. D. (1976). A controlled evaluation of behavior modification with
conduct problem children. Journal of Consulting and Clinical Psychology, 44(4), 586–
596. https://doi.org/10.1037/0022-006X.44.4.586
Knight, V. F., Huber, H. B., Kuntz, E. M., Carter, E. W., & Juarez, A. P. (2019). Instructional
practices, priorities, and preparedness for educating students with autism and intellectual

VALIDITY OF SERVICES RENDERED
36
disability. Focus on Autism and Other Disabilities, 34, 3-14.
doi:10.1177/1088357618755794
Kupferstein, H. (2018). Evidence of increased PTSD symptoms in autistics exposed to applied
behavior analysis. Advances in Autism, 4(1), 19-29. http://dx.doi.org/10.1108/AIA-08-
2017-0016
Kurth, J. A. (2015). Educational placement of students with autism: The impact of state of
residence. Focus on Autism and Other Developmental Disabilities, 30(4), 249-256.
https://doi.org/10.1177/1088357614547891
Lambert, J.M., Copeland, B.A., Paranczak, J.L., Macdonald, M.J., Torelli, J.T., Houchins-Juarez
N.J. (2022 [preprints here]). Evaluation of a function informed and mechanisms-based
framework for treating challenging behavior. Journal of Applied Behavior Analysis.
Lambert, J.M., Paranczak, J.L., Copeland, B.A., Houchins-Juarez N.J., & Macdonald, M.J. (2022
[preprints here]). Exploring the validity of university-based practicum tailored to develop
expertise in addressing challenging behavior. Journal of Applied Behavior Analysis.
Lauderdale-Littin, S., Howell, E., & Blacher, J. (2013). Educational placement for children with
autism spectrum disorders in public and non-public school settings: The impact of social
skills and behavior problems. Education and Training in Autism and Developmental
Disabilities, 48(4), 469-478. https://www.jstor.org/stable/24232504
Lebow, J. (1982). Consumer satisfaction with mental health treatment. Psychological Bulletin,
91(2), 244-259. https://doi.org/10.1037/0033-2909.91.2.244
Ledford, J. R., Hall, E., Conder, E., & Lane, J. D. (2016). Research for young children with
autism spectrum disorders: Evidence of social and ecological validity. Topics in Early

VALIDITY OF SERVICES RENDERED
37
Childhood Special Education, 35(4), 223–233.
https://doi.org/10.1177/0271121415585956
Lloyd, B. P., Torelli, J. N., & Pollack, M. S. (2020). Practitioner perspectives on hypothesis
testing strategies in the context of functional behavior assessment. Journal of Behavioral
Education, 30, 1-27. https://doi.org/10.1007/s10864-020-09384-4
Maloney, K. B., & Hopkins, B. L. (1973). The modification of sentence structure and its
relationship to subjective judgments of creativity in writing. Journal of Applied Behavior
Analysis, 6(3), 425-433. https://doi.org/10.1901/jaba.1973.6-425
Mash, E. J., & Terdal, L. G. (1981). Behavioral assessment of childhood disturbances. In E. J.
Mash & L. G. Terdal (Eds.), Behavioral assessment of childhood disorders (pp. 3-76).
New York: Guilford.
McMahon, R. J., & Forehand, R. L. (1983). Consumer satisfaction in behavioral treatment of
children: Types, issues, and recommendations. Behavior Therapy, 14(2), 209-225.
https://doi.org/10.1016/S0005-7894(83)80111-7
Mechner, F., & Jones, L. (2011). Effects of sequential aspects of learning history. Revista
mexicana de análisis de la conducta, 37(1), 109-138.
https://doi.org/10.5514/rmac.v37.i1.24688
Milton, D. (2018). A critique of the use of applied behavioural analysis (ABA): On behalf of the
Neurodiversity manifesto steering group. https://kar.kent.ac.uk/id/eprint/69268
Moore, T. C., Wehby, J. H., Oliver, R. M., Chow, J. C., Gordon, J. R., & Mahany, L. A. (2017).
Teachers’ reported knowledge and implementation of research-based classroom and
behavior management strategies. Remedial and Special Education, 38(4), 222-232.
https://doi.org/10.1177/0741932516683631

VALIDITY OF SERVICES RENDERED
38
Park, E. Y., & Blair, K. S. C. (2019). Social validity assessment in behavior interventions for
young children: A systematic review. Topics in Early Childhood Special
Education, 39(3), 156-169. https://doi.org/10.1177/0271121419860195
Patton, M. Q. (2014). Qualitative research & evaluation methods: Integrating theory and
practice. Sage publications.
Patridge, E. F., & Bardyn, T. P. (2018). Research electronic data capture (REDCap). Journal of
the Medical Library Association: JMLA, 106(1), 142.
Perone, M. (2003). Negative effects of positive reinforcement. The Behavior Analyst, 26(1), 1-
14. https://doi.org/10.1007/BF03392064
Perrin, J., Morris, C., & Kestner, K. (2021). Resurgence of clinically relevant behavior: A
systematic review. Education and Treatment of Children, 1-20.
https://doi.org/10.1007/s43494-021-00054-2
Powers, M. B., Vörding, M. B. Z. V. S., & Emmelkamp, P. M. (2009). Acceptance and
commitment therapy: A meta-analytic review. Psychotherapy and Psychosomatics, 78(2),
73-80. https://doi.org/10.1159/000190790
Rooker, G. W., Jessel, J., Kurtz, P. F., & Hagopian, L. P. (2013). Functional communication
training with and without alternative reinforcement and punishment: An analysis of 58
applications. Journal of Applied Behavior Analysis, 46(4), 708-722.
https://doi.org/10.1002/jaba.76
Sandbank, M., Chow, J., Bottema‐Beutel, K., & Woynaroski, T. (2021). Evaluating evidence‐
based practice in light of the boundedness and proximity of outcomes: Capturing the
scope of change. Autism research: official journal of the International Society for Autism
Research, 14(8), 1536–1542. https://doi.org/10.1002/aur.2527

VALIDITY OF SERVICES RENDERED
39
Schwartz, I. S., & Baer, D. M. (1991). Social validity assessments: Is current practice state of the
art? Journal of Applied Behavior Analysis, 24(2), 189–204.
https://doi.org/10.1901/jaba.1991.24-189
Shyman, E. (2016). The reinforcement of ableism: Normality, the medical model of disability,
and humanism in applied behavior analysis and ASD. Intellectual and developmental
disabilities, 54(5), 366-376. https://doi.org/10.1352/1934-9556-54.5.366
Skinner, B. F. (1957). Verbal behavior. New York: Appleton-Century-Crofts.
Snodgrass, M. R., Chung, M. Y., Meadan, H., & Halle, J. W. (2018). Social validity in single-
case research: A systematic literature review of prevalence and application. Research in
Developmental Disabilities, 74, 160–173. https://doi.org/10.1016/j.ridd.2018.01.007
Snyder, K., Lambert, J., & Twohig, M. P. (2011). Defusion: A behavior-analytic strategy for
addressing private events. Behavior Analysis in Practice, 4(2), 4-13.
https://doi.org/10.1007/BF03391779
Staats, A. W. (2006). Positive and negative reinforcers: How about the second and third
functions?. The Behavior Analyst, 29(2), 271.
Wacker, D. P. (2018). The mentoring program in the Department of Pediatrics, the University of
Iowa. Behavior Analysis in Practice, 11(3), 189-193. https://doi.org/10.1007/s40617-018-
0221-4
Wacker, D. P., Schieltz, K. M., Berg, W. K., Harding, J. W., Dalmau, Y. C. P., & Lee, J. F.
(2017). The long-term effects of functional communication training conducted in young
children’s home settings. Education & Treatment of Children, 40(1), 43-56.
https://doi.org/10.1353/etc.2017.0003

VALIDITY OF SERVICES RENDERED
40
Ware, J. E. (1978). Effects of acquiescent response set on patient satisfaction ratings. Medical
Care, 16(4), 327-336. https://doi.org/10.1097/00005650-197804000-00005
Ware, J. E., Davies-Avery, A., & Stewart, A. L. (1978). The measurement and meaning of
patient satisfaction. Health and Medical Care Services Review, 1, 1-15.
Wolf, M. M. (1978). Social validity: The case for subjective measurement or how applied
behavior analysis is finding its heart. Journal of Applied Behavior Analysis, 11(2), 203-
214. https://doi.org/10.1901/jaba.1978.11-203
Yoder, P., Lloyd, B., & Symons, F. (2018). Observational Measurement of Behavior (2nd
Edition). Paul H. Brookes Publishing Co.

Table 1
Scoring system for testing the statistical significance of respondent reports of categorical changes in the pre/post prevalence,
intensity, and location of challenging behavior, as well as access to inclusive contexts.
Score
Scale
0
1
2
3
4
5
Prevalence
never
< 1 per month
1-3 times per month
1-6 times per week
1-10 times per day
1 or more times per hour
Intensity
--
not severe
slightly severe
moderately severe
very severe
extremely severe
Location
never
rarely
sometimes
often
always
--
Access
no access
occasional
intermittent
frequent
constant
--

Table 2
Survey Results
Survey Prompt
% Agreement
Mode
History with Related Services
The BAC was the first service received
20.7% (6 of 29)
Previous experiences with related services weren’t helpful
6.9% (2 of 29)
Previous related services had been helpful, but didn’t address CB
69% (20 of 29)
Previous related services provided training on strategies to decrease the child's CB
58.6% (17 of 29)
Sometimes (10)
Related services successfully addressed CB, but it came back
3.4% (1 of 29)
Heard about the BAC through a friend or colleague recommendation
34.5% (10 of 29)
Heard about the BAC through a teacher recommendation
6.9% (2 of 29)
Heard about the BAC through a doctor or therapist recommendation
44.8% (13 of 29)
Heard about the BAC because I work at Vanderbilt and knew about the BAC
6.9% (2 of 29)
Heard about the BAC because the BAC contacted them
13.8% (4 of 29)
Heard about the BAC through an online search
6.9% (2 of 29)
Participated in BAC b/c I experienced the child’s CB
41.4% (12 of 29)
Participated in BAC b/c several people, including me, experienced the child’s CB
58.6% (17 of 29)
I expected the intervention process … to result in permanent improvement in CB
86.2% (25 of 29)
Mostly Agree (14)
BAC Goals
Practitioner Training
I knew the team assigned to me was supervised by a qualified BCBA
100% (29 of 29)
Completely Agree (27)
I knew the team assigned to me consisted of practitioners in training
100% (29 of 29)
Completely Agree (24)
Practitioner training decreased the quality of service provided through the BAC
20.7% (6 of 29)
Do Not Agree (21)
I enjoyed that my experience with the BAC contributed to practitioner training
100% (29 of 29)
Completely Agree (20)
Research
I knew the child may have been involved in a research project
100% (29 of 29)
Completely Agree (22)
This research decreased the quality of service provided to the child
10.3% (3 of 29)
Do Not Agree (24)
I enjoyed that my experience with the BAC contributed to research
100% (29 of 29)
Completely Agree (18)
Service
I could not have paid for BAC services
72.4% (21 of 29)
Completely Agree (8)
I would not have paid for BAC services
6.9% (2 of 29)
Do Not Agree (15)

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Paying…would have motivated me to attend…appts and learn…the intervention
6.9% (2 of 29)
Do Not Agree (15)
BAC Methods
Informed Consent
I understood the assessment process completed with the child
100% (29 of 29)
Strongly Agree (15)
I understood the intervention process completed with the child
100% (29 of 29)
Strongly Agree (16)
There were additional question I wished I asked the team before we started
17.2% (5 of 29)
Do Not Agree (18)
There were additional question I wished the team had asked me before we started
24.1% (7 of 29)
Do Not Agree (19)
Instructional Approach
The team took the time to explain the rationale behind “high-stakes” roleplaying...
96.6% (28 of 29)
Completely Agree (20)
I understood the rationale behind this practice
96.6% (28 of 29)
Completely Agree (20)
I think this approach worked and developed new skills for the child
89.7% (26 of 29)
Completely Agree (14)
Skills that were learned in the separated settings generalized to our everyday life
89.7% (26 of 29)
Completely Agree (12)
Treatment Dosage
Would have benefited from appts more often (e.g., 3-5 days per week)
48.3% (14 of 29)
Would have benefited from appts less often (e.g., 1 day per week)
0%
Would have benefited from appts lasting longer (e.g., 3-4 hrs)
10.3% (3 of 29)
Would have benefited from appts lasting shorter (e.g., 1 hr)
17.2% (5 of 29)
Would have benefited from appts across a longer period of time (e.g., 4-6 mo)
72.4% (21 of 29)
Would have benefited from appts across a shorter period of time (e.g., 1-2 mo)
6.9% (2 of 29)
Stakeholder Training
Stakeholder Involvement and Behavior Skills Training (BST)
I enjoyed being included in the child’s intervention process
96.6% (28 of 29)
Strongly Agree (24)
I wished I was involved sooner in the intervention process
44.8% (13 of 29)
Do Not Agree (13)
How I was trained aligned with the BST framework
93.3% (27 of 29)
Completely Agree (16)
The parent/teacher training process was enjoyable and informative
96.6% (28 of 29)
Strongly Agree (15)
(Training) allowed me to support the child in academics, recreation, & family life
86.2% (25 of 29)
Mostly Agree (13)
I wished I received additional parent/teacher training
58.6% (17 of 29)
Do Not Agree (7)
Mostly Agree (7)
Discharge Summary
I read the discharge summary
75.9% (22 of 29)
Someone else read the discharge summary
13.8% (4 of 29)
I value the discharge summary as an instructional tool
79.3% (23 of 29)
Strongly Agree (14)
I value the discharge summary as a memento
44.8% (13 of 29)
Do Not Agree (7)

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Discharge Video (n=23)
I watched the discharge video
87% (20 of 23)
Someone else watched the discharge video
39.1% (9 of 23)
I value the discharge video as an instructional tool
91.3% (21 of 23)
Strongly Agree (10)
I value the discharge video as a memento
65.2% (15 of 23)
Strongly Agree (7)
Exigencies of BAC Participation
There were sacrifices I made while the child was in the BAC
86.2% (25 of 29)
Somewhat Agree (10)
Working with the therapeutic team disrupted daily life and routines
41.4% (12 of 29)
Do Not Agree (11)
The benefits of involvement in the BAC outweighed the sacrifices
58.6% (17 of 29)
Strongly Agree (15)
Bedside Manner of Service Providers
The therapeutic team was respectful of family and cultural needs and preferences
100% (29 of 29)
Strongly Agree (23)
The therapeutic team addressed all problems promptly
96.6% (28 of 29)
Strongly Agree (15)
BAC Outcomes
Maintenance
After…the BAC, challenging behavior returned
51.7% (15 of 29)
After…the BAC, I stopped using the intervention but later returned to it
20.7% (6 of 29)
Do you or someone else still use the intervention?
86.2% (25 of 29)
In the home
82.8% (24 of 29)
In school
31% (9 of 29)
In therapy
13.8% (4 of 29)
In the community
27.6% (8 of 29)
Doctor appointments
3.4% (1 of 29)
Why?
It works and is still needed
56.6% (17 of 29)
Somewhat Agree (7)
Mostly Agree (7)
The child likes it
48.3% (14 of 29)
Slightly Agree (9)
I like it
51.7% (15 of 29)
Somewhat Agree (9)
Other
13.8% (4 of 29)
NR (22)
Why Not?
It worked and is no longer needed
13.8% (4 of 29)
NR (17)
It was not useful
3.4% (1 of 29)
NR (19)
It was too difficult to implement
10.3% (3 of 29)
NR (19)
It was too time consuming to implement
13.8% (4 of 29)
NR (19)

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Other
17.2% (5 of 29)
NR (23)
Overall Impact and Satisfaction
Working with the therapeutic team decreased the child's challenging behavior
79.3% (23 of 29)
Somewhat Agree (8)
Mostly Agree (8)
Working with the therapeutic team increased the child's appropriate behavior
86.2% (25 of 29)
Mostly Agree (13)
I thought the team … had a positive impact on the child
100% (29 of 29)
Strongly Agree (19)
I had an overall positive reaction to my experience with the BAC
100% (29 of 29)
Strongly Agree (20)
The BAC increased my desire for additional related services for my child
86.2% (25 of 29)
Strongly Agree (13)
I am very satisfied with the child's BAC experience
93.1% (27 of 29)
Strongly Agree (16)
Note: Agreement scales were five points and entailed 1 = Do not agree or not at all; 2 = Slightly agree; 3 = Somewhat agree; 4 =
Mostly agree; 5 = Strongly or completely agree. Percentages depict the spectrum of responses determined by researchers to reflect a
meaningful degree of agreement with the survey prompt. Importantly, we did not consider scale-value 2 (slightly agree) to be a
meaningful degree of agreement. CB = challenging behavior; NR = No response

Table 3
Outcomes Comparison (BAC 4 & BAC 7)
Child Demographics
Treatment Plan
Child Outcomes
BAC
Respondent Report
Age
Sex
IDEA
Com
CB
F
Teaching Mechanisms
% Reduction
Prevalence
Intensity
Location
RE
EO
Pre
Post
Pre
Post
Pre
Post
BAC
4
4
M
ASD
1
PA
E
T
DRA + Ext (F Sr)
Multiple Schedule + leaning
100%
69%
28
33
28
32
12
20
BAC
7
7
F
ASD
ED
4
PA
VA
PD
E
NCR
DRA + Ext (F +Arbitrary Sr)
Chained schedules + leaning
Levels desc (F-based SP)
Levels asc (MRDRO, comply, mand)
100%
100%
31
6
37
3
16
1
BAC
22
11
M
ASD
OHI
4
PA
PD
SIB
DRA + Ext
Chained schedules + leaning
Levels desc (F-based SP)
Levels asc (MRDRO, FCT [A, T, E])
Multiple Schedules
F-based NCR
DRO (Arbitrary Sr)
-Visual Schedules
-Choice Board
-Self-Monitoring Token System
97%
100%
31
10
36
14
16
6
Open-Ended Feedback (Prompt 2: How would you describe your overall experience participating in the BAC?)
BAC
4
I'm sad to say, but it was just another empty therapy for us overall. Not for lack of skills by the therapists, nor work at home.
(Client’s name) is very severely impacted by autism and has continually regressed since age two. He currently resides in a crisis
home at age 10.
BAC
7
I cannot say how much BAC changed our lives. I will never forget how much they helped with my child and myself. I was a
prisoner in my own home and was not able to live and neither was my child. The progress and change my daughter has made is
shocking. My daughter is now in school and able to learn. We are able to go on trips eat out and enjoy life. She is now able to
have a relationship with her brother and you would never have dreamed the child in the video is her today. I hate to think where
we would be today if I had not allowed BAC in my home and worked with them.

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BAC
22
I think that the team was fabulous and compassionate and I appreciate the help and support during an unbelievably challenging
time very much. Some of my borderline answers are more based on the fact that I feel like a lot of his behaviors may have been
somewhat out of his control due to brain inflammation/PANDAS (diagnosed by [Dr. Name] that summer)- we are still trying to
piece together this puzzle and some ongoing check-ins interventions refreshers would be great if possible.
Note: Teaching mechanisms referred to in this table are described in depth in Lambert, Copeland et al. (2022 [here]). IDEA =
Disability eligibility category; ED = emotional disturbance; OHI; Other Health Impairment; Com = communication; 1 = no expressive
communication; 4 = full fluency; CB = challenging behavior; PA = physical aggression; VA = verbal aggression; PD = property
destruction; SIB = self-injurious behavior; F = function; E = escape; T = tangible; Sr = reinforcement; desc = descension; asc =
ascension; MRDRO = momentary resetting differential reinforcement of other behavior; RE = Aggregate performance during final
three sessions/trials of the response elimination condition; EO = Aggregate performance during final three sessions/trials of the EO
tolerance training condition; Pre = composite scores reflecting prevalence, intensity, and location of various manifestations of
challenging behavior prior to BAC services; Post = composite scores reflecting prevalence, intensity, and location of various
manifestations of challenging behavior after BAC services.

Figure 1
Composite scores for before and after reports of the prevalence, intensity, and location of
challenging behavior, as well as access to inclusive environments
Note: Data reported by mothers from highlighted case studies (i.e., BAC 4, BAC 7, BAC 22) are
distinguished to facilitate comparisons. CB = Challenging behavior; ns = not statistically
significant
0
5
10
15
20
25
30
35
40
M = 23.03
M = 15.10
t (28) = 5.44, p < .001
Before BAC After BAC
0
5
10
15
20
M = 12.17
M = 6.87
t (28) = 5.23, p < .001
M = 23.45
M = 15.21
t (28) = 5.03, p < .001
Before BAC After BAC
M =10.52 M = 11.07
t (28) = -.60, ns
Composite Score (By Case)
Time Period Considered
CB Prevalence CB Intensity
CB Location Access to Inclusive Environments
(Undesirable)
(Desirable)
(Undesirable)
(Desirable)
(Undesirable)
(Desirable) (Undesirable)
(Desirable)
BAC 4
BAC 7
BAC 22