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Caregiver Telehealth Training on Antecedent Strategies to Increase Children's Instruction Following in the Home

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Title: Caregiver Telehealth Training on Antecedent Strategies to Increase Children's Instruction Following in the Home
Language: English
Authors: Hunter C. King (ORCID 0000-0002-8877-7214), Aaron J. Fischer, Daniel D. Houalihan, John L. Davis, Keith C. Radley III, William R. Jenson
Source: Journal of Behavioral Education. 2025 34(1):26-52.
Availability: Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
Peer Reviewed: Y
Page Count: 27
Publication Date: 2025
Document Type: Journal Articles
Reports - Research
Descriptors: Child Caregivers, Caregiver Training, Telecommunications, Videoconferencing, Caregiver Child Relationship, Home Study, Home Instruction, Instructional Effectiveness
DOI: 10.1007/s10864-023-09528-2
ISSN: 1053-0819
1573-3513
Abstract: In two studies, three caregivers of neurotypical children were trained via telehealth to deliver two antecedent strategies to increase instruction following in the home. Dependent measures included initiation latency and task completion with high- and low-probability instructions. In Study 1, a modified pretrial delivery procedure was evaluated in which caregivers jointly engaged with their child in a moderately preferred activity prior to the issuance of a predetermined instruction. Results showed that initiation latencies for low-p instructions trended downward for two of three children, while latencies for high-p instructions remained low and stable for two of three children. In Study 2, the three low-p instructions with the highest initiation latencies in Study 1 were further targeted with the high-probability instructional sequence. Using a multiple baseline across behaviors design, results showed decreased initiation latencies and increased levels of task completion for all three children. The results of both evaluations are discussed and practical issues are considered for future research on the use of technology to support caregiver's delivery of instruction-following programs in homes.
Abstractor: As Provided
Entry Date: 2025
Accession Number: EJ1485356
Database: ERIC
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  Value: <anid>AN0184231747;41z01mar.25;2025Apr07.04:59;v2.2.500</anid> <title id="AN0184231747-1">Caregiver Telehealth Training on Antecedent Strategies to Increase Children's Instruction Following in the Home </title> <p>In two studies, three caregivers of neurotypical children were trained via telehealth to deliver two antecedent strategies to increase instruction following in the home. Dependent measures included initiation latency and task completion with high- and low-probability instructions. In Study 1, a modified pretrial delivery procedure was evaluated in which caregivers jointly engaged with their child in a moderately preferred activity prior to the issuance of a predetermined instruction. Results showed that initiation latencies for low-p instructions trended downward for two of three children, while latencies for high-p instructions remained low and stable for two of three children. In Study 2, the three low-p instructions with the highest initiation latencies in Study 1 were further targeted with the high-probability instructional sequence. Using a multiple baseline across behaviors design, results showed decreased initiation latencies and increased levels of task completion for all three children. The results of both evaluations are discussed and practical issues are considered for future research on the use of technology to support caregiver's delivery of instruction-following programs in homes.</p> <p>Keywords: Compliance; High-probability instructional sequence; Pretrial delivery; Telehealth; Caregiver training</p> <p>Copyright comment Springer Nature or its licensor (e.g. a society or other partner) holds exclusive rights to this article under a publishing agreement with the author(s) or other rightsholder(s); author self-archiving of the accepted manuscript version of this article is solely governed by the terms of such publishing agreement and applicable law.</p> <hd id="AN0184231747-2">Introduction</hd> <p>Instruction following is often defined as a child's initiation and completion of a specific request, whereas task refusal is viewed as doing anything other than what was asked (Kalb & Loeber, [<reflink idref="bib25" id="ref1">25</reflink>]; Radley & Dart, [<reflink idref="bib44" id="ref2">44</reflink>]). While it is common for young children to express their agency through refusal early in their development, caregivers often indicate refusal in the home as a primary referral concern for treatment (McMahon & Forehand, [<reflink idref="bib37" id="ref3">37</reflink>]). In the absence of early intervention, excessive difficulties with instruction following can impede children's academic engagement, social-emotional development, and participation in organized activities (Gion et al., 2014). Fortunately, a literature base has been established supporting antecedent strategies to encourage children's instruction following (Lipschultz & Wilder, [<reflink idref="bib34" id="ref4">34</reflink>]; Radley & Dart, [<reflink idref="bib44" id="ref5">44</reflink>]). These studies refer to a class of behavioral interventions that aim to prevent challenging behavior from occurring by modifying aspects of the environment prior to its occurrence (Ducharme et al., [<reflink idref="bib14" id="ref6">14</reflink>]).</p> <p>With homes often serving as the environment in which children are initially exposed to rules and structure, caregivers are uniquely positioned to impact children's propensity for instruction following. While a large body of research and clinical data lend to the effectiveness of behavioral interventions implemented within a clinic-based model, home-based programming affords several practical advantages specific to parental involvement, generalization, and cost-effectiveness (Leaf et al., [<reflink idref="bib28" id="ref7">28</reflink>]). Equally important, prevention-focused strategies implemented within the home might be more appropriate for children who engage in mild task refusal and have greater appeal among caregivers less willing to bear the repeated occurrence of problem behavior to implement consequent strategies (Radley & Dart, [<reflink idref="bib44" id="ref8">44</reflink>]). Antecedent strategies might prove especially amendable to homes given their relatively low response effort and potential to be naturally integrated into daily interactions between caregivers and children (Bacotti et al., [<reflink idref="bib2" id="ref9">2</reflink>]).</p> <hd id="AN0184231747-3">High Probability Instructional Sequences</hd> <p>The high probability instructional sequence (HPIS; Mace et al., [<reflink idref="bib36" id="ref10">36</reflink>]) is touted as one of the most effective antecedent strategies for increasing instruction following with low-probability (low-<emph>p</emph>) instructions (Radley & Dart, [<reflink idref="bib44" id="ref11">44</reflink>]). The typical high-<emph>p</emph> sequence involves the delivery of several high-<emph>p</emph> instructions immediately before the delivery of a low-<emph>p</emph> instruction, with verbal praise delivered following successful completion of each instruction. Low-<emph>p</emph> instructions are those in which a child is less likely to follow, often measured as a percentage of compliance (e.g., ≤ 40%; Axelrod et al., 2012; Belfiore et al., [<reflink idref="bib3" id="ref12">3</reflink>]) or initiation latency (e.g., ≥ 10 s; Davis et al., [<reflink idref="bib10" id="ref13">10</reflink>]; Davis & Axe, [<reflink idref="bib9" id="ref14">9</reflink>]; Mace et al., [<reflink idref="bib36" id="ref15">36</reflink>]). In contrast, high-<emph>p</emph> instructions are associated with a higher percentage of instruction following (≥ 80%; Belfiore et al., [<reflink idref="bib3" id="ref16">3</reflink>]; Mace et al., [<reflink idref="bib36" id="ref17">36</reflink>]) and reduced initiation latencies (≤ 5 s; Rosales et al., [<reflink idref="bib49" id="ref18">49</reflink>]). The HPIS has shown to be effective in children with (Axelrod & Zank, [<reflink idref="bib1" id="ref19">1</reflink>]; Pitts & Daymond, [<reflink idref="bib43" id="ref20">43</reflink>]) and without developmental disabilities (Bullock & Normand, [<reflink idref="bib5" id="ref21">5</reflink>]; Wilder et al., [<reflink idref="bib57" id="ref22">57</reflink>]) and to produce meaningful increases in completion of academic and transition requests in school settings (Axelrod & Zank, [<reflink idref="bib1" id="ref23">1</reflink>]; Belfiore et al., [<reflink idref="bib3" id="ref24">3</reflink>]) and mealtime requests in children with food selectivity (Ewry & Fryling, [<reflink idref="bib18" id="ref25">18</reflink>]).</p> <p>While several studies demonstrated the use of coaching to promote caregivers' adherence to the HPIS under controlled conditions (Patel et al., [<reflink idref="bib40" id="ref26">40</reflink>]; Penrod et al., [<reflink idref="bib41" id="ref27">41</reflink>]; Ray et al., [<reflink idref="bib46" id="ref28">46</reflink>]), evaluations have also occurred within common living areas of homes (Ewry & Fryling, [<reflink idref="bib18" id="ref29">18</reflink>]; Humm et al., [<reflink idref="bib24" id="ref30">24</reflink>]; Smith & Lerman, [<reflink idref="bib52" id="ref31">52</reflink>]). For example, Humm et al. ([<reflink idref="bib24" id="ref32">24</reflink>]) trained three caregivers of children with developmental disabilities to deliver the HPIS and guided compliance at home using a procedural manual supplemented by brief therapist instruction. Study findings revealed increases in completion of low-<emph>p</emph> instructions for all children and that caregivers implemented both procedures with high levels of integrity. Additionally, Ewry and Fryling ([<reflink idref="bib18" id="ref33">18</reflink>]) evaluated the HPIS for addressing food selectivity in an adolescent male with autism spectrum disorder. All sessions occurred at the family's dinner table where caregivers presented three high-<emph>p</emph> bites of preferred food prior to one low-<emph>p</emph> bite of nonpreferred food. Their findings showed that acceptance of low-<emph>p</emph> bites increased (90–100%) following the implementation of the HPIS and that caregivers strongly adhered to HPIS components. Lastly, Smith and Lerman ([<reflink idref="bib52" id="ref34">52</reflink>]) trained caregivers of two children to the implement guided compliance and the HPIS in their home with high levels of treatment integrity. While guided compliance was associated with higher levels of instruction following, both strategies were found to be effective and acceptable among caregivers. While these studies add to a growing literature on the effects of the HPIS in the home, more research is needed considering given some of the noteworthy challenges (e.g., scheduling conflicts due to heightened childcare and work demands, environmental control) associated with successful implementation of behavioral strategies under natural conditions.</p> <hd id="AN0184231747-4">Pretrial Delivery</hd> <p>Importantly, scholars have questioned the necessity of a response requirement to increase instruction following, as with the HPIS. Often termed response-independent delivery of preferred stimuli (Bullock & Normand, [<reflink idref="bib5" id="ref35">5</reflink>]; Normand & Beaulieu, [<reflink idref="bib39" id="ref36">39</reflink>]) or pretrial delivery (Hodges et al., [<reflink idref="bib23" id="ref37">23</reflink>]), preferred stimuli are delivered independent of responding prior to the issuance of a low-<emph>p</emph> instruction. Currently, several variations of pretrial delivery have been systematically evaluated that vary with respect to schedules of reinforcement, reinforcer density and magnitude, and the temporal relationship between stimuli delivery and the low-<emph>p</emph> instruction. For instance, in the first evaluation of the intervention, Bullock and Normand ([<reflink idref="bib5" id="ref38">5</reflink>]) compared the differential effects of a fixed-time (FT) 10 s delivery of preferred edibles and the HPIS on instruction following with two typically developing male children. Study procedures occurred within designated areas of participants' home and sessions were delivered in blocks of trials. During pretrial delivery sessions, one edible was delivered response-independently every 10 s during a 30 s interval, the completion of which signaled the delivery of the low-<emph>p</emph> instruction. Using a multiple baseline with an embedded multielement design, findings showed each strategy resulted in comparable increases in instruction following with both participants. Extending these findings, Normand and Beaulieu ([<reflink idref="bib39" id="ref39">39</reflink>]) sought to address several limitations of Bullock and Normand's study by evaluating a FT 10 s delivery of preferred items using a reversal design independent of the HPIS. Similar findings were obtained, suggesting that a FT schedule of reinforcement effectively increased instruction following for two of three children with a developmental disability.</p> <p>In a procedural variation, Hodges et al., ([<reflink idref="bib23" id="ref40">23</reflink>]; Experiment 1) evaluated stimulus magnitude on instruction following among four children with a developmental disability in a hospital setting. In contrast to Bullock and Normand's arrangement of a FT schedule, Hodges et al. ([<reflink idref="bib23" id="ref41">23</reflink>]) alternated between the delivery of 5, 1, and zero edibles immediately prior to a low-<emph>p</emph> instruction, which occurred once every minute. Study findings showed that higher magnitude edible stimuli (i.e., 5 edibles) produced the greatest increase in instruction following with each child. In Experiment 2, Hodges et al. evaluated response-independent delivery of varying durations of preferred leisure items on instruction following with three male children in a clinic. In a counterbalanced fashion, children experienced 0 s, 30 s, and 3 min of access to a leisure item prior to a low-<emph>p</emph> instruction. In the 0 s condition, the leisure item was shown participants, but never presented. Like Experiment 1, the highest levels of instruction following were observed in the condition with the highest magnitude of stimuli (i.e., 3 min). Lastly, Lipschultz and Wilder ([<reflink idref="bib34" id="ref42">34</reflink>]) evaluated whether instruction following with three typically developing children was more sensitive to contingent or response-independent reinforcement. Findings showed that contingent reinforcement was associated with greater increases in instruction following for all participants.</p> <p>In sum, researchers have evaluated the effects of stimulus magnitude and density of reinforcement during pretrial delivery, with higher magnitude stimuli and denser, time-based schedules associated with the greatest increase in instruction following. Notwithstanding these outcomes, few evaluations of the intervention exist, suggesting that research is needed to identify the conditions underlying the effectiveness of response-independent reinforcement to increase instruction following in homes and with distinct populations. This is especially relevant to home-based programs in which caregivers are trained to implement instruction-following strategies with their children. It is possible that meaningful outcomes can be achieved with less rigorous arrangements that lend themselves to the home environments and those with potential to enhance adult–child relationship quality via joint engagement with child-directed leisure activities.</p> <hd id="AN0184231747-5">Caregiver Training on Antecedent Strategies</hd> <p>Increasing caregiver's knowledge and capacity to deliver behavioral strategies in home and clinic settings is often achieved through behavioral skills training (BST: Crane, [<reflink idref="bib8" id="ref43">8</reflink>]). Typically delivered in person, studies show that BST can effectively increase caregiver's delivery of antecedent strategies, such as guided compliance (Miles & Wilder, [<reflink idref="bib38" id="ref44">38</reflink>]), three-step prompting procedure (Drifke et al., [<reflink idref="bib13" id="ref45">13</reflink>]), and the HPIS (Humm et al., [<reflink idref="bib24" id="ref46">24</reflink>]). Notwithstanding these outcomes, several barriers to in-person training may exist for caregivers with heightened work and childcare responsibilities and those who reside in rural communities that are geographically distant from community resources (Unholz-Bowden et al., [<reflink idref="bib55" id="ref47">55</reflink>]). Researchers have increasingly focused on telehealth as a medium through which to train caregivers on behavioral strategies. For instance, a series of recent publications report on the efficacy and feasibility of telehealth for training caregivers on functional analysis (Gerow et al., [<reflink idref="bib20" id="ref48">20</reflink>]; Lerman et al., [<reflink idref="bib30" id="ref49">30</reflink>]), differential reinforcement of alternative behavior (Lindgren et al., [<reflink idref="bib33" id="ref50">33</reflink>]), and preference assessments (Dimian et al., [<reflink idref="bib11" id="ref51">11</reflink>]), and that desirable outcomes have been demonstrated in children with and without developmental and intellectual disabilities (Kunze et al., [<reflink idref="bib27" id="ref52">27</reflink>]). While not exhaustive, these studies represent an important contribution to the behavior consultation literature by increasing caregiver's access to effective treatment without the financial burden associated with transportation to and costs for receiving behavioral interventions in community settings (Lindgren et al., [<reflink idref="bib32" id="ref53">32</reflink>]).</p> <hd id="AN0184231747-6">Purpose</hd> <p>The purpose of the current study was to evaluate the feasibility of training caregivers via telehealth on pretrial delivery and the HPIS in their home and the effect of each strategy on children's instruction following. This study extends research on caregiver implementation of the HPIS in the home and serves as the first evaluation for pretrial delivery. Additionally, pretrial delivery was modified such that one session was conducted per day and reinforcement was held relatively constant in the form of ongoing caregiver-child engagement for purposes of feasibility and social validity. This modification accommodates the busy workloads of caregivers by reducing the complexity of the intervention. The current study aims to address the following research questions (RQs).</p> <p></p> <ulist> <item> RQ1: In Study 1, is there a relation between pretrial delivery and changes in high- and low-<emph>p</emph> instruction following with young neurotypical children, evidenced by a high percentage of task completion and a downward trend in initiation latency across intervention sessions?</item> <p></p> <item> RQ2: In Study 2, is there a functional relationship between the HPIS and a decrease in initiation latency and increase in completion of low-<emph>p</emph> instructions with young neurotypical children, evidenced by treatment effect across instructions?</item> <p></p> <item> RQ3: Can caregivers implement pretrial delivery and the HPIS, evidenced by high percentages of procedural integrity?</item> <p></p> <item> RQ4: Is technology a useful medium through which to train caregivers on each strategy, evidenced by high ratings of acceptability?</item> </ulist> <hd id="AN0184231747-7">Study 1</hd> <p></p> <hd id="AN0184231747-8">Participants and Setting</hd> <p>The current study received Institutional Board Approval from an affiliate university in the Mountain West region of the USA. Inclusion criteria consisted of neurotypical children who were 3–6 years of age, exhibited persistent task refusal, and had not previously received treatment for task refusal. Participants were recruited with flyers posted on two social media platforms (e.g., Facebook and Twitter) and through community-based referrals. A total of four caregivers provided consent to participate, all of whom were college educated, with one pursuing a graduate degree in a health-related discipline. One caregiver did not complete the study due to competing work demands. Thus, the final sample consisted of three caregiver-child dyads.</p> <p>Hank was a 5-year-old White male who engaged in active task refusal when engaged with technology in the form of continuing to direct his eye gaze and physical orientation to the technology and persistent vocal protest (e.g., "No", and "I don't want to"). Hank's mother conducted sessions in the living room and Hank's bedroom. Kent was a 4-year-old White male who actively refused caregiver requests in the form of questioning the purpose of his caregivers' request (e.g., "Why should I do that?) and vocal protest (e.g., "No, I don't want to"). Kent presented with anxious tendencies that typically occurred within the context of task refusal, such as screaming when he is not allowed to cloth himself in several different rooms within the household (i.e., shirt in the living room; pants in the kitchen). Kent's mother conducted sessions in their living room, bathroom, and at the kitchen table. Lastly, Geoffrey was a 3-year-old White male who actively refused caregiver instructions to clean his room, terminate preferred activities, and initiate age-appropriate educational activities. Geoffrey's refusal took the form of persistent vocal protest, screaming, and walking away after an instruction was delivered. Geoffrey's mother conducted sessions in the living room, bedroom, playroom, and kitchen. A school psychology doctoral candidate and a board-certified behavior analyst served as the consultant.</p> <hd id="AN0184231747-9">Materials and Measures</hd> <p>Procedures were conducted in two settings and through the Health Insurance Portability and Accountability Act (HIPAA;1996) compliant videoconferencing platform, Zoom Pro®. The consultant remotely trained caregivers from a 10ft by12ft residential office. Caregivers received training and delivered strategies in common areas within their residence, as previously described. The consultant used a laptop (Apple MacBook Pro Retina Display, M1, 2020) connected to an external monitor adapted with a NexiGo™ webcam (1080p; 30 FPS). Throughout the study, caregivers used either their personal laptop with an embedded webcam or a smartphone to record sessions and to receive training and ongoing consultation. Following each session, recorded videos were emailed to the consultant for data collection purposes and asynchronous performance feedback via email. All videos were stored on a HIPAA-compliant, online storage platform (i.e., Box). Each residence was equipped with a broadband wireless internet connection. All pre- and post-measures were adapted to virtual measures (i.e., Google Forms) for convenience and to preserve the telehealth nature of the current study.</p> <p>The Compliance Probability Questionnaire (CPQ; Drain, [<reflink idref="bib12" id="ref54">12</reflink>]) was used to identify a minimum of five high-<emph>p</emph> and five low-<emph>p</emph> instructions for further analysis. The CPQ includes 100 instructions across nine categories (e.g., dressing, hygiene, play, academic, social, mealtime, clean up, transport, general) that are commonly delivered in home settings. Caregivers rated their child's likelihood of completing each instruction on a 5-point Likert scale (1 = <emph>almost always</emph>; 5 = <emph>skill not learned</emph>). While efforts were made to select high-<emph>p</emph> and low-<emph>p</emph> instructions based on response effort (i.e., single-step vs. multi-step), greater consideration was given to caregiver's specific identification of instructions for purposes of social validity.</p> <p>Three acceptability surveys were completed post-treatment. Caregivers completed the Technology Acceptance Model Instrument-Fast Form (FF-TAM; Chin et al., [<reflink idref="bib6" id="ref55">6</reflink>]) to assess their acceptability of technology in terms of usefulness and ease of use. Caregivers also completed the Behavior Intervention Rating Scale (BIRS; Von Brock & Elliott, [<reflink idref="bib56" id="ref56">56</reflink>]) to assess perceived acceptability and effectiveness of a designed intervention. Slight modifications were made to the verbiage of questions to reflect <emph>caregiver</emph> perceptions of child outcomes in a <emph>home</emph> setting. Lastly, caregivers completed the Consultation Evaluation Form (CEF; Erchul, [<reflink idref="bib15" id="ref57">15</reflink>]) as a measure of perceived effectiveness of the consultant.</p> <hd id="AN0184231747-10">Response Definition and Measurement</hd> <p>The dependent variables were (a) initiation latency in seconds, and (b) task completion. Initiation latency was defined as the time in seconds (i.e., 10 s; Normand & Beaulieu; Wilder et al., [<reflink idref="bib57" id="ref58">57</reflink>]) from the delivery of the instruction to when the instruction was initiated, while task completion was defined as the child's successful completion of the instruction (yes/no).</p> <hd id="AN0184231747-11">Procedural Integrity</hd> <p>Procedural integrity was evaluated for caregiver adherence to pretrial delivery components. To calculate procedural integrity, the number of steps completed accurately were divided by the total number of steps and multiplied by 100. For Hank's mother, mean integrity values for pretrial delivery were 96.00% (80–100%) for high-<emph>p</emph> sessions and 100% for low-<emph>p</emph> sessions. For Kent's mother, mean integrity values for pretrial delivery were 100% across all high-<emph>p</emph> and low-<emph>p</emph> sessions. During pretrial delivery, Geoffrey's mother obtained a mean integrity value of 100% for high-<emph>p</emph> sessions and 82% (80–100%) for low-<emph>p</emph> sessions.</p> <hd id="AN0184231747-12">Interobserver Agreement</hd> <p>A second observer independently scored 33% of sessions for interobserver agreement (IOA). IOA was calculated for confirmation probes, caregiver integrity, and pretrial delivery outcomes. For initiation latency, agreement was scored if the two observers' latencies fell within 1 s (Robinson et al., [<reflink idref="bib48" id="ref59">48</reflink>]). For task completion, agreement was scored if the two observers indicated whether the child successfully completed the instruction (yes/no). Regarding caregiver integrity, IOA for Hank's mother averaged 100% and 93.33% (85–100%) for high-<emph>p</emph> and low-<emph>p</emph> sessions, respectively, and 100% for initiation latency and task completion for both instruction types. For Kent's mother, mean IOA values were 100% and 95.83% (85–100%) for high-<emph>p</emph> and low-<emph>p</emph> sessions, respectively, and 100% for initiation latency and task completion for both instruction types. For Geoffrey's mother, mean IOA values were 86.6% (71–00%) and 100% for high-<emph>p</emph> and low-<emph>p</emph> sessions, respectively, and 100% for initiation latency and task completion for both instruction types. Mean IOA for initiation latency and task completion during confirmation probes was 100% across caregivers for all high-<emph>p</emph> and low-<emph>p</emph> instructions.</p> <hd id="AN0184231747-13">Experimental Design</hd> <p>A multielement design (MED; Wolery et al., [<reflink idref="bib59" id="ref60">59</reflink>]) without a baseline was used to evaluate whether high- and low-<emph>p</emph> pretrial delivery sessions were associated with different levels of initiation latency and task completion. Although a baseline can be incorporated into the MED, it is unnecessary for comparing the effects of two or more elements (Cooper et al., [<reflink idref="bib7" id="ref61">7</reflink>]; Lewandowski et al., [<reflink idref="bib31" id="ref62">31</reflink>]). Visual analysis served as the primary means for analyzing within-phase data patterns of trend, level, and variability (Kratochwill et al., [<reflink idref="bib26" id="ref63">26</reflink>]). Figures depicting study outcomes maintained a data point per <emph>x</emph>- to <emph>y</emph>-axis ratio (DPPXYR) of ≥ 0.14 (Radley et al., [<reflink idref="bib45" id="ref64">45</reflink>]).</p> <hd id="AN0184231747-14">Procedure</hd> <p></p> <hd id="AN0184231747-15">Functional Behavior Assessment Interview</hd> <p>The consultant conducted an open-ended functional behavior assessment interview (FBAI; Murdock et al., 2005) with caregivers about their child's task refusal. The interview served to operationally define refusal, identify the environmental variables proported to surround the occurrence of refusal, and explore the effectivness of previous attempts to increase instruction following in the home. Caregivers reported that task refusal often occurred following an instruction to complete a nonpreferred task or terminate engagement with a preferred item/activity. Additionally, caregivers indicated having used one or more strategies (i.e., contingent reinforcement, time out, coaxing) to encourage instruction following; however, neither strategy was reported effective.</p> <hd id="AN0184231747-16">Confirmation Probes</hd> <p>Using procedures similar to those described by Stephenson and Hanley ([<reflink idref="bib54" id="ref65">54</reflink>]), a descriptive assessment was conducted to confirm the degree of instruction following with each of the five high-<emph>p</emph> and five low-<emph>p</emph> instructions identified from the CPQ. Caregivers recorded themselves issuing each of the 10 instructions three times over the course of one week, which resulted in a total of 30 confirmation probes. Caregivers were instructed to withhold attention for instruction following and task refusal. Instructions were selected based on caregiver responses to the CPQ, except for one that Geoffrey's mother requested specifically (i.e., "Watch, Baby Signing Time"). Geoffrey actively refused to view the educational video, which served to provide education on developmentally appropriate adaptive skills in preparation for his upcoming enrollment in pre-K.</p> <p>Depicted in Table 1 are the results of confirmation probes across instructions for each child. During probe sessions, Hank completed 100% of high-<emph>p</emph> instructions and initiated each within 1.17 s (0.18–3.3 s). Hank did not initiate any of the low-<emph>p</emph> instructions. Kent completed 100% of high-<emph>p</emph> instructions and initiated each within 0.92 s (0.56–2.03 s). He did not initiate any of the low-<emph>p</emph> instructions. Geoffrey completed 100% of high-<emph>p</emph> instructions and initiated each within 0.83 s (0.40–1.31 s). While Geoffrey did not complete any of the low-<emph>p</emph> instructions, he initiated "Get a cup" within 4.68 s (3.81–5.56 s) during two of three probes and "Put toy away" within 1.12 s during one probe. In each instance, Geoffrey proceeded to walk in the appropriate direction (i.e., kitchen or toy chest) then altered course without completing the task.</p> <p>Table 1 Confirmation probes for high- and low-<emph>p</emph> instruction</p> <p> <ephtml> <table frame="hsides" rules="groups"><thead><tr><th align="left" rowspan="2"><p>Child</p></th><th align="left" rowspan="2"><p>Instruction</p></th><th align="left" colspan="2"><p>Outcome</p></th></tr><tr><th align="left"><p>Task completion</p></th><th align="left"><p>Avg. latency (s)</p></th></tr></thead><tbody><tr><td align="left" rowspan="12"><p>Hank</p></td><td align="left" colspan="3"><p>High-probability</p></td></tr><tr><td align="left"><p> Show me a big smile</p></td><td align="left"><p>3/3</p></td><td align="left"><p>0.18</p></td></tr><tr><td align="left"><p> Give mommy a hug</p></td><td align="left"><p>3/3</p></td><td align="left"><p>0.53</p></td></tr><tr><td align="left"><p> Give me a high five</p></td><td align="left"><p>3/3</p></td><td align="left"><p>0.54</p></td></tr><tr><td align="left"><p> Go use the potty</p></td><td align="left"><p>3/3</p></td><td align="left"><p>1.30</p></td></tr><tr><td align="left"><p> Tell me your favorite color</p></td><td align="left"><p>3/3</p></td><td align="left"><p>3.33</p></td></tr><tr><td align="left" colspan="3"><p>Low-probability</p></td></tr><tr><td align="left"><p> Make your bed</p></td><td align="left"><p>0/3</p></td><td align="left"><p>–</p></td></tr><tr><td align="left"><p> Turn off your tablet</p></td><td align="left"><p>0/3</p></td><td align="left"><p>–</p></td></tr><tr><td align="left"><p> Put your jacket on</p></td><td align="left"><p>0/3</p></td><td align="left"><p>–</p></td></tr><tr><td align="left"><p> Throw X in the trash</p></td><td align="left"><p>0/3</p></td><td align="left"><p>–</p></td></tr><tr><td align="left"><p> Get a water bottle</p></td><td align="left"><p>0/3</p></td><td align="left"><p>–</p></td></tr><tr><td align="left" rowspan="12"><p>Kent</p></td><td align="left" colspan="3"><p>High-probability</p></td></tr><tr><td align="left"><p> Tell me your favorite color</p></td><td align="left"><p>3/3</p></td><td align="left"><p>0.56</p></td></tr><tr><td align="left"><p> Give me a high five</p></td><td align="left"><p>3/3</p></td><td align="left"><p>0.48</p></td></tr><tr><td align="left"><p> Touch your nose</p></td><td align="left"><p>3/3</p></td><td align="left"><p>0.51</p></td></tr><tr><td align="left"><p> Stand on one leg</p></td><td align="left"><p>3/3</p></td><td align="left"><p>1.05</p></td></tr><tr><td align="left"><p> What color is your shirt</p></td><td align="left"><p>3/3</p></td><td align="left"><p>2.03</p></td></tr><tr><td align="left" colspan="3"><p>Low-probability</p></td></tr><tr><td align="left"><p> Brush your teeth</p></td><td align="left"><p>0/3</p></td><td align="left"><p>–</p></td></tr><tr><td align="left"><p> Wash your hands</p></td><td align="left"><p>0/3</p></td><td align="left"><p>–</p></td></tr><tr><td align="left"><p> Get a water bottle</p></td><td align="left"><p>0/3</p></td><td align="left"><p>–</p></td></tr><tr><td align="left"><p> Sit down at the table</p></td><td align="left"><p>0/3</p></td><td align="left"><p>–</p></td></tr><tr><td align="left"><p> Take a bit of your food</p></td><td align="left"><p>0/3</p></td><td align="left"><p>–</p></td></tr><tr><td align="left" rowspan="12"><p>Geoffrey</p></td><td align="left" colspan="3"><p>High-probability</p></td></tr><tr><td align="left"><p> Touch your nose</p></td><td align="left"><p>3/3</p></td><td align="left"><p>0.40</p></td></tr><tr><td align="left"><p> What is your favorite color</p></td><td align="left"><p>3/3</p></td><td align="left"><p>0.96</p></td></tr><tr><td align="left"><p> Grab your ear</p></td><td align="left"><p>3/3</p></td><td align="left"><p>0.79</p></td></tr><tr><td align="left"><p> Clap your hands</p></td><td align="left"><p>3/3</p></td><td align="left"><p>0.85</p></td></tr><tr><td align="left"><p> Get a ball from your bin</p></td><td align="left"><p>3/3</p></td><td align="left"><p>1.31</p></td></tr><tr><td align="left" colspan="3"><p>Low-probability</p></td></tr><tr><td align="left"><p> Get your cup</p></td><td align="left"><p>0/3</p></td><td align="left"><p>4.68</p></td></tr><tr><td align="left"><p> Put your dish in the sink</p></td><td align="left"><p>0/3</p></td><td align="left"><p>–</p></td></tr><tr><td align="left"><p> Watch baby signing time</p></td><td align="left"><p>0/3</p></td><td align="left"><p>–</p></td></tr><tr><td align="left"><p> Put your toy in the bin</p></td><td align="left"><p>0/3</p></td><td align="left"><p>1.12</p></td></tr><tr><td align="left"><p> Put your shirt in the bin</p></td><td align="left"><p>0/3</p></td><td align="left"><p>–</p></td></tr></tbody></table> </ephtml> </p> <hd id="AN0184231747-17">Free Operant Preference Assessment</hd> <p>Caregivers conducted a free operant preference assessment to identify a list of potentially reinforcing activities to be used during pretrial delivery. Assessment procedures were similar to those described by Roane et al. ([<reflink idref="bib47" id="ref66">47</reflink>]), with two exceptions. That is, caregivers unobtrusively observed their child's natural selection of activities (rather than a pre-determined array) and sessions were 10 min in duration (rather than 5 min). Caregivers conducted one session each day over the course of one week and documented the frequency with which activities were selected and duration of engagement for each. A preference hierarchy was established according to how often and for how long children engaged in specific activities. Following, the consultant conducted one videoconference session with each caregiver review assessment data.</p> <p>Hank displayed a high preference for two Tablet games (i.e., Ninja Turtles, Batman), moderate preference for two Tablet games (i.e., Rescue Bot, Farming) and Tic Tac Toe, and mild preference for Slap Jacket<sups>®</sups> and rock paper scissors. Kent demonstrated a high preference for bubble machine and make-believe ice cream truck, a moderate preference for being read to by his mother, dancing with his mother, and make-believe superhero, and a mild preference for Uno. Lastly, Geoffrey displayed a high preference for basketball, a moderate preference for make-believe dinosaur play, being read to by his mother, and playing with non-tech toys in his bedroom, and a mild preference for coloring alone.</p> <hd id="AN0184231747-18">Pretrial Delivery</hd> <p></p> <hd id="AN0184231747-19">Training</hd> <p>The consultant delivered synchronous BST via videoconferencing to increase caregivers' adherence to pretrial delivery procedures, which included a six-step checklist: (<reflink idref="bib1" id="ref67">1</reflink>) caregiver positions recording device in view of session area; (<reflink idref="bib2" id="ref68">2</reflink>) caregiver does not ask questions and only makes statements; (<reflink idref="bib3" id="ref69">3</reflink>) caregiver actively engages in a moderately preferred activity with their child; (<reflink idref="bib4" id="ref70">4</reflink>) the activity lasts between 2 to 3 min; (<reflink idref="bib5" id="ref71">5</reflink>) caregiver issues predetermined high- or low-<emph>p</emph> instruction at the end of the interval; and (<reflink idref="bib6" id="ref72">6</reflink>) caregiver withholds attention throughout and following the interval regardless of their child's response. The consultant conducted one synchronous training session with each caregiver that ranged from 25 to 35 min. The consultant described the purpose of pretrial delivery, modeled each step, then provided performance feedback to caregivers during and after role play scenarios. During initial role play scenarios, the therapist acted as the caregiver and the caregiver as the child. Roles were then switched during subsequent scenarios and training continued until each caregiver demonstrated 100% fidelity across three consecutive trials.</p> <hd id="AN0184231747-20">Implementation</hd> <p>At predetermined times of the day that corresponded to the respective instruction issued, caregivers implemented one high-<emph>p</emph> session and one low-<emph>p</emph> session each day, across five days. Each session consisted of a single trial that entailed the delivery of either a high-<emph>p</emph> or low-<emph>p</emph> instruction. Hank's treatment included six sessions due to his mother's accidental delivery of the instruction "Pause Tablet," which was not identified from the CPQ. Sessions occurred within 10 ft of a respective area for low-<emph>p</emph> instruction that required the child to physically move to complete the task, such as within 10 ft of a trash can for throwing away an item (Hank), the kitchen sink for putting a dish away (Geoffrey), and the bathroom sink for brushing teeth/washing hands (Kent). Given Hank's propensity for task refusal when engaged with technology, high-<emph>p</emph> and low-<emph>p</emph> pretrial delivery sessions involved joint engagement with moderately preferred Tablet games. If children initiated the instruction within 10 s, caregivers continued recording to provide sufficient time to complete the instruction and ceased recording if their child stopped engaging in the instruction at any point. If their child did not initiate the request within 10 s, the recording ended, and children were free to re-engage in the activity by themselves. This criterion was used as studies show that 10 s post-instruction interval to be sufficient for most children (Shriver & Allen, 1977; Wruble et al., 1991). A task completion criterion was not implemented due to the variable duration needed to complete certain instructions (e.g., washing hands vs. throwing item in the trash).</p> <hd id="AN0184231747-21">Results</hd> <p>Figure 1 depicts the results of each child's treatment. Hank's average session duration was 2 min 35 s (2:05 min–3:00 min). During pretrial delivery, he completed 80% of low-<emph>p</emph> instructions and 100% of high-<emph>p</emph> instructions across sessions. The average initiation latency to low-<emph>p</emph> instructions was 5.66 s (1.50–10.5 s). At the start of treatment, there was a steady increasing trended in initiation latency before an abrupt decrease in level during the last treatment session. Average high-<emph>p</emph> initiation latency was 0.40 s (0.25–1.00 s), which remained fairly stable across sessions.</p> <p>Graph: Fig. 1 Results of pre-trial delivery for Hank (top panel), Kent (middle panel), and Geoffrey (bottom panel). Note: Low-p instructions are denoted with circles and high-p instructions with triangles. Gray data points indicate task refusal and are positioned above the highest point on the y axis</p> <p>Kent's average session duration was 2 min 45 s (2:10 min–2:55 min). He completed 100% of high-<emph>p</emph> and low-<emph>p</emph> instructions across sessions. On average, Kent initiated low-<emph>p</emph> instructions within 3.20 s (0.75–7.00 s), which steadily decreased in trend and level across sessions. Kent initiated high-<emph>p</emph> instructions within 1.09 s (0.65–1.30 s). Latency levels remained low and stable.</p> <p>Geoffrey's average session duration was 2 min 15 s (2:00 min–2:25 min). He completed 80% of high-<emph>p</emph> and 100% of low-<emph>p</emph> instructions across sessions. On average, he initiated low-<emph>p</emph> instructions within 4.34 s (1.81–9.02 s), which trended downward and stabilized to low levels during the last two sessions. He initiated high-<emph>p</emph> instructions each within 2.41 s (1.30–4.21 s). With the exception of session 4, his initiation latency decreased in level and trend over the course of treatment.</p> <p>Regarding acceptability measures, caregiver ratings on the BIRS reflected high levels of treatment acceptability for Kent's (<emph>M</emph> = 5.00; <emph>SD</emph> = 0.00), Hank's (<emph>M</emph> = 4.70; <emph>SD</emph> = 0.47), and Geoffrey's mother (<emph>M</emph> = 4.58; <emph>SD</emph> = 0.96). On the FF-TAM, both Hank's and Kent's mother indicated very high levels of usefulness (<emph>M</emph> = 3.00; <emph>SD =</emph> 0.0) and ease of use (<emph>M</emph> = 3.00; <emph>SD </emph>= 0.00), while Geoffrey's mother indicated high levels of usefulness (<emph>M</emph> = 2.66; <emph>SD</emph> = 0.49) and ease of use (<emph>M</emph> = 2.83; <emph>SD</emph> = 0.38). Regarding technology to increase adherence to pretrial delivery components, both Hank's and Kent's mothers endorsed very high levels for both usefulness and ease of use (<emph>M</emph> = 3.00; <emph>SD</emph> = 0.00), while Geoffrey's mother endorsed high levels of usefulness (<emph>M</emph> = 2.91; <emph>SD</emph> = 0.21) and very high levels of ease of use (<emph>M</emph> = 3.00; <emph>SD</emph> = 0.00). On the CEF, all three mothers perceived the consultant to be highly effective, evidenced by a mean rating of 7.0.</p> <hd id="AN0184231747-22">Discussion</hd> <p>The results of Study 1 showed that initiation latencies with low-<emph>p</emph> instructions trended downward for two of three children, which is consistent with the variable outcomes reported in previous studies (Bullock & Normand, [<reflink idref="bib5" id="ref73">5</reflink>]; Lipschultz & Wilder, 2017; Normand & Beaulieu, [<reflink idref="bib39" id="ref74">39</reflink>]), suggesting that continuous joint-engagement may serve as a viable alternative to leaner FT schedules of reinforcement to promote instruction following. In contrast to previous studies, the present evaluation was conducted via telehealth in homes, focused on initiation latency as a primary dependent variable, and involved continuous joint engagement between a caregiver and child. Although reinforcer density varies between continuous and thinner FT schedules, both permit contact with preferred stimuli prior to the delivery of a low-<emph>p</emph> instruction. Thus, it's possible that similar mechanisms underly the effects of FT and continuous reinforcement on instruction following during pretrial delivery. For instance, prior studies reference motivational effects (Hodges et al., [<reflink idref="bib23" id="ref75">23</reflink>]; Normand & Beaulieu, [<reflink idref="bib39" id="ref76">39</reflink>]), suggesting that continuous reinforcement during pretrial delivery might have functioned as an abolishing operation (AO) for escape from the low-<emph>p</emph> instruction and abated escape-maintained behavior.</p> <p>During post-treatment interviews, each caregiver reported collateral changes in non-targeted behaviors, such as decreased tantrums and increased functional communication (Geoffrey), decreased separation anxiety (Kent), and increased chore completion (Hank). This finding aligns with previous research on the documented effects of presession pairing on rapport quality during early intervention programs, which has almost exclusively been conducted in highly controlled settings with clinicians (Lugo et al., [<reflink idref="bib35" id="ref77">35</reflink>]; Shillingsburg et al., [<reflink idref="bib51" id="ref78">51</reflink>]). Furthermore, caregivers reported high levels of treatment and technology acceptability and demonstrated high levels of procedural integrity, which likely factored into the positive outcomes observed for two of the three children. These outcomes suggest that, with sufficient training, the flexibility afforded by technology can be harnessed to support caregiver's delivery of antecedent instruction-following strategies in the home. All said, the findings of Study 1 demonstrate the feasibility of training caregivers to deliver pretrial delivery under natural conditions (i.e., home) while maintaining work and childcare responsibilities.</p> <p>The results of Study 1 should be interpreted in light of several limitations, the first of which regards the multielement design used to evaluate the relation between pretrial delivery and study outcomes. While the absence of a baseline does not preclude our ability to compare the relation between pretrial delivery and study outcomes, the inclusion of baseline data would have provided a measure of each child's pre-intervention performance and, accordingly, the ability to conduct between phase contrasts. While confirmation probes offer some degree of baseline instruction following, the conditions under which low-<emph>p</emph> instructions were issued were not standardized between probe and pretrial delivery sessions. Additionally, in contrast to previous research (Bullock & Normand, [<reflink idref="bib5" id="ref79">5</reflink>]; Normand & Beaulieu, [<reflink idref="bib39" id="ref80">39</reflink>]), only one instruction (i.e., one trial) was issued during each high- and low-<emph>p</emph> session, as opposed to blocks of trials. While the inclusion of blocked trials would provide a more robust evaluation of the relationship between high- and low-<emph>p</emph> conditions and instructional outcomes, doing so would have required caregivers to further modify their schedules; social validity remained a primary focus given the degree of participation required on behalf of caregivers. Future research on caregiver-implemented pretrial delivery in homes should initially prioritize the use of a more rigorous experimental design with a baseline condition to evaluate the presence of a functional relation and conduct blocks of trials within sessions.</p> <p>Additionally, the response effort required to complete low-<emph>p</emph> instructions differed for each child, limiting the generality of study findings to typically developing children. This decision was made to account for caregiver preference and the degree of work involved in their participation. To the extent possible, future researchers should prioritize the delivery of the same instructions across sessions or ensure each entails a similar degree of response effort. In addition, the use of technology to facilitate study procedures in the home posed some challenges related to environmental control. There were several sessions in which siblings entered the intervention setting and engaged with the child participant. Future researchers may wish to discuss with caregivers the feasibility of conducting sessions in areas of the home with limited distractions to preserve the internal validity of assessment and treatment procedures.</p> <hd id="AN0184231747-23">Study 2</hd> <p>Noting mixed findings reported in previous pretrial delivery studies (Normand & Beaulieu, [<reflink idref="bib39" id="ref81">39</reflink>]), and that contingent reinforcement might be necessary to sufficiently increase instruction following (Lipschultz & Wilder, [<reflink idref="bib34" id="ref82">34</reflink>]), caregivers were trained to deliver a more rigorous antecedent intervention, the high probability instructional sequence (HPIS). Thus, for each child, the three low-<emph>p</emph> instructions with the highest initiation latency in the pretrial delivery evaluation were further targeted with the HPIS.</p> <hd id="AN0184231747-24">Participants and Setting</hd> <p>All three caregiver-child dyads in Study 1 participated. Sessions were conducted in the same living areas within caregivers' homes (i.e., living room, kitchen, bathroom, bedroom).</p> <hd id="AN0184231747-25">Material and Measures</hd> <p>Similar to the first evaluation, caregivers used their personal computer or smartphone to record sessions within their home and emailed these to the consultant for performance feedback and data collection purposes. The consultant remotely conducted procedures from the same residential office using the same laptop and webcam. Caregivers completed digital-versions of the FF-TAM, BIRS, and the CEF post-treatment.</p> <hd id="AN0184231747-26">Response Definition and Measurement</hd> <p>Initiation latency and task completion were scored as previously described in Study 1. The three low-<emph>p</emph> instructions with the highest initiation latency in the pretrial delivery evaluation were further targeted with the HPIS. For Hank, these included, "Get a water bottle," "Throw this in the trash," and "Turn off your tablet." The HPIS was delivered to Hank while engaged with his tablet. Considering that successful task completion would require him to first disengage from his tablet, his mother conducted three probes to evaluate whether he would successfully divert his attention from the tablet to comply with high-<emph>p</emph> instructions. Each probe entailed the delivery of five high-<emph>p</emph> instructions with inter-prompt times of ≤ 5 s and no programmed reinforcement for instruction following. Hank successfully completed 100% of high-<emph>p</emph> instructions across all probes. For Kent, the three low-<emph>p</emph> instructions included, "Wash your hands," "Brush your teeth," and "Sit down at the table." The three low-<emph>p</emph> instructions for Geoffrey included, "Put your cup away," "Put your shirt/pant in the hamper," and "Watch Baby Signing Time." Additionally, Kent's mother identified three new high-<emph>p</emph> instructions that were introduced during the last two treatment sessions: "Turn in a circle," "Shake your head," and "Give me a hug."</p> <hd id="AN0184231747-27">Procedural Integrity</hd> <p>Procedural integrity was calculated based on caregivers' adherence to HPIS components. To calculate procedural integrity, the number of steps completed accurately were divided by the total number of steps and multiplied by 100. Integrity was 100% for Hank's mother during baseline sessions, while her treatment integrity was calculated to be 95.5% (75–100%) for "Throw this in the trash," 100% for "Get a water bottle," and 85% (75–100%) for "Turn off your tablet." For Kent, mean caregiver integrity during baseline was 100%, while her integrity during treatment was 95.5% (75–100%) for "Wash your hands," 93.7% (75–100%) for "Brush your teeth," and 100% for "Sit down at the table." Geoffrey's mother obtained a mean integrity value of 100% during baseline sessions, while her treatment integrity for "Put your cup away" was 75.00% (50–100%), 79.16% (75–100%) for "Put your shirt/pant away," and 81.25% (75–100%) for "Watch Baby Signing Time."</p> <hd id="AN0184231747-28">Interobserver Agreement</hd> <p>An independent observer coded 33% of recorded sessions for procedural integrity and HPIS outcomes during baseline and treatment sessions. Mean IOA for caregiver integrity and child outcomes was calculated as a percentage by dividing the number of sessions with agreement by the total number of sessions and multiplied by 100. For procedural integrity, mean IOA for Hank's mother was 93.7% (75–100%) for the low-<emph>p</emph> instruction "Throw this in the trash," 100% for "Get a water bottle," and 87.5% (75–100%) for "Turn off your Tablet." Mean IOA for Kent's mother was 93.7% (75–100%) for "Wash your hands," 91.6% (75–100%) for "Brush your teeth," and 87.5% (75–100%) for "Sit down at the table." Lastly, for Geoffrey's mother, mean IOA was 93.75% (75–100%) for "Put your cup away," 93.75% (75–100%) for "Put your shirt/pant away," and 100% for "Watch Baby Signing Time."</p> <p>Regarding intervention outcomes, mean IOA values for Hank's and Geoffrey's initiation latency and task completion were 100% during baseline and treatment for each low-<emph>p</emph> instruction. Mean IOA for Kent's initiation latency and task completion was 100% during baseline for all low-<emph>p</emph> instructions, while mean agreement for initiation latency during treatment was 87.5% (75–100%) for "Wash your hands," 83% (66–100%) for "Brush your teeth," and 100% for "Sit down at the table."</p> <hd id="AN0184231747-29">Experimental Design</hd> <p>A multiple baseline across behaviors design (Gast et al., [<reflink idref="bib19" id="ref83">19</reflink>]) was used to evaluate effects of the HPIS on initiation latency and task completion with low-<emph>p</emph> instructions. Tau-U effect sizes (ES) were calculated to evaluate the degree to which the treatment resulted in changes in initiation latency with low-<emph>p</emph> instructions, while task completion (yes/no) was reported as a percentage of occurrence across sessions. Visual analysis served as a means for analyzing data and figures depicting outcomes maintained a DPPXYR of ≥ 14.</p> <hd id="AN0184231747-30">Procedure</hd> <p></p> <hd id="AN0184231747-31">High-Probability Instructional Sequence</hd> <p></p> <hd id="AN0184231747-32">Training</hd> <p>The consultant delivered synchronous BST to increase caregiver's adherence to HPIS components, which included a four-step checklist: (<reflink idref="bib1" id="ref84">1</reflink>) during baseline sessions, caregiver issues one low-<emph>p</emph> instruction and withholds attention for task completion or refusal; (<reflink idref="bib2" id="ref85">2</reflink>) during treatment sessions, caregiver delivers five high-<emph>p</emph> instructions with inter-prompt times ≤ 5; (<reflink idref="bib3" id="ref86">3</reflink>) caregiver s provides verbal praise for task completion with each high-<emph>p</emph> instruction and (<reflink idref="bib4" id="ref87">4</reflink>) caregiver delivers one low-<emph>p</emph> instruction within 5 s of the last high-<emph>p</emph> instruction and withholds attention for task completion or refusal. On average, training lasted between 20 and 30 min and continued until each caregiver demonstrated 100% integrity across three trials.</p> <hd id="AN0184231747-33">Implementation</hd> <p>Caregivers conducted one session for each low-<emph>p</emph> instruction, resulting in a total of three sessions per day. Session duration varied according to whether instructions were in baseline or treatment. Sessions were delivered consecutively across 14 days, and caregivers were instructed to implement sessions during times of the day that aligned with the specific instruction to be delivered. The mean baseline session duration was 11 s (6–16 s), while treatment sessions averaged 54 s (33–65 s). During baseline, caregivers stood within 1.5 ft of their child and presented the low-<emph>p</emph> instruction with the recording device within view of the child. Caregivers withheld attention for task refusal and task completion with low-<emph>p</emph> instructions. During the intervention phase, all procedures remained the same except caregivers issued the same five high-<emph>p</emph> instructions delivered in Study 1 prior to a low-<emph>p</emph> instruction. As in Study 1, if children initiated the instruction, caregivers continued recording to provide sufficient time to complete the instruction and ceased recording if their child stopped engaging in the instruction at any point.</p> <hd id="AN0184231747-34">Results</hd> <p>Figures 2, 3 and 4 depict the results of each child's treatment. During baseline, Hank initiated 0% of instructions to "Throw this in the trash." Upon treatment, his task completion abruptly increased to and remained at 100%. On average, he initiated the low-<emph>p</emph> instruction within 5.34 s (3.02–9.10 s), which remained variable throughout treatment. During baseline, Hank initiated 0% of instructions to "Get a water bottle." By contrast, he completed 87% of instructions during treatment and demonstrated an average initiation latency of 5.28 s (2.22–8.45 s) that remained variable before trending upward during the final two treatment sessions. During baseline, Hank did not initiate the low-<emph>p</emph> instruction to "Turn off tablet." During treatment, Hank completed 40% of low-<emph>p</emph> instructions. An immediate treatment effect was not observed given the first instance of task completion occurred during the fourth treatment session. His latency data for "Turn off tablet" decreased in level across the last two final treatment sessions. Hank completed 100% of high-<emph>p</emph> instructions during treatment. Tau-U ESs revealed the HPIS had a large negative effect of − 0.63 (<emph>SE</emph> = 0.29) for "Throw this in the trash," a large negative effect of − 0.74 (<emph>SE </emph>= 0.25) for "Get a water bottle," and a moderate negative effect of − 0.57 (<emph>SE</emph> = 0.31) for "Turn off your tablet." Visual analysis suggests the absence of a functional relationship given the absence of an immediate change in instruction following in tier 3.</p> <p>Graph: Fig. 2 Results of Hank's high probability instructional sequence. Note: Black circles indicate instruction following occurred, while gray circles indicate task refusal occurred and are positioned above the highest point on the y-axis</p> <p>Graph: Fig. 3 Results of Kent's high probability instructional sequence. Note: Black circles indicate instruction following occurred, while gray circles indicate task refusal occurred and are positioned above the highest point on the y-axis</p> <p>Graph: Fig. 4 Results of Geoffrey's high probability instructional sequence. Note: Black circles indicate instruction following occurred, while gray circles indicate task refusal occurred and are positioned above the highest point on the y-axis</p> <p>During baseline, Kent initiated 0% of low-<emph>p</emph> instructions to "Wash your hands." When treatment was implemented, task completion increased to 72% across treatment sessions, with a range of 0–100%. Task completion occurred at 100% across most sessions, with the exception of sessions 6, 10, and 12. Of the sessions in which task completion occurred, he demonstrated an average initiation latency of 1.74 s (0.82–4.12 s) that remained fairly low in level, yet variable across treatment. During baseline, Kent initiated 0% of instructions to "Brush your teeth." During treatment, he completed 85.7% of instructions and demonstrated an average initiation latency of 1.57 s (1.01–2.5 s). Lastly, during baseline, Kent initiated 0% of instructions to "Sit down." In contrast, he completed 100% of instructions during treatment and initiated each within 2.62 s (0.76–6.10 s), which briefly trended upward then downward. Kent completed 100% of high-<emph>p</emph> instructions during treatment. Tau-U ESs revealed the treatment had a moderate, negative effect of − 0.49 (<emph>SE</emph> = 0.33) for "Wash your hands," a large negative effect of − 0.74 (<emph>SE</emph> = 0.25) for "Brush your teeth," and a very large negative effect of − 0.91 (<emph>SE</emph> = 0.15) for "Sit down." Visual analysis indicates a functional relationship between the HPIS and changes in instruction following.</p> <p>During baseline, Geoffrey initiated 0% of low-<emph>p</emph> instructions to "Put your cup away." In treatment, task completion increased to and remained at 100% with an average initiation latency of 1.72 s (0.52–4.20 s) that trended downward before stabilizing to low levels. During baseline, Geoffrey completed one instruction to "Put your clothes away" with an initiation latency of 1.32 s. In treatment, he completed 87.5% of instructions and displayed an average initiation latency of 1.36 s (0.45–3.15 s) that trended downward and stabilized to low levels. Lastly, Geoffrey demonstrated variable levels of task completion and initiation latency during baseline with the low-<emph>p</emph> instruction, "Watch Baby Signing Time." Task completion was observed during three of nine baseline sessions (33%) with a mean initiation latency of 1.52 s (0.95–2.52 s). When treatment was introduced, task completion immediately increased to and remained at 100% across sessions. Geoffrey's initiation latencies remained low and stable, with a mean latency of 0.60 s (0.35–0.89 s). Geoffrey completed 100% of high-<emph>p</emph> instructions during treatment. Tau-U ESs revealed a large negative effect of − 0.65 (<emph>SE</emph> = 0.10) for "Put your cup away", a moderate, negative effect of − 0.59 (<emph>SE</emph> = 0.31) for "Put your clothes away," and a large, negative effect of − 0.77 (<emph>SE</emph> = 0.24) for "Watch Baby Signing Time." Visual analysis suggests a functional relationship, evidenced by immediate changes in instruction following with treatment.</p> <p>On the BIRS, responses from Hank's (<emph>M</emph> = 4.62; <emph>SD</emph> = 0.31), Kent's (<emph>M</emph> = 4.33; <emph>SD </emph>= 0.25), and Geoffrey's mother (<emph>M</emph> = 4.45; <emph>SD </emph>= 0.93) reflected high levels of treatment acceptability. On the FF-TAM, Hank's and Kent's mothers indicated very high levels of usefulness (<emph>M</emph> = 3.00; <emph>SD</emph> = 0.0) and ease of use (<emph>M</emph> = 3.00; <emph>SD</emph> = 0.0), while Geoffrey's mother endorsed high levels of usefulness (<emph>M</emph> = 2.83; <emph>SD</emph> = 0.40) and very high levels of ease of use (<emph>M</emph> = 3.00; <emph>SD</emph> = 0.00). Regarding the use of technology to increase their adherence to HPIS components, all three mothers endorsed very high levels of acceptability for usefulness (<emph>M</emph> = 3.00; <emph>SD</emph> = 0.00) and ease of use (<emph>M</emph> = 3.00; <emph>SD</emph> = 0.00). On the CEF, all three mothers perceived the consultant to be highly effective, evidenced by their mean rating of 7.0.</p> <hd id="AN0184231747-35">Discussion</hd> <p>The results of Study 2 showed that all three children exhibited decreased initiation latencies and higher percentages of task completion during treatment. Further, caregivers provided high scores on acceptability measures, suggesting that telehealth was perceived to be a feasible modality in which to conduct study procedures and the HPIS as effective for increasing instruction following. These findings are consistent with extant literature on the effects of the HPIS to promote instruction following (Lee, [<reflink idref="bib29" id="ref88">29</reflink>]; Radley & Dart, [<reflink idref="bib44" id="ref89">44</reflink>]) and the use of telehealth to support caregivers' delivery of antecedent interventions (Kunze et al., [<reflink idref="bib27" id="ref90">27</reflink>]).</p> <p>Regarding Hank's performance<bold><emph>,</emph></bold> the absence of an immediate effect with the instruction "Turn off your tablet" was not surprising given his history of refusal with instructions to disengage from technology. Like Study 1, it is possible that MOs factor into this outcome. While task completion with "Throw this in the trash" and "Get a water bottle" resulted in continued access with his tablet, the low-<emph>p</emph> instruction "Turn off your tablet" may have signaled the unavailability of preferred activity for an unspecified period. It is also possible that the quality of reinforcement delivered during the HPIS did not sufficiently function as an AO for escape from instructions to terminate use of his tablet, which is consistent with prior research indicating that lower quality reinforcers (e.g., praise) can result in lower levels of instruction following (Wilder et al., [<reflink idref="bib57" id="ref91">57</reflink>]) compared to higher quality reinforcers. Hank's performance also aligns with Hoffman et al.'s ([<reflink idref="bib22" id="ref92">22</reflink>]) study on the relative efficacy of low- and high-tech stimuli, which showed that participants more frequently approached and engaged with high-tech items (e.g., video games) for longer durations. Hoffman et al.'s findings are particularly relevant to contemporary youth considering the ubiquitous presence of technology in school and home settings (Sohn et al., [<reflink idref="bib53" id="ref93">53</reflink>]). Considering this, analysts should remain cognizant of the magnitude and breadth of reinforcing functions afforded by certain high-tech stimuli (i.e., greater engagement and stimulation) due to their potential to function as a powerful establishing operation for escape from requests to terminate their use.</p> <p>Kent's tendency to question his mother's instructions may have factored into his variable response with the low-<emph>p</emph> instruction "Wash your hands." That is, it is possible that Kent had become averse to his mother's delivery of the same five high-<emph>p</emph> instructions three times per day, evidenced by a noticeable change in Kent's facial expression (i.e., furrowed eyebrow) and head orientation (i.e., angled away from mother) in session 10. Considering Kent's response, future research might consider confirming levels of instruction following with a higher number of high-<emph>p</emph> instructions to be counterbalanced across sessions or introduced contingent on a noticeable change in a child's verbal or nonverbal behavior. At some point, Wilder et al. ([<reflink idref="bib57" id="ref94">57</reflink>]) cautioned that participants might become satiated by reinforcers delivered for completion of high-<emph>p</emph> instructions. They recommended a gradual increase in the number of high-<emph>p</emph> instructions might be of practical use in terms of avoiding satiation, which might also have the additive benefit of reduced handling costs on behalf of the implementor (Hoffman et al., [<reflink idref="bib22" id="ref95">22</reflink>]).</p> <p>Importantly, Study 2 included several limitations. For example, each of Hank's low-<emph>p</emph> instructions required him to engage in two behaviors: disengage from a high preference activity (i.e., tablet) prior to initiating a low-<emph>p</emph> instruction. Indeed, the topography of this instruction may increase the external validity of the findings given it resembles instructions often delivered in school and home settings (Wilder et al., [<reflink idref="bib57" id="ref96">57</reflink>]). Yet, given that Hank was the only child engaged with technology during the HPIS, caution is warranted when generalizing his treatment outcomes to typically developing children.</p> <p>Additionally, despite having met a training-based criterion prior to treatment, Geoffrey's mother was observed, on several occasions, to deliver variable high-<emph>p</emph> to low-<emph>p</emph> ratios (3:1 to 5:1) and forgo praise statements after instances of instruction following. It is possible that integrity errors impacted Geoffrey's behavior; however, these errors are consistent with previous HPIS research on the relative efficacy of unprogrammed reinforcement (Pits & Daymond, [<reflink idref="bib43" id="ref97">43</reflink>]) and varying high-<emph>p</emph> to low-<emph>p</emph> ratios (Axelrod & Zank, [<reflink idref="bib1" id="ref98">1</reflink>]; Ertle et al., [<reflink idref="bib16" id="ref99">16</reflink>]). When narrative feedback falls short of maintaining high levels of procedural integrity, clinicians may consider a more rigorous feedback modality, such as in-vivo modeling during a videoconferencing call (Schieltz et al., [<reflink idref="bib50" id="ref100">50</reflink>]). Alternatively, consultants may consider a more flexible, asynchronous feedback modality in which caregivers are provided with access to pre-recorded training videos depicting key features of the behavior program (Phaneuf & McIntyre, [<reflink idref="bib42" id="ref101">42</reflink>]).</p> <p>Lastly, the absence of follow-up probes makes it difficult to evaluate the degree to which instruction-following outcomes and caregiver's treatment integrity maintained post-treatment. Anecdotally, each mother reported that their child's instruction following remained high approximately two months post-treatment. Despite the view that anecdotal report poses several threats to internal validity, Wolf ([<reflink idref="bib58" id="ref102">58</reflink>]) touted the importance of consumer feedback in his original conceptualization of social validity. Considering this, anecdotal caregiver report helped to assess whether the interventions were useful for families and that there were lasting effects from the view of the caregiver.</p> <hd id="AN0184231747-36">Conclusion</hd> <p>This study considers the degree of empirical support for each antecedent strategy. For instance, previous research on pretrial delivery reports mixed findings (Bullock & Normand, [<reflink idref="bib5" id="ref103">5</reflink>]; Lipschultz & Wilder, [<reflink idref="bib34" id="ref104">34</reflink>]; Normand & Beaulieu, [<reflink idref="bib39" id="ref105">39</reflink>]), while the HPIS is often referenced as one of the most effective antecedent strategies for increasing instruction following (Radley & Dart, [<reflink idref="bib44" id="ref106">44</reflink>]). Nonetheless, caregiver ratings on the BIRS indicated that both strategies were perceived as highly effective for improving their child's instruction following. In addition, present findings extend a limited number of studies in which caregivers were trained to deliver the HPIS in their home and represent a preliminary evaluation of caregiver-delivered pretrial delivery. The current study also contributes to a growing literature on telehealth-mediated caregiver training (Unholz-Bowen et al., [<reflink idref="bib55" id="ref107">55</reflink>]) by demonstrating the first evaluation for pretrial delivery and the HPIS. It is possible that the flexibility afforded by technology to facilitate study procedures factored into caregivers' completion of both evaluations, which is important given the degree of involvement required for participation.</p> <p>As a model of service provision, telehealth is commonly touted for its efficiency in terms of treatment delivery, travel costs, and geographical reach (Fischer et al., [<reflink idref="bib17" id="ref108">17</reflink>]; Lindgren et al., [<reflink idref="bib32" id="ref109">32</reflink>]). Strong consideration should be given to the resources and skills (e.g., hardware, stable WIFI, digital literacy) needed to implement resource-intensive programs as deficits could depress the efficiency of remotely delivered behavioral supports. As analysts continue to evaluate the parameters of telehealth as medium for rending supports in homes, formative evaluations should consider environmental and contextual factors underlying the implementation of single or multicomponent behavior programs of varying complexity (Brand et al., [<reflink idref="bib4" id="ref110">4</reflink>]).</p> <hd id="AN0184231747-37">Data Availability</hd> <p>All data generated during this study are available from the corresponding author on reasonable request.</p> <hd id="AN0184231747-38">Declarations</hd> <p></p> <hd id="AN0184231747-39">Conflict of interest</hd> <p>The authors declare that they have no conflict of interest.</p> <hd id="AN0184231747-40">Publisher's Note</hd> <p>Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.</p> <ref id="AN0184231747-41"> <title> References </title> <blist> <bibl id="bib1" idref="ref19" type="bt">1</bibl> <bibtext> Axelrod MI, Zank AJ. 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  Data: Caregiver Telehealth Training on Antecedent Strategies to Increase Children's Instruction Following in the Home
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  Label: Language
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  Data: English
– Name: Author
  Label: Authors
  Group: Au
  Data: <searchLink fieldCode="AR" term="%22Hunter+C%2E+King%22">Hunter C. King</searchLink> (ORCID <externalLink term="http://orcid.org/0000-0002-8877-7214">0000-0002-8877-7214</externalLink>)<br /><searchLink fieldCode="AR" term="%22Aaron+J%2E+Fischer%22">Aaron J. Fischer</searchLink><br /><searchLink fieldCode="AR" term="%22Daniel+D%2E+Houalihan%22">Daniel D. Houalihan</searchLink><br /><searchLink fieldCode="AR" term="%22John+L%2E+Davis%22">John L. Davis</searchLink><br /><searchLink fieldCode="AR" term="%22Keith+C%2E+Radley+III%22">Keith C. Radley III</searchLink><br /><searchLink fieldCode="AR" term="%22William+R%2E+Jenson%22">William R. Jenson</searchLink>
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  Data: <searchLink fieldCode="SO" term="%22Journal+of+Behavioral+Education%22"><i>Journal of Behavioral Education</i></searchLink>. 2025 34(1):26-52.
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  Data: Springer. Available from: Springer Nature. One New York Plaza, Suite 4600, New York, NY 10004. Tel: 800-777-4643; Tel: 212-460-1500; Fax: 212-460-1700; e-mail: customerservice@springernature.com; Web site: https://link.springer.com/
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  Data: Y
– Name: Pages
  Label: Page Count
  Group: Src
  Data: 27
– Name: DatePubCY
  Label: Publication Date
  Group: Date
  Data: 2025
– Name: TypeDocument
  Label: Document Type
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  Data: Journal Articles<br />Reports - Research
– Name: Subject
  Label: Descriptors
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  Data: <searchLink fieldCode="DE" term="%22Child+Caregivers%22">Child Caregivers</searchLink><br /><searchLink fieldCode="DE" term="%22Caregiver+Training%22">Caregiver Training</searchLink><br /><searchLink fieldCode="DE" term="%22Telecommunications%22">Telecommunications</searchLink><br /><searchLink fieldCode="DE" term="%22Videoconferencing%22">Videoconferencing</searchLink><br /><searchLink fieldCode="DE" term="%22Caregiver+Child+Relationship%22">Caregiver Child Relationship</searchLink><br /><searchLink fieldCode="DE" term="%22Home+Study%22">Home Study</searchLink><br /><searchLink fieldCode="DE" term="%22Home+Instruction%22">Home Instruction</searchLink><br /><searchLink fieldCode="DE" term="%22Instructional+Effectiveness%22">Instructional Effectiveness</searchLink>
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  Data: 10.1007/s10864-023-09528-2
– Name: ISSN
  Label: ISSN
  Group: ISSN
  Data: 1053-0819<br />1573-3513
– Name: Abstract
  Label: Abstract
  Group: Ab
  Data: In two studies, three caregivers of neurotypical children were trained via telehealth to deliver two antecedent strategies to increase instruction following in the home. Dependent measures included initiation latency and task completion with high- and low-probability instructions. In Study 1, a modified pretrial delivery procedure was evaluated in which caregivers jointly engaged with their child in a moderately preferred activity prior to the issuance of a predetermined instruction. Results showed that initiation latencies for low-p instructions trended downward for two of three children, while latencies for high-p instructions remained low and stable for two of three children. In Study 2, the three low-p instructions with the highest initiation latencies in Study 1 were further targeted with the high-probability instructional sequence. Using a multiple baseline across behaviors design, results showed decreased initiation latencies and increased levels of task completion for all three children. The results of both evaluations are discussed and practical issues are considered for future research on the use of technology to support caregiver's delivery of instruction-following programs in homes.
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  Data: 2025
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  Data: EJ1485356
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        Value: 10.1007/s10864-023-09528-2
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      – Text: English
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        PageCount: 27
        StartPage: 26
    Subjects:
      – SubjectFull: Child Caregivers
        Type: general
      – SubjectFull: Caregiver Training
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      – SubjectFull: Telecommunications
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      – SubjectFull: Home Instruction
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      – SubjectFull: Instructional Effectiveness
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      – TitleFull: Caregiver Telehealth Training on Antecedent Strategies to Increase Children's Instruction Following in the Home
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