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Over the counter service versus training and treatment efficacy: what will behavioral health rehabilitation (wrap-around) programs strive to be?

This article is a part of the on-going series of operational, management and consulting issues that appear in developing and running a behavioral health rehabilitation (wrap-around) program. It is recommended that readers begin this series with reading the first article in the first issue of the behavior analyst today (e.g., Cautilli & Clarke, 2000) and work through all of the articles. These articles draw on an organizational behavior management perspective to structure what many have come to see as unstructured at best. Services rendered in the child's home, school and community. Since the first article, we have set out to cover three major objectives: keeping costs low , scheduling in an efficient manner (Cautilli, Rosenwasser, & Clarke, 2000), and enhancing performance of the key players (Cautilli & Santilli-Connor, 2000; Hancock, Cautilli, Clarke, & Rosenwasser, 2000; Thomas & Cautilli, 2000). These objectives often lead to trade-offs between components. For example, the cost of a new supervisor is often a trade-off against the increased performance to the teams under the supervisor's care. It becomes important to recognize that tradeoffs in training, education of key personnel, and a process of developing a continuum of care through expertise and specialization instead of simply developing new programs to provide a continuum of care will ultimately prove more efficacious. Additionally "forms" compliance should never replace sound clinical decision-making. Also, the way that BHRP programs build partnerships is important to the smooth functioning of such programs. This paper discusses these issues while examining the direction that BHRP's should not but unfortunately seem to have taken.


The goal of Behavioral Health Rehabilitation Programs (BHRPs) that wish to survive in the current health care environment is to create an agency that fosters a continuous learning environment. Such an environment will increase employee dedication and loyalty, through the use of training to build skills of employees and take an active role in professional development. Thomas & Cautilli, (2000) suggest that such agencies will foster development and promote Behavior Specialist Consultants (BSC), Mobile Therapists (MT) and Therapeutic Staff Support (TSS) who become expert in the treatment of specific issues facing children in their care. This allows the agency to expand their continuum, while increasing the efficacy of their treatment. Pre-service training that focuses on clinical issues likely to be encountered in the field will greatly improve the quality and effectiveness of the services the clinician will provide (Thomas & Cautilli, 2000). These practices will be especially important during the predicted future worker shortages in the mental health field, where potential workers can be particularly "choosey" about their employment opportunities.

While studies have shown that organizations routinely invest as much as 85% of their income in salaries to compensate adequately trained professionals they invest only as much as 1% of income to maintain or improve the skills of their current professionals. Current data suggests that a 30:1 ratio of increase in job performance can be obtained for each investment in training and education of employees. Yet much of the training offered by BHRPs focuses on "paperwork" and "policy" over performance, management, and increasing clinical effectiveness. We suggest that BHRPs should reinvest 3-5% of their gross salaries into professional development for their employees. This money should be targeted for education programs and training in performance enhancement, time management, managerial enhancement, and specific clinical training.

In order to ensure that BHRPs are attracting and retaining the "best" clinicians, training should be linked to employee compensation packages through the use of skill based pay systems. In a skill based pay system employee pay is based on the knowledge and skills that the employee can demonstrate. The skills reflected in this type of plan go beyond the immediate skills required for the current job. This type of reinforcement often motivates attendance at trainings and in conjunction with adequate supervision can increase the overall efficacy of the clinician. Side effects of such pay systems are dramatic increases in the volume of training demanded by the professional staff. Additionally skill-based pay systems require audits to continually evaluate employee skills to ensure that competencies exist. Regular outcome studies can enhance the program's ability to meet the staff's needs. The costs for these are far outweighed by the benefits to organizations that strive to provide the highest quality of care and efficacy of treatment. Quality programs should continually evaluate training programs.


Consultation has been shown to decrease special education referrals (Ponti, Zins, & Granden, 1988). This establishes the BHRPs can be of particular use to the school systems. BHRPs that demonstrate ability to successfully reach shared goals with the school system will have an advantage over BHRPs which do not, especially in the wake of the Kellner decision. In this case the court acknowledged that the ultimate responsibility for children's right to a free and appropriate education rests with the school system. Ponti et al. (1988) found that consultation programs that are most successful in reducing the need to move the child into higher level of care meet the DURABLE framework. The DURABLE model includes the following institutional supports to ensure success: discussing, understanding, reinforcing, adapting, building, learning and evaluating. These are also applicable to the current state of behavioral health rehabilitation services and suggest why such services have had difficulty with cost control. We discuss these concepts applying them to BHRPs and suggesting that many of these steps have still not occurred between many community elements such as schools, community groups and the mental health providers who perform BHRP in that community.

Discussing is where the program staff meets the community. Meeting before services begin, the mission, goals, and objectives for the BHRP are discussed and reviewed. Community input is sought. The eventual goal of a BHRP is to function in a symbiotic partnership with these systems to enhance their functions. Thus input into how these services are best rendered is reviewed. Discussion also occurs with the new program staff in setting up schedules of supervision, training, program timelines, and rights and responsibilities of those who will enroll in the program.

Understanding is the community's response to the suggestions. Communities should determine the level of expected need and how much reliance they will have on the program. The community in the form of the school or neighborhood needs to decide if they want this service and what the benefits are of having this service. For example, the school may profit from decreased need for special education classes.

Reinforcing is critical to program staff such as BSC and external personnel to the program. What are the reinforcers to the school, neighborhood, or family for participating in this program? When should they expect to see benefit and what types of benefits should they expect to see? For example, recognition of the greater and expanding role of the teacher could be highlighted by explaining how this form of professional development should provide immediate and long-term benefits to the teacher.

Acquiring is a critical but often missed feature. Acquiring is training those who desire to receive the service, descriptions and specification as to what the service is about. For example, a school might have an in-service on the role and function of a BSC or any other staff that they may potentially use in their school. Staff community agencies should also receive this training.

Building refers to establishing close relationships between supervisory staff in the BHRP and the administrators in the community program, such as teachers or principals. Both sides should understand and have realistic expectations of what each brings into the relationship and what each can do. The roles and functions of staff from both agencies would be clearly delineated.

Learning is a supervisory component on both sides. Both sides need to learn their role and function in the set up and maintenance of the new program. For example, BSCs or TSSs may receive pre-service training on the legal and ethical issues of the school system in general with specific focus on the history and cultural practices of the schools in the area. Staff should be trained to be sensitive to using before and after school hours for consultation and that consultation should only occur during a time convenient for the teacher. School personnel may receive training on what consultation is and the teaming process. Expectations would be clearly communicated.

Evaluation is a critical and often omitted function. Have BHRPs had a positive impact not just on the children that they serve but also on the community? Do teachers feel that they are better equipped to handle children with emotional and behavioral disorders? These are questions that evaluation in BHRP has failed to answer.


Probably the most critical training that behavior analyst can receive is training on how to be a consultant. Unfortunately, most training programs in applied behavior analysis do not have a strong training component in consultation but in therapy. Consultation differs from therapy in that in consultation the consultant works with the consultee to change the behavior of the client (Bergan & Kratochwill, 1990). In therapy the therapist uses himself or herself as the direct source of client change.

Since consultation is an indirect service delivery model, it has several advantages over therapy. The first and primary advantage is that it helps to develop the community so that more people have the skills to help children with emotional and behavioral disorders. Second, it allows professionals to provide needed services to many clients at once.

From a behavioral perspective, what the consultant says during the consultation interview is critical to the implementation of the plan (Kratochwill, Van Someren, & Sheridan, 1989). Some research has shown this to be true. Bergan and Tombari (1975,1976) found that the more complete a problem identification interview is the better the overall chances for treatment outcome success. Thus Bergan's (1977) model stresses that the consultant should structure the interview to guide the consultee through the problem solving process. This system codes consultant and consultee verbal interactions along dimensions of content, process and control.

It is our belief that coursework in behavioral consultation, in which behavior theory is applied to help specify and code consultant and consultee interactions, will improve consultants' ability to intervene effectively. Bergan and Kratochwill (1990) suggest that training helps give the consultant the tools to monitor and receive feedback on his/her own verbal behavior. Thus this behavior can be subject to intervention. While this is not a paper on Bergan's (1977) system of consultation, one example might be helpful in understanding. A consultant who fails to summarize points then elicit validation may believe that the consulting relationship is going well only to find that the consultee does not implement the plan that the consultant develops because s/he does not agree with the environmental sources of the problem. Kratochwill et al. (1989) have a very interesting model for training behavioral consultants that can be readily developed into a training/workshop format.

If behavior specialists have not had this type of training, then we suggest at least twelve hours of pre-service training specifically in behavioral consultation with focus on interviewing from a behavioral perspective. In such training the participants should be scored on their verbal skills with video taped role-plays. Interviews are scored by the systems that Bergan (1977) developed and given frequent feedback on performance. This training is in addition to specific training in treatment models for the target population (e.g., individuals with autism, ADHD, depression, schizophrenia). Training in administrative matters such as documentation (treatment plans) and timelines is also essential.

Cautilli and Thomas have developed the following training programs as a means to address these critical functions of Behavior Specialist Consultant in the field:

Problem Identification, Analysis and Plan Implementation and Evaluation

This workshop presents the basics of Bergan's model of behavioral consultation. It outlines the problem-solving model and helps participants to skillfully draw on their knowledge of Behavior Analysis and functional Behavioral Assessment to guide solutions. Through stronger understand of the consultation process, consultants will improve their ability to interview consultee, develop collaborative relationships and use the principles of Applied Behavior Analysis in an effective service delivery model. In addition, participants will learn what teachers value in the consultation process. They learn ways to conduct brief interviews that help teachers establish goals and strong behavioral objectives as well as develop specific interventions to achieve those objectives.

Behavioral Parent Training

Behavioral parent training is currently the treatment of choice for parents of children with conduct and oppositional defiant disorders. In addition, behavioral parent training has demonstrated efficacy in the management of children with attention deficit disorder. Training parents in basic techniques of behavior modification will be explored as well as the research supporting the efficacy of these treatments. This workshop trains parent trainers.

Introduction to Behavioral Assessment

This workshop is a general overview of behavioral assessment. It offers participants exposure to several standardized instruments commonly used in behavioral assessment such as the Behavior Assessment Systems for Children, the Walker-McConnel Scale, Connors ADHD/DSM IV Scale, and the School Social Behavior Scales. In addition, this workshop offers an introduction to adaptive behavior assessments such as the ABS: RC-2, ABS: S2, Gilliam Autism Rating Scale and language and learning assessments like the ABLLS and Verbal Behavior Observational Assessment. Use of standardized behavioral assessment scales, is the beginning of an outcome based program and programs can be evaluated by changes in standard scores for children in the program.

Introduction to Functional Assessment and Functional Analysis

This workshop is designed to give participants a firm working knowledge of differences between functional assessment and functional analysis. Participants will also demonstrate selection of key elements of functional assessment and design a functional assessment strategy when given an example of problem behaviors and environment. Participants will demonstrate knowledge of all areas of functional assessment/analysis

Introduction to Behavioral Development in an Ecological Context

Participants will be exposed to Bijou's model of behavioral development. This model comes from within the behavior analytic tradition and offers much to the study of developmental psychopathology and developmental deficits. Finally this model will be reintegrated into Brofennbrenner's model of ecology.

Best Practices in Writing Treatment Plans

This workshop explores the treatment planning process. It links treatment planning to the consultation process. Participants learn to review establishing goals and objectives and write goals and objectives to facilitate the learning of appropriate social behavior. Training is also given in designing interventions in collaboration with teachers and families, allocation of time from treatment team members, and energizing members around activities and interventions that need to be performed. Participants will bring a recent copy of a treatment plan and relevant information pertaining to the individual and write a treatment plan with instructor guidance using best practices.

Resistance and Treatment Integrity

Resistance functions to lessen therapeutic suggestions and interventions. This workshop will look at the common reasons that resistance occurs and interventions that might help in lessening resistance for consultees. The use of these techniques to build and strengthen program integrity as well as techniques from organizational behavior management literature will also be explored.

De-Escalating Children with Serious Emotional and Behavioral Problems

The escalation cycle can be seen as a series of behavioral chains. Interruption of the chain can restore students with emotional and behavioral disorders back to a calm state. In addition, effective interventions during the escalation cycle can teach children self-control. This workshop is designed to help participants to recognize the steps in the escalation cycle and to create interventions with the goal of decreasing escalation at each step.

Teaching Language to Children with Developmental Disabilities

This workshop investigates the most relevant procedures for teaching language to children with developmental disabilities. This workshop includes the functional analysis of verbal behavior and particularly emphasizes the importance of both speaker and listener behavior in the development of language from a functional analytical framework

Developing Effective Discrete Trial Training Curricula

This workshop teaches participants to design and properly implement discrete trial training programs that meet the needs of children with developmental disabilities, offering structure and easily understood training procedures for 1:1 trainers, without ignoring the functional development of verbal behavior, response induction or stimulus generalization. Procedures are also reviewed to develop socialization and play skills.


Luthans and Lockwood (1984) studied what good versus effective managers really do. They found that often good managers (defined as those who receive the quickest promotions) spend a considerable amount of time, networking, politicking, and reinforcing their employees' performances. In stark contrast, those managers rated effective by employees were those who monitored work, had good communication between themselves and their supervisees, and applied motivational systems that were performance based. Thus managers who are effective engage in specific behaviors that lead to changes in the staff who work for them.

These practices have been formulated into programs often referred to as behavioral supervision practices. A growing body of research supports the use of behavioral supervision in increasing quality, integrity, and staff performance (see Babcock, Fleming, & Oliver, 1998). Both large scale and long-term studies exist to demonstrate that behavioral supervision in the community can achieve the goal of greater quality and staff performance (Parsons, Schepis, Reid, McCarn, & Green, 1987).


Servicing begins with an adequate evaluation. An old Italian expression is that a fish rots from the head down. This means that if the head (the evaluation is rotten) then the entire fish will soon rot (the teams performance). We suggest that evaluations for BHRPs follow the standards of IDEA 97. The Office of Mental Health should develop language and standards for evaluation of children similar to that mandated in The Individuals with Disabilities Education Act (IDEA) reauthorization of 1997. IDEA states in section 614 b, 2, under evaluation procedures:

(2) Conduct of Evaluation--In conducting the evaluation the local educational

agency shall (A) Use a variety of assessment tools and strategies to gather

relevant functional and developmental information, including information

provided by the parent, that may assist in determining whether the child is

a child with a disability....(B) not use any single procedure as the sole criterion

for determining whether a child is a child with a disability ... (C) use technically

sound instruments that may assess the relative contribution of cognitive

and behavioral factors, in addition to physical or developmental factors.

(IDEA Amendments, 20 U.S. C., 614(b)(2))

In addition to formal behavioral and standardized assessment, a thorough functional behavioral assessment of the child and the family should be conducted. This assessment should create a competing behaviors model for intervention and should be accompanied by a skills assessment.

Also, the following factors are important to ensuring that the project is comprehensive from a planning perspective:

* Functional assessment of the child and the family

* Identifying the project customer (family, teacher, child)

* Establish the end service

* Set objectives

* Estimate the total resources and time required

* Decide on the form of service organization (Activity schedule of the

* needed interventions for the child)

* Make key staffing arrangements (culturally sound, matching staff skill with the family and child's needs)

* Define the major tasks required (i.e., who does what interventions)

* Establish a cost projection

Each of these should be considered when planning service interventions. Omitting this type of comprehensive planning may result ineffective service delivery.

Since interdisciplinary teams are loosely coupled systems (Hantula, 1995), it becomes important for management at the supervisory level to control conflicts and confusion. Conflicts and confusion between team members with competing goals can lead to under servicing of clients having multiple service needs (Roberts, 1989). It is important that under servicing have a zero tolerance level. These areas of under servicing must be tracked and addressed in supervisory sessions for they may show that a team member is not sure of the treatment, including his/her role and responsibility. Under servicing outliers in evaluation of hours for client's needs to be tracked and statistical process control methods should be used to identify outliers.

Supervisors need to then engage in clinical review of the case to determine how to bring the services back in line with other services or if the client is in the wrong level of care. It eventually becomes the focus of the supervisor, through the supervision process, to attempt to control competing goals, criteria for success, and areas of possible divergence.


A matter of importance in any project is the accurate identification, acquisition, assignment, and implementation of needed resources. In order for BHRPs to be effective in meeting its clinical goals it is necessary to practice effective scheduling.

There are several goals that need to be accomplished through effective scheduling. First and foremost, the evaluation needs to be completed in a timely and efficient manner to allow adequate time for the team to develop a plan. This process may include developing a detailed work breakdown structure, estimating the time required for each task, prioritizing or sequencing the tasks in order (chaining), developing a start time and target time for each task, determining a budget for each task, and assigning team members to each task. The tasks need to specify who will do what, where, when and how.

Once all these question are answered the result will be a clear specific plan individualized to meet the child's needs with goals and objectives that are measurable, with the ultimate goal being a positive outcome. Agency managers and team leaders must have effective skills in project management (PERT and GANNT) and task assessment (VTA) as well as effective delegation in order to efficiently meet the needs of their clientele and ensure the success of the BHRP.


For the program to be effective for children in BHRP, the agency and the team leader should exert some control over the process. This means that they should: monitor actual time, costs, outcomes, and performance, compare planned with actual figures, determine what corrective action is needed (for example if a BSC's monthly summary indicates that a child has failed to progress two months in a row, then an action plan would state what should be done to ensure that progress occurs), evaluate alternative corrective actions and finally the team should take appropriate corrective action.

We suggest that as a part of ongoing training and development for supervisors and managers in BHRPs training occur in the areas of management by objective, management by exception, performance enhancement, time management and effective task delegation. Training is necessary in behavioral supervision practices, statistical process control and in the area of appropriate and accurate clinical review. We suggest that this type of ongoing training and development may not only have benefit to the organization but more importantly to the consumer of services.


Tracy, Tannenbaum, & Kavanagh (1995) have suggested the following practices to facilitate generalization of learned skills from the training workshop to the job setting: (1) Supervisors need to encourage and set goals for trainees to use new skills and behavior acquired during training. (2) Task cues should be readily used. These cues are characteristics of a trainee's job that prompts the trainee to use new skills or behavior learned in the training. (3) Feedback from supervisors can be an excellent consequence. If supervisors support the application of the new skill and behavior acquired in the training it is much more likely to generalize. (4) Lack of punishment is important. Trainees should not be openly discouraged from using the new skill and behaviors acquired during the training. (5) Reinforcement is critical. Natural reinforcement is preferred but might not exist to the extent needed to maintain the behavior in the initial use. Trainees should receive external rewards for using the new skill and behaviors learned in the training. (6) Use of natural reinforcers--for training material to adequately generalize, the new behavior should fit into the person's learning history and be practiced to fluency, where it becomes automatic. Trainees should have the intrinsic sense that the behavior "feels right." (7) Trainees should create their own system for monitoring their performance of a new skill and learn to recognize that lapses into old patterns of behavior are natural and should not indicate that the trainee should give up trying.

Lapses to old patterns of behavior are common but careful supervision can be helpful in decreasing these lapses (Marx, 1982). Trainees should be taught that it is acceptable to ask supervisors and other staff for help with the execution of a particular skill. For training to be effective it must be incorporated into an entire performance management program. Such programs should identify key behaviors for the staff to perform (e.g., continuous interaction with the child or giving a specified number of effective descriptive praises in a 1 hour period). Second, the program should use a measurement system to assess whether these behaviors are exhibited. Third, the program should tell the employee of the behaviors to be expected, even making a formal goal with the employee on how often the behavior should be performed. Finally, feedback and reinforcement are provided to the employee (Anderson, Crowell, Sucec, Gilligan, & Winkoff, 1983).

One way to ensure that ineffective training (i.e., the failure to generalize the learned skills) does not occur is to use the mobile behavioral auditor as a field coach. Mobile behavioral auditors would be trained to identify target skills that TSS workers should perform. This may include rules about effective communication with the child, how to present frequent descriptive praise, or other techniques. Mobile behavioral auditors would also be trained to be an effective model (Latham & Saari, 1979). They observe the TSS worker engage in the behavior and provide feedback and reinforcement for the TSS worker's performance. The skill should be practiced until the TSS worker is fluent. Finally, the TSS worker and the mobile behavioral auditor should review the treatment plan, in particular the activity schedule for the TSS worker included in the plan, and use it as the basis for an action plan for when and where to use the skill.

All trainings should be evaluated to determine: (1) if the training program is meeting the set behavioral objectives for the program (2) if the objectives are being transferred to the day to day performance of the staff (3) if the trainees believe that the content was adequate and relevant to the job that they need to perform (4) the financial benefit and cost to the agency (5) specific trainings should be compared with respect to cost benefit analysis and the most effective trainings selected.


Ft. Bragg was a large-scale and well-funded study comparing contimuum of care service delivery models to the mental health services delivered as usual. It was disappointing to many supporting contiuum of care models that Ft. Bragg was better liked by consumers but overall was not found to provide improved outcomes. Furthermore, it was more expensive. While some are arguing that the Fort Bragg study (Bickman, 1996) clearly launched a fatal bullet into the continuum of care model of service delivery (see Sechrest & Walsh, 1997), others are attempting to analyze what factors led to the apparent failure. Several apparent myths have developed with regard to the Fort Bragg study. Some have argued within CASSP that Fort Bragg did not represent a continuum of care since it was a developing system, instead of a mature system. While this argument may hold some merit, the program was preplanned for a number of years, and then ran for almost a full year before even beginning data collection. Data was collected in three waves with some of the data being almost 3 years later than this (Bickman, Gutherie, Foster, Lambert, Summerfelt, Breda, & Heflinger, 1995). The second myth is that the Fort Bragg study was methodologically unsound. While no study is an island, Fort Bragg was measured against the Cook and Campbell (1979) standards and found to be of excellent quality (Sechrest & Walsh).

Weisz, Han, and Valeri offered a common sense approach (1996) when they investigated if empirically validated treatments such as those outlined by the American Psychological Associations Clinical Psychology Division 25 (Task Force on Promotion and Dissemination of Psychological Procedures of Clinical Psychology, 1995) were used in the treatment carried out in the agencies. The answer appears to suggest no. Bickman (1996) suggested that "a very impressive structure was built on very a weak foundation." (p. 695). As has been known for some time empirically validated treatments are rarely used in the clinical setting (Kazdin, Bass, Ayers, & Rodgers, 1990). If this is the case, then Fort Bragg may simply represent the equivalent of going to a drug store to buy a product for losing hair. The drug store may offer many conveniences (i.e., access to many types of products and quick check out lines). In addition, it may offer excellent services (i.e., very friendly store personnel). But unless it sells a product with minoxidil, the customer will not stop losing hair. It appears that the drug store known as Fort Bragg did offer more services (of particular but non therapeutic note was case management) and was higher in customer satisfaction (Bickman, 1996) but the fact remains the minoxidil was not there. Now other hair products did exist (i.e., health products and vitamins) but these products lack empirical support.

In terms of efficacy, it is doubtful that a continuum of care program that provides services to children with autism based on other models will be as successful as an ABA program in habilitation. It is also doubtful that an art therapy program for children with ADHD or ODD will be as effective as a multi-systemic program (Henggler, Schoenwald, Borduin, Rowland & Cunningham, 1998) or a two stage operant parent training program (i.e., Hapf, 1969; Eyeberg & Robinson, 1982; HambreeKegin & McNeil, 1995; Forehand & McMahon, 1981; Barkley, 1987) or even a contingency management program in the classroom (i.e., McNeil, 1995). Even techniques that are well supported for other types of problems may fail in children with attention deficit disorder. For example, cognitive therapy techniques have often been shown to be ineffective with children with ADHD, thus one would expect that a continuum of care program built on such principles would be ineffective.

Too often nonprofit institutions obsessed with the idea and the push to become a continuum of care service agency attempt to achieve this goal by providing larger service offerings. Inadequately trained and ill-prepared staff members are quickly pushed to the limit to provide more and more services in an already loosely organized and poorly managed service system. More often than not, services become justified not based on outcome data but on conformity to the completion of a model of having every level of care available. Agencies become a central source of self-justification. Outcomes become pushed aside and people spend more time writing reports about reports instead of attempting to streamline paperwork and enhance treatment services. These factors drive up cost and time requirements, while adding little in value to the overall quality of the program. In short, everything that we have come to hate about bureaucratic institutions (e.g., the movement of such institutions toward mediocrity instead of excellence) becomes true.

Fort Bragg can be summed up as this: Effective, even stellar, service delivery cannot make a poor product effective. The practice of adding more services without any focus on outcomes do little more then drive up costs, without improving outcomes and quality. An enhanced focus on training, education, management, performance, and critical review of organization process and efficacy of treatment will allow us to avoid the "Fort Bragg Syndrome".


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Author:Adkins-Ruff, Tracey; Cautilli, Joseph D.; Clarke, Karen; Thomas, C.A.
Publication:The Behavior Analyst Today
Geographic Code:1USA
Date:Jan 1, 2001
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