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Acceptability of Interventions for Aggressive Behavior inLong-Term Care Settings: Comparing Ratings and

Hierarchical Selection

Jonathan C. BakerSouthern Illinois University, Carbondale

Linda A. LeBlancAuburn University

Fifty-six active treatment team members in long-termnursing care facilities completed an online survey assessingtreatment acceptability of modern behavioral, pharmaco-logical, and sensory interventions. A traditional treatmentacceptability rating scale was compared to treatmentselections in a paired-options format. Unlike earlierresearch, there were no significant differences in accept-ability between the 3 interventions on the traditional ratingscale. However, ratings and selections were significantlycorrelated for behavioral and pharmacological interven-tions. The clinical significance of such relations and theimplications for the use of treatment ratings is discussed.

THE ACCEPTABILITY OF A recommended treatment tothe individuals who will implement or experiencethe procedures is thought to directly impact thelikelihood of adoption and effective implementa-tion of the intervention (Burgio, Sinnott, Janosky,

& Hohman, 1992; Kazdin, 1980; Wolf, 1978).Researchers have usually measured interventionacceptability using ratings scales such as theTreatment Evaluation Inventory (TEI; Kazdin) orthe Treatment Evaluation Inventory–Short Form(TEI-SF; Kelley, Heffer, Gresham, & Elliott, 1989),which sample aspects of acceptability—such as theappeal of an intervention, the likelihood of use, andthe appropriateness of the intervention. Factorssuch as the high cost, practical implementationdifficulty, and perceived unethical nature of theintervention typically negatively impact the accept-ability of an intervention (Burgio et al.; Kazdin;Miltenberger, 1990). In addition, the experiences ofthe respondent who rates intervention acceptabilitycan also impact ratings (e.g., prior knowledgeabout and experience with the intervention havinga positive impact on ratings; Boothe & Borrego,2004; Cowan & Sheridan, 2003).In the late 1980s and early 1990s, prolific use of

physical and chemical restraints as interventions forolder adults with behavior problems in long-termcare settings sparked the development of noninva-sive positive behavioral interventions for problembehaviors as an alternative to chemical restraints(Burgio et al., 1992). Early evidence indicated thatsuch interventions were effective in addressing thebehavioral needs of older adults (Burgio et al.).Despite this evidence, researchers cautioned that inother areas of behavior analysis, effective interven-tions had not been adopted due to perceivedunacceptability and argued that acceptabilityshould be measured in aging settings (Burgio et al.).

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Behavior Therapy 42 (2011) 30–41

We would like to thank all of the nursing home directors, as wellas the Alzheimer's Association of Minnesota-North Dakota, theOhio Health Care Association/Ohio Centers for Assisted Living, theHealth Care Association of Michigan, the Michigan CountyMedical Care Facilities Council, Quality Behavioral Solutions,Inc., and the Midwest Region of Heartland HCCs for theirassistance with disseminating the survey to nursing home staffacross the Midwest.

Address correspondence to Jonathan C. Baker, Ph.D., Reha-bilitation Institute, Southern Illinois University Carbondale,Carbondale, Il 62901; e-mail: jonathan.c.baker@siu.edu.0005-7894/10/030–041/$1.00/0© 2010 Association for Behavioral and Cognitive Therapies. Published byElsevier Ltd. All rights reserved.

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As a result, a number of investigations examinedtreatment acceptability for behavioral interventionsin nursing home settings.In general, these investigations, which involved

reading vignettes describing different types ofinterventions, found results that were strikinglysimilar to the overall body of literature on accept-ability for behavioral interventions (Carter, 2007;Elliot, 1988; Miltenberger, 1990): Behavioralinterventions were rated as acceptable and oftenrated higher than pharmacological interventions(Burgio, Cotter, et al., 1995; Burgio, Hardin,Sinnott, Janosky, & Hohman, 1995; Burgio &Sinnott, 1989; 1990; Burgio et al., 1992; Lunder-vold, Lewin, & Bourland, 1990; Lundervold,Young, Bourland, & Jackson, 1991; Osterkamp,Mathews, Burgio, & Hardin, 1997). For example,Burgio and Sinnott (1989) found that collegeundergraduate students, adults, and day centerstaff (aged 60 and older) rated differential rein-forcement of incompatible behavior (DRI) thehighest, followed by medication, then time-out(TO). Other studies confirmed these findings (e.g.,Burgio & Sinnott; Osterkamp et al.). Burgio andSinnott also found that with cognitively intact olderadults raters, medication was rated higher than TOon the cognitively impaired vignette, suggestingthat more restrictive interventions were deemedmore acceptable as cognitive impairment increased.Another variable that appeared to affect accept-ability of TO and medication was place ofresidence. Burgio et al. (1992) found that forphysicians, medication was rated significantlyhigher for the community-dwelling vignette thanfor the nursing home vignette.Recent treatment advances present a need to

update the treatments investigated in treatmentacceptability studies with this population, as thetreatments examined in these earlier studies nolonger reflect current best practice in behavioralgerontology or in medicine. These new treatmentshave different characteristics (e.g., lower side effectprofiles, differing levels of effort and effectiveness)that might affect treatment acceptability substan-tially. For example, behavioral gerontologists haveadopted function-based treatments as best clinicalpractice (Baker, Hanley, & Mathews, 2006;Buchanan & Fisher, 2002; Carr & LeBlanc, 2003;Dwyer-Moore & Dixon, 2007). Function-basedtreatments consist of identifying stimuli maintain-ing behavior (e.g., attention) and incorporatingthose stimuli into the treatment (e.g., differentialreinforcement of an alternative behavior, whereattention is the reinforcer). In comparison, non-function-based treatments (e.g., differential rein-forcement of an alternative behavior) consist of

identifying preferred but arbitrary stimuli, likefood, that serve as the reinforcers. A non-function-based treatment typically results in anintervention that must overpower the existingcontingency (e.g., the consumer can engage in thetarget behavior, resulting in attention, or engagein the alternative behavior, resulting in food;Carr, Coriaty, & Dozier, 2000). Another exampleof treatment advances can be seen in the area ofmedication. The original studies on acceptabilityin geriatric settings always included the medicationHaldol, a typical antipsychotic medication with asevere side-effect profile (Liperoti et al., 2003;Schneider, 1999; Wang et al., 2005). In recentyears, atypical antipsychotic medications (Schneider,1999) have been developed with lesser side effectprofiles, which may affect acceptability. Finally,since the early studies were conducted, sensory-based interventions have been developed and havebeen growing in popularity (Burgio & Fisher,2000). Sensory-based interventions include techni-ques aimed at regulating the stimulation olderadults experience. Common stimulation therapiesinclude providing music or white noise in a quietsetting (Burgio & Fisher). Another sensory-basedintervention, which came out of geriatric psychiatry,is bright light therapy (Ancoli-Israel et al., 2003).Also known as circadian therapy, it is designed toaddress poor sleep and lack of exposure to sunlight,both of which are common in older adults withdementia living in nursing homes and are believedto be related to sensory deficits that lead toaggression (Lyketsos, Veiel, Baker, & Steel, 1999).Circadian therapy involves exposing the participantto a specific light (10,000 lux) for a specifiedduration (typically less than 1 hour; Lyketsos et al.,1999). Thus, these newer interventions might bemore acceptable than those included in prior studiesand the relative acceptability of these interventionsmight also differ substantially.In addition to the need for updated interventions,

researchers have noted a disparity between treatmentacceptability ratings and intervention adoption fortypically and nontypically developing child andadolescent settings (e.g., Kemp, Miltenberger, &Lumley, 1996). Similarly, findings of relatively highacceptability of behavioral interventions have nottranslated into treatment adoption in nursing homesettings (Baker et al., 2006; Burgio, Cotter, et al.,1995; Burgio,Hardin, et al., 1995; Burgio&Sinnott,1989, 1990; Burgio et al., 1992; Lundervold et al.,1990; Lundervold et al., 1991; Osterkamp et al.,1997). Kemp et al. (1996) suggest that behavioralinterventions are generally rated highly, potentiallydue to social desirability (i.e., “faking good”). Kempet al. administered the TEI-SF to three groups, with

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two of the groups experiencing nonstandard instruc-tions indicating that they should either think abouthow their boss would want them to respond orabout their own response rather than their bosses.Although no differential effects were observed,Kemp et al. suggested that either there is no socialdesirability effect or that the different instructionswere not effective discriminative stimuli.As an alternative to the social desirability

hypothesis, it is possible that rating scale measuresof treatment acceptability are simply not the rightmeans of assessing behavior associated with inter-vention adoption. That is, assessing acceptabilitymay not tell us much about subsequent choice (i.e.,adoption of one intervention over another, imple-mentation of an intervention or electing to imple-ment no intervention). In the preference assessmentliterature, strategies have been developed to presentchoices between two or more potentially preferredstimuli (e.g., DeLeon & Iwata, 1996; Fisher et al.,1992). This type of assessment has consistentlyproven to result in more differentiated and predic-tive patterns of preference than assessments thathave a person respond to only one option at a time(Pace, Ivancic, Edwards, Iwata, & Page, 1985). Asimilar approach might be applied to the treatmentacceptability preparations to determine whetherchoice-based responses confirm the results of priortreatment acceptability studies, which used a singlepresentation and rating format. For example,consumers could be asked to choose one interven-tion over another in paired presentations, and theresults might differ from those generated bycompleting rating scales.The purpose of the present investigation was

two-fold: (a) to advance previous research using up-to-date treatments and (b) to attempt to obtainmeasures of treatment acceptability using a meth-odology other than rating scales. In order to expandupon previous geriatric treatment acceptabilityresearch, the present investigation included treat-ment descriptions with function-based treatments,newer pharmacological interventions, and a com-bination of sensory-based interventions. To inves-tigate a new potential methodology for obtaining

treatment acceptability, participants, who weretreatment decision makers in nursing homes,completed standard ratings of acceptability andalso were required to choose between interventionsthey would most likely recommend to implement todeal with problem behaviors in their facility. Theseratings and selections were then compared todetermine the degree and direction of the relationbetween the two measures.

Methodparticipants and settings

Active treatment team members in long-term caresettings were recruited from nursing homes inMichigan, Ohio, Indiana, Wisconsin, Illinois, andMinnesota. Participants were recruited by directcalls to nursing homes and email or newsletterdistribution by state agencies (e.g., Michigan HealthCare Association) and nonprofit organizations (e.g.,Alzheimer's Association). The researcher called thenursing home administrator to obtain permission tocontact active treatment team members. Uponapproval, administrators either directly distributeda link to the website containing the assessment toactive treatment team members or provided theresearchers with the emails of active treatment teammembers. Upon opening the web page, theinformed consent process was initiated and partici-pants learned that completers would be eligible toparticipate in a random-draw lottery for one ofseven $50 prizes. Next, participants encountered ageneral demographic questionnaire with responsesin the format of yes/no, multiple choice, or alpha-numeric open-ended. These questions includedwhether the participant was, or had been in thepast 6 months, involved in treatment decisions for aresident with dementia who engaged in aggression.It also included age, gender, duration of employ-ment at the nursing home, history of encounteringaggression in the nursing home, and treatmentsusually implemented for aggression. Recruitingresulted in 131 people attempting the survey with56 completing a sufficient number of items to allowinclusion in the database (see Tables 1 and 2 for

Table 1Demographic Information for Participants

Age Sex Years ofexperience

Treatment recommended in past six months

Behavioral Pharmacological Sensory

Mean 45.25 8 (M)/48(F) 15.32 NA NA NARange 27-67 NA 1-37 NA NA NASD 10.3 NA 10.3 NA NA NAN NA NA NA 49 46 48

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demographic information and job titles). That is, 75potential participants were lost to attrition. Of theremaining 56, three completed all questions foronly two of the three interventions, resulting in asample size of 53 for acceptability of behavioralintervention and 56 for the other two conditions.Over three quarters of noncompleters exited thesurvey within 3 minutes (i.e., 3 minutes correspondsto the point at which the demographic question-naire might have been completed or at the verybeginning of the first video). All assessments werecompleted online from a computer in the partici-pant's home state.

materials

A technology service at Western Michigan Univer-sity hosted the survey and exported the results intoa statistical analysis program. The functioning ofthe website was assessed once every week for theduration of the study (28 weeks) and informationpresentation was at 100% for all tests. Theassessments were presented in a multimedia formatthat included: (a) a video vignette with a voice-overdescription of the problematic behavior; (b) anelectronic version of each treatment vignette andTEI-SF (Kelley, Heffer, Gresham, & Elliott, 1989);and (c) an electronic treatment selection question-naire. On average, completion of the entire studytook about 21 minutes (range=5 to 83 minutes).Three participants took over an hour to completethe assessment, indicating that these participantsprobably left the assessment open while notworking on it (i.e., they were doing other thingsand then came back to the assessment). Without

these three outliers, the average time to completethe study was 18 minutes (range: 5 to 38).

Video VignetteTreatment acceptability researchers have argued thatvideo vignettes are more ecologically valid thanpaper vignettes (Foxx, McHenry, & Bremer, 1996).Therefore, the assessment used video vignettes thatdepicted a confederate older adult and a staffperson. The older adult confederate, referred to as“Margery” in the videos, portrayed a 76-year-oldwoman who was described as partially ambulatorybut appeared in a wheelchair during all scenes. Shewas described as having mild to moderate stageAlzheimer's disease. The confederate staff personportrayed a woman in her mid to late 40 s. Thevideo vignette was 1 minute and depicted situationsin which staff attempted to help Margery withtasks (e.g., bathing, toileting) and immediatelystepped back or removed the demand after problembehavior and several other relaxed positive socialinteractions, suggesting escape as the maintainingvariable for aggressive behavior. During the video,a voice-over described Margery (as noted above)and the behaviors in which she engaged (aggressivebehaviors included hitting, pushing, and kicking).The video was presented as a time lapse over thecourse of several days and contained several shotsof Margery being aggressive in a number of areasand activities.

Treatment DescriptionsFollowing the problem behavior vignette video,auditory descriptions of the three treatments were

Table 2Job Titles for Participants⁎

Behavioral Sensory Pharmacological

Director of Nursing 10 10 10Administrator 10 10 10Social Worker 6 8 8Executive Director 5 5 5Registered Nurse 4 4 4Risk Management Specialist 3 3 3No Information 3 3 3Assistant Director of Activities 2 3 3Director of Activities 2 2 2Licensed Practicing Nursing 2 2 2Minimum Data Set Nurse 2 2 2Associate of Nursing 1 1 1Director of Social Services 1 1 1Recreation Therapist 1 1 1Clinical Coordinator 1 1 1Total 53 56 56

⁎ Three participants did not complete the behavioral ratings and selections, but did complete pharmacological and sensory ratings andselections. Therefore, participant job title information is presented by treatment.

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presented while a still picture of the treatment wasdisplayed on the screen. All treatments weredescribed in nontechnical terms and a randomnumbers generator determined the order of pre-sentation of the three treatments for each partic-ipant. Each treatment description lasted 1 minute.Research indicates that the type of intervention,regardless of details, can influence acceptability.Therefore, certain details in the vignettes anddescriptions were included to counterbalancedetails that have been shown to stack acceptabilityin the direction of one treatment, including: (a)presenting Margery as having dementia (i.e.,potentially increasing the acceptability of morerestrictive interventions; Burgio & Sinnott, 1990);(b) presenting Margery as living in a nursing home(i.e., potentially decreasing the acceptability ofbehavioral interventions; Burgio et al., 1992); (c)accurately presenting the pharmacological treat-ments as taking the least amount of time (less timeincreases acceptability; Tarnowski et al., 1987);and (d) presenting all treatments as generallyeffective, which has been shown to either haveno effect (Kazdin, 1981) or increase the accept-ability of treatments (Von Brock & Elliot, 1987).The clinical significance of the effect was notreported to ensure that none of the treatments(e.g., the behavioral treatment) had an advantageover another (e.g., pharmacological and sensory).Also, no information was presented noting thatatypical-antipsychotics are not approved for adultswith Alzheimer's and actually increase the chanceof death (Food and Drug Administration, 2005).

Communication training. The behavioral, func-tion-based intervention was called communicationtraining and consisted of functional communicationtraining (FCT). The visual that was presentedduring the voice-over was of Margery sitting inher wheelchair, handing the CNA a card that read,“PLEASE STEP BACK.” The treatment descriptionindicated to participants that a psychologist hadalready worked with Margery to teach her to handstaff a card asking them to back away, rather thanhitting staff. Communication training (i.e., FCT)consisted of staff prompting Margery to use hercard if she wanted a break before an activity. IfMargery became aggressive, staff again promptedher to ask for a break. As soon as she did, the staffperson was to remove materials or step away for30 s. The description noted that the treatmentrequired an hour of training, consistent implemen-tation by all staff working with her, and that the fulleffect could take a week or two to be seen. Thedescription also noted that the intervention wasdesigned to address the fact that due to Margery'sdementia, aggression had become the most effective

way to ask for a break and this intervention willgive her a more appropriate response.

Sensory. The sensory-based treatment, calledlight and sensory therapy, was a treatment packageconsisting of circadian and stimulation therapy,both of which are common sensory interventionsused with older adults with dementia living innursing homes (Ancoli-Israel et al., 2003; Burgio &Fisher, 2000). The visual that was presented duringthe voice-over was Margery sitting in a recliningchair, looking at a “light” (a paper laminatorturned on its side to look like a tall rectangularlight, similar to 10,000 lux lights) on a table next toher. The treatment description stated that it wasdeveloped by an occupational therapist and wasbeing used because Margery appeared to be “sundowning” (i.e., becoming more aggressive towardthe end of the day) and overstimulated. Lighttherapy (i.e., circadian therapy) consisted ofMargery sitting in front of a special bright light(10,000 lux) for 1 hour every morning. Over thecourse of the day, if she was aggressive, staff wouldimplement stimulation therapy by taking her to herroom to listen to classical music (i.e., contra-indicated for escape-maintained aggression). Thedescription noted that the treatment required20 minutes of training, turning the light on andoff in the morning, and taking Margery to herroom to listen to music whenever she becameaggressive. The description also noted that thetreatment was designed to address the fact that dueto Margery's dementia, her sleep cycle was off andshe had difficulty handling overstimulating situa-tions; this intervention would reduce stimulationand help regulate her sleep schedule to address“sun-downing.”

Pharmacological. The pharmacological treat-ment consists of an atypical neuroleptic, Risperdal,being prescribed at a 1.0 mg/day dosage. Risperdolwas selected as the pharmacological interventionbecause it is a common atypical antipsychotic usedwith older adults with dementia (Schnieder, 1999).The visual that was presented during the voice-overwasMargery sitting in her wheelchair putting a “pill”(a single tablet of Tums) in her mouth, with the nursehanding her a cup of water. The treatment involvedthe administration of the medication and checkingcertain physiological signs for side effects or compli-cations (Schneider). The treatment description statedthat it required 20 minutes of training on the signs ofside effects and that the nurse would administer themedication. The description also noted that thetreatment was prescribed by Margery's doctor afterseveral medical tests determined that Margery'sAlzheimer's disease had progressed, producing ag-gression. It also noted that the treatment was designed

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to address neurochemical changes in Margery's braindue to the deteriorating effects of Alzheimer's diseaseby regulating those neurochemicals.

Adapted Version of the TEI-SFThe TEI-SF has been shown to have similarreliability and validity to the TEI. For example,using the factor analysis from the TEI as a basis foritem selection on the TEI-SF, Kelley et al. (1989)demonstrated that a factor analysis of the TEI-SFrevealed the similar two-factor structure as the TEIand found internal consistency measures for theTEI-SF (α=0.85) were similar to those of the TEI(α=0.89, 0.97), though the TEI-SF took less time tofill out and was written at an easier reading level.Therefore, the current study utilized the TEI-SFadapted by Burgio and colleagues that includedwording to make the questions pertinent to olderadults instead of children (see Figure 1).

Treatment Selection QuestionnaireFollowing all treatment description and TEI-SFs,participants completed the treatment preferenceportion of the study. Participants were providedwith a brief review/summary of each intervention.Following the summary, participants were presented

with two potential interventions, communicationtraining or pharmacological. Participants were thenasked to selectwhich course of action theywouldmostlikely recommend for others to implement withMargery if she was a resident in their facility. Inaddition to the three interventions described above, anadditional option of referral to another facility wasincluded. No description of the referral treatment wasprovided, as there was no formal training necessary torefer a patient to another facility. During eachpresentation, the participants were presented withtwo treatments as well as the option to select neither.Once a participant selected an option, anothercombination of two treatments was presented alongwith the option for neither. This continued until allfour treatments/courses of action were paired withevery other treatment/course of action and a “neither”option. This presentation simulated a paired stimuluspreference assessment where two possible options arepresented simultaneously and every optionwas pairedwith every other option (Fisher et al., 1992).

Treatment QuestionnaireFollowing treatment selection, participants completedthe treatment questionnaire. This questionnaireincluded yes/no, multiple choice, and alpha-numeric

Scale:

1 2 3 4 5

Strongly Disagree Neutral Agree Strongly

Disagree Agree

Questions:

1. I find this treatment to be an acceptable way of dealing with the woman's problem behavior

2. I would be willing to use this procedure if I had to change an older adult's problem behavior

3. I believe that it would be acceptable to use this treatment without older adult's consent

4. I like the procedures used in this treatment

5. I believe this treatment is likely to be effective

*6. I believe the woman will experience discomfort during the treatment

7. I believe this treatment is likely to result in permanent improvement

8. I believe it would be acceptable to use this treatment with individuals who cannot choose

treatments for themselves

9. Overall, I have a positive reaction to this treatment

*Note: scale is reversed when scoring this item

FIGURE 1 The Adapted TEI-SF.

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open-ended format questions. Questions included: (a)how many consumers the participant had workedwith who engaged in aggression; (b) the types ofaggression; (c) whether any received a behavioraltreatment (if so, how many consumers received this,what was the intervention, was it successful, whetherthey would try it again, did it cost more or less thanother treatments); (d) if behavioral interventions werenot selected, why not; (e) whether any received asensory treatment (if so, what was the intervention,was it successful, whether they would try it again, didit cost more or less than other treatments); and (f)whether any receivedmedication as a treatment (if so,what was the medication, was it successful, whetherthey would try it again, did it cost more or less thanother treatments).

procedures

Participants experienced the online assessments inthe following order: (a) informed consent; (b)demographics; (c) problem behavior vignette; (d)randomly selected treatment one description/videoand TEI-SF (a random numbers generator deter-mined the order of presentation). The video of thetreatment and the TEI-SF were on the same page, toallow participants to review the treatment again ifthey desired); (e) repeat of description/video andTEI-SF for the remaining two interventions inrandom order; (f) randomly selected treatmentselection question one, followed by the remainingfive treatment selections questions in random order;(g) treatment use questionnaire.

ResultsCronbach's alpha was calculated for the adaptedTEI-SF to evaluate the reliability (i.e., internalconsistency) of the measure. Obtained Cronbach'salpha for the reliability of the adapted TEI-SF was0.857, similar to that obtained for the TEI-SF inother studies (Kelley et al., 1989). A one-wayANOVA was conducted on the mean totalacceptability scores for the treatments to determineany significant differences in means. The obtainedF (0.809) was not significant when compared tothe critical F (F2,53=3.17). The top panel of Figure2 shows a bar graph of the means for eachtreatment. A similar analysis was conducted forthe mean selection percentage for the treatments(see bottom panel of Figure 2). Theobtained F (37.485) was significant when com-pared with the critical F (F2,53=3.17) indicatingthat at least one condition was different from theothers. Therefore, post hoc tests (Tamhane's T2,due to significant non-homogenous variance)indicated that none of the three treatments (FCT,

sensory, pharmacological) differed significantlyfrom each other, though each was significantlydifferent from referral or neither, which were notsignificantly different from each other.Comparisons were also made between the total

treatment acceptability score and the selectionpercentage for all participants. The correlationbetween all treatment ratings and all treatmentselections (N=165: 56 + 56 + 53, as eachparticipant completed three sets of ratings andselections that could be compared) was r(165)=.192, p=.017, a statistically significant finding.Comparisons between rating and selection werealso made for each treatment. The correlation forFCT ratings versus selection percentage was r(53)=0.298, p=.035, achieving statistical significance.The correlation for sensory ratings with selectionpercentage was r(56)=-.045, p=.749, and was notsignificant. The correlation for pharmacologicalratings with selection percentage was r(56)=0.304,p=.028, achieving statistical significance. Thus,ratings were significantly correlated with selectionfor FCT and pharmacological treatments but notfor sensory treatments. Comparisons made amongselection percentage and Question 2 on the TEI-SF(“I would be willing to use this procedure if I had tochange an older adult's problem behavior”) yieldedsimilar results: the correlation forQuestion 2 ratings

44

39

34

29

24

19

14

1009080706050403020100

9FCT

FCT

Sensory

Sensory

Pharm.

Pharm. None Referral

28.68 29.427.57

59.39 58.7949.7

10.3 9.09

FIGURE 2 Top panel shows mean TEI-SF ratings for behavioral,sensory, and pharmacological treatments. The dashed linecorresponds to a mean total score of 27 and a classification ofneutral. Bottom panel contains mean selection percentage forbehavioral, sensory, pharmacological treatments, “none,” andreferrals.

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for FCT with selection percentage was r (53)=0.296, p= .037; the correlation for sensory wasr(56)= -.030, p= .832; and the correlation forpharmacological was r(56)= .274, p=.050. Thus,Question 2 ratings were significantly correlatedwith selection percentage for pharmacological andFCT ratings, while the relation between themeasures did not approach significance for thesensory condition.Finally, Point Bi-Serial correlations were calcu-

lated to determine the degree and direction of therelation between treatment ratings and the dichot-omous (i.e., yes or no) measure of treatments usedin the nursing home. No treatment use questionswere significantly correlated with treatment ratings.Only one treatment use question was significantlycorrelated with treatment selection percentage. Thequestion, “If it [the behavioral treatment] was notsuccessful, was another form of behavioral treat-ment used prior to medication?” was highlycorrelated with selection of FCT, r(56)=0.430,p=.016, indicating that higher selection percen-tages were related to answering yes, rather than no,on this question.

DiscussionDevelopment of new interventions over the pasttwo decades created a need to update the treatmentacceptability literature for interventions used witholder individuals with dementia. Additionally, thepublished literature on treatment acceptabilityexclusively used ratings scales without measuresof actual treatment adoption. The current studyattempted to incorporate new interventions with arelatively untargeted population (i.e., active treat-ment team decision makers) and new technology toreevaluate treatment acceptability for interventionswith nursing home residents. As a result, threeimportant findings emerged.The first important finding was the lack of

differentiation between treatments with overallaverages of 27 (neutral rating) for each interven-tion. These results should be viewed in light of thefact that this study used an adapted measure ofacceptability and the sample size. First, this studyinvolved an adapted measure of acceptability, theadapted TEI-SF. The adapted TEI-SF was used toreduce the amount of time participants spentcompleting the assessment. Although findingswith regard to internal consistency were similar tothose obtained for the TEI-SF in previous studies(Kelley, Heffer, Gresham, & Elliott, 1989), it isunclear what influence this measure might have hadon ratings. Second, prior studies had larger samplesizes, and it is possible that including more

participants might have resulted in more differen-tiated results. In addition to sample size and anadapted measure, the seeming contradicting resultsobtained in the present study should be consideredin the context of two purposeful methodologicalchanges in this study compared to previous studies.One purposeful methodological change in this

study is related to the characteristics of thetreatments included in the assessment. The currentstudy used Risperdal, an atypical antipsychoticwith a much less severe side effect profile thanHaldol (Schneider, 1999). Risperdal was endorsedas a pharmacological intervention used in the prior6 months for 28 of the 37 respondents who listedspecific medications used, indicating that Risperdaland its milder side-effect profile was probably quitefamiliar and acceptable as a medication used tocontrol behavior. Previous research (e.g., Burgio &Sinnot, 1990) also used punishment in comparisonto DRI and medication with no option for a sensorytreatment. Research has shown that sensory treat-ments can be as effective as medication (though theeffects are not long lasting) and that there is agrowing trend in the use and popularity of suchinterventions (Burgio& Fisher, 2000). The fact thatsensory treatments constitute an alternative torestraint (OBRA, 1987), coupled with using afunction-based behavioral treatment that wastopographically different from what most partici-pants had experienced (e.g., providing activities andredirection) may have decreased the saliency of thebehavioral intervention as the most acceptableintervention for the older adult in the vignette.Another purposeful methodological change in

this study is related to certain details in the vignettesand descriptions. The vignette and treatmentdescriptions included several balanced details relatedto strengths and weaknesses (as described below) tolimit the potential that details about the studies, asopposed to actual experience, would result in biastoward one treatment over another. Previous studies(e.g., Burgio & Sinnot, 1990) examined differencesin acceptability based on specific manipulation ofdetails of the presentation and other factors.Although this approach illustrated important find-ings about some of the factors that can alteracceptability, the goal of the current study was notto change acceptability. Rather, we sought to samplethe acceptability of current interventions based onprior experiences with those interventions. Thus,information was presented in a manner designed tominimize variability in ratings due to factorsassociated with presentation style and content. Assuch, this practice may have produced a leveling ofacceptability ratings in accordance with findingsfrom previous research that directly manipulated

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content and presentation variables (Carter, 2007;Elliot, 1988; Miltenberger, 1990). For example,reinforcement-based treatments (e.g., FCT) havebeen found to be more acceptable (i.e., a strength)while restraint-based treatments (e.g., pharmacolog-ical) have been found to be less acceptable (i.e., aweakness; Carter, 2007; Elliot, 1988; Miltenberger,1990; Reimers, Wacker, & Koepl, 1987). Based onthese results, presenting the pharmacological inter-ventionmay have resulted in lower ratings comparedto the other interventions based solely on the type ofintervention (i.e., higher ratings of acceptability forreinforcement-based interventions). Therefore, addi-tional details were included (e.g., the amount of timeit took to train the intervention, a weakness for thereinforcement-based intervention and a strength ofthe pharmacological intervention). Pharmacologicaltreatments take less training in preparation fordelivery than sensory or behavioral interventions,which should have resulted in pharmacologicaltreatments being more acceptable than sensory andboth should have been more acceptable than FCT(Tarnowski, Kelly, & Mendowlitz, 1987). Finally,all treatments were described as effective, which hasbeen shown to either have no effect (Kazdin, 1981)or increase the acceptability of treatments (VonBrock & Elliot, 1987). The clinical significance ofthe effect was not reported to ensure that none of thetreatments (e.g., the behavioral treatment) had anadvantage over another (e.g., pharmacological andsensory). In sum, by combining accurate descriptionsand details of interventions that have been shown toinfluence acceptability with updated treatmentdescriptions, the result was virtually undifferentiatedratings.In addition to undifferentiated ratings in treat-

ment acceptability, a second important finding ofthis investigation was related to the relationbetween ratings and selections. Pearson product–moment correlations were significant when com-paring all ratings and selection percentages (i.e.,N=165), as well as when comparing ratings toselection percentage for FCT and pharmacologicalintervention, but not for the sensory intervention.Question 2 from the TEI-SF was significantly andpositively correlated with FCT and pharmacolog-ical selection percentages. Therefore, ratings andselection percentages were significantly correlatedfor all but the comparison of sensory ratings andselection percentages. However, the highest corre-lation was only r= .304. Given that treatmentacceptability surveys are designed to serve aspredictors for treatment adoption, a strongerrelationship between ratings and questions askingparticipants which treatments they would adoptwould have been expected. As such, researchers

should be cautious about interpreting the results ofacceptability surveys as indicative of treatmentadoption.The third and final important finding was

preliminary support of treatment selection as amore accurate measure with respect to treatmentadoption. Support for this finding comes from twopieces of evidence. The first is the endorsement ofreferral and “nothing” courses of action duringtreatment selections. Both were selected 10% of thetime they were presented in the treatment selections.These options have never been presented withtreatment ratings, but in theory should be compa-rable to a total rating of 9 (i.e., a 1/strongly disagreeon each of the nine questions) on the TEI-SF, whichwould indicate strong disagreement with theacceptability and subsequent adoption of a treat-ment. Only 2 participants rated any treatment as a9 (one participant rated FCT and pharmacologicalas a 9 and did not rate the sensory intervention,while the other rated all treatments a 9). On theother hand, 22 participants selected referral or“neither” at some point in the treatment sections,indicating that though the majority would not ratea treatment with strong disagreement, they wouldnot select a treatment once the option was presented(the participant mentioned above who rated alltreatments as a 9 selected FCT 100%, sensory 66%,and none 16%).The second piece of preliminary evidence that

selections are a more accurate measure is thecorrelation between selections and treatment use.Participants were initially asked how many of theresidents engaging in aggression in the prior 6months received a behavioral treatment. They werethen asked, “If the behavioral treatment did notwork, was another used before using pharmaco-logical treatments?” The fact that treatment selec-tions were positively correlated with answering yesto this question while treatment ratings were notcorrelated with answering yes on this questionindicates that treatment selections may be moreclosely related to past behavior. That is, for thoseparticipants who indicated that they typicallyrecommend behavioral interventions, they tendedto choose the behavioral intervention as the mostlikely course of action they would take during thetreatment selection.In addition to these three important findings, a

number of limitations are important to note. First,this study was analog in nature, meaning thatparticipants did not actually implement the treat-ment following selection or rating. Although over80% of participants reported having recommendedthese treatments in the 6 months prior to the study,there is no guarantee that the behavioral, sensory,

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and pharmacological treatments they recom-mended took the same form as those in this study.Second, this study sampled the acceptability oftreatments for only one topographical class ofbehavior: aggression. It may be possible thatacceptability for the three interventions mighthave been different if another problematic behaviorhad been used as the target.Another limitation to the findings is participant

selection and self-selection. Many more nursinghomes and participants were contacted thanactually completed the entire survey, which createsthe possibility that those who were contacted butdid not complete the survey might have respondeddifferently than those who completed the assess-ment. Along the same lines, 130 people attemptedthe survey, though only 56 completed it (i.e., a 41%completion rate). Researchers estimate “breakoff”level (i.e., respondents who begin a web-basedsurvey but do not complete it) medians to beanywhere from 16% to 34% (Peytchev, 2009).Thus, this study had a higher than usual breakofflevel. Most of these participants exited the studywithin the first 3 minutes. Two potential causes ofthis might be that: (a) participants decided the studywould take too long, despite information indicatingthe average completion time was 10 to 20 minutes,or (b) the video did not work for the participant andthey therefore exited the survey. Anecdotally, theresearchers received feedback supporting the latterof these two possibilities. As a result, informationwas included on the video page noting that thevideo required two to three clicks before it wouldplay. Treatment integrity data indicated that thevideo continued to work through the study, thoughmultiple clicks were sometimes necessary. Had allparticipants completed the survey, the results mayhave differed. Additionally, participants were onlyrecruited from the Midwest portion of the UnitedStates while previous projects have recruited fromthe East Coast or nationally. Finally, althoughnursing home administrators, who were contactedby phone, confirmed that participants from theirfacility were treatment decision makers, there wasno such confirmation for participants recruited byother means (other than the fact that they chose“yes” on the demographic question when asked ifthey were a decision maker).The results of the correlation between treatment

ratings and selections present a conceptual issue asto why treatment ratings and treatment selectionsmight differ. Due to methodological constraints, adefinitive statement cannot be made as to which, ifeither, is a more accurate measure of adoptionbehaviors than the other. Therefore, it is onlypossible to hypothesize why ranking a treatment on

a Likert-type scale would not be more stronglyrelated to selecting those same treatments from anarray. One argument is that the TEI-SF total scorerepresents a collection of factors, some of which arenot related to treatment adoption (the focus of thetreatment selection question). However, Question 2from the TEI-SF directly asks about treatmentadoption, and was strongly correlated to the TEI-SFtotal score for FCT, sensory, and pharmacological(r= .853, .908, and .909, respectively, withpb .0001 for all). Additionally, it is not unreason-able to assume that Question 2 would be correlatedwith the treatment selection question, since both aredirectly related to treatment adoption. Question 2was correlated with selection for FCT and phar-macological, but not for sensory. Thus, the mostparsimonious conceptualization of why the resultswere not more closely related is that questionsinvolving ratings sample a different repertoire thantreatment selection questions, and at this point,there is not enough evidence to determine whichrepertoire is tied to treatment adoption behaviors.Previous researchers have questioned the validity ofthe results obtained through treatment ratings (e.g.,Kemp et al., 1996), but to date, researchers havenot questioned the validity of ratings as a way tosample behavior. The results of this study provideevidence that such questioning is warranted.Treatment selections, in lieu of treatment ratings,

represent only the first step toward identifying thecontingencies that affect treatment adoption. Asnoted earlier, the current methodology did not lookat actual treatment adoption behaviors, so it ispossible that considering this methodology moreaccurate may be premature. Further research isneeded to determine treatment adoption in thecontext of actual treatment implementation. Thatis, future research should focus on obtaining actualmeasures of treatment adoption when multipleoptions are available. For example, researchersmight train participants to implement two or moreempirically supported treatments while collectingdata on treatment integrity. Following a period ofacquisition in which participants demonstrateappropriate levels of integrity, researchers mightremove overt data collection methods and deter-mine which intervention the participants choose toimplement when the researchers “leave,” as well asthe level of integrity, both of which would be strongindicators of treatment adoption. Additionally, insituations where behavioral interventions are notadopted, researchers can begin to determine manip-ulations that can influence adoption (cf. Hanley,Iwata, & Lindberg, 1999). Such information mightlead researchers toward the development of viabletreatments in nursing home settings. Whether such

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methodologies are practical or viable in nursinghome settings is something for future research todetermine. Regardless, the results of the currentstudy provide the impetus to begin to investigatefurther into treatment acceptability methodology.

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RECEIVED: September 23, 2009ACCEPTED: April 20, 2010Available online 21 September 2010

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