A review of choice research with people with severe and profound developmental disabilities

Pergamon

Research in DevelopmentalDisabilities, Vol. 17, No. 5, pp. 391--411, 1996 Copyright © 1996 Elsevier Science Ltd Pdntexl in the USA. All fights reserved 0891-4222/96 $15.00 + .00

PII S0891-4222(96)00025-X

A Review of Choice Research With People With Severe and Profound Developmental Disabilities Giulio E. tancioni University of Leiden

Mark F. O'Reilly University College Dublin

Eric Emerson University of Manchester

During the last 15-20 years, a significant amount of research has focused on the issue of choice among people affected by severe-profoand developmental disabilities. Studies have been directed at (a) assessing the ability of those people to choose between different options and express preferences that could be used for reinforcement or occupational purposes, (b) building choice opportunities within those people's daily situations, and (c) evaluating the possible effects of choice making on those people's performance and behavior. This paper reviews the aforementioned studies and comments on the main findings and related questions.

Until the end of the 1970s, very little attention has been paid to providing choice to people with severe-profound developmental disabilities (Bannerman, Sheldon, Sherman, & Harchik, 1990; Goode & Gaddy, 1976; Guess, Benson, Requests for reprints should be sent to G. E. Lancioni, Department of Psychology, University of Leiden, Wassenaarseweg 52, 2333 AK Leiden, The Netherlands.

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& Siegel-Causey, 1985; Newton, Homer, & Lund, 1991; Rynders & Friedlander, 1972). Providing choice to these people is here intended as presenting them with concurrent options from which they can select the preferred one (Dattilo, 1986, 1987; Guess et al., 1985). One reason for this apparent lack of attention to choice may have been that professionals working with people with severe-profound developmental disabilities were principally interested in setting rehabilitation goals and deciding the best teaching procedures for reaching them (Bannerrnan et al., 1990; Kishi, Teelucksingh, Zollers, Park-Lee, & Meyer, 1988; Lindsey & Luckasson, 1991). Another reason may have been the notion, common in most rehabilitation and care settings, that allowing those people the opportunity to make choices may not be in their best interest, for example, it may not help them acquire skills and independent functioning or may be detrimental to their health and well-being (see Bannerman et al., 1990; Brown, Belz, Corsi, & Wenig, 1993; Shevin & Klein, 1984). Finally, professionals must have realized that people with severe-profound developmental disabilities may not be able to deal with choice situations presented in a conventional (e.g., verbal) format and require special choice conditions in order to respond purposefully (Goode & Gaddy, 1976; Houghton, Bronicki, & Guess, 1987; Northup, Jones, Broussard, & George, 1995). During the last 15-20 years, a number of studies have concentrated on choice with people affected by severe-profound developmental disabilities. The studies can be divided into three general categories. The first category concerns those aimed at assessing the people's abilities to make choices between different options and thereby express preferences that could be used for reinforcement or occupational purposes (e.g., Dattilo, 1986, 1987; Derby et al., 1995). The second category concerns studies aimed at building choice opportunities within the people's daily situations (e.g., Parsons & Reid, 1990). The third category concerns studies aimed at evaluating the effects of choice making on the people's performance and behavior (e.g., Dyer, Dunlap, & Winterling, 1990). This paper reviews the aforementioned studies and comments on the main findings and some related questions. The aim is to help the reader determine (a) whether people with severe-profound developmental disabilities can make choices between (among) options; (b) whether their choice behavior can be considered "purposeful"; (c) in which daily situations choice opportunities have been provided and/or could be provided without risk and controversy; and (d) the level of evidence so far available in favor of the assumption that choice making is beneficial for the subjects. Table 1 provides a list of the three categories of studies mentioned above. For every study listed, the table reports the number of subjects with severe or profound developmental disabilities participating, their age, the type of stimuli used in the choice, the choice presentation format (i.e., whether pairs or groups of stimuli were presented), and the findings. The findings for the first two categories of studies are classified as positive, positive with no control, or mixed. Positive is used if the subjects

tao

TABLE 1

(1)

Assessing Subjects' Choice Making

(3)

(2)

(Areas)

Categories

2 1

Derby et al. (1995) Nozaki & Mochizuki (1995)

3

1

Mathy-Laikko et al. (1989)

Mithaug & Hanawalt (1978)

3

Dattilo & Mirenda (1987)

4

1

Dattilo (1987)

Reid & Hurlbut (1977)

9

Buyer et al. (1987)

3

2 3 4 3 8 3 7

Houlihan et al. (1992) Sigafoos & Dempsey (1992) Belfiore et al. (1994) Vollmer et al. (1994) Windsor et ai. (1994) Paclawskyj & Vollmer (1995) Sigafoos et al. (1995)

Dattilo (1986)

3 5

No. Subjects

Fisher et al. (1992) Parsons & Reid (1990)

Studies

19-21

31-34

3,7 27

8

10-12

7

13-20

6-10

4,4 6-7 23-38 3-4 18-30 8-13 7-17

3-10 27-43

Subjects' Agea

Objects for tasks

Pictures for activities

Toys Object-signals

Switches with various stim.

Switches with various stim.

Switches with various stim.

Chairs with or without stim.

Switches with various stim.

Food, drink & other items Food & drink items Drink items Food, drink & other items Food & drink items Food, drink & other items Food, drink & other items

Food, drink & other items Food & drink items

Choice Alternatives

Positive No Control Positivec

Positive No Control Positive No Control Positive No Control Positive No Control Positive No Control Positive Positive No Control

Positive Positive No Control Positive Positive Mixed Positive Mixed Positive Mixed

Findings

(Table continued on next page)

Pairs

Group

Pairs Group

Group

Pairs

Pairs

Pairs

Pairs

Group Pairs Pairs Pairs Pairs & Group Pairs Pairs

Pairs Pairs

Choice Format b

Studies Listed According to Categories and Areas with Number and Age of Subjects, Type of Choice Alternatives, Choice Format, and Findings

Building Choice Opportun. in Daily Contexts

Categories

(2)

(1)

(Areas)

1

3 1

Sigafoos et al. (1993) Schepis & Reid (1995)

Lancioni et al. (1993b)

16

Parsons et al. (1993)

1

5 3

Parsons & Reid (1990) Reid & Parsons (1991)

Lancioni et al. (1993a)

1

4

Lancioni et al. (1995)

Locke & Mirenda (1988)

14

No. Subjects

Newton et al. (I 993)

Studies

36

18

17-20 23

20-60

-20-37

11

20-34

22-55

Subjects' Agea

TABLE 1. Continued

Objects for activ. & reinf.

Objects for activities

Food & drink items Food, drink & leisure items

Food & drink items

Food & drink items Food & drink items

Food & drink items

Objects for work conditions

Words/objects for activities

Choice Alternatives

Pairs

Pairs & Group

Pairs Group

Pairs

Pairs Pairs

Group

Pairs

Pairs

Choice Format b

Positive No Control Positive

Positive No Control Positive Positive No Control Positive No Control Mixed Positive No Control

Positive No Control Positive

Findings

Mason et al. (1989) Dyer et al. (1990) Realon et al. (1990) Kearney et al. (1995) Smith et al. (1995)

Rice & Nelson (1988) Parsons et al. (1990) LaMore & Nelson (1993) Bambara et al. (1994) Bambara et al. (1995)

(1)

(2)

? 2 ? 5 1

1 3 3 19 4

2 l

----50

4 5-11 23-42 -33-34

20,24 19

Note. ? = The number of subjects with severe-profound developmental disabilities is not known. - - = No specific information is available. aThe subjects' age was rounded to the closest year to avoid decimal points. bGroup format included the simultaneous presentation of 3 - 6 items. eThe control procedure was applied by Mithaug and Mar (1980). dThe findings reflect general group data.

Evaluating the Effects of Choice Making

Lancioni, Oliva, et al. (1993) Lancioni et al. (1994)

_

Objects for a task Objects for tasks Objects for a task Objects for tasks Words for task steps

Reinforcing items

_

Reinforcing items Tasks & reinf, items Words/switches for leisure items

Slides for activ. & reinf. Objects for activities

Group Pairs Group Pairs Pairs

Pairs Group Pairs __ Group

Pairs Pairs

Positived Mixed Positive d Mixed Positive

Positive Positive Positive Positive d Mixed

Positive Positive No Control

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managed to make choices between (among) options successfully and a "control" procedure (see below) suggested that their choice behavior was purposeful rather than casual. Positive with no control is used if no control procedure was available. Mixed is used when subjects failed to respond in many choice trials or a control procedure raised doubts as to the purposefulness of their choice behavior. For the last category of studies, only positive and mixed are used. Positive means that choice making had positive effects on the subjects' performance or behavior. Mixed is used when those effects were (highly) doubtful or present only in some subjects. FIRST CATEGORY OF STUDIES: ASSESSING SUBJECTS' CHOICE MAKING

The studies included in this first category are rather heterogeneous with regard to the choice options used. These options covered three main areas: (1) food and drink items alone or combined with other potentially attractive items, (2) visual, auditory, vibrotactile, tactile-social, or vestibular stimulation, and (3) activities/tasks or work conditions. 1. Assessing Subjects' Choice Making With Food and Drink Items Alone or Combined With Other Potentially Attractive Items

Nine studies have been carried out in this area concerning food and drink items (Belfiore, Browder, & Mace, 1994; Fisher et al., 1992; Houlihan, BatesPurple, Jones, & Sloane, 1992; Paclawskyj & Vollmer, 1995; Parsons & Reid, 1990; Sigafoos & Dempsey, 1992; Sigafoos, Laurie, & Pennell, 1995; Vollmer, Marcus, & LeBlanc, 1994; Windsor, Pichr, & Locke, 1994). For example, the study by Fisher et al. (1992) presented 16 stimuli in pairs. Each choice trial started with two stimuli presented about 70 cm in front of the subject. Subject's approach to one of the stimuli resulted in the subject's access to that stimulus and removal of the other. An approach to both stimuli was prevented. If the subject did not approach any of the stimuli within 5 s, the therapist prompted (i.e., made the subject sample each stimulus for 5 s). Afterwards, the two stimuli were displayed again in front of the subject. Subject's failure to approach any of the two ended the trial with the removal of both stimuli. A trial with two other stimuli then started. Three children with severe-profound developmental disabilities participated as subjects. The findings indicated that (a) the subjects chose successfully, showing different levels of preference for the various stimuli and (b) the highly preferred stimuli were subsequently found to be effective in increasing the subjects' task responding (i.e., to function as genuine reinforcers). The study by Windsor et al. (1994) assessed choice making with eight adult subjects. Group and pair presentations were used. In the group presentations, the six food/drink items selected for a subject were displayed concurrently. In

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each pair presentation, 2 of the 6 items available were displayed. The findings could be summarized as follows. Several subjects showed similar responding across the two choice situations, thus indicated similar preferences. Other subjects made somewhat different choices indicating different preferences in the two situations.

2. Assessing Subjects' Choice Making With Visual, Auditory, Vibrotactile, Tactile-Social or Vestibular Stimulation Seven studies can be listed within the area of visual, auditory, vibrotactile, tactile-social, or vestibular stimulation (Buyer, Berkson, Winnega, & Morton, 1987; Dattilo, 1986, 1987; Dattilo & Mirenda, 1987; Derby et al., 1995; Mathy-Laikko et al., 1989; Nozaki & Mochizuki, 1995). For example, Buyer et al. (1987) used pair presentations with nine subjects whose median age was nearly 16 years. One pair of conditions consisted of a chair the subjects could rock on their own (active vestibular stimulation) and a chair that was rocked by a research assistant (passive vestibular stimulation). A second pair consisted of the passive stimulation (chair rocked by the research assistant) and a stationary, no-stimulation condition (the chair was immobilized). A third pair included the active condition and the stationary condition. Each assessment session was divided into two parts: a 2-min orientation period (1 min in each chair) and a 5-min choice period. At the beginning of the choice period, the subject was placed in front of the two chairs (about 1.5 m away from each chair) and asked to sit down. The subjects were free to move from one chair to the other. They were recorded as preferring one chair if they spent more than 2.5 min in that chair. The results indicated that subjects generally chose the active stimulation more frequently than the passive stimulation and this condition more frequently than the stationary chair. Yet, the preference differences were large only for subjects with higher Vineland scores. The study by Dattilo (1987) included a 7-year-old child as subject. The child was presented with three choice conditions (each involving two options). The first condition involved visual and auditory stimulation, the second condition visual and vibrotactile stimulation, the third condition vibrotactile and auditory stimulation. The child was provided with two switches that he could use to choose one stimulation or the other available at the time. At the beginning of each choice condition, the child was taught to discriminate between switches. Switch covers of different colors and textures were used for this purpose. When the child had associated the switch covers with the types of stimulation, short assessment periods were presented. The activation of a switch caused a 15-s stimulation (the type of stimulation corresponding to that switch). Each choice condition was maintained until the subject's responding had stabilized. The child chose successfully and showed a clear preference hierarchy with the auditory stimulation (music) as the most frequently chosen option and the vibrotactile stimulation (a vibrating pad) as the least frequently chosen option.

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3. Assessing Subjects' Choice Making With Activities~Tasks or Work Conditions

Four studies have been conducted within this area concerning activities/tasks or work conditions (Lancioni, Oliva, Andreoni, & Pirani, 1995; Mithaug & Hanawalt, 1978; Newton, Ard, & Homer, 1993; Reid & Hurlbut, 1977). For example, Mithaug and Hanawalt (1978) assessed the choice responding of three adults in relation to prevocational tasks. The assessment was carried out through pair presentations. Each choice trial consisted of the presentation of a tray with two objects representing two tasks. As soon as the subject had selected one object, the corresponding task was presented. The subject was to work on it for 7 min. Thereafter, he/she had a small break followed by a new choice trial. Through this method, the authors observed that the subjects had most preferred (frequently chosen) tasks, least preferred (rarely chosen) tasks, and moderately preferred tasks. Subsequently, Mithaug and Mar (1980) extended this study to check on the purposefulness of the subjects' choice (preference) responses. Their data provided a clear indication of purposefulness: the subjects' selection of a favorite task declined when such a selection was followed by the presentation of a nonpreferred task and vice versa. The study by Newton et al. (1993) included 14 adults. Trials involving the presentation of pairs of home and community activities served for assessing the subjects' choice responding. If a subject chose an activity, this was immediately provided. If a subject did not choose an activity within 15 s, the pair was presented again. All subjects were successful in carrying out their choices. Specific activity preferences were observed. SECOND CATEGORY OF STUDIES: BUILDING CHOICE OPPORTUNITIES IN DALLY CONTEXTS The second category of studies is based on the notion that (a) people with severe-profound developmental disabilities can (learn to) make choices and express preferences, and (b) choice opportunities do contribute to improve these people's appearance and possibly their quality of life (Bannerman et al., 1990; Felce & Perry, 1995; Kishi et al., 1988; Meyer, Eichinger, & Park-Lee, 1987; West & Parent, 1992). The studies could be divided into two groups directed at different areas, one group aimed at building choice opportunities within regular meals and snack/leisure situations and another group aimed at building choice opportunities within occupational situations. 1. Building Choice Opportunities Within Regular Meals and Snack/Leisure Situations

Six studies can be listed within the area of regular meals and snack/leisure situations (Locke & Mirenda, 1988; Parsons, McCam, & Reid, 1993; Parsons

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& Reid, 1990; Reid & Parsons, 1991; Schepis & Reid, 1995; Sigafoos, Roberts, Couzens, & Kerr, 1993). For example, Reid and Parsons (1991) worked with three women. The study was directed at providing the women choice making opportunities in relation to their noon meal. Prior to the beginning of the meal, the assigned staff member offered each woman the choices that had been identified as viable. At each choice occasion, two food or drink items were placed in front of the woman and she was asked to pick one. If the woman picked up and ate/drank one of the two items within 10 s, the chosen item was included in the meal. If the woman did not pick up any of the two items within 10 s, the staff member encouraged her to taste both of them. Thereafter, the two items were again presented and the woman asked to take one. The results of the study indicated that during the baseline, the women were presented with virtually no choice. Subsequently, the average number of choice opportunities for the three women ranged between about 5 and 8 for each meal. The study by Parsons et al. (1993) was an extension of the authors' previous research. The study involved 16 subjects belonging to four different classrooms. The objective was to increase the choice opportunities (for food and drink items) available to the subjects during their snack period. The results were comparable with those obtained in the previous study.

2. Building Choice Opportunities Within Occupational Situations Four studies have been carried out with the aim of building choice opportunities within the occupational situations of subjects with severe-profound multiple disabilities (Lancioni, Bellini, & Oliva, 1993a, b; Lancioni, Oliva, & Bracalente, 1994; Lancioni, Oliva, Meazzini, & Marconi, 1993). For example, the study by Lancioni et al. (1993b) was aimed at building choice opportunities within a robot-assisted program available for a man with blindness and deafness in addition to mental retardation. At the start of a session, the subject was accompanied to a choice station. Here he found two objects (representing two activities). He was to choose one of the objects, detach a tag from it and match it to a corresponding one on the robot. This matching operation informed the robot as to the activity chosen and the route to reach it. At the end of the activity, the robot would take the subject back to the choice station where a new choice opportunity was available. The new choice opportunity could involve two objects representing two activities or an object representing an activity and an inactive vibrator which signaled a known reinforcing event. The second type of choices served as control choices that would help monitor the subject's purposefulness in choice making. [A purposeful subject was expected to choose the vibrator.] The results indicated that there were activities chosen in more than 75% of the trials and activities chosen very rarely. Moreover, during the control trials the subject consistently chose the vibrator.

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The study by Lancioni, Oliva et al. (1993) was similar to that described above except for the following aspects. First, the two young adults participating as subjects in the latter study had functional visual ability. Second, the choice opportunities were built within a computer-aided occupational program in which visual stimuli were used for representing the choices between activities or between activities and reinforcing events. The results of the latter study were comparable with those of the former one.

THIRD CATEGORY OF STUDIES: EVALUATING THE EFFECTS OF CHOICE MAKING Within this third category, two groups of studies (two areas) can be identified: one was concerned with the effects of the subjects' choice of the reinforcer or of both the reinforcer and task material; the other was concerned with the effects of the subjects' choice of task material or task steps.

1. Effects of the Subjects' Choice of the Reinforcer or Reinforcer and Task Material Five studies can be listed within this area (Dyer et al., 1990; Kearney, Durand, & Mindell, 1995; Mason, McGee, Farmer-Dougan, & Risley, 1989; Realon, Favell, & Lowerre, 1990; Smith, Iwata, & Shore, 1995). For example, the study by Smith et al. (1995) was an extension of the research carried out by Mason et al. (1989) and examined the effects of consequences (reinforcers) selected by staff personnel versus those chosen by the subjects themselves on task performance. Four adult subjects were involved in the study. The sessions in which the subjects could choose the reinforcer started with the experimenter placing a sample of all available reinforcers on the table and asking the subject to choose one. The first stimulus for which the subject reached was then used as reinforcer. It was delivered after the first task response and then after every five responses. The other sessions started with the experimenter selecting one of the reinforcers. This was then used after the first task response and subsequently after every five responses. The findings indicated that there were no clear performance differences between the two types of sessions. More specifically, subject's selection of reinforcers did not produce improved task performance over experimenter's selection of reinforcers. The study by Dyer et al. (1990) involved three children. During the choice condition, the children were allowed to choose the task they were to perform and the reinforcer they were going to receive throughout the task. During the no-choice condition the same tasks and the same reinforcers available in the choice were directly attributed by the work supervisor. The data indicated that in the choice condition the subjects had much lower levels of problem behavior than in the no-choice condition.

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2. Effects of Subjects' Choice of Task Material~Steps Four studies have assessed the effects of subjects' choice of task material on general work performace (Bambara, Ager, & Koger, 1994; LaMore & Nelson, 1993; Parsons, Reid, Reynolds, & Bumgarner, 1990; Rice & Nelson, 1988). One study has assessed the effects of a subject's choice of task steps on work performance and behavior (Bambara, Koeger, Katzer, & Davenport, 1995). For example, Parsons et al. (1990) carried out their study with four subjects, two of which were affected by severe mental retardation and thus are within the range of this paper. They identified three work periods during the day. During each work period, one of three conditions was applied. The conditions consisted of (a) assigning a subject to work on a high-preference task, (b) assigning a subject to work on a low-preference task, and (c) allowing a subject to choose the task on which to work. The data indicated that when the subjects were assigned the low-preference task, their on-task level was about 46%. When they were assigned a high-preference task and when they could choose a task (normally a high-preference one) on which to work, their on-task level was about 90%. There was no visible difference between these two conditions. Bambara et al. (1995) required a 50-year-old man to perform routine tasks. In the no-choice condition, the man was given instructions about single task steps that he was to carry out. In the choice condition, the instructions allowed him to choose between pairs of steps (e.g., between taking the vacuum cleaner to the office or to the living room). The results indicated that in the no-choice condition the subject had very few task initiations (i.e., few steps performed) and high levels of protest, which often degenerated into challenging behavior. By contrast, in the choice condition, the subject showed high levels of task initiations, low levels of protest, and negligible levels of challenging behavior. C O M M E N T S ON T H E S U B J E C T S ' C H O I C E M A K I N G The findings of the studies included in the first two categories have been labeled as mixed only four times. In three of those four times, mixed was used due to problems in the establishment of choice making (Belfiore et al., 1994; Sigafoos et al., 1993, 1995). Belfiore et al. (1994) have reported that four subjects did not virtually respond to choice trials concerning drink items in one setting while responding at moderate to high levels in a second setting used for the study. Sigafoos et al. (1993) have reported that one of their three subjects displayed very few choices within a snack situation in which choice opportunities (between drink and food items) were provided. Finally, Sigafoos et al. (1995) have reported high frequencies of no response in choice trials concerning food, drink, and leisure items with a group of seven girls affected by the Rett syndrome. The reasons for the unsatisfactory response levels are not clear. One may argue that the establishment of consistent choice responding can require a relatively extended intervention period with prompting and prompt fading for subjects with a

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history of passivity. Such an extended intervention was not available, particularly in the study by Sigafoos et al. (1993). The establishment of choice responding may require the use of more than one pair of stimuli to avoid that lack of interest in the stimuli, or associations between the stimuli and specific settings could prevent the subjects' responding. This was not the case in the study by Belfiore et al. (1994). Although one could say that lack of choice making may represent a clear choice, that is, the subject's refusal of the alternatives available (Nozaki & Mochizuki, 1995; Reid & Parsons, 1991; Sigafoos et al., 1995), such an assumption would need to be substantiated. The only way to substantiate it would be to show that the subject is performing choice responses in other situations involving different choice alternatives. In other words, one can attribute a choice value to the lack of responding only when the subject has shown choice making ability. In view of the above, two general points can be made. First, the overall picture provided by the studies reviewed is that most people with severe-profound developmental disabilities can cope with choice situations and perform choice responses. Second, a number of cases may exist in which choice making can be obtained only after appropriate intervention. At present, no clear guidelines are available as to how to organize such an intervention. One could suggest an extended practice with stimulus pairs within which one of the stimuli is known to be highly attractive (Lancioni, Oliva et al., 1993; MathyLaikko et al., 1989). Response prompting, prompt fading, and other procedures for overcoming positional responding may also be required (Duker & Moonen, 1985; Lancioni, Oliva, et al., 1993; Parsons et al., 1993). COMMENTS ON THE PURPOSEFULNESS OF THE SUBJECTS' CHOICE M A K I N G Twelve of the studies included in the first two categories have used special control procedures to check whether the subjects' choice making could be considered purposeful (Derby et al., 1995; Fisher et al., 1992; Houlihan et al., 1992; Lancioni et al., 1993b; Lancioni, Oliva, et a1.,1993; Lancioni et al., 1995; Mithaug & Mar, 1980; Paclawskyj & Vollmer, 1995; Parsons & Reid, 1990; Sigafoos & Dempsey, 1992; Vollmer et al., 1994; Windsor et al., 1994). The first procedure consisted of applying the most frequently chosen stimuli contingent upon task responding. If this increased as a consequence of the aforementioned stimuli, the conclusion was that such stimuli worked as reinforcers. This in turn supported the assumption that the subjects' choice responding was purposeful (Fisher et al., 1992; Houlihan et al., 1992; Paclawskyj & Vollmer, 1995). A second procedure relied on the use of two different choice formats or choice contexts (Parsons & Reid, 1990; Windsor et al., 1994). The demonstration that the most frequently chosen stimuli during group presentations or in a laboratory situation were also the most preferred stimuli during pair presentations or in a daily context supported the notion that the subjects were consistent (purposeful) in their choices/preferences.

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A third procedure relied on the mismatch between what the subject chose and what he/she was provided with (Mithaug & Mar, 1980; Sigafoos & Dempsey, 1992). More specifically, the subject was provided with the nonchosen alternative. Refusal of this alternative or a change in the choice responding were interpreted as indirect demonstrations of the subject's genuine preference for the alternative originally chosen. A fourth procedure consisted of presenting highly chosen stimuli and checking whether they increased the subjects' engagement or reduced their problem behavior more than infrequently chosen stimuli (Derby et al., 1995; VoUmer et al., 1994). If so, one assumed that the subjects' prevalent choice of the former stimuli was purposeful. A fifth procedure consisted of checking the subjects' alermess/attention by means of control trials in which one of the alternatives was a highly reinforcing item (Lancioni et al., 1993b; Lancioni, Oliva, et al., 1993; Lancioni et al., 1995). A subject who did not miss this item was considered to be very alert during the choice, aware of the situation at hand, and capable of expressing a genuine preference. The data obtained with the aforementioned procedures have generally suggested purposefulness of the subjects' choice-making behavior. The findings of only one of the 12 studies using control procedures have been labeled as mixed (Windsor et al., 1994). These authors reported that for some subjects the most favored item differed according to the choice formats (i.e., pair and group presentations). With regard to the study by Sigafoos and Dempsey (1992), the findings were labeled positive in spite of the fact that two of the three subjects did not consistently refuse the nonchosen item in the mismatch procedure. In other studies, purposeful choice making seemed to emerge only after relatively long periods of choice practice (Lancioni, Oliva, et al., 1993; Parsons & Reid, 1990). The aforementioned procedures for checking the purposefulness of choice behavior seem to represent a variety of rather powerful tools that may enable one to draw fairly reliable conclusions. An additional strategy that could occasionally be useful in this context is the manipulation of the conditions preceding the choice session. The manipulation would be aimed at making one of the choice alternatives more attractive. Consequently, a subject would be expected to choose that alternative if purposeful in his/her behavior (Iwata & Michael, 1994; Locke & Mirenda, 1988; Vollmer & Iwata, 1991). COMMENTS ON T H E USE OF C H O I C E OPPORTUNITIES W I T H I N T H E SUBJECTS' DAILY CONTEXTS The emerging consensus is that people with developmental disabilities have the right to make choices and staff the duty to provide them with the opportunities for choice (see Bannerman et al., 1990; Brown etal., 1993). This consensus has found some practical applications in the daily reality of people with severe-profound developmental disabilities, namely, in connection with (a) the

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food and drink items for regular meals and snack/leisure situations and (b) the activities for independent occupational periods (Lancioni et al., 1993b; Lancioni, Oliva, et al. 1993; Lancioni et al., 1994; Locke & Mirenda, 1988; Parsons et al., 1990, 1993; Parsons & Reid, 1990). These applications constitute an organized, albeit circumscribed, answer to the expectations raised in the field (e.g., Bannerman et al., 1990; Guess et al., 1985; Lindsey & Luckasson, 1991). Furthermore, these applications appear noncontroversial. They provide the subjects with realistic and tangible choice alternatives. They do not require staff to invest significant levels of extra time and thus do not occur to the detriment of other disabled people cared for by the same staff. They do not contemplate the possibility of dangerous options for the subjects (e.g., do not involve choice alternatives that could be connected with health hazards or with forms of problem behavior). They are not in conflict with the general goals of rehabilitation and treatment programs (e.g., the subjects' acquisition of independent occupation and self-help skills). In view of the above, two questions arise. The first is which other choice situations can be considered noncontroversial and easy to add to those already investigated (food and drink items and occupational activities). The second question is which choice situations would be controversial and thus require special caution or control/corrective mechanisms. Among the possibly noncontroversial situations, one could include (a) the activity condition (e.g., choice between working alone or with others, between working on a series of different activities or on a series of identical/similar activities); (b) clothing arrangements (e.g., choice between types of pants, between shirts and jumpers, and between different shoes); (c) aspects of personal grooming (e.g., choice between different toothpastes, between different deodorants or perfumes); and (d) the relaxing condition (e.g., choice between sitting alone or with a companion, between having music or some other leisure option). Choice situations would be controversial if they allow the subjects to (a) remain too passive (e.g., choice between activity and nonactivity; see Lalli, Mauk, Goh, & Merlino, 1994), (b) avoid the use of acquired self-help skills (e.g., choice between dressing himself/herself and being dressed by a staff person; see Shevin & Klein, 1984), (c) spend significant periods of the day in bed (e.g., choice between some familiar activity and lying in bed; see O'Reilly, 1995), and (d) reject health checks and the use of medication (e.g., choice between taking some medication or taking a food or drink item; see Smith, 1994; Spangler, Gilman, & La Borde, 1990). COMMENTS ON T H E EFFECTS OF CHOICE ON SUBJECTS' P E R F O R M A N C E A N D BEHAVIOR Acknowledgement of people's right to have choice oppo~unities has usually been accompanied by discussion of the beneficial effects of choice making (Bannerman et al., 1990; Newton et al., 1991). With regard to the latter point, it

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may be useful here to (a) recapitulate the evidence provided by the studies reviewed above and (b) compare this evidence with the results of studies not included in the review because they involved subjects with mild or moderate developmental disabilities. The evidence provided by the studies reviewed above is somewhat conflicting. On the one hand, Rice and Nelson (1988), Mason et al. (1989), Dyer et al. (1990), Realon et al. (1990), LaMore and Nelson (1993), Bambara et al. (1995), and Kearney et al. (1995) indicated that choice making had beneficial effects. Yet, the group data reported by some of these studies should be interpreted with great caution (Kearney et al., 1995; LaMore & Nelson, 1993; Rice & Nelson, 1988). On the other hand, Parsons et al. (1990), Bambara et al. (1994), and Smith et al. (1995) cast doubts as to the beneficial effects of choice making. Parsons et al. (1990) and Bambara et al. (1994) reported essentially no performance difference between the situation in which the subjects were allowed to choose a task (usually a highly preferred one) and the situation in which a highly preferred task was directly presented to them. Similarly, Smith et al. (1995) reported that whether a favorite reinforcer was chosen by or presented to the subjects made no difference on their performance. A definitely positive picture of the effects of choice making seems to emerge from the studies not reviewed above because they involved subjects with mild or moderate developmental disabilities (Cosden, Gannon, & Haring, 1995; Dunlap et al., 1994; Dunlap, Kern-Dunlap, Clarke, & Robbins, 1991). Cosden et al. (1995) reported that students' control over reinforcers and tasks resulted in higher levels of performance than students' control over reinforcers alone or teacher's control. Students also demonstrated higher levels of performance when they had control over a single component (reinforcer or task) than under teacher's control. Dunlap et al. (1991) observed the virtual disappearance of disruptive behavior and the increase in on-task behavior when the subject involved in their study was allowed to choose the tasks for the sessions. Similar results were also reported by Dunlap et al. (1994). In view of the aforementioned evidence, several considerations may be put forward. First, choice making is very likely to provide beneficial effects for people with less severe disabilities, even if the choice situations only allow them to choose the same tasks and reinforcers provided by the teachers (i.e., not necessarily the most preferred ones; see Cosden et al., 1995; Dunlap et al., 1994). The opportunity to choose tasks and reinforcers may give these subjects a sense of control over the situation that increases their motivation and reduces any conflict with external power (Baer, Tishelman, Degler, Osnes, & Stokes, 1992; Bowers, Clement, Fantuzzo, & Sorensen, 1985; Stancliffe, 1995). Second, choice making is more likely to provide beneficial effects for persons with severe-profound disabilities when it allows them to obtain the most preferred tasks and reinforcers. The opportunity to access highly preferred materials can facilitate occupational engagement and reduce the level of problem behavior (Bambara et al., 1994, 1995; Dattilo & Rusch, 1985; Derby et al., 1995; Dyer, 1989; Emerson, 1995; Favell & Cannon, 1976; Foster-Johnson,

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Ferro, & Dunlap, 1994; Koegel, Dyer, & Bell, 1987; Parsons et al., 1990; Vollmer et al., 1994). Third, the fact that clear performance or behavior differences are not detected within certain study situations does not necessarily mean that choice making does not produce any beneficial effects for the subjects. It may also mean that the present strategies for checking the beneficial effects are insufficient (Lancioni, Oliva, et al., 1993). Fourth, although no evidence exists in this respect, one could argue that choice making can produce some indirect beneficial effects as well. One may assume that a subject appears more capable and advanced (shows a better image) when choosing tasks and reinforcers than when being provided with them. A better image may promote positive attention by staff and a higher level of acceptance within the daily environment (Lancioni, 1994). CONCLUDING REMARKS In conclusion, three general points can be made. First, most people with severe-profound developmental disabilities seem to be capable of making choices and expressing preferences. Intervention strategies, however, should be defined for helping those individuals who have difficulties responding in choice situations. The intervention strategies would probably involve extended practice with stimulus pairs within which one of the stimuli is highly attractive as well as response prompting, prompt fading, and specific remedial measures against positional responding (Duker & Moonen, 1985; Gothelf, Crimmins, Mercer, & Finocchiaro, 1994; Lancioni, Oliva, et al., 1993; Parsons et al., 1993). Second, building choice opportunities within the people's daily context is still a rather new and limited experience. The extension of this experience seems to be highly desirable also in view of the increasing demand for choice that care and rehabilitation environments face. An important role in pursuing this objective may be played by the availability of technological aids (e.g., computer-aided occupational programs, electrical switches, voice output communication aids). People with severe-profound multiple disabilities will be much more likely to acquire occupational and communication skills as well as choice making responses with the support of those aids (Dattilo & Camarata, 1991; Kennedy & Haring, 1993, Lancioni & Oliva, 1988; Locke & Mirenda, 1988; Mathy-Laikko et al., 1989; Romski & Sevick, 1988; Schepis & Reid, 1995; Wacker, Berg, Wiggins, Muldoon, & Cavanaugh, 1985; Wacker, Wiggins, Fowler, & Berg, 1988). Third, the assumption that choice making has beneficial effects on the subjects needs further assessment. To this end, one may combine the methods used by previous research with some systematic observation of the subjects' behavioral expressions during choice and no-choice situations. It may be that during the choice situations some subjects display smiles, vocalizations, or other expressions that staff recognize as associated with reinforcement/pleasure

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(Goode & Gaddy, 1976). The aforementioned recording could be supplemented by an assessment of the subjects' preference between choice and no-choice situations. This could be carded out by presenting pairs of stimuli already associated with the two situations and checking the subjects' responding. REFERENCES Baer, R. A., Tishelman, A. C., Degler, J. D., Osnes, P. G., & Stokes, T. F. (1992). Effects of selfvs. experimenter-selection of rewards on classroom behavior in young children. Education and Treatment of Children, 15, 1-14. Bambara, L. M., Ager, C., & Koger, F. (1994). The effects of choice and task preference on the work performance of adults with severe disabilities. Journal of Applied Behavior Analysis, 27, 555-556. Bambara, L. M., Koger, F., Katzer, T., & Davenport, T. A. (1995). Embedding choice in the context of dally routines: An experimental case study. Journal of the Association for Persons with Severe Handicaps, 20, 185-195. Bannerman, D. J., Sheldon, J. B., Sherman, J. A., & Harchik, A. E. (1990). Balancing the right to habilitation with the right to personal liberties: The rights of people with developmental disabilities to eat too many doughnuts and take a nap. Journal of Applied Behavior Analysis, 23, 79-89. Belfiore, P. J., Browder, D. M., & Mace, C. (1994). Assessing choice-making and preference in adults with profound mental retardation across community and center-based settings. Journal of Behavioral Education, 4, 217-225. Bowers, D. S., Clement, P. W., Fantuzzo, J. W., & Sorensen, D. A. (1985). Effects of teacheradministered and self-administered reinforcers on learning disabled children. Behavior Therapy, 16, 357-369. Brown, F., Belz, P., Corsi, L., & Wenig, B. (1993). Choice diversity for people with severe disabilities. Education and Training in Mental Retardation, 28, 318-326. Buyer, L. S., Berkson, G., Winnega, M. A., & Morton, L. (1987). Stimulation and control as components of stereotyped body rocking. American Journal of Mental Deficiency, 91, 543-547. Cosden, M., Gannon, C., & Haring, T. G. (1995). Teacher-control versus student-control over choice of task and reinforcement for students with severe behavior problems. Journal of Behavioral Education, 5, 11-27. Dattilo, J. (1986). Computerized assessment of preferences for severely handicapped individuals. Journal of Applied Behavior Analysis, 19, 445~148. Dattilo, J. (1987). Computerized assessment of leisure preferences: A replication. Education and Training in Mental Retardation, 22, 128-133. Dattilo, J., & Camarata, S. (1991). Facilitating conversation through self-initiated augmentative communication treatment. Journal of Applied Behavior Analys&, 24, 369-378. Dattilo, J., & Mirenda, P. (1987). An application of a leisure preference assessment protocol for persons with severe handicaps. Journal of the Association for Persons with Severe Handicaps, 12, 306-311. Dattilo, J., & Rusch, F. R. (1985). Effects of choice on leisure participation for persons with severe handicaps. Journal of the Association for Persons with Severe Handicaps, 10, 194-199. Derby, K. M., Wacker, D. P., Andelman, M., Berg, W., Drew, J., Asmus, J., Prouty, A.-M., & Laffey, P. (1995). Two measures of preference during forced-choice assessments. Journal of Applied Behavior Analysis, 28, 345-346. Duker, P. C., & Moonen, X. M. (1985). A program to increase manual signs with severely/profoundly mentally retarded students in natural environments. Applied Research in Mental Retardation, 6, 147-158. Dunlap, G., DePerczel, M., Clarke, S., Wilson, D., Wright, S., White, R., & Gomez, A. (1994). Choice making to promote adaptive behavior for students with emotional and behavioral challenges. Journal of Applied Behavior Analysis, 27, 505-518.

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Dunlap, G., Kern-Dunlap, L., Clarke, S., & Robbins, E R. (1991). Functional assessment, curricular revision, and severe behavior problems. Journal of Applied Behavior Analysis, 24, 387-397. Dyer, K. (1989). The effects of preference on spontaneous verbal requests in individuals with autism. Journal of the Association for Persons with Severe Handicaps, 14, 184-189. Dyer, K., Dunlap, G., & Winterling, V. (1990). Effects of choice making on the serious problem behaviors of students with severe handicaps. Journal of Applied Behavior Analysis, 23, 515-524. Emerson, E. (1995). Challenging behavior: Analysis and intervention in people with severe learning difficulties. Cambridge, U.K.: Cambridge University Press. Favell, J. E., & Cannon, P. R. (1976). Evaluation of entertainment materials for severely retarded persons. American Journal of Mental Deficiency, 81,357-361. Felce, D., & Perry, J. (1995). Quality of life: Its definition and measurement. Research in Developmental Disabilities, 16, 51-74. Fisher, W., Piazza, C. C., Bowman, L. G., Hagopian, L. P., Owens, J. C., & Slevin, I. (1992). A comparison of two approaches for identifying reinforcers for persons with severe and profound disabilities. Journal of Applied Behavior Analysis, 25, 491-498. Foster-Johnson, L., Ferro, J., & Dunlap, G. (1994). Preferred curricular activities and reduced problem behaviors in students with intellectual disabilities. Journal of Applied Behavior Analysis, 27, 493-504. Goode, D. A., & Gaddy, M. R. (1976). Ascertaining choice with alingual, deaf-blind and retarded clients. Mental Retardation, 14, 10-13. Gothelf, C. R., Crimmins, D. B., Mercer, C. A., & Finocchiaro, P. A. (1994). Teaching choicemaking skills to students who are deaf-blind. Teaching Exceptional Children, 26, 13-15. Guess, D., Benson, H. A., & Siegel-Causey, E. (1985). Concepts and issues related to choice-making and autonomy among persons with severe disabilities. Journal of the Association for Persons with Severe Handicaps, 10, 79-86. Houghton, J., Bronicki, G. J. B., & Guess, D. (1987). Opportunities to express preferences and make choices among students with severe disabilities in classroom settings. Journal of the Association for Persons with Severe Handicaps, 12, 18-27. Houlihan, D. D., Bates-Purple, R., Jones, R. N., & Sloane, H. N. (1992). The simultaneous presentation procedure: Use in selecting reinforcers for behavioral intervention. Education and Treatment of Children, 15, 244-254. Iwata, B. A., & Michael, J. L. (1994). Applied implications of theory and research on the nature of reinforcement. Journal of Applied Behavior Analysis, 27, 183-193. Kearney, C. A., Durand, V. M., & Mindell, J. A. (1995). It's not where but how you live: Choice and adaptive/maladaptive behavior in persons with severe handicaps. Journal of Developmental and Physical Disabilities, 7, 11-24. Kennedy, C. H., & Haring, T. G. (1993). Teaching choice making during social interactions to students with profound multiple disabilities. Journal of Applied Behavior Analysis, 26, 63-76. Kishi, G., Teelucksingh, B., Zollers, N., Park-Lee, S., & Meyer, L. (1988). Daily decision-making in community residences: A social comparison of adults with and without mental retardation. American Journal on Mental Retardation, 92, 430-435. Koegel, R. L., Dyer, K., & Bell, L. K. (1987). The influence of child-preferred activities on autistic children's social behavior. Journal of Applied Behavior Analysis, 20, 243-252. Lalli, J. S., Mauk, J. E., Goh, H., & Merlino, J. (1994). Successful behavioral intervention to treat children who are reluctant to ambulate. Developmental Medicine and Child Neurology, 36, 625-629. LaMore, K. L., & Nelson, D. L. (1993). The effects of options on performance of an art project in adults with mental disabilities. American Journal of Occupational Therapy, 47, 397401. Lancioni, G. E. (1994). Procedures for promoting independent activity in people with severe and profound learning disability: A brief review. Mental Handicap Research, 7, 237-256. Lancioni, G. E., Bellini, D., & Oliva, D. (1993a). A robot to provide multihandicapped blind persons with physical guidance and activity choices. Journal of Developmental and Physical Disabilities, 5, 337-348.

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Lancioni, G. E., Bellini, D., & Oliva, D. (1993b). Building choice opportunities within a robotassisted occupational program: A case study. Behavioral Residential Treatment, 8, 219-226. Lancioni, G. E., & Oliva, D. (1988). A computer-aided programme for promoting unsupervised activities for multihandicapped adolescents. Journal of Mental Deficiency Research, 32, 125-136. Lancioni, G. E., Oliva, D., Andreoni, S., & Pirani, P. (1995). Working with a peer versus working alone: A preliminary assessment of preferences with four persons with multiple handicaps. Journal of Developmental and Physical Disabilities, 7, 67-8 I. Lancioni, G. E., Oliva, D., & Bracalente, S. (1994). An electronic guidance system for multihandicapped blind persons: Evaluating its effectiveness and likableness. Behavioral Interventions, 9, 93-103. Lancioni, G. E., Oliva, D., Meazzini, P., & Marconi, N. (1993). Building choice opportunities within occupational programmes for persons with profound developmental disabilities. Journal of Intellectual Disability Research, 37, 23-39. Lindsey, P., & Luckasson, R. (1991). Consent screening interview for community residential placement: Report on the initial pilot study data. Mental Retardation, 29, 119-124. Locke, P. A., & Mirenda, P. (1988). A computer-supported communication approach for a child with severe communication, visual, and cognitive impairments: A case study. Augmentative and Alternative Communication, 4, 15-22. Mason, S. A., McGee, G. G., Farmer-Dougan, V., & Risley, T. R. (1989). A practical strategy for ongoing reinforcement assessment. Journal of Applied Behavior Analysis, 22, 171-179. Mathy-Laikko, P., Iacono, T., Ratcliff, A., Villarruel, E, Yoder, D., & Vanderheiden, G. (1989). Teaching a child with multiple disabilities to use a tactile augmentative communication device. Augmentative and Alternative Communication, 5, 249-256. Meyer, L. H., Eichinger, J., & Park-Lee, S. (1987). A validation of program quality indicators in educational services for students with severe disabilities. Journal of the Association for Persons with Severe Handicaps, 12, 251-263. Mithaug, D. E., & Hanawalt, D. A. (1978). The validation of procedures to assess prevocational task preferences in retarded adults. Journal of Applied Behavior Analysis, 11, 153-162. Mithaug, D. E., & Mar, D. K. (1980). The relation between choosing and working prevocational tasks in two severely retarded young adults. Journal of Applied Behavior Analysis, 13, 177-182. Newton, J. S., Ard, W. R., & Homer, R. H. (1993). Validating predicted activity preferences of individuals with severe disabilities. Journal of Applied Behavior Analysis, 26, 239-245. Newton, J. S., Homer, R. H., & Lund, L. (1991). Honoring activity preferences in individualized plan development: A descriptive analysis. Journal of the Association for Persons with Severe Handicaps, 16, 207-212. Northup, J., Jones, K., Broussard, C., & George, T. (1995). A preliminary comparison of reinforcer assessment methods for children with attention deficit hyperactivity disorder. Journal of Applied Behavior Analysis, 28, 99-100. Nozaki, K., & Mochizuki, A. (1995). Assessing choice making of a person with profound disabilities: A preliminary analysis. Journal of the Association for Persons with Severe Handicaps, 20, 196-201. O'Reilly, M. E (1995). Functional analysis and treatment of escape-maintained aggression correlated with sleep deprivation. Journal of Applied Behavior Analysis, 28, 225-226. Paclawskyj, T. R., & Vollmer, T. R. (1995). Reinforcer assessment for children with developmental disabilities and visual impairments. Journal of Applied Behavior Analysis, 28, 219-224. Parsons, M. B., McCam, J. E., & Reid, D. H. (1993). Evaluating and increasing meal-related choices throughout a service setting for people with severe disabilities. Journal of the Association for Persons with Severe Handicaps, 18, 253-260. Parsons, M. B., & Reid, D. H. (1990). Assessing food preferences among persons with profound mental retardation: Providing opportunities to make choice. Journal of Applied Behavior Analysis, 23, 183-195.

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Parsons, M. B., Reid, D. H., Reynolds, J., & Bumgarner, M. (1990). Effects of chosen versus assigned jobs on the work performance of persons with severe handicaps. Journal of Applied Behavior Analysis, 23, 253-258. Realon, R. E., Favell, J. E., & Lowerre, A. (1990). The effects of making choice on engagement levels with persons who are profoundly multiply handicapped. Education and Training in Mental Retardation, 25, 299-305. Reid, D. H., & Hurlbut, B. (1977). Teaching nonvocal communication skills to multihandicapped retarded adults. Journal of Applied Behavior Analysis, 10, 591-603. Reid, D. H., & Parsons, M. B. (1991). Making choice a routine part of mealtimes for persons with profound mental retardation. Behavioral Residential Treatment, 6, 249-261. Rice, M. S., & Nelson, D. L. (1988). Effect of choice making on the self-care activity in mentally retarded adult and adolescent males. The Occupational Therapy Journal of Research, 8, 176-185. Romski, M. A., & Sevick, R. A. (1988). Augmentative and alternative communication systems: Considerations for individuals with severe intellectual disabilities. Augmentative and Alternative Communication, 4, 83-93. Rynders, J. E., & Friedlander, B. Z. (1972). Preferences in institutionalized severely retarded children for selected visual stimulus material presented as operant reinforcement. American Journal of Mental Deficiency, 76, 568-573. Schepis, M. M., & Reid, D. H. (1995). Effects of a voice output communication aid on interactions between support personnel and an individual with multiple disabilities. Journal of Applied Behavior Analysis, 28, 73-77. Shevin, M., & Klein, N. K. (1984). The importance of choice-making skills for students with severe disabilities. Journal of the Association for Persons with Severe Handicaps, 3, 159-166. Sigafoos, J., & Dempsey, R. (1992). Assessing choice making among children with multiple disabilities. Journal of Applied Behavior Analysis, 25, 747-755. Sigafoos, J., Laurie, S., & Pennell, D. (1995). Preliminary assessment of choice making among children with Rett syndrome. Journal of the Association for Persons with Severe Handicaps, 20, 175-184. Sigafoos, J., Roberts, D., Couzens, D., & Kerr, M. (1993). Providing opportunities for choicemaking and turn-taking to adults with multiple disabilities. Journal of Developmental and Physical Disabilities, 5, 297-310. Smith, J. D. (1994). The revised AAMR definition of mental retardation: The MRDD position. Education and Training in Mental Retardation and Developmental Disabilities, 29, 179-183. Smith, R. G., Iwata, B. A., & Shore, B. A. (1995). Effects of subject- versus experimenter-selected reinforcers on the behavior of individuals with profound developmental disabilities. Journal of

Applied Behavior Analysis, 28, 61-71. Spangler, P., Gilman, B., & La Borde, R. (1990). Frequency and type of incidents occurring in urban-based group homes. Journal of Mental Deficiency Research, 34, 371-378. Stancliffe, R. J. (1995). Assessing opportunities for choice-making: A comparison of self- and staff reports. American Journal on Mental Retardation, 99, 418--429. Vollmer, T. R., & Iwata, B. A. (1991). Establishing operations and reinforcement effects. Journal of Applied Behavior Analysis, 24, 279-291. Vollmer, T. R., Marcus, B. A., & LeBlanc, L. (1994). Treatment of self-injury and hand mouthing following inconclusive functional analysis. Journal of Applied Behavior Analysis, 27, 331-344. Wacker, D. P., Berg, W. K., Wiggins, B., Muldoon, M., & Cavanaugh, J. (1985). Evaluation of reinforcer preferences for profoundly handicapped students. Journal of Applied Behavior Analysis, 18, 173-178. Wacker, D. P., Wiggins, B., Fowler, M., & Berg, W. K. (1988). Training students with profound and multiple handicaps to make requests via microswitches. Journal of Applied Behavior Analysis, 21, 331-343.

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West, M. D., & Parent, W. S. (1992). Consumer choice and empowerment in supported employment services: Issues and strategies. Journal of the Association for Persons with Severe Handicaps, 17, 47-52. Windsor, J., Pich6 L. M., & Locke, P. A. (1994). Preference testing: A comparison of two presentation methods. Research in Developmental Disabilities, 15, 439-455.