Rehearsing the behavior is an important part of behavioral skills training because it:

Behavioral Skills Training

Behavioral Skills Training [BST] is a treatment package consisting of multiple treatment components that has been proven to be effective for training a wide variety of skills, simple and complex, in people in a wide variety of populations, including children and adults with and without disabilities. Several variations of BST exist, but the general model includes 1] verbal instruction, 2] modeling, 3] rehearsal or role-play, and 4] feedback. In other words, the therapist first explains the skill to the learner. Then the therapist models how to do it. Then the therapist invites the learner to rehearse the skill with the therapist. The therapist and learner can switch roles, especially if doing so makes the process more fun for the learner. During role-play, the therapist gives the learner live feedback on her performance. Role-play continues until the learner consistently demonstrates excellent performance. After role-playing is complete, the therapist should arrange for a real-life test of the skill. If the learner performs well, the skill is then placed on a maintenance schedule. If the learner does not perform well, the therapist should give in situ feedback and implement further rehearsal. See the safety section of Chapter 13 for examples of how BST can be used to teach safety skills. BST is also particularly useful for parent and staff training, and examples of how to use it for parent training are provided in Chapter 9.

Components of Behavioral Skills Training

BST is an active-response training procedure that has proven effective for teaching individuals a variety of new skills [e.g., Fleming, Oliver, & Bolton, 1996]. BST has been effectively used to train parents to implement various procedures such as incidental teaching [Hsieh, Wilder, & Abellon, 2011], guided compliance [Miles & Wilder, 2009], feeding protocols [Pangborn et al., 2013], and correct implementation of functional assessment and treatment protocols [Shayne & Miltenberger, 2013]. BST is also effective in teaching staff skills such as how to conduct specific behavioral assessments [Barnes, Mellor, & Rehfeldt, 2014], and how to teach peer-to-peer manding [Madzharova, Sturmey, & Jones, 2012] among many others [e.g., Love, Carr, LeBlanc, & Kisamore, 2013].

BST involves four critical components: instruction, modeling, rehearsal, and feedback [Miltenberger, 2003]. These components are typically implemented until a pre-set performance criterion is met [e.g., 80% accurate for multiple sessions; 100% accurate on a critical component; see section on How to Evaluate and Monitor Progress]. Parsons et al. [2012] described a six-step BST protocol for conducting training with a group of staff members with precise details for each phase of BST. Instructions can be oral or written, but should be clear, brief, and limited in number [e.g., include no more than five specific items or steps per instructional bout]. Written reminders or “aids” should be used to supplement the oral instructional portion. Instructions often include what to do, when to do it, and things to avoid doing. Instructions should include visuals to support text and response opportunities about the information [e.g., answering questions, restating, performing part of the task] to check for understanding of the material. The next step of BST, modeling, can be implemented live or via video and should include multiple, clear demonstrations of the target in different settings, with different performers, and with different materials and responses as appropriate. The model can include nonexemplars and the consequences associated with the procedural error, explicitly described as such. Modeling can include active participation such as having individuals describe what is occurring [i.e., the steps of the procedure, errors that occur]. Finally, during the rehearsal and feedback phase, the easiest component might be trained to mastery first with prompts and praise as needed. The instructor can then slowly increase the level of difficulty while continuing to praise and prompt accurate performance and then fading prompts and making the schedule of praise intermittent. It is important for individuals to continue practicing the skill at increasingly difficult levels until no prompts are needed and accuracy scores are high [e.g., 80% or higher of steps completed correctly on multiple consecutive attempts].

The following clinical case example illustrates the effective use of BST to teach the mother and 11-year-old sister of an 8-year-old female with developmental delay to implement an effective intervention to cross driveways safely [Veazey, Valentino, & LeBlanc, 2014]. A behavior analyst met directly with the family in their home approximately three times per week for 2-h sessions to develop the intervention and provide training. The behavioral intervention for the child consisted of a rule plus differential reinforcement of alternative behavior [DRA] with response blocking. Specifically, the therapist stated the rule “When you get to a driveway, look to see if a car is moving, and then let me know if it is safe to cross.” A preferred tangible item was provided for looking both ways before crossing and for correctly labeling whether it was “safe” or “not safe” to cross. Attempts to cross the driveway without looking were blocked. An ABAB reversal design was utilized to assess the effectiveness of the intervention [see Figure 1, left panel]. During the initial baseline phase, she did not cross any driveways safely. During treatment, the percentage of driveways crossed safely quickly increased, reaching a final percentage of 100. A brief reversal indicated she crossed only 50% and 30% of driveways safely. When treatment was reinstated, safe driveway crossing increased to 100% and the results maintained at a 4-month maintenance probe. The schedule of reinforcement for safe driveway crossing was successfully faded from an edible or sticker provided on a fixed-ratio [FR 1] schedule during the first phase of treatment, to tokens [conditioned after the reversal phase] on an FR-1 schedule, to social praise only on an FR-1 schedule.

When the intervention was demonstrated effective, BST was implemented at session 19 to teach the mother and sister to implement the effective intervention. Training consisted of describing the intervention, modeling the intervention with the child while the mother and sister observed, and providing multiple opportunities for the mother and sister to practice implementing the intervention with immediate feedback on performance. Procedural integrity data were collected on the percentage of all steps of the procedure implemented correctly for each training session and subsequent implementation session. See Figure 2 for the procedural integrity data sheet and steps of the protocol. During the baseline phase, the mother and sister did not implement any steps of the intervention correctly. Once BST was conducted, correct implementation increased immediately with the mother to 100% and remained perfect for six consecutive sessions. Correct responding for the sister was more variable, but with continued training she too implemented the intervention with 100% integrity across three consecutive sessions [see Figure 1, right panel].

Cognitive Behavioral Skills Training

Cognitive behavioral skills training programs focus on teaching skills to modify beliefs or behaviors associated with high-risk drinking. The majority of programs are multimodal, including both specific alcohol-focused skills training [e.g., expectancy challenge procedures, self-monitoring of alcohol use and problems, blood-alcohol discrimination training] and general life skills [e.g., stress and time management training, assertiveness skills]. Many of these programs also incorporate information, values-clarification and/or normative re-education components.

To date, the majority of studies evaluating the efficacy of cognitive behavioral interventions for drinking have utilized a multi-component skills training condition. Larimer and Cronce [2002] identified seven studies evaluating a total of ten multi-component skills training interventions. Of these, seven interventions demonstrated significant positive effects on alcohol consumption, harms, or both [Garvin et al., 1990; Kivlahan et al., 1990; Baer et al., 1992; Miller, 1999].

Two of three alcohol-focused skills training programs reviewed by Larimer and Cronce [2002] showed statistically significant positive effects at short-term follow-up [Darkes and Goldman, 1993, 1998]. These studies all incorporated an expectancy challenge component which aimed to assist drinkers to recognize how the subjective effects of alcohol are largely determined by a person's expectancies of those effects and not predominantly [if at all] by the alcohol itself. In the first study [Darkes and Goldman, 1993], heavy-drinking male participants were randomly assigned to traditional alcohol education, expectancy challenge or control conditions. Participants in the expectancy challenge condition were required to consume drinks in a social setting and then guess which participants had consumed alcohol and which a placebo. These participants also received information about placebo effects and expectancies, and students monitored their expectancies for a 4-week period. Two weeks post-treatment, participants in the expectancy challenge group reported a significant decrease in their alcohol consumption compared with participants in the other conditions. In a similar study [Darkes and Goldman, 1998], 54 heavy-drinking males were assigned to either a control group or one of two expectancy challenge conditions targeting [i] social expectancies using the procedure described above, or [ii] arousal expectancies using sedating cues or problem-solving tasks. Six weeks after treatment, participants in all three conditions had reduced their alcohol consumption; however, the largest reductions were demonstrated in the two expectancy conditions. In the third study, by Jones et al. [1995], students participated in an intervention that included didactic information and discussion about alcohol expectancies; self-monitoring of expectancies; and randomization to an expectancy challenge in which students were given an alcoholic or placebo beverage [but not in the presence of other students]. Results showed an overall trend toward positive effects on drinking, but there was no effect by condition. Further analysis indicated that only those involved in the self-challenge component of the intervention had significantly reduced consumption. Taken together, findings from these three studies suggest that expectancy challenge procedures may decrease alcohol consumption among males. However, to evaluate this prevention approach more fully, larger-scale studies with longer follow-up periods are needed to replicate these findings in both men and women.

Larimer and Cronce [2002] reviewed three other studies that evaluated self-monitoring or self-assessment of alcohol use [Garvin et al., 1990; Cronin, 1996; Miller, 1999]. All three studies indicated significant positive effects of this strategy on either drinking levels, harms, or both. Cronin [1996] compared consumption rates and problems in students randomly assigned to a self-monitoring or control group. The intervention group was required to complete a diary anticipating alcohol consumption and problems for the upcoming semester break. Students who completed the diary reported significantly fewer negative consequences at the end of the semester break than did students in the control group. In another study by Garvin et al. [1990], students asked to record their daily alcohol consumption over a period of 7 weeks reported lower consumption at the 5-month follow-up than students in either an alcohol-education or assessment-only control group. Finally, Miller [1999] compared college students who participated in three computerized assessments of their drinking with students who also participated in a two-session peer-delivered alcohol skills training program, or in a two-session computerized peer-facilitated interactive group, or who were randomly allocated to a control group. At the 6-month follow-up, students in all three intervention groups reported decreases in drinking and consequences compared with students in the control group. Larimer and Cronce therefore concluded that current research provides support for the role of self-monitoring/assessment in promoting drinking change.

Taken together, several cognitive behavioral interventions, including specific, global and multi-component skills training, have demonstrated positive changes in drinking and related consequences. Larimer and Cronce [2002] noted that research designs evaluating these interventions have generally been more rigorous that those studies evaluating educational programs, but pointed out that methodological limitations were still evident in this research, primarily due to small sample sizes and relatively high attrition rates among some studies. In general, however, they concluded that that current research generally supports the efficacy of cognitive behavioral approaches.

Peer-Implemented Training

Another promising approach for increasing the accessibility of BST and IST is the use of peer tutoring. Jostad et al. [2008] trained 6- and 7-year-old children to teach gun safety skills to 4- and 5-year-old children. After the 6- and 7-year-old trainers participated in BST to learn how to conduct BST and IST with the younger children, they used BST and IST successfully with little adult assistance to teach the skills to the younger children. All children who were trained by a peer demonstrated the skills during in situ assessments, confirming suggestions by Jostad and Miltenberger [2004] that peer training of safety skills may be both feasible and practical. Consistent with findings from Himle, Miltenberger, Flessner, et al. [2004] and Miltenberger et al. [2004], half of the children demonstrated the skills following BST, and half demonstrated the skills only after IST. These findings have been further extended to abduction prevention skills by Tarasenko, Miltenberger, Brower-Breitwieser, and Bosch [2010]. In this study, two child trainers effectively trained three peers to say “no,” leave the area, and tell an adult when lured by a stranger. Although the research examining the utility of peer trainers is limited, it appears that peer-implemented training approaches can be effective and practical for teaching safety skills to children. The use of peers as trainers merits further research.

Social skills facilitators' and coaches' training

The social skills facilitators and coaches are trained using BST prior to the onset of intervention. The BST training consists of instruction, modeling, practice, and feedback. Written instructions and summaries of the instructional steps are provided to the facilitators and coaches. During training there are opportunities to ask questions. The 10-step instructional sequence of PREP4Work is outlined as a task analysis checklist and used as a method of assessing fidelity of intervention delivery. The fidelity checks are conducted periodically across the duration of intervention. Corrective feedback is provided during training sessions, with a clear explanation on how the skill is performed and recorded if incorrect. Each facilitator and coach is required to obtain a score of 100% during training to progress to intervention delivery. The facilitators are tasked with teaching the social skills within the intervention sessions, whereas the coaches are required to oversee the behavior support strategies and deliver the in situ practice sessions within the community.

Direct measures and indirect standardized assessments are used to evaluate learners’ performance before and after intervention [Walsh et al., 2018; Walsh, Holloway, et al., 2019; Walsh, Lydon, et al., 2019]. Direct measures of performance, prior to intervention, are taken at baseline and again post intervention within the learner’s typical environment. As such, the assessor aims to create an ES for each of the target skills, whereby the environment is set up in such a way as to establish the opportunities for the learner to emit the target social skills. For example, when greeting your employer or job coach has been positively reinforced by social attention, deprivation of the employer’s/job coaches attention [e.g., as a result of a weekend off work] would increase the effectiveness of such attention as a reinforcer on Monday morning upon returning to work [establishing operations]. Similarly, when conversing with a colleague has been positively reinforced by peer attention, satiation as a result of working with that person in a 1:1 setting for an entire day would decrease the effectiveness of such attention as a reinforcer [abolishing operation]. A further example might include when the target skills of “joining in with others” have been mastered within the group instructional sessions, the coach may create an ES, whereby the learner goes for coffee with a group of peers to provide the opportunity to practice “joining in with others” during typical conversations outside of the instructional sessions. No feedback is given during these sessions, and the coach records data on the independent performance of the learner within this real-world scenario. Should the skill not be demonstrated within this session, the team will review the target and can decide to provide further in situ training opportunities or more group exercises within the instructional sessions. In the PREP4Work intervention, each of the 30 target social skills is operationally defined and tested across the natural environment pre- and postintervention.

Indirect assessments include measures taken with the learner and significant others. The SRS-2 [Constantino & Gruber, 2012] and SSIS [Gresham & Elliott, 2008] are used to evaluate the impact of social skills intervention. The ACCESS placement assessment is used to assess outcomes post intervention. Such a mix of assessments provide researchers and clinicians with the opportunity to evaluate the overall impact of the intervention for the individual. In essence, the standardized assessments provide an evaluation of the overall impact of the PREP4Work intervention. The direct assessments provide a more individualized assessment of each learner’s performance, as well as the opportunity to make specific changes [e.g., provide more learning opportunities or include more visual supports for a given lesson] when evaluating the learning patterns. This is achieved by assessing each learner on the target social skills preintervention and ongoing throughout the intervention. For example, the direct skills preassessment provides specific information on the skill deficits of the learner, then the ongoing monitoring of learner performance gives information on the rate of acquisition, as well as the number of criteria achieved. This learning pattern can be unique to the individual and when analyzed provides information to the intervention team on when to progress to the next target skill, when additional learning opportunities are required, or when/if any additional supports would benefit the learner. There is a further test of performance conducted in the community [e.g., coffee shop] outside of the classroom setting. This assessment is taken during typical social exchanges and in the absence of corrective feedback from the facilitators or coaches. The information gathered gives an indication of the skill learned within the structured teaching environment has transferred to real-world situations. This assessment for skill transfer [i.e., generalization] can also be conducted by employing peers [blind to the procedural elements] to role play a series of social exchanges that are representative of real-world scenarios.

The intervention is delivered within a small group setting [i.e., 6–7 learners]. This allows for adequate opportunities to respond, paired dyad work, individualization where needed [e.g., creation of additional learning opportunities], and implementation of appropriate schedules of reinforcement. The intervention is delivered for two sessions per week [1.5 h per session] across a period of 20 weeks or approximately 5 months.

The same lesson sequence delivery is employed for each social skills group. At the outset of a lesson, the social skills facilitator reviews the previous lesson and behavior contracts [Step 1] and then introduces the new target social skill [Step 2]. Visual supports depicting the social rules are displayed and used to facilitate learning. Following this, video models depicting incorrect and correct examples of the target skills are presented [Steps 3 and 4]. The facilitator then discusses the critical features of the target skill to aid the learners to identify the important aspects of the target skill [Step 5] and central message [Step 6]. An assessment of the learners’ accuracy in identifying the presence or absence of critical skill features takes place in Step 7, through the presentation of further novel video models and a series of prescripted questions. Step 8 involves role plays, whereby learners are provided with social scenarios and opportunities to role play the target skills with a peer. As part of the social skills training, learners are provided with situational role-play cards during each session. The role plays are used to practice new skills. The facilitators incorporate examples of familiar social situations that learners are likely to encounter when using the target skills in their natural settings. During role-play sessions, feedback is delivered immediately in the form of praise for correct responses or describing incorrect elements following an incorrect response, which typically follows the discrete trial instruction model. Learners are required to pass a criterion of 100% correct across two role plays to progress. A test of knowledge is also taken, whereby learners are asked two open-ended questions to assess knowledge [i.e., describe the target skill and identify critical features]. Step 9 involves a discussion around the application of the target skill in the natural environment and learners are required to complete a generalization plan. This plan sets out an agreement to practice the skill across the learner’s typical routines [Step 10].

PREP4Work intervention incorporates strategies to promote generalization, to enhance treatment outcomes. PREP4Work aims to: [1] employ training in the natural setting; [2] establish naturally occurring reinforcement contingencies; [3] utilize multiple exemplars during instruction; and [4] incorporate materials and social scenarios from the naturally occurring setting. Training in the learner’s natural setting is an important part of the intervention and is delivered in two ways. In the first instance, the coaches create real-life ES within the learner’s workplace or community setting. The coach provides feedback on whether the learner responds correctly under the ES. These in situ training sessions provide the learner with direct learning opportunities of naturally occurring ES. Furthermore, as these opportunities are typically present in the learner’s environment, it is likely that multiple further opportunities are created when the coach is not directly present.

Generalization planning is also discussed prior to the learner finishing each group session. This involves the learner working with the facilitator to identify the naturally occurring ES within their own work and community settings to practice the skills. The facilitator supports the learner to write a “contract to practice.” This involves the learner providing examples of when it was likely for the skill to be warranted and with whom it could be practiced, as well as a description of the target skill to be emitted by the learner, and then the naturally occurring reinforcer that might be expected [e.g., smile]. In this way, the learner can identify their own naturally occurring ES for a given skill and outline how they would practice the skill. Both the learner and facilitator sign the document, and the facilitator checks this agreement at the beginning of each new session, delivering reinforcement contingent upon meeting the agreement terms [i.e., progress chart]. In addition, these sessions provide learners with the opportunities to discuss any particular barriers for practice, and the facilitator can support the individual to problem solve potential solutions to overcome the identified barriers.

Within the social skills group, learners are provided with multiple opportunities to practice the target skills and those already mastered from previous lessons. The facilitator also provides reinforcement for naturally occurring social exchanges within the group. Reinforcement is delivered in the form of social attention, social nonverbal behavior [e.g., smile, laugh, attention], and social vocal behavior [e.g., “That’s great, thank you”]. The reinforcers selected are chosen to reflect the naturally occurring contingencies [i.e., attention/praise/response] typically observed within the community. The schedule by which the reinforcement is delivered is also mirrored upon the typical social contingencies within the community. Furthermore, staff within the community or workplace settings are appraised of the target skills mastered and those in acquisition. This is achieved by publically posting target social skills. In this way, further social skills practice opportunities are created by other members in the environment. Parents/caregivers also receive workshops on the program and are notified of the skills mastered and those in acquisition. Parents are given opportunities to discuss the skills, identify opportunities to practice, methods of reinforcer delivery, error correction procedures, and to problem solve barriers to skill acquisition.

Cognitive Behavioral Skills

School-based approaches to substance abuse prevention emphasizing cognitive behavioral skills training to enhance social resistance skills and other general life skills have been found to produce both short-term and long-term effects on the prevention of hallucinogen use. Botvin and colleagues [2000] were one of the first to examine the effects of such programs on hallucinogen use using a random sample of 3597 seventh graders from rural and suburban schools in New York State further randomized into either an intervention or control group. Throughout the 15-session program, students in the intervention group were taught cognitive behavior skills for building self-esteem, resisting advertising pressure, managing anxiety, communicating effectively, developing personal relationships, and asserting rights. Furthermore, information regarding the immediate negative consequences of drug use, the decreasing social desirability of use, and the actual prevalence rates among adults and adolescents was provided. Booster sessions designed to review and reinforce the material covered during the first year of intervention were provided in eighth and ninth grades. Conversely, students in the control group received no information on cognitive behavioral skills and drug use. A subsample of 447 students from the original cohort was reinterviewed at the end of 12th grade [mean age 18.1 years], and 13% of the participants in the intervention group reported lifetime use of hallucinogens compared with 21% of the control group. Such findings suggest that prevention programs with cognitive behavioral skills training carried out during middle school produced observable and durable prevention efforts after high school with regard to hallucinogen use.

Project Towards No Drug Abuse [Project TND] is a drug abuse prevention program targeting high-risk adolescents attending continuation high schools, which are alternative schools that youths attend after they transfer out of the regular school system due to functional problems such as conduct problems and drug use. Project TND utilized a classroom-based curriculum that included sessions teaching effective listening skills, chemical dependency issues, alternative coping skills, and encouraged making no-drug-use decisions. In addition to the classroom curriculum, a community program component was added to allow students to participate in activities. To examine the long-term effects of the program, Sun and colleagues [2006] selected a subsample [n = 725] of the original cohort of 3813 students was recruited from 21 CHSs with complete annual follow-up up to 5 years after the program. Of the 725 participants, 32% were randomized to the control group, 33% were in the classroom curriculum only group, and 34% were in the classroom and community group. At the 1-year follow-up assessment, 30-day hard drug [hallucinogen, cocaine, stimulants, inhalants, depressants, PCP, steroids, and heroin] use was higher in the control group than both the classroom-only and classroom and community groups. Similarly, by the 5-year follow-up, the frequency of hard drug use in the last month by those in the classroom-only intervention was less than half that in the control group; for those in the classroom and community intervention it was one-fifth that of the control group [Sun et al., 2006]. Such findings demonstrate that Project TND has long-term effects on prevention of drug use in continuation high school students.

Assertive training aims to enable individuals to do what they really want to do in social situations. As a substance-use prevention strategy, assertive training rests on the assumption that many youths who would otherwise abstain from using drugs reluctantly participate in drug use because they lack the interpersonal skills necessary to separate themselves from such situations [Horan et al., 1982]. Horan and colleagues conducted an assertive training program among 72 eighth graders to assess its effect on drug use. A behavioral measure of assertiveness was first taken among the 142 ninth graders enrolled in a public school, and the least assertive 36 males and 36 females were selected to participate in the program. Individuals were then randomized into assertion training treatment, placebo treatment, and no-treatment groups. The students in the assertion training group received five 45-min sessions with counselors instructing them about assertiveness and live modeling of assertive responses to a particular training stimulus involving peer pressure to use drugs through role playing. The placebo treatment involved discussions with students about assertiveness, peer pressure, and drug use; the no-treatment control students received no instructions from counselors and did not participate in any discussions. Immediately after the intervention, assertiveness was found to be significantly higher in the assertion training group than both the placebo and no-treatment groups. At the 3-year follow-up, although no significant difference was found in the mean frequency of lifetime hallucinogen use among the three groups, the assertion training group did report significantly lower frequency in lifetime hard drug use [which included hallucinogens, barbiturates, amphetamines, cocaine, and heroin] than the placebo and no-treatment groups. Horan and colleagues hypothesized that the lack of significant differences found in hallucinogen use among the treatment groups was due to the low prevalence [6.9%] of hallucinogen use in the sample. However, the lower usage of hard drugs, which included hallucinogens, in the assertion training group could indicate that assertion training could be a productive strategy for hallucinogen use prevention.

7.19.4.3.1.1 Psychoeducation Interventions

Psychoeducation, behavioral learning, behavioral skills training

Eldridge et al. [1997] compared the effects of a psychoeducation intervention relative to a brief individual behavioral skills training intervention geared towards reducing sexual risk behaviors in women with substance addiction. Participants were 117 women who had been court-ordered to an inpatient drug treatment program. They were evaluated for sexual risk behavior, and attitudes toward HIV prevention and condom use at baseline, post-intervention, and 2 months after discharge from the drug program. Women in both conditions had reduced drug use and drug-related high-risk sex activities at follow-up. Results indicated that both interventions were helpful in improving positive attitudes toward HIV prevention, and reported greater partner agreement with condom use at the post intervention assessment. However, at 2-month follow-up women in the behavioral skills training group continued to show improvement in communication and condom application skills, whereas women in the psychoeducation group did not. Moreover, women in the behavioral skills group had increased their condom use at follow-up [from 35.7 percent to 49.5 percent of incidences of vaginal intercourse] while women in the psychoeducation group evidenced a decrease in frequency of condom use [28.8 percent to 15.8 percent].

Behavioral Skills Training [BST]

Research by Wurtele, as described earlier [Wurtele et al., 1986, 1987, 1989], demonstrated that BST was superior to informational approaches to teaching sexual abuse prevention skills to children. However, the primary limitation of this work and other research evaluating BST for teaching sexual abuse prevention skills [e.g., Harvey et al., 1988] is that assessment relied on verbal report rather than assessment of actual skills when presented with a simulated sexual abuse lure. As a result, the conclusions that can be drawn from these studies are limited; it just is not known whether children who demonstrated increased sexual abuse prevention knowledge in these studies would use sexual abuse prevention skills if ever faced with a sexual abuse lure. Without in situ assessments, actual benefit to the children participating in the studies cannot be measured.

Other research evaluating BST to teach sexual abuse prevention skills used verbal report assessment and in situ assessment [Miltenberger & Thiesse-Duffy, 1988; Miltenberger et al., 1990] to evaluate the effectiveness of the program. However, the in situ assessment evaluated the children’s responses to an abduction lure from a stranger in a public place, rather than a sexual abuse lure from a known individual. Therefore, the authors did not evaluate sexual abuse prevention skills in their in situ assessment and, as a result, no conclusions can be drawn about the effectiveness of the training program for teaching actual sexual abuse prevention skills. Similarly, Haseltine & Miltenberger [1990] evaluated a BST program for teaching sexual abuse prevention skills to women with mild intellectual disabilities, but assessed abduction prevention skills [responses to a lure to leave with a stranger] rather than sexual abuse prevention skills. Again, no conclusions could be drawn about the effectiveness of the BST program for teaching the women to respond to sexual abuse lures.

Researchers evaluating BST for teaching other safety skills have used in situ assessments to evaluate the training programs [e.g., Gatheridge et al., 2004; Himle, Miltenberger, Gatheridge, et al., 2004; Miltenberger et al., 2004, 2005]. Considering the similarity of safety skills taught in this research to sexual abuse prevention skills [recognize, avoid, escape, report], the results of this research have direct relevance for teaching sexual abuse prevention skills. This research has produced mixed findings regarding the effectiveness of BST for promoting the use of safety skills when children are faced with a simulated safety threat during an in situ assessment. Himle, Miltenberger, Gatheridge, & Flessner [2004] showed that 4- and 5-year-olds demonstrated firearm injury prevention skills in role-play assessments following a BST program, but that the same children did not use the skills when they found a gun during in situ assessments. On the other hand, Gatheridge et al. [2004] found that many of the 6- and 7-year-olds who participated in the same BST program did use the firearm injury prevention skills during in situ assessments following training.

In follow-up to these studies, Himle, Miltenberger, Flessner, & Gatheridge [2004] and Miltenberger et al. [2004] evaluated individual BST with booster sessions for teaching firearm injury prevention skills to 4–5-year-olds and 6–7-year-olds, respectively. Himle, Miltenberger, Flessner, & Gatheridge found that 3 out of 8 participants engaged in the safety skills during in situ assessments following BST, and Miltenberger et al. found that 3 out of 6 children engaged in the safety skills upon finding a gun during an in situ assessment following BST. These studies and others [e.g., Jostad, Miltenberger, Kelso, & Knudson, 2008] suggest that BST for teaching safety skills for firearm injury prevention is effective for about half of the participants. Other research evaluating BST for teaching abduction prevention skills showed it was effective [as measured with in situ assessments] for most, but not all, participants [Poche et al., 1981, 1988]. Unfortunately, researchers have not identified any methods to determine which children will benefit from BST and which children will need additional training. Across the studies in which BST was not entirely effective, IST was the additional training method found to be effective for children who did not benefit from BST.

Patient cognitive and emotional representations of diabetic foot ulcer risk and foot self-care

An important limitation of the earlier DFU educational trials is their exclusive focus on foot self-care knowledge and behavioral skills training: none of these studies addressed potential psychosocial factors underlying patients’ foot self-care actions. Vileikyte et al. [2006a] reported on the development and validation of the Patient Interpretation of Neuropathy [PIN] questionnaire, an instrument for assessing cognitive and emotional factors associated with foot self-care. This 39-item instrument consists of nine scales capturing patients’ common-sense misconceptions about DFU risks, their level of understanding of practitioner information, and foot problem-specific emotional responses. Using the PIN instrument and path modeling technique, we examined the ways patient common-sense models of DFU risks combine with medical information, specific emotional responses, and prior DFU in predicting stable foot self-care behavioral patterns over 18 months of follow-up [Vileikyte, 2008]. We demonstrated that patient misconceptions: “good circulation means healthy feet” and “the development/worsening of DFU would be accompanied by pain,” predicted potentially foot-damaging behaviors. In contrast, accurate interpretation of medical information about the nature of DFU risks and understanding of the causal pathways linking DN to DFU predicted more preventive foot self-care both directly and indirectly, i.e., by correcting the patient misconceptions and altering emotional reactions. Prior DFU also predicted better preventive foot self-care and less potentially foot-damaging behaviors both directly and by correcting the patient misconceptions. The total model explained 30% of preventive and 25% of potentially foot-damaging behaviors [Fig. 14.2].