Level 1 Research: Where the Rubber Meets the Road in the Treatment of Serious Mental and Physical Health Problems.

Level 1 Research: Where the Rubber Meets the Road in the Treatment of Serious Mental and Physical Health Problems. Abstract Level 1 research (Hawkins & Matthews, 1999, is an underutilizedstrategy for monitoring clinical cases, demonstrating accountability inapplied settings, and maximizing applied clinicians' effectivenessin the delivery of psychological service. Two single-case examples arepresented using Level 1 research to guide the clinician clinician/cli��ni��cian/ (kli-nish��in) an expert clinical physician and teacher. cli��ni��ciann. (s) to sociallyacceptable resolution of problems. The first case is a 14-year-old girlin an out-of-home care setting who presented seriously escalateddisruptive behavior, including assault. She had an extensive history ofsexual and physical abuse and a diagnosis of borderline personalitydisorder bor��der��line personality disordern.A personality disorder marked by a long-standing pattern of instability in interpersonal relationships, behavior, mood, and self-image that can interfere with social or occupational functioning or cause extreme . Moreover, she was a candidate for an extensive series ofcranial cranial/cra��ni��al/ (-al)1. pertaining to the cranium.2. toward the head end of the body; a synonym of superior in humans and other bipeds.cra��ni��aladj. facial surgeries for a badly repaired cleft palate cleft palate,incomplete fusion of bones of the palate. The cleft may be confined to the soft palate at the back of the mouth; it may include the hard palate, or roof of the mouth; or it may extend through the gum and lip, producing a gap in the teeth and a cleft . However,without emotional and behavioral stability the cranial facial team wouldnot operate. Level 1 research strategies were used to modify a tokeneconomy Noun 1. token economy - a form of behavior therapy that has been used in some mental institutions; patients are rewarded with tokens for appropriate behavior and the tokens may be cashed in for valued rewards , monitor and teach treatment fidelity, identify setting events,monitor effects of medication and intensive psychot herapy, andultimately as evidence for behavioral and emotional stability. Thesecond case is a 12-year-old boy with escalating nocturnal enuresis nocturnal enuresisn.See bed-wetting.Nocturnal enuresisInvoluntary discharge of urine during the night.Mentioned in: Bed-Wettingnocturnal enuresisMedtalk Bed-wetting, see there wholived in a residential care setting. Ongoing Level 1 data (including anenuresis enuresisRepeated urination into bedding or clothing, usually at night, in a normal child old enough to have completed toilet training. Enuresis may be voluntary or involuntary. It may run in families. item) were already being easily and efficiently collectedthrough the use of a 28-item behavioral problems checklist (Parent DailyReport; Chamberlain & Reid, 1987). Interventionists used the chartedbedwetting item for descriptive analyses and to monitor interventions. It is commonly known, but rarely reflected on, that there is no apriori a prioriIn epistemology, knowledge that is independent of all particular experiences, as opposed to a posteriori (or empirical) knowledge, which derives from experience. way to know if a given clinical intervention will work on anindividual case. Two impediments IMPEDIMENTS, contracts. Legal objections to the making of a contract. Impediments which relate to the person are those of minority, want of reason, coverture, and the like; they are sometimes called disabilities. Vide Incapacity. 2. to judging whether an intervention willwork are limits to generalization gen��er��al��i��za��tionn.1. The act or an instance of generalizing.2. A principle, a statement, or an idea having general application. and measurement of effects usingglobal reports. For example, even if a given intervention is known to beinvolved in clinical improvement by group studies or single casestudies, there are limits to the generalization of the conclusions ofboth types of studies; and when global reports are used as measures ofimprovement approximately two thirds of clients or parents will indicatethat there are significant improvements m problem behaviors when in factthere are not (Patterson, 1982). Unfortunately, even though these factsare fairly well known to researchers and clinicians, very littleprogress has been made in reducing reliance on global reports in theassessment of treatment outcome. Level 1 research (Hawkins &Matthews, 1999) is an underutilized strategy for monitori ng clinicalcases, demonstrating accountability in applied settings, and efficientlyimproving the assessment of treatment outcome over that provided byglobal reports. Although clinical researchers, therapists, and otherinterventionists face some daunting daunt?tr.v. daunt��ed, daunt��ing, dauntsTo abate the courage of; discourage. See Synonyms at dismay.[Middle English daunten, from Old French danter, from Latin obstacles in trying to ascertainclinical change on an individual basis when working in applied settings,measurement systems can be developed that employ frequent measurementand provide the interventionist and client with information that is lessresponsive to biases than the typical "how did things go thisweek?" This paper presents two case examples of the use of Level 1research techniques to monitor and improve the delivery of clinicalservices. Case# 1 Susan was a 14-year-old girl living in a Specialized TreatmentProgram (Moore, Osgood, Larzelere, & Chamberlain, 1994) group homethat was using a Teaching-Family (Daly, Coughlin, & Baron, 1984;Father Flanagan's Boys' Home, 1986; Phillips, 1968; Phillips,Phillips, Fixen, & Wolf, 1974) model of care. She had developed veryescalated and severe disruptive behavior, including assault. Inaddition, Susan had a severe cleft palate that had been badly repairedand caused her continuous grief. Her speech and appearance wereaffected, and she did not like how she looked or sounded. She had anofficial psychiatric diagnosis of borderline personality disorder andborderline borderline/bor��der��line/ (-lin) of a phenomenon, straddling the dividing line between two categories. borderlineintellectual ability. Her personal history included repeatedand severe sexual abuse and exploitation, neglect, and abandonment. Theintervention to be described was important for two reasons; due to herassaultive as��saul��tive?adj.Inclined to or suggestive of violent attack: "The reduction of cinema to assaultive images ... has produced a disincarnated, lightweight cinema that doesn't demand anyone's full attention"behavior she was in jeopardy of losing her placement in theprogram and experiencing another disruption, and she needed a series ofc ranial facial surgeries to better repair her cleft and improve herappearance. The cranial facial surgeons would not operate on her unlessher behavior and emotions stabilized and they were sure that she wouldfollow post-operative procedures. She also had to be able to toleratefour or five different surgical procedures Surgical procedures have long and possibly daunting names. The meaning of many surgical procedure names can often be understood if the name is broken into parts. For example in splenectomy, "ectomy" is a suffix meaning the removal of a part of the body. "Splene-" means spleen. over five or six months,including having her jaw wired shut for a few weeks. Method, Treatment, and Results Initial Assessment Because of her many problems, initial attempts to changeSusan's behavior using the point and level token economy already inplace in this setting were not successful. Our judgment was that thetoken reinforcers were too abstract, not immediate enough, and thereforenot very reinforcing. The surrogate surrogaten. 1) a person acting on behalf of another or a substitute, including a woman who gives birth to a baby of a mother who is unable to carry the child. 2) a judge in some states (notably New York) responsible only for probates, estates, and adoptions. parents in the group home wereextensively trained in the implementation of the point and level tokeneconomy and had four years of experience working with adolescents usingthis system, but they did not really understand the concept ofreinforcement. They specifically stated that they preferred to use thepunishment routines embedded Inserted into. See embedded system. in the point and level system and believedthat it was these negative consequences that best changed behavior insevere cases; however it is more likely that they resorted to the use ofthese punishment routines when the initial treatment failed for thereasons described above. Initial Treatment and Assessment Procedures Data collection. Because of the high frequency and intensity ofbehavior we did not collect a no-treatment baseline, as is often thecase in applied settings. So, data collection began in conjunction withour initial intervention. We made a tracking form for collecting data onSusan's out-of-control tantrums or "fits," includingtheir frequency, intensity, and duration, with space for comments onsetting events (see Figure 1). The five point "intensity"scale was developed in collaboration with the surrogate parents andrepresented levels of behavior that were out of adult control: passive,sarcastic sar��cas��tic?adj.1. Expressing or marked by sarcasm.2. Given to using sarcasm.[sarc(asm) + -astic, as in enthusiastic. verbiage verbiage - When the context involves a software or hardware system, this refers to documentation. This term borrows the connotations of mainstream "verbiage" to suggest that the documentation is of marginal utility and that the motives behind its production have little to do with , swearing/yelling, throwing things, and physicalassault. Passive out-of-control meant that she would not follow anyadult instructions and/or compliance requests. Initial token phase. At the same time, we changed to a lesscomplex, more concrete system that used a poker-chip-like token. Thesurrogate parents doubted that this new program would work and stated apreference for the use of higher amplitude amplitude(ăm`plĭtd'), in physics, maximum displacement from a zero value or rest position. punishment, but we told theparents that before an increase in punishment could be considered weneeded to be sure that appropriate reinforcement procedures would notwork. During the ten days of this token system treatment the surrogateparents used the charts to point out that "the new program does notwork." The "initial token" phase data in Figure 2 showthe number of hours out-of-control incidents lasted each day, while the"initial token" data in Figure 3 show the intensity of eachout-of-control incident each day. As the data show, Susan could cuss,scream, and throw things for hours; and during two of these episodes,assaulted the surrogate mother surrogate mother,a woman who agrees, usually by contract and for a fee, to bear a child for a couple who are childless because the wife is infertile or physically incapable of carrying a developing fetus. . During this phase she had anout-of-control incident on seven of the 10 days, with a mean duration of2.7 hours, a mean intensity of 3.7, and never more than one day betweenincidents. A verbal review of how the parents were using the new token systemsuggested that the tokens were not used very often. Our directobservation confirmed this; Susan only received three tokens in a sixhour period. The parents again wanted more severe punishment (probablydue to the seriousness of the physical assaults), and administrativestaff questioned the feasibility of maintaining this youth in aresidential setting. However, the treatment team insisted that the rateof reinforcement In behaviorism, rate of reinforcement is number of reinforcements per time, usually per minute. Symbol of this rate is usually Rf. Its first major exponent was B. F. Skinner (1939). It is used in the Matching Law. be increased before anything else was done, and parentswere instructed to give her a minimum of 8-14 chips an hour for anythingshe did that was positive or pro-social, and if they had to, to startmaking-up reasons to give her chips. Increased token delivery. The results of this intervention, seen inFigures 2 and 3, demonstrate a significant reduction in herout-of-control behavior. For example, only 36% of the days during thisphase had an out-of-control incident, the mean duration was reduced to1.42 hours, the mean intensity was reduced to three, and as many as fivedays passed between incidents. Moreover, an inquiry into the two mostintense days of out-of-control behavior found that an assistant to theparents was alone with the youth all day and did not use the new system.Thus, the effects of this intervention may have been even greater if notfor this treatment fidelity problem. Even though we were able to obtaina marked reduction in the frequency, duration, and intensity of herbehavioral outbursts, her behavior was still not in a range that couldbe maintained for a long period of time in a family setting. Further Treatment Modifications and Results We decided to try adding a trial of Lithium lithium(lĭth`ēəm)[Gr.,=stone], metallic chemical element; symbol Li; at. no. 3; at. wt. 6.941; m.p. about 180.54°C;; b.p. about 1,342°C;; sp. gr. .534 at 20°C;; valence +1. Lithium is a soft, silver-white metal. and intensivepsychotherapy psychotherapy,treatment of mental and emotional disorders using psychological methods. Psychotherapy, thus, does not include physiological interventions, such as drug therapy or electroconvulsive therapy, although it may be used in combination with such methods. along with continued use of the tokens. The psychotherapywas provided by a private practice Ph.D. level psychologist and occurredtwice per week for one to two hours. This therapy focused onSusan's history of physical and severe sexual abuse, herabandonment by biological and adoptive parents adoptive parentsSocial medicine Persons who lawfully adopt children, who are generally married couples but may be single persons, including homosexuals; most APs are married , the impact of thesetraumas on her current relationships, the relationship of these traumasto her difficulty modulating her behavior and emotions, her continuingto place herself at risk of sexual and physical exploitation in oppositesex relationships, and the importance of behavioral stability so thatshe could have the cranial facial surgery she wanted and needed. Duringthis and the following phase, we manipulated the levels of her Lithiumseveral times and ultimately reduced the dosage dosage/dos��age/ (do��saj) the determination and regulation of the size, frequency, and number of doses. dos��agen.1. Administration of a therapeutic agent in prescribed amounts. . The days without-of-control behavior were further reduced to 26%, with a meanduration of 1.5 hours and a mean intensity of 2.8, with as many as 11days be tween tween?n.A child between middle childhood and adolesence, usually between 8 and 12 years old.[Blend of teen1 and between.] incidents. In addition, use of the ongoing graphing helped staff begin tonotice a pattern of out-of-control incidents around her menstruation menstruation,periodic flow of blood and cells from the lining of the uterus in humans and most other primates, occurring about every 28 days in women. Menstruation commences at puberty (usually between age 10 and 17). . Wethen developed a soft intervention of warm support and loweredexpectations immediately before and during her periods. The warm supportconsisted of increased and planned "special" one-on-one timewith the surrogate mother that included specific help and instructionwith self nurturing (e.g., mineral baths, facials, warm tea speciallyformulated for women, etc.). But perhaps more important, it appearedthat the parents' awareness that this pattern was correlated withher period and would only last a few days made it easier for them todeal with her outbursts more gently and effectively. During this phaseher out-of-control incidents were reduced to 19% of days, a meanduration of 1.5, and a mean intensity of 2.3; with as many as 30 daysbetween episodes. Moreover, during this phase the psychologist stated that Susan hadmade sufficient progress in psychotherapy and in her responses to dailyliving that there was not sufficient reason for ongoing psychotherapyand this part of treatment was terminated. In addition, medication wasreduced, and her overall progress and graphs were used to convince thecranial facial team that she was now an appropriate candidate forsurgery. Discussion During these interventions, Susan completed the series of surgeries(which greatly improved her appearance and speech), tolerated a periodof long-term psychotherapy focusing on her trauma and abuse, andincreased her achievement in school. The daily logs and the graphs werevery useful in encouraging the parents and other staff to followtreatment directives, helping the parents better learn positiveapproaches to behavior change Behavior change refers to any transformation or modification of human behavior. Such changes can occur intentionally, through behavior modification, without intention, or change rapidly in situations of mental illness. , deepening their understand ofreinforcement, evaluating medication trials, and convincing a team ofsurgeons that Susan could tolerate a series of extensive surgicalprocedures. In addition, the surrogate parents who collected the datapresented here, learned about collecting simple but powerful data,including frequency, duration, and intensity. It should also be noted that the graphing procedures used duringSusan's interventions were ongoing and included such things astreatment aims and other aspects that for clarity are not included inthe figures presented here. For example, we put medication trials andlevels in our ongoing graphs, as well as other psycho-social (i.e.,contextual) events, due to their possible functional relationship to heroutbursts. These details from our "working graphs" are omittedhere for simplicity of presentation. A visual analysis of the graphs may suggest that the medication andpsychotherapy interventions did not increase the treatment gains overthose already being obtained by the increased token intervention. Thatis, there appears to be an ongoing reduction in frequency, duration, andintensity of Susan's behavior with the increased token interventionand the further reductions during the use of lithium and psychotherapymay have occurred without the addition of these interventions.Additionally, there was not an increase in problem behavior when themedication was eventually eliminated. However, it was the distinctclinical impression of all persons involved in the care of Susan thatthe medication and psychotherapy interventions were helpful,particularly on behaviors not directly captured by the data collectionform but that were related in multidimensional mul��ti��di��men��sion��al?adj.Of, relating to, or having several dimensions.multi��di��men ways to the levels andfrequency of behaviors documented by the graphs. For example, we noticed a positive impact of these additionalinterventions on Susan's daily levels of irritability irritability/ir��ri��ta��bil��i��ty/ (ir?i-tah-bil��i-te) the quality of being irritable.myotatic irritability? the ability of a muscle to contract in response to stretching. , her abilityto tolerate interpersonal conflict and stress, her attention,concentration, and memory, her ability to tolerate and learn fromteaching interactions, her sleep patterns, and her behavior andachievement in school. Further, an alternative reason that there was noincrease in problem behavior after medication was eliminated from hertreatment was that she had learned skills and behavioral routines thatwere more pro-social and adaptive than her previous routines. It wasalso our impression that medication and psychotherapy had an interactiveand synergistic effect Synergistic effectA violation of value-additivity in that the value of a combination is greater than the sum of the individual values. with each other and with the token intervention,thus making it possible for her to be "available" and betterable to participate in learning trials and to become firm in the use ofher new behavior routines under multiple stimulus conditions andcontexts. Thus, the use of Level 1 research strategies have thepotential to increase the quality of information and the clinicaldecisions that the interventionists make, but that data generated fromLevel 1 approaches may not be the only information or strategy used tomake important treatment decisions. Case# 2 Background David was David Was (born David Weiss, 26 October 1952, Detroit) is, with his stage-brother Don Was, the founder of the influential 1980s pop group, Was (Not Was).Reviewed by The New York Times a 12-year-old boy who had serious emotional andbehavioral problems as a result of a severe history of unpredictable andnoncontingent physical abuse from a biological father. Immediatelybefore his placement in the setting where this intervention took place--Father Flanagan's Boys' Home (Boys Town), Nebraska-- he hadbeen placed and discharged as unsuccessful from three hospitals inTexas. Moreover, his mother reported that he had exhausted the entirestate hospital system and that he was refused any further state hospitaltreatment in the state of Texas. He was able to obtain placement in ourtreatment setting only because he had a relative who worked there. Inour setting, a large residential group home facility, David wasoriginally placed in a regular group home (8-10 other youth) where hequickly exhausted the resources and was extremely disruptive to thetreatment being provided to the other youths. He was hospitalized atleast twice for suicidal su��i��cid��aladj.1. Of or relating to suicide.2. Likely to attempt suicide. and out-of-control behavior. The psychiatricdiagnoses included, Fetal Alcohol Syndrome fetal alcohol syndrome(FAS), pattern of physical, developmental, and psychological abnormalities seen in babies born to mothers who consumed alcohol during pregnancy. , possible Fragile X Syndrome Fragile X SyndromeDefinitionFragile X syndrome is the most common form of inherited mental retardation. Individuals with this condition have developmental delay, variable levels of mental retardation, and behavioral and emotional difficulties. ,Complex Post-traumatic Stress Syndrome, and, our favorite, "he hasa funny brain." Genetic workups were all negative. Localpsychiatrists indicated that they did not want to work with this youth,and they questioned why he was in a treatment home rather than returnedto his mother and whatever level of care the state of Texas could offer. After his second hospitalization hospitalization/hos��pi��tal��iza��tion/ (hos?pi-t'l-i-za��shun)1. the placing of a patient in a hospital for treatment.2. the term of confinement in a hospital. he was moved to a specializedtreatment program on campus where the number of other youths in a homewas reduced to 3-4 and staff was specially trained. He then experiencedanother hospitalization. His biological mother indicated she was veryfearful of his being returned to her care and believed he wouldultimately be placed back in a state hospital where he had not done welland would get worse. Therefore, it was decided to conduct a majormedication trial in the treatment home to reduce his out-of-control andextremely disruptive behavior. The focus on this report will be on a side effect of the medicationtrial, which was his escalating nocturnal enuresis. Method, Treatment, and Results Initial Assessment Ongoing Level 1 data (including an enuresis item) were alreadybeing easily and efficiently collected through the use of a 28-itembehavioral problems checklist (Parent Daily Report or PDR PDRA trademark for Physicians' Desk Reference, a group of reference books containing drug listings, especially one for prescription drugs.PDR; Chamberlain& Reid, 1987). Data from the bedwetting item of this ongoing datacollection were graphed. The graphed bedwetting data were then used fordescriptive analyses (Lerman & Iwata, 1993) of the escalatingnocturnal enuresis. From October 17, 1990, through March 16, 1991, Davidhad periodic incidents of nocturnal enuresis (see Figure 4). During thisperiod and along with his other difficulties, he was treated twice by aurologist UrologistA physician who deals with the study and treatment of disorders of the urinary tract in women and the urogenital system in men.Mentioned in: Congenital Bladder Anomalies, Lithotripsy, Men's Health, Overactive Bladderurologist with medications for this problem. The implementation and theeffects of the enuresis medication interventions were not tracked, butthe surrogate parents did not think they were effective and thesemedications had not been used since December. On or about March 17, thesurrogate parents began to notice a more consistent and frequent patternin bedwetting. This behavior initially occurred a pproximately everyother night; however, it soon became a nightly occurrence. In an attempt to help with this difficulty, the surrogate parentsand a behavioral consultant began a descriptive analysis of theclient's psychosocial psychosocial/psy��cho��so��cial/ (si?ko-so��shul) pertaining to or involving both psychic and social aspects. psy��cho��so��cialadj.Involving aspects of both social and psychological behavior. environment in an attempt to determineanything that may have been contributing to the bedwetting. The firstpossibility was the client's medication, which had been increasedon February 12, when he began taking 300 mg of Lithium three times perday, and on March 6, when this Mellaril dosage increased by 50 mg perday. The surrogate parents and the consultant thought this medicationincrease could have something to do with the increase in bedwettingbehavior; but they also thought that something else could becontributing to this situation (e.g., "he likes to pee peeVox populi Micturate, urinate thebed," "he is too lazy to get up," "he drinks toomuch before bedtime bedtimeSleep disorders The time when one attempts to fall asleep–as distinguished from the time when one gets into bed "). However, a typical bedwetting interventionplan was implemented. Restricted Liquids Treatment The surrogate parents began to monitor the client's liquidintake up to two hours before his bedtime and made sure he used therestroom before going to bed. They continued this for approximately twoweeks; but the PDR data showed that it had no favorable fa��vor��a��ble?adj.1. Advantageous; helpful: favorable winds.2. Encouraging; propitious: a favorable diagnosis.3. effect on theboy's bedwetting and may have been detrimental. Nighttime Waking Treatment On April 3, the consultant and surrogate parents decided that thenext plan would be to wake up David after he had been asleepapproximately 3.5 to 4 hours and allow him to use the restroom. Theclient's surrogate father and the in-home assistant implementedthis treatment plan nightly, and as can be seen in Figure 4 it wasextremely successful. Further Treatment Modifications and Results After almost three months of no bedwetting David again had fiveincidents of bedwetting. As fate would have it "As Fate Would Have It" is an episode of the science fiction television series The 4400. SynopsisNTAC offers Jordan Collier protection when Maia has a morbid premonition. , and unknown to theconsultant, during this period the urologist was conducting a follow-upassessment on David's bedwetting problem. The surrogate parentsmentioned to the urologist the relapse in bedwetting behavior, but theydid not mention that there was an out-of-order bathroom or that therehad been a previous successful intervention. The urologist wanted toexplore the client's bladder to see if there was a structuralreason for the bedwetting. Before this exploratory surgery Exploratory surgery is a diagnostic method used by doctors when trying to find a diagnosis for an ailment. It can be performed in both humans and animals, but it is far more common in animals. , staff askedpermission to conduct another descriptive analysis in an attempt tofigure out what was contributing to this recurrence recurrence/re��cur��rence/ (-ker��ens) the return of symptoms after a remission.recur��rent re��cur��rencen.1. and to avoid havingDavid go through an invasive and potentially painful medical procedure. The analysis revealed that the relapse in bedwetting behavior wasoccurring during a time when the upstairs bathroom was being remodeledand was out of order. Therefore, David had to use a restroom in the coldand mostly dark basement. The surrogate parents also reported that,after they got him up, they did not always monitor him closely to besure that he used the restroom. Further analysis suggested that Davidmay David May may refer to: David May (computer scientist), a British Computer Scientist. David May (footballer), a retired English footballer. have been up and in the restroom, but in such a daze, that he maynot have actually voided void��ed?adj. HeraldryHaving the central area cut out or left vacant, leaving an outline or narrow border: a voided lozenge.his bladder. After discussing the new analysis of David's behavior, thesurrogate parents monitored him closely; making sure that he actuallydid void his bladder while in the bathroom, and, as can be seen inFigure 4, at that point the client's bedwetting behavior againended. After the urologist was informed of the out-of-order bathroom,the analyses, and the successful interventions, he indicated that he nolonger believed the medical procedure was necessary. Discussion This is an example of how PDR can be used as Level 1 research tomonitor and develop clinical interventions. The PDR itself is easy touse; once parents get use to the items, it generally takes less thanfive minutes to fill out and phone the data in to a receptionist oranswering machine. The data can be graphed daily and/or entered into acomputer (e.g., spreadsheets, statistical packages, databases) forgraphing. We believe data collection and descriptive analysis saved thisyouth, who had already had a very traumatic life, from an unnecessaryand invasive medical procedure. As is sometimes the case with youths who have serious behavioralexcesses across settings and people, as David and Susan did, thoseinvolved with the youth were distracted by the level and intensity ofbehaviors and drifted toward mentalistic men��tal��ism?n.1. Parapsychological activities, such as telepathy and mind reading.2. The belief that some mental phenomena cannot be explained by physical laws. constructs in their attempts toexplain the behavior problems. When problem behavior is embedded withinother serious behavioral and emotional problems, the use of Level 1 dataand graphing procedures helps to block this natural drift toward the useof mentalistic constructs and less-effective, often punitiveinterventions. It is also our experience that the graphs are reinforcingto the interventionists and motivate personnel and parents to be morecreative in developing and "tinkering tin��ker?n.1. A traveling mender of metal household utensils.2. Chiefly British A member of any of various traditionally itinerant groups of people living especially in Scotland and Ireland; a traveler.3. " (Baer, 1977) withsolutions for problematic behaviors. In summary, the clinical case studies presented here suggest thatLevel 1 research strategies have significant potential to help improvethe delivery of clinical services to a wide range of troubled andtroubling human behaviors at minimum cost (financial or otherwise). Whatseems needed at this point is research evaluating the use of Level 1research techniques by direct manipulation of them as independentvariables. Additional stages in the development of these strategiesshould include the development and dissemination disseminationMedtalk The spread of a pernicious process–eg, CA, acute infection Oncology Metastasis, see there of monitoring tools(e.g., PDR, Biofeedback biofeedback,method for learning to increase one's ability to control biological responses, such as blood pressure, muscle tension, and heart rate. Sophisticated instruments are often used to measure physiological responses and make them apparent to the patient, who protocols) that are efficient and costeffective, teaching Level 1 strategies in pre-service and in-servicetrainings, and including Level 1 clinical practices in discussions andpresentations of "best practices." References Baer, D. M. (1977). Perhaps it would be better not to knoweverything. Journal of Applied Behavior Analysis The Journal of Applied Behavior Analysis (JABA) was established in 1968 as a The Journal of Applied Behavior Analysis is a peer-reviewed, psychology journal, that publishes research about applications of the experimental analysis of behavior to problems of social importance. , 20, 167-172. Chamberlain, P. & Reid, J. R. (1987). Parent observation andreport of child symptoms. Behavioral Assessment., 9, 97-109. Daly, D. L., Coughlin, D. D., & Baron, R. L. (1984). TheBoys' Town Family Home Program. In Speaking for Children (Vol. 3,pp. 3-27). Lincoln, NB: The Junior League of Nebraska. Father Flanagan's Boys' Home. (1986). Boys' TownFamily Home Program Training Manual. Boys' Town, NE: Author. Hawkins, R. P., & Mathews, J. R. (1999). Frequent monitoring ofclinical outcomes: Research and accountability for clinical practice.Education and Treatment of Children, 22, 2, 117-135. Lerman, D. C., & Iwata, B. A. (1993). Descriptive andexperimental analyses of variables maintaining self-injurious behavior.Journal of Applied Behavior Analysis, 26, 293-319. Moore, K. J., Osgood, D. W., Larzelere, R. E., & Chamberlain,p. (1994). Use of pooled time series in the study of naturally occurringclinical events and problem behavior in a foster care setting. Journalof Consulting and Clinical Psychology The Journal of Consulting and Clinical Psychology (JCCP) is a bimonthly psychology journal of the American Psychological Association. Its focus is on treatment and prevention in all areas of clinical and clinical-health psychology and especially on topics that appeal to a broad , 62, 718-728. Patterson, C. R. (1982). Coercive co��er��cive?adj.Characterized by or inclined to coercion.co��ercive��ly adv. family process: A social learningapproach. Eugene, OR: Castalia Publishing Company. Phillips, E. L. (1968). Achievement Place: Token reinforcementprocedures in a homestyle rehabilitation rehabilitation:see physical therapy. setting for"predelinquent" boys. Journal of Applied Behavior Analysis, 1,213-223. Phillips, E. L., Phillips, E. A., Fixen, D. L., & Wolf, M. M.(1974). The Teaching family handbook. Lawrence: The University of Kansas The University of Kansas (often referred to as KU or just Kansas) is an institution of higher learning in Lawrence, Kansas. The main campus resides atop Mount Oread. Printing Service. [Graph omitted] [Graph omitted]