Brief Experimental Analysis of Sight Word Interventions: A

391242
1242Baranek et al.Behavior Modification
BMO35110.1177/014544551039
Brief Experimental
Analysis of Sight
Word Interventions: A Comparison
of Acquisition and
Maintenance of
Detected Interventions
Behavior Modification
35(1) 78­–94
© The Author(s) 2011
Reprints and permission: http://www.
sagepub.com/journalsPermissions.nav
DOI: 10.1177/0145445510391242
http://bmo.sagepub.com
Amy Baranek1, Daniel M. Fienup2,
and Gary Pace1
Abstract
The purpose of this study was to examine utility of a brief experimental
analysis (BEA) in determining effective sight word interventions for a student
with a history of difficulty with acquiring sight word recognition. Ten interventions were compared in a BEA. Following the BEA, an extended analysis was
conducted that compared the two most effective interventions (from the
BEA) with a control condition. Even though the BEA found two interventions
to be relatively equal, one of the two interventions resulted in acquisition in
half the sessions as the other intervention and this was replicated in a second
extended analysis. Implications for BEA and recommendations for future
research are discussed.
Keywords
acquisition, brain injury, brief experimental analysis, sight words
1
The May Center for Education and Neurorehabilitation, Brockton, MA, USA
City University of New York, Flushing, NY, USA
2
Corresponding Author:
Daniel M. Fienup, Department of Psychology, Queens College, 65-30 Kissena Blvd.,
Flushing, NY 11367
Email: [email protected]
Baranek et al.
79
Brief experimental analysis (BEA) is a process in which multiple interventions for academic instruction can be compared to determine which intervention is best suited for an individual student (Burns & Wagner, 2008; Daly,
Martens, Hamler, Dool, & Eckert, 1999). Across interventions, instructional
variables are manipulated to examine the effects on student learning. From a
cost-benefit perspective, this is an advantageous assessment. A BEA takes
approximately the same amount of time as a standardized test once it has been
administered and scored. Unlike a norm-referenced standardized test, the BEA
process gathers information about which interventions are likely to benefit a
student’s academic acquisition, which is in line with best practices for academic assessment (Burns & Wagner, 2008; Shinn, 2002). This assessment
also decreases the chance that practitioners will invest time implementing an
intervention that is ineffective.
The instructional hierarchy is a model that has been employed to determine
interventions for targeting skill deficits (Daly, Lentz, & Boyer, 1996). This
model conceptualizes a learner as falling in one of four phases (acquisition,
fluency, generalization, or adaptation). Different interventions are implemented
to target different levels of the hierarchy (Burns & Wagner, 2008; Eckert,
Ardoin, Daisey, & Scarola, 2000; VanAuken, Chafouleas, Bradley, & Martens,
2002; Wilber & Cushman, 2006). Typically, students referred for BEAs are
learning to acquire a skill (i.e., become accurate) or become fluent (i.e., quicker)
with that skill (Eckert et al., 2000). BEA provides an effective application
of a data-based, decision-making approach to compare interventions to find
the best intervention for implementation before time is invested in one particular intervention (Burns & Wagner, 2008; Eckert et al., 2000).
BEA has been introduced to the field within the last 10 years and has had
limited application reported in the literature, mainly focusing on oral reading
fluency (Burns & Wagner, 2008; Daly, Bonfiglio, Mattson, Persampieri, &
Forman-Yates, 2006; Daly et al., 1999; Gortmaker, Daly, McCurdy, Persampieri,
& Hergenrader, 2007; VanAuken et al., 2002; Welsch, 2007). In addition,
BEAs have been utilized to examine interventions for improving oral reading comprehension (McComas et al., 1996), mathematics (Codding et al.,
2009), letter formation (Burns, Ganuza, & London, 2009), and spelling
(McComas et al., 1996). It seems logical that this type of assessment could
be used to determine effective interventions for an even broader array of
academic skills.
The BEA is used to determine which intervention(s) produce the largest
immediate gains in performance. Typically, an extended analysis is conducted
after the BEA to evaluate the effectiveness of the intervention chosen from the
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Behavior Modification 35(1)
BEA (VanAuken et al., 2002; Wilber & Cushman, 2006). During the extended
analysis, most research in this area compared the most promising intervention
from the BEA with a baseline, or no intervention, condition (e.g., Burns et al.,
2009; Daly et al., 2006; Eckert et al., 2000; Gortmaker et al., 2007; McComas
et al., 1996). These studies found that the interventions found to be effective
during the BEA produce responding above and beyond baseline responding.
Going a step further, VanAuken et al. (2002) examined the utility of this
assessment by comparing the effects of the highest and lowest performing
interventions (from the BEA) in an extended analysis. Although marginally
better performance was found using the most promising intervention, the
study produced mixed results about the utility of BEA. Welsch (2007) also
tested the utility of a BEA. Four children were exposed to a BEA, followed
by an extended analysis, and a continued demonstration of the best treatment.
In two of the four cases, the highest performing intervention during the BEA
produced the highest performance during the extended analysis, but in two
cases, a lower performing intervention from the BEA produced the highest
performance during the extended analysis. In three of these cases there was
considerable overlap between the two interventions during the extended analysis and in only one case the results of the BEA replicated during the extended
analysis with no overlapping data points during the extended analysis. Although
it is well known that BEA can identify effective academic interventions that
will produce better-than-baseline performance, more research is needed to
find whether a BEA is sensitive enough to detect the differential effectiveness
of academic interventions.
A BEA is most useful when there are several known empirically supported
interventions for a particular academic subject. When this is the case, the BEA
can be used to distinguish which interventions are effective and not effective
for the target learner. Functional skills are the academic focus for many individuals with developmental disabilities (Collins, Evans, Creech-Galloway,
Karl, & Miller, 2007). One such functional skill is the recognition of sight
words. Sight words are any words that are read through word recognition. In
a meta-analysis that examined the teaching of sight words for individuals
with an intellectual disability, Browder and Xin (1998) found that there were
a wide variety of effective sight word interventions. These authors came to
this conclusion by comparing the overall percentage of nonoverlapping data
(PND) points for different intervention effects. Some of the effective interventions included performance feedback, modeling reading, pairing pictures
with words and fading the pictures, and providing incentives for correct sight
word reading.
Baranek et al.
81
Browder and Xin’s (1998) findings suggest that many of the interventions
for sight word acquisition are adequate for teaching the skill. To best determine
the appropriate intervention for a particular student, based on the many options
available, other methods are needed. The purpose of this study was to examine
effectiveness of using a BEA to determine effective sight word interventions
for a student with difficulties acquiring sight words. A secondary goal of this
research is to conduct an extended analysis comparing multiple promising
interventions to examine the ability of BEA to identify differentially effective
interventions.
Method
Participant and Setting
Huey was an 11-year-old male who attended a private school for students
with brain injury and other neurological disorders. He was a new student
who had attended the school for 1 month prior to the start of this study.
A record review revealed he had diagnoses of diffused cortical dysgenesis,
mild mental retardation, and attention deficit/hyperactivity disorder. Huey
was assessed on admission, and it was found he had a limited ability to comprehend presented language and formulate responses. In addition, Huey was
found to have lower word reading than predicted from his cognitive potential.
It was found that Huey needed multiple opportunities for review of material
to show learning.
Huey was referred to the first author by his classroom teacher because
of a difficulty in acquiring accurate sight word recognition. Prior to the
study, Huey’s teacher had used errorless teaching procedures to teach sight
word recognition. On referral, academic data for sight word acquisition were
reviewed, and it was confirmed that with the use of an errorless learning
technique, Huey had failed to acquire any sight words during his daily oneto-one sight words instruction during the first month at this school. Huey
was being instructed on preprimer and primer dolch list words based on the
Individualized Education Plan (IEP) he was being served under on admission to the school. Huey was assessed on all dolch list words to identify
known and unknown words before intervention began. Dolch words are
words that occur at a high frequency in readings. They are broken into different levels: preprimer, primer, first grade, second grade, third grade, and
a list of nouns. These levels are ordered by difficulty.
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Behavior Modification 35(1)
All sessions were conducted in a quiet conference room in the school. The
room had six smaller tables and Huey was allowed to choose the table where
he and the instructors sat. The instructor sat across the table from Huey.
Materials
The bulk of the materials for this study involved sight words that were printed
on paper. All words were between three and five letters long and typed in
Comic Sans MS 24-size font. All words were pretested using flashcards and
test lists. Flashcards were 12.7 cm by 7.6 cm with the text centered on the
flashcard. Appendix A provides an exemplar of a test list, with the words presented in rows and columns. Training lists varied in format, but the majority of
lists were identical to test lists. Variations of the lists will be described in the
respective descriptions of the training conditions.
In between training and testing, the experimenter played games with Huey.
This included card games and tic-tac-toe. These games were identified by
Huey’s classroom teacher and vocally verified as preferred activities by Huey.
Response Definition and Dependent Variables
The target behavior was the correct reading of a sight word. A correctly read
word was defined as a word pronounced accurately and in the right tense.
Each individual sound of a word needed to be enunciated with no additional
sounds to be marked as correct. If Huey corrected himself, that is, he incorrectly labeled a sight word but then started over with that word and labeled
it correctly immediately, that response was recorded as correct. Errors were
words read incorrectly or if there was no response within 3 s. Words were
clustered into lists of 10 words. Percentage correct was calculated following
each test of a word list. The dependent variable was the percentage of words
read correctly.
Procedure
Sessions were conducted four to five times a week. The length of the sessions varied based on the student’s behavior but generally lasted around
20 min. For each intervention conditions, Huey was exposed to the intervention strategy three times consecutively, unless otherwise specified. Then the
experimenter played a nonrelated game with Huey for 5 min (e.g., card game).
Baranek et al.
83
Last, the experimenter presented Huey with a test list (see Appendix A for an
example), during which no accuracy feedback was provided.
Sight word selection. Huey’s sight word recognition was assessed across
two formats: flash cards and word lists of dolch word that were mixed level
(preprimer, primer, etc.). Words were randomly assigned to groups of 10 words.
Each of these word sets was consistent across the two formats. All words were
assessed using both formats. If Huey was unable to accurately read words
across both formats, the word was eligible for inclusion into words lists for
the BEA and extended analysis.
The process of eliminating known words and retaining unknown words
produced a large pool of unknown words. From this pool, words were randomly assigned to new word sets of 10 words each. The only caveat was that
if two words were chosen for a list that had the same first letter, the last word
chosen was placed back into the pool and a new word was drawn for assignment to the list. This resulted in many novel 10 word sight word lists. During
the BEA, each intervention condition was assigned a novel word list. This was
also the same during the extended analysis with the exception of the control
condition. The control conditions (described in more detail below) used the
incentive condition word lists from the BEA because no instruction was provided on these words.
BEA. The goal of the BEA was to determine which interventions had
the most immediate positive impact on Huey’s accuracy of site reading.
Evidence-based reading interventions were selected for evaluation in the BEA
(VanAuken et al., 2002). Some of these strategies were designed for reading
fluency but were easy to adapt to reading sight words. Using novel word lists
for each intervention, Huey was exposed to each intervention one time. The
order in which the interventions were conducted was determined randomly,
with the exception of the last incentive condition. The last condition was
added to evaluate an incentive with a higher criterion.
Eight different types of interventions were evaluated in this study. Each
intervention began with instructions that articulated the behavior of the experimenter (e.g., “I will begin by reading the list of words to you” for passage
preview) and Huey (e.g., “When you come to a word you do not know, sound
it out” for phonics). During an intervention, correctly read words were praised
by the experimenter. An error, or no response within 3 s, resulted in the experimenter supplying the correct answer, unless otherwise specified.
A wide variety of strategies were tested in the BEA. All but one strategy
involved practicing the list with the particular strategy three times. The strategies
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Behavior Modification 35(1)
involved different approaches to reading a sight word (e.g., phonics) and different prompting strategies (e.g., pairing picture with word, within stimulus
prompt). The conditions are described in the order in which they were conducted (even though the order was randomly determined). The first condition,
Repeated Readings and Passage Preview, involved having Huey read along
a word list while the instructor read the words aloud followed by Huey
independently reading the list three times (VanAuken et al., 2002). The second
condition, Increased Trials, involved practicing each word on the list 10 times
with instructor providing feedback (Ferkis, Belfiore, & Skinner, 1997). The
third condition, Within Stimulus Prompt, involved changing the stimuli
so that the first letter of each word was larger and red (Belfiore, Grskovic,
Murphy, & Zentall, 1996). The Flashcards With Pictures involved inserting
Boardmaker® pictures that represented the word to the right of each word as
in Appendix B (Didden, de Graaff, Nelemans, Vooren, & Lancioni, 2006;
Fossett & Mirenda, 2006). To make sure the relationship between a picture and a word was clear, these stimuli were presented as flashcards. The
fifth condition, Phonics, involved prompting Huey to sound out words and
model sounding out words when he made an error (Daly, Johnson, & LeClair,
2009). The sixth condition, Incentive (Eckert et al., 2000), involved making
a highly preferred activity contingent on a particular outcome: two words
read correctly. This condition did not involve any formal teaching. Huey
was told the contingency and the test began. The criterion for the incentive
was determined based on the median pretest performance on the word lists.
The seventh condition was a Folding-in condition (Shapiro, 2004). In this
condition, the ratio of 70:30 (known:unknown) words was used. Known
words were those words identified from the pretests as words Huey read
correctly on word lists and flash cards. The eighth intervention, Repeated
Readings, involved practicing the list of words three times with instructor
feedback (Ferkis et al., 1997; VanAuken et al., 2002). The last condition was
another Incentive condition where the criterion was set at four or more words
read correctly.
Extended analysis. Following completion of the BEA, an extended analysis
was conducted that examined the acquisition and maintenance of sight word
reading using interventions that were found to produce the greatest increases
in Huey’s sight word reading during the BEA (Wilber & Cushman, 2006).The
two sight word interventions found to produce the greatest immediate effect
during the BEA were then implemented for the student using an alternating
treatments design (VanAuken et al., 2002) until mastery of word lists was
Baranek et al.
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attained. Mastery of a list was defined a three consecutive sessions with
90% accuracy or above. Follow-up data were collected at 1-week intervals
following mastery of a word list. Maintenance sessions did not involve any
instruction, only the respective test was administered. Following the mastery
of two word lists using intervention selected from the BEA, the extended
analysis was replicated with novel word lists.
A control condition was also implemented to ensure that the effects of the
interventions were in fact caused by the interventions and not from educational activities occurring in Huey’s classroom or other extraexperimental
variables. The control condition involved no intervention, only testing. Data
were gathered on the two interventions and control condition during each
session. The order of conditions was randomized for each session.
Experimental Design
An alternating treatments design was used to evaluate sight word acquisition
and maintenance (Hayes, Barlow, & Nelson-Gray, 1999) during both the BEA
and extended analyses. During the BEA, Huey was exposed to each intervention one time. Thus, these data were evaluated for differences in level as a
change in neither trend nor variability was possible (Martens, Eckert, Bradley,
& Ardoin, 1999).
Interobserver Agreement (IOA) and Treatment Integrity
IOA was collected for 44% of the BEA sessions and 23% of the extended
analysis conditions. IOA was calculated by dividing the number of agreements by the number of agreements plus disagreements and multiplying the
resulting number by 100 (Martin & Pear, 1996). During the BEA, IOA averaged 99.5% (range = 98-100). During the extended analysis, IOA averaged
96% (range = 90-100). Cohen’s kappa was also calculated as an additional
measure of agreement. Kappa was calculated by subtracting the probability
of chance agreement by the observed agreement and dividing that number by
one minus the probability of chance agreement. The probability of chance
agreement was 0.5 because a word was scored as read correctly or incorrectly. During the BEA, kappa was 0.99. Kappa during the extended analysis was 0.92.
Treatment integrity data were collected for 44% of the BEA sessions and
23% of the extended analysis sessions. Treatment integrity was collected by
creating a task analysis of the steps to be performed for administering a test
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Behavior Modification 35(1)
Figure 1. Data from the Brief Experimental Analysis.
Note: Each condition represents data obtained after conducting the specified intervention.
Each condition was assigned a novel word list, all of which were composed of words that
were read incorrectly during sight word selection phase.
or training. An independent observer checked off boxes of steps that were
completed and the percentage of correctly completed steps was calculated.
Integrity was 100% for the BEA and the extended analysis.
Results
Figure 1 displays results of the BEA. Accuracy ranged from 0% to 40%
correct. The Flashcards With Pictures and Phonics intervention procedures
were most effective in producing accurate responding during testing. Both
interventions resulted in 40% accuracy on tests. These interventions were
used in the extended analysis and compared to a control condition. Figure 2
displays the results of the extended analysis. During the first comparison
(top panel, Figure 1), Huey mastered a word list in six sessions using the
Flashcards With Pictures intervention and averaged 80% accuracy during
the three 1-week interval maintenance tests. Using the Phonics intervention,
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Figure 2. Results of the Extended Analysis for Both Sets of Words.
Note: Open shapes represent maintenance data, which were collected in 1-week intervals
following mastery of a list.
Huey mastered a word list in 12 sessions and averaged 63% on the maintenance tests. For the control condition, Huey averaged 13% correct responding (range = 0-20). The extended analysis was replicated using a second set
of word lists (bottom panel, Figure 2). Huey mastered the Flashcards With
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Behavior Modification 35(1)
Pictures list in 12 sessions and averaged 90% correct on the maintenance
tests. With the Phonics intervention, Huey mastered the list of words in 23
sessions and averaged 100% correct on the maintenance tests. Across the
two extended analyses, Huey required about twice as many sessions to master word lists using the Phonics intervention as compared to lists using the
Flashcards With Pictures intervention. During the first extended analysis, the
Flashcards With Pictures resulted in 80% accurate maintenance responding
while there was a substantial drop in accuracy for the Phonics list; however,
during the second extended analysis, both word lists were maintained at mastery level accuracy during the maintenance tests. During both extended analyses, the control condition list did not increase, meaning that the interventions,
and not extraneous factors, led to increases in sight word reading accuracy.
Discussion
BEA is a useful tool for determining which interventions are likely to help
a student who is demonstrating academic difficulties. The general utility of
BEA has been demonstrated for oral reading fluency (e.g., Daly et al., 1999;
Gortmaker et al., 2007; Welsch, 2007), reading comprehension (McComas
et al., 1996), mathematics (Codding et al., 2009), handwriting (Burns et al.,
2009), and spelling (McComas et al., 1996). This study extends the previous
research by demonstrating the utility of BEA in identifying effective sight
word reading interventions. Prior to this investigation, Huey had failed to
acquire a single sight word in the 2 months while at his private school. The
BEA identified two teaching procedures that were then demonstrated to be
effective in increasing sight word acquisition for this student.
Utility of BEA has been analyzed on different levels. The majority of this
research selects a high-performing intervention from a BEA and compares
the effects of that intervention with baseline performance (e.g., Burns et al.,
2009; Daly et al., 2006; Eckert et al., 2000; Gortmaker et al., 2007; McComas,
et al., 1996). The utility of a BEA can be further tested by comparing two
relatively unequal interventions (VanAuken et al., 2002) or two relatively
equal interventions (Welsch, 2007) in an extended analysis. In the current
study, the two interventions that were compared in the extended analysis
were the two highest performing interventions during the BEA. These interventions produced the same results during the BEA. On the basis of the
results of the BEA, one would predict that the two interventions should produce relatively equal results in an extended analysis. This was not the case. In
terms of acquisition, the Phonics interventions produced mastery in twice as
Baranek et al.
89
many sessions as the Flashcards With Pictures interventions. The maintenance
data were mixed. For the first set of word lists, the Flashcard With Picture
intervention produced 80% accurate maintenance responding while the Phonics
intervention produced lower results (M = 66%). For the second set of word
lists, both interventions produced mastery-level maintenance responding with
a slight advantage for Phonics (100% vs. 90%). Overall, the Flashcard With
Pictures intervention produced quicker acquisition and more robust maintenance than did the Phonics intervention, even though the BEA identified the
two interventions as equivalent.
The nature of the target skill in this study (sight word acquisition) allowed
for a different analysis of the utility of a BEA than previous studies. Previous
studies have examined oral reading fluency (VanAuken et al., 2002; Welsch,
2007), which is at a higher level on the instructional hierarchy (Daly et al., 1996).
Acquisition of a skill involves accuracy, whereas fluency involves accuracy
and rapid responding. By examining the utility of a BEA with a skill in the
acquisition phase, we were able to clearly demonstrate the number of exposures to each intervention that were required for the student to master specific
sight words.
The results of the current study confirm that the BEA is effective in identifying interventions that are likely to produce above-baseline academic performance but calls into question whether this assessment can identify differentially
effective interventions. This is not to argue that the BEA is not useful, but the
strengths and limitations of any system should be fully acknowledged. From a
cost-benefit perspective, the benefit of conducting a BEA is that many interventions can be tested in a short amount of time and there is ample evidence that
selecting the highest performing intervention will lead to higher academic performance as compared with baseline (e.g., Burns et al., 2009; Daly et al., 2006;
Eckert et al., 2000; Gortmaker et al., 2007; McComas, 1996). The cost is
that the brief nature of the assessment may mask the true effects of interventions.
Based on the BEA from the current study, the data indicated that selecting either
Flashcards With Pictures or Phonics would lead to effective acquisition, which
was demonstrated as true. However, as the extended analysis reveals, selecting
the Flashcards With Pictures intervention will produce twice as many acquired
sight words in any given time period. This is an issue of efficiency. A BEA may
best be suited for identifying effective interventions as opposed to identifying
efficient interventions. However, by supplementing a BEA with an extended
analysis, information on effectiveness and efficiency can be gathered.
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Behavior Modification 35(1)
Future research could address the potential limitations of a BEA. Studies
could be conducted that examine the comparative effectiveness of the hierarchy of interventions produced from this assessment. The design of a BEA
could also be examined. Brief does not necessarily mean one observation of
each intervention effect. Perhaps a BEA that involves two or more samples of
each intervention would produce a more robust intervention hierarchy. If one
considered the first data point for each intervention of the two extended analyses (in this study) as part of the BEA, then Flashcards With Pictures would
have scores of 40%, 60%, and 20%, whereas Phonics would have scores of
40%, 40%, and 10%. The additional data points would indicate that the
Flashcards With Pictures intervention was slightly more effective than the
Phonics intervention. This lends some evidence to the argument that more
data points could potentially produce more robust intervention hierarchies.
More research on the number of BEA samples would be useful for practitioners who can then weigh the amount of time an assessment requires with the
benefits that are likely to occur from one way of conducting a BEA to another
way.
A limitation of this intervention was the fact that only one student participated in this study and only one academic area was targeted. This limits the
generalization of these results. These findings could be unique to this student,
unique to sight word acquisition, or unique to this combination. Therefore,
this type of research should be conducted with a variety of students and academic content to truly assess the utility of BEA to differentially identify
effective academic interventions.
With increased use of BEA in applied setting, researchers should continue
research on the appropriateness of a BEA to identify effective interventions for
academic deficits. Research on the utility and the limits of this type of assessment are needed so that practitioners can weigh the strengths and weaknesses
of this type of assessment. The assumption of this body of research is that this
is an effective tool for intervention identification. However, this assessment
really gauges the immediate impact of intervention strategies. Some strategies
may have impacts that only emerge over time. For instance, one could argue
that, while in the short run, Flashcards With Pictures is a more efficient strategy
than Phonics for this child, Phonics would be a better strategy in the long run
because Phonics is a broader skill that is more likely to generalize to new
words. Flashcards and Pictures, however, is a strategy that is not likely to teach
anything beyond the immediate words. Continued research is needed to better
articulate the strengths and limitations of BEA.
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Baranek et al.
Appendix A
Sample Test Word List
but
how
then
can
old
where
Appendix B
Flashcards With Pictures Words
did
pull
for
she
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Behavior Modification 35(1)
Acknowledgment
The authors thank Sara Whitcomb for her helpful suggestions on an earlier version of
this manuscript.
Declaration of Conflicting Interests
The authors declared no potential conflicts of interests with respect to the authorship
and/or publication of this article.
Funding
The authors received no financial support for the research and/or authorship of this
article.
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Bios
Amy Baranek is currently a clinical director at the May Center for Education and
Neurorehabilitation. She received her MA in clinical psychology from Minnesota
State University and is completing her PhD in school psychology from the University
of Southern Mississippi. Her research interests include skill acquisition and habit
reversal in the developmentally delayed population.
Daniel M. Fienup is currently an assistant professor at Queens College of the City
University of New York. He received an MS in behavior analysis and therapy from
Southern Illinois University, a PhD in school psychology from Illinois State
University, and is a board certified behavior analyst-doctoral. His research interests
include the assessment of academic skills difficulties, and effective and efficient
academic instruction.
Gary Pace is currently a supervising psychologist at the May Center for Education
and Neurorehabilitation. He received his PhD in experimental psychology from the
University of Kentucky and is a board certified behavior analyst-doctoral. His research
interests include the assessment and treatment of severe behavior problems.