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Early basic research showed that increases in required response effort (or force) produced effects that resembled those produced by punishment. A recent study by Alling and Poling determined some subtle differences between the two behavior-change strategies, but also confirmed that increasing required effort is an effective response-reduction procedure with enduring effects. In this paper we summarize basic research on response effort and explore the role of effort in diverse applied areas including deceleration of aberrant behavior, attention deficit hyperactivity disorder, oral habits, health care appointment keeping, littering, indexes of functional disability, and problem solving. We conclude that renewed interest in response effort as an independent variable is justified because of its potent effects and because the political constraints imposed on punishment- and reinforcement-based procedures have yet to be imposed on procedures that entail manipulations of response effort.

Range and Cotton (1995) showed that many of the articles reviewed in their study did not include a line specifying institutional review board-approved procurement of informed parental permission and child assent for child research. Range and Cotton stated that the absence of the line suggests a lack of sensitivity to permission/assent issues, implied that many authors of the articles did not obtain permission/assent, and said those who did but did not report it were camouflaging those who did not. In this article, the logic of these points is refuted, the ethics of the Range and Cotton study are questioned, and its potential divisiveness is lamented.

Pediatricians are often asked to advise parents who are having difficulty managing the oppositional behaviors of their toddlers and preschool-age children. A large number of articles provide advice to pediatricians and parents on effective disciplinary strategies. However, despite the fact that verbal explanations, reasoning, and instructions are commonly used by parents, few articles directly address the use of these strategies to affect children's behavior. In this paper, we review studies that explicitly investigate the ability of adults' verbal explanations or instructions to alter the behavior of young children. These studies suggest that under most circumstances, verbal explanations and instructions are not effective in changing young children's problem behaviors. We then discuss how theories in developmental and behavioral psychology help explain the limitations of using verbal reasoning and instructions to change young children's problem behaviors. Finally, we provide some recommendations for parents on the use of verbal explanations and instructions in disciplining young children.

We evaluated the effects of two health education teaching methods, a pamphlet based on a task-analyzed checklist and two professionally developed films, on the completeness, accuracy, and maintenance of testicular self-examinations (TSE). Subjects (N = 48) were videotaped while performing a TSE after training and at a follow-up visit. Direct observation of the tapes showed that checklist-based training resulted in more complete and longer TSEs (p < .05). Social validation ratings, however, suggested that physicians were unable to discriminate reliably the performances of subjects taught using the two methods. Accuracy of detection of simulated lesions on plastic models was also similar for the two groups. Adherence to TSE recommendations was high during the study, but declined across the follow-up period. Further study is needed to promote adherence to TSE and to document the effects of early detection on morbidity and mortality of testicular cancer.

It is estimated that enuresis affects 5 to 7 million children in the United States. Although the problem is common and well known, appropriate and effective treatment is not always provided. This may be due to the many etiological theories associated with this condition as well as a correspondingly high number of interventions. The present paper summarizes the empirical literature regarding primary nocturnal enuresis (PNE), with an emphasis on pharmacological and behavioral interventions. The data support the view that children with enuresis have a wide range of negative experiences that can affect self-esteem and development, but that enuresis is not associated with significant psychiatric or behavioral difficulties. Given the strong empirical support for several interventions for PNE, children who have this condition should not go untreated.

Publisher Summary Nocturnal enuresis, or enuresis, is a very common parasomnia affecting 5–7 million children annually. It is largely an inherited condition wherein children involuntarily pass urine while asleep. Nocturnal enuresis affects 15–20 percent of 5-year-old children, with as many as 10 percent of those children remaining wet at 10 years of age. Prevalence rates tend to be somewhat higher for boys than girls throughout. By 12 years of age, approximately 8 percent of boys and 4 percent of girls continue to be enuretic. Treatment is often deferred until age 6 or 7, because enuresis shows a steady decline with age and has an annual spontaneous remission rate of approximately 15 percent. In addition, younger children may be less motivated to participate in treatment. After the age of 6 or 7, however, numerous reasons for treatment arise. Nocturnal wetting episodes inexorably interfere with participation in recreational activities (such as sleepovers, overnight trips, and camp), thus imposing an obstacle to important social and developmental experiences. Chronic bedwetting also can result in sleep disruption for the child and other family members. In addition, incontinence is a leading cause of child abuse. Finally, a child with enuresis may develop an unhealthy low self regard that interferes with effective psychosocial development.

Child health-care appointments that are not kept are an important pediatric problem. Previous research has shown that reducing effort (with a parking pass) and reminding patients (with mailed and telephone reminders) significantly improved appointment keeping for first-time and patient-scheduled appointments. This study, using a posttest-only group design, evaluated the effects of various combinations of that intervention applied to clinic-scheduled follow-up appointments. All combinations of the intervention significantly increased cancellations, but none increased appointments kept or decreased appointments not kept significantly. Log linear analyses showed that the lag time between scheduling and the appointment significantly influenced appointment keeping. The results suggest that if clinics want to increase cancellations, a mailed reminder and effort reduction are sufficient. To increase appointment keeping, other interventions, such as reduced lag time, may be necessary.

We evaluated the accuracy of primary health care providers' predictions of parents' adherence to their children's short-term antibiotic regimen and a scheduled follow-up appointment. Adherence predictions were compared with objective measures of the parents' adherence. Providers were poor predictors of nonadherence, greatly overestimating the percentage of parents who would be adherent. Nonadherence is typically addressed by applying adherence improvement strategies to all patients. Recent pediatric research, however, suggests that applying contingency-based interventions for adherent patients can result in later nonadherence if the strategies are withdrawn. Inaccurate predictions of adherence will result in many nonadherent patients not receiving a needed intervention. The results indicate the need for strong behavioral predictors that result in more accurate identification of patient nonadherence to guide further applications of adherence improvement strategies.

Many psychologists believe a Kuhnian revolution—a competitive event between incommensurate paradigms in which a winner displaces losers after chaotic upheaval— has occurred in psychology. Cognitive psychology is said to be displacing behavioral psychology and psychoanalysis, but few published data support this thesis. Social science citation records from the leading journals in cognitive psychology, behavioral psychology, and psychoanalysis between 1979 and 1988 were analyzed. Results show an increasing trend for cognitive psychology but also high citation rates with no downward trends for behavioral psychology. Citation rates for psychoanalysis are not as high, but indications of decline are marginal. These findings do not support the Kuhnian displacement thesis on changes in modern psychology.

Injuries are the major causes of death for children. Pediatric psychology offers significant contributions to the multidisciplinary efforts necessary to prevent injuries and reduce harm to children. This Task Force Report reviews epidemiological data, characteristics of children's injuries, passive and active interventions for reducing injuries, and research, policy, and evaluation issues for individual and community injury control efforts. Directions for future pediatric psychology efforts are identified and placed in a context of collaborative efforts required to advance the control of children's injuries. Language: en

Behavior analysis is a generic science, and Skinner's vision for it was that it would become a mainstream force, relevant for most if not all human concerns, major and minor. Clearly his vision has not been realized. Determining why this is the case would require a complex multifactorial analysis. One likely factor is that the majority of its basic science findings have been obtained from the study of rats and pigeons. Another likely factor, one directly addressed by this paper, is that the majority of its applied science findings have been obtained from the study of people in only one tail of the normal distribution. Regardless, those outside the field see the relevance of behavior analysis to general human affairs as very limited. Whether the path behavior analysis is on will lead to widespread perception of mainstream relevance anytime soon seems doubtful. An alternative route would involve integrating it with a field that has already made the trip successfully. A premier example involves primary medical care. This paper argues for the integration of behavior analysis with pediatric primary care, sketches a method for its accomplishment, and uses diurnal enuresis to illustrate the requirements of the method.

This study examines the effects of a "transitional object" (surgical cloth) on the thumb sucking of a 3-year-old boy in two conditions: while sitting in the lap of his physical therapist and while alone in his crib. Sucking occurred when the cloth was present and did not occur when it was absent, regardless of condition. These results are discussed in terms of establishing operations, object attachment, and application.

Reviews data on the identification of child behavior disturbance by health care providers in the pediatric primary care setting. The literature indicates that pediatric primary care providers underidentify children's mental health problems. The effectiveness of screening efforts are reviewed with an emphasis on issues relevant to problem identification with disadvantaged children and families.

Toilet training is becoming an increasingly important child care issue as child raising becomes an institutional enterprise. This paper reviews the literature of the last 40 years, focusing on the epidemiology of the development of day and night bladder control. The studies indicate that bladder control is usually obtained between 24 months and 48 months of age. Many variations exist between studies, especially the endpoint used to indicate completion of training. Modifying the endpoint used and the related training practices could decrease the age at which children are trained.

We evaluated parent use of DRI to treat high rate disruptive behavior in their severely handicapped four-year old son. We used a withdrawal experimental design for the analysis. Both parents used DRI with equivalent accuracy and effectiveness resulting in substantial direct and collateral treatment effects.

Evaluated treatment for thumb-sucking in a randomized trial. Study included 22 children, ages 4-11, who displayed chronic thumb-sucking. Treatment included aversive taste and a reward system. Significant results were obtained at posttest, with 12 cessations at 3-month follow-up and 20 at 1 year. Participating parents, pediatricians, and pediatric psychologists validated treatment acceptability. Results support the treatment as an alternative to common medical and dental advice about thumb-sucking. Directions for future research are discussed.

Among the most common, persistent, and stressful presenting complaints in primary medical care for children are two disorders involving developmentally inappropriate elimination of waste–enuresis (urine) and encopresis (feces). The author emphasizes that, although evaluation and treatment of these conditions absolutely requires the direct involvement of a physician, ideal management involves a partnership between the physician, therapist, and family. This united, empirically supported, biobehavioral approach can alleviate incontinence and eliminate or at least minimize the possibility of the damaging overinterpretation and dangerous forms of treatment that blemished the approach to enuresis and encopresis from antiquity throughout large portions of the twentieth century. Enuresis and encopresis are among the most treatable of all child behavior problems. The most effective treatments for enuresis and encopresis are multicomponent and effortful and therefore motivation to participate in treatment, by parents and children, is a significant concern. The chapter outlines the essential components of successful treatments following the evidence-base in the professional literature.

In this chapter we reviewed a variety of harmful medical and non medical problems associated with tic disorders, trichotillomania, and other RBDs. We also attempted to explain the potential etiology of the concerns, and discussed possible strategies for their clinical management. Although this chapter summarized the extant research on these topics, it is clear that the lines of investigation are either in their early stages or have yet to inaugurated. For example, the epidemiology of secondary non medical problems is incomplete across disorders and research on the cause of these problems is incomplete for some disorders (e.g., tic disorders) and missing entirely for others (e.g., nail biting). The empirical literature on psychological and/or behavioral treatments for the harmful effects of RBDs is also quite limited. Although we describe or propose a sample of interventions to address at least some problems associated with RBDs, few of these have been scientifically evaluated in that context. There are examples of other important research agendas scattered throughout this chapter. It is our ardent hope that research on the sequelae of RBDs will expand sufficiently to achieve a goal of paramount importance for those afflicted, elimination or substantial reduction in related harm.

Objective To evaluate the Bedtime Pass Program (BPP), an extinction-based procedure for treating bedtime resistance in typically developing children. Methods A randomized, controlled trial in which nineteen 3- to 6-year-old children demonstrating bedtime resistance were randomly assigned to a Bedtime Pass or Monitoring Control group. The experimental condition involved parent monitoring plus the Bedtime Pass: a card exchangeable for one parental visit or excused departure from the room after bedtime, with parents ignoring subsequent bids for attention. Results Children in the Bedtime Pass condition left their rooms and called and cried out significantly less frequently than controls. They demonstrated significant reductions in the time required to quiet each night. Treatment effects were maintained at 3-month follow-up. Parents reported high levels of satisfaction and treatment acceptability. Conclusions BPP is a noncomplex, socially acceptable, effective treatment for bedtime resistance. It retains the powerful effects of extinction-based procedures without the "extinction burst."

The authors evaluated the effects of response prevention, a treatment previously shown to be effective for routine thumb sucking and suggested to be effective for early onset trichotillomania, applied to hair pulling in a 2-year-old. Response prevention was used alone in two settings (bedtime and naptime) and combined with a brief time out in another (daytime). The authors also used a novel assessment, weight of hairs pulled, and the results indicated complete cessation of hair pulling. Corresponding photographic evidence indicated complete regrowth of hair lost to pulling. These results add to a growing literature suggesting early onset hair pulling may be more appropriately classified as a benignhabit thanas trichotillomania.

Trichotillomania is a behavioral disorder characterized by habitual hair pulling resulting in alopecia. Although once considered extremely rare, a recent survey study of college freshmen suggests a lifetime prevalence of more than 3% in females and more than 1% in males.1 The recent literature on trichotillomania has emphasized the pharmacologic treatment of adolescents and adults. Some studies have reported decreased hair pulling in response to treatment with the antiobsessional medications clomipramine and fluoxetine2,3 However, Christenson and colleagues4 failed to demonstrate benefit from fluoxetine, and in a preliminary report Rothbaum and Ninan5 found greater decreases in hair pulling with a behavioral intervention than with clomipramine.

Chronic thumb sucking in school-age children may reduce peer social acceptance, an important contributor to social development. The influence of thumb sucking on social acceptance was assessed among 40 first-grade children, who were shown four slides of two 7-year-old children (one boy, one girl) in two poses (one thumb sucking, one not). After viewing each slide in their classrooms, the children answered 10 numerically weighted questions related to peer acceptance. To limit the possibility that the children would determine the girl and boy were the same in each pose, the slide presentation was counterbalanced across two sessions 1 week apart. Using a repeated-measures analysis of variance, the authors compared composite scores on each question for both poses. The results indicate that while in the thumb-sucking pose, the children were rated as significantly less intelligent, happy, attractive, likable, and fun and less desirable as a friend, playmate, seatmate, classmate, and neighbor than when they were in the non-thumb-sucking pose. These findings suggest that the risk of reduced social acceptance should be added to the list of potentially harmful effects of chronic thumb sucking in school-age children.

We studied how rewarding youth in residential care for publicly reporting positive social behavior influenced the social interactions and acceptance of their most socially isolated peers. Results showed that the intervention resulted in substantial improvements in social interactions by the previously isolated peers. Peer acceptance ratings also improved for 2 of the target youths.

We assessed the academic performance of a 14-year-old boy with insect phobia in the context of feared stimuli. The dependent measure was math calculation rate across three conditions that varied therapist statements about the presence of crickets and the actual presence of live crickets. Subsequent treatment consisted of graduated exposure and contingent rewards for math problem completion. Assessment results indicated that the boy's performance was consistently low in the presence of live crickets but not when he was spuriously informed that crickets were present (the primary referral concern). Treatment results indicated no effect from exposure alone and a dramatic effect when exposure was combined with contingent rewards.

To determine if primary nocturnal enuresis (PNE) is accompanied by significant behavioral comorbidity.A survey design using a standardized behavioral rating scale.Behavioral pediatric clinics in the Midwest.Subjects with PNE (n=92) were selected from 122 consecutive referrals for enuresis. Criteria included age 5 years or older, PNE status, and wetting frequency of at least once per week. The clinical sample without PNE (n=92) was randomly selected from 429 consecutive referrals to the same pediatric clinics, stratified for age and sex. The nonclinical sample (n=92) was randomly selected by strata from the standardization sample (N=614) of the behavioral checklist used in the study.The Eyberg Child Behavior Inventory (ECBI), a standardized parent report scale, was used to measure the degree of behavioral comorbidity. The ECBI yields 2 scores, Problem Intensity and Problem Number.Results from 2 separate 3 (group) x 2 (sex) analyses of variance indicated a significant main effect for group on Problem Intensity and Problem Number (P.001). For Problem Intensity, post hoc comparisons indicated the mean of the PNE sample was significantly higher than the mean of the nonclinical sample (P.05), but the mean scores of the clinical sample were significantly higher than those of both the PNE and nonclinical samples (P.05). For Problem Number, post hoc comparisons revealed the means of the PNE and nonclinical samples did not differ from each other (P.05) but were lower than the mean of the clinical sample (P.05).Primary nocturnal enuresis does not present with significant behavioral comorbidity in most cases. The results suggest that, with the exception of an extraordinary clinical presentation, pediatricians should treat PNE as a common biobehavioral problem without a psychiatric component.

Historically, anxiety has been a dominant subject in mainstream psychology but an incidental or even insignificant one in behavior analysis. We discuss several reasons for this discrepancy. We follow with a behavior-analytic conceptualization of anxiety that could just as easily be applied to emotion in general. Its primary points are (a) that languageable humans have an extraordinary capacity to derive relations between events and that it is a simple matter to show that neutral stimuli can acquire discriminative functions indirectly with no direct training; (b) that private events can readily acquire discriminative functions; (c) that anxiety disorders seem to occur with little apparent direct learning or that the amount of direct learning is extraordinarily out of proportion with the amount of responding; and (d) that the primary function of anxious behavior is experiential avoidance. We conclude that the most interesting aspects of anxiety disorders may occur as a function of derived rather than direct relations between public events and overt and private responses with avoidance functions. Implicit in this conclusion and explicit in the paper is the assertion that anxiety is a suitable subject for behavior-analytic study.

This chapter will discuss enuresis and encopresis, the two most commonly occurring elimination disorders in children. Although the primary clinical features of both disorders are medical/organic, a fusion of medical, psychological, and behavioral literature supports biobehavioral methods of assessment and treatment as state of the art. For many years, the interpretation and treatment of both problems was governed primarily by a psychological perspective. This perspective shifted with respect to imputation of personal responsibility. Elimination disorders were initially perceived as volitional acts occurring as a function of character defect; thus, treatment tended to be highly punitive (Glicklich, 1951; Levine, 1982). Although a cultural residue of this early characterological perspective remains (i.e., children are still frequently punished for urinary and fecal accidents), toward the middle of this century the characterological position was superseded by a psychopathological perspective. This position lifted the emphasis on volition and personal responsibility and instead emphasized variables such as aberrant family dynamics and toilet training practices and their potentially maladaptive influence on subsequent psychic development (Sperling, 1982; Warson, Caldwell, Warinner, & Kirk, 1954). In the past two decades, the strictly psychopathological perspective has shifted to the aforementioned biobehavioral perspective (Friman, 1986, 1995; Friman & Chrisophersen, 1986; Houts, 1991; Levine, 1982; Mellon & Houts, 1995; Warzak & Friman, 1994). Our approach to assessment and treatment will be guided by that perspective.

Peter Lamal’s response to our paper on anxiety (Friman, Hayes, & Wilson, 1998) is as much a critique of Skinner’s approach to private events (e.g., Skinner, 1984) as it is a critique of our paper. Skinner’s position constituted a rebuttal to the ubiquitous dualistic notion that behavior is but a mere manifestation of unseen cognitive and emotional processes that have vitalistic primacy. Skinner attempted to eliminate this dualism by defining all human activity as behavior, even when the activity is observable to the actor alone. In contrast, Lamal claims that private events have merely putative or hypothetical status as behavior and that only public events can be studied scientifically. But by excluding private events from definitions of behavior because they are so inherently different from public events, Lamal has merely adopted a different form of dualism. We side with Skinner’s more thoroughgoing nondualistic stance. Lamal relies heavily on Zuriff, who claimed that ‘‘no evidence is currently available to show that verbal responses enter into causal relationships with private events or that these private events are stimuli in the sense of conforming to the same laws as their

We evaluated the effectiveness of an abbreviated habit reversal procedure to reduce maladaptive oral self-biting in an adolescent boy in residential care. Treatment involved a combination of relaxation and two competing responses. Results of a withdrawal design and two posttreatment medical evaluations indicated that the intervention eliminated the biting and the tissue damage it caused.

We studied how rewarding peers for publicly reporting positive aspects of a socially rejected girl's behavior affected her social interactions and acceptance. The results indicated that positive peer reports reduced negative social interactions (to near zero) and increased positive interactions (to above 70%). In addition, social acceptance ratings of the girl increased from pre- to postintervention.

Studied the relationship between chronic thumb-sucking and behavior problems reflective of psychopathology. Compared scores on the Child Behavior Checklist (CBCL) and Eyberg Child Behavior Inventory (ECBI) for matched samples of thumb-sucking, referred, and nonreferred children. Mean scores for the thumb-sucking and nonreferred samples were equivalent and were significantly lower than scores for the referred sample. Comparing scores for older children (8-14 years) and younger children (4-7 years) did not produce a significant interaction. Correlating measures of thumb-sucking severity with ECBI and CBCL scores produced only 8 (of 42) significant correlations and a mean correlation of only .09. Collectively our results provide little support for the theoretically derived notion that thumb-sucking is necessarily a symptom of psychopathology.

• Thumb-sucking and object attachment commonly occur during childhood. Object attachment is usually harmless, but thumb-sucking can lead to complications when chronically practiced by older children. Effective thumb-sucking treatment is available, but to my knowledge, it has not been evaluated on thumb-sucking children who are also attached to objects. This study, using a multiple baseline design, shows treatment eliminated thumb-sucking in eight thumb-sucking children with concurrent attachment and that seven of the children subsequently lost interest in their attachment object. (AJDC. 1990;144:1316-1318)

A multiple baseline across three providers showed that each provider, using only differential reinforcement of incompatible behavior (DRI), substantially reduced high-rate out-of-seat behavior in a highly disruptive 4-year-old boy with severe disabilities. During the experiment, duration of the boy's in-seat behavior expanded from less than 1 min to 20 min. Furthermore, during the intervention, the providers' use of physical restraint decreased to near-zero levels, even though restraint and DRI could he used together. Although not specifically targeted, the boy's appropriate toy play also increased during DRI.

We evaluated the effect fit of underwear had on sperm production in two healthy adult males in their early thirties. The subjects alternated from wearing tight fitting bikini type briefs to loose fitting boxer type briefs in an ABAB withdrawal design. Conditions lasted three months and were alternated twice resulting in a one year study. The initial condition for each subject was randomly determined with the laboratory technologist blind to the conditions. Four semen parameters were analyzed in this study: sperm density, total number of sperm, total number of motile sperm, and total number of motile sperm per hour of abstinence. The results showed the semen parameters gradually decreased in tight conditions and gradually increased during loose conditions. Although preliminary, the results support the commonly held but undocumented belief that the fit of men's underwear can influence sperm production.

The incidence of testicular cancer is rapidly increasing. It is highly curable when detected and treated early, yet 500 to 1,000 men die from this cancer each year. Most victims are young men whose deaths account for a large number of potential years of life lost. Risk factors for testicular cancer are known but they cannot account for the increase in incidence. Only one age group, men between 15 and 34 years, is currently exhibiting an increase in incidence and mortality and should therefore comprise the primary at-risk group. Health education for the at-risk group, including promotion of regular and accurate testicular self-examination (TSE), could lead to earlier tumor detection and treatment and thereby save lives.