A consecutive case review of token systems

used to reduce socially maintained

challenging behavior in individuals with
intellectual and developmental delays
Mindy Scheithauer1, Tom Cariveau1, Nathan A. Call1, Hailey Ormand1,
SethClark2
Marcus Autism Center, Childrens Healthcare of Atlanta, Emory University School of Medicine, Atlanta, GA,
1

USA, 2Marcus Autism Center, Childrens Healthcare of Atlanta, Atlanta, GA, USA

Objectives: The current paper describes the use of token systems in a behavioral day-treatment unit for severe
challenging behavior using a consecutive case review spanning three years.
Methods: Experimenters reviewed 96 patient case files, 24 of which implemented some token system as a
component of the individuals treatment package. Aspects of each token system (including schedules of token
delivery and exchange; inclusion of token training and response cost; and types of backup reinforcers delivered),
and participant characteristics were coded.
Results: Token systems were most frequently employed during differential reinforcement for alternative behavior
(DRA, most commonly for compliance) or differential reinforcement of other behavior (DRO). Tokens were most
frequently used in an instructional context. Several commonalities were identified (e.g. restriction of backup
reinforcers between token exchanges and initial dense schedules of reinforcement). Compared to past reviews,
this sample had an over-representation of individuals with challenging behavior maintained by escape, multiply
maintained challenging behavior, and individuals for which the function was not identified in a functional analysis.
Treatment packages including token systems resulted in a reduction in challenging behavior for 91.67% of
participants, with 70.83% exhibiting at least an 80% reduction.
Conclusion: Our findings suggest that token systems may be a beneficial component of treatment plans used
to address challenging behavior. Some common components should likely be included in all token systems and
specific client variables may guide decisions related to idiosyncratic treatments.
Keywords: Functional analysis, Challenging behavior, Token economy, Token system

In 1968, Ayllon and Azrin described a series of studies
in which they utilized token-based reinforcement sys-
tems with individuals diagnosed with severe psychiatric
disorders in a hospital setting (Ayllon and Azrin 1968).
Across six experiments, the authors demonstrated that
providing participants with opportunities to earn tokens
that could later be exchanged for tangible rewards or priv-
ileges increased a wide range of work and self-care tasks.
Although other examples of token economies preceded
this work (e.g. Cowles 1937; Kelleher and Gollub 1962;
Wolfe 1936), Ayllon and Azrin demonstrated the useful-
ness of token systems in applied contexts in a manner
that garnered the interest of clinicians and researchers.
As a result, the use of token reinforcement systems has
since spread tremendously. Interventions that include
token systems are now nearly ubiquitous in settings like
Correspondence to: Mindy Scheithauer, Marcus Autism Center, Childrens
Healthcare of Atlanta, Emory University School of Medicine. Email: Mindy.
Scheithauer@choa.org
preschool and elementary school classrooms (Boegli and
Wasik 1978; Filcheck et al. 2004), special education set-
tings (McCullagh and Vaal 1975), group homes (Handen
et al.1984), and psychiatric hospitals (Birchwood et al.
1989; Kazdin 1982; Matson and Boisjoli 2009).
Simply put, in the context of reinforcement systems,
tokens are objects or symbols that can be exchanged for
goods or services (Hackenberg 2009). Within the behavior
analytic literature, tokens are generally considered to serve
as conditioned reinforcers because they initially have no
inherent value. Instead, any reinforcing efficacy possessed
by the tokens has been acquired through having been paired
with backup reinforcers. The fact that tokens can serve as
conditioned reinforcers has many advantages to clinicians.
For example, tokens are convenient because they can be
delivered frequently without interrupting ongoing activi-
ties and exchanged for a backup reinforcer at some later,
more convenient time (Hupp et al. 2002). Thus, research-
ers originally viewed tokens as a way to bridge delays

The British Society of Developmental Disabilities 2016

DOI 10.1080/20473869.2016.1177925 International Journal of Developmental Disabilities 2016VOL. 62 NO. 3 157
Scheithauer et al. A consecutive case review of token systems
to reinforcement (Jackson and Hackenberg 1996; Kazdin
2001; Kazdin and Bootzin 1972; Stromer et al. 2000).
Additionally, tokens can generally be delivered on a
much denser schedule than primary reinforcers because
there is less chance of satiation for two main reasons
(Moher et al. 2008). First, tokens are not consumed in
the same sense as many primary reinforcers. Second, when
used as generalized conditioned reinforcers, meaning they
have been paired with a variety of backup reinforcers,
tokens can increase the probability that there will be suf-
ficient deprivation for at least one backup reinforcer that
will maintain desired behaviors (Skinner 1953, p. 77).
Another significant advantage of token reinforcement
systems is their flexibility. That is, token systems are
highly adaptable to a wide range of behaviors and clini-
cal needs. Most commonly, token economies have been
used with individuals with autism spectrum disorders and
other developmental disabilities to increase prosocial and
adaptive behaviors (Matson and Boisjoli 2009), such as
those related to school conduct (e.g. remaining in seat)
and academic performance (Cotler et al. 1972; Nay and
Legum 1976; Tarbox et al. 2006). However, token econo-
mies have also been frequently employed to reduce chal-
lenging behaviors, such as disruptive behavior (Zlomke
and Zlomke 2003), aggression (LePage et al. 2003), inap-
propriate sexual behavior (LeBlanc et al. 2000), and severe
food refusal (Kahng et al. 2003).
Although they are widely used to address challeng-
ing behaviors, a recent review of token economies found
that published accounts varied substantially in terms of
reported effectiveness (Maggin et al. 2011). This incon-
sistency in the results of token economies could stem from
the many possible procedural variations. For example, in
a seminal review on token economies, Hackenberg (2009)
explained that a token economy comprised three intercon-
nected schedules of reinforcement, each of which can vary
widely and influence the effectiveness of the entire token
economy. The token-production schedule refers to how
long an individual must work or how much of a behav-
ior they must emit to earn a token. For example, a child
may earn a token after each behavior (e.g. after each math
problem completed), after a set number of behaviors (e.g.
after every three math problems completed), or after a set
period of time (e.g. an entire class period without challeng-
ing behavior). The exchange-production schedule refers
to when opportunities to exchange tokens for the backup
reinforcers arise. For example, a token economy can be
arranged such that a student can exchange tokens as soon
as one is earned (Fixed Ratio (FR) 1 exchange-production
schedule), after they have accumulated 10 tokens (FR 10
exchange-production schedule), or at a certain time such
as the end of the school day (Fixed Time (FT) 6h). The
token-exchange schedule refers to how much of the backup
reinforcer is delivered for each token. Thus, this schedule
can be considered the unit-price of the backup rein-
forcer. If each token is equivalent to one unit of the backup
158 International Journal of Developmental Disabilities 2016VOL. 62
reinforcer (e.g. one token equals one piece of candy), then
the token-exchange is set at a FR 1. However, other unit
prices could also be set (e.g. ten tokens equivalent to one
unit of the backup reinforcer [FR 10]).
Frequently, dense schedules for each of these compo-
nents are in place at the start of the intervention. In other
words, what the individual must do to earn a token may
be minimal, tokens can be exchanged frequently or imme-
diately, and/or large portions of the backup reinforcer are
provided for each token. However, systematic methods for
thinning schedules of reinforcement are usually employed
so that the final treatment is more manageable (Hagopian
et al. 2011).
Similarly, variations exist in the type of backup rein-
forcers delivered following token exchanges. In some
cases, exchanging tokens produces access to a single
consistent reinforcer (Kahng et al. 2003). This approach
is most likely to be effective when challenging behavior
is exclusively maintained by this particular reinforcer.
For example, a treatment for challenging behavior that is
maintained by negative reinforcement (e.g. a break from
demands), might include a token economy in which
tokens are always exchanged for breaks from tasks
(e.g. McComas et al. 2000). However, in other cases a
variety of backup reinforcers are available (Carton and
Schweitzer 1996; Zlmoke and Zlomke 2003), making
it possible to have different exchange schedules for
different backup reinforcers (e.g. 1 token=candy, 10
tokens=a new toy). This procedure is referred to as a
menu of reinforcers.
Another way in which token-based interventions can
vary is the degree to which tokens are explicitly paired
with the backup reinforcers. In many cases, conducting
specific token training ensures that the tokens are asso-
ciated with the backup reinforcer, and therefore serve as
a conditioned reinforcer (Moher et al. 2008). However,
token training is not always necessary, as verbal stimuli
explaining contingencies may be sufficient for tokens to
become conditioned reinforcers (e.g. contingency-specify-
ing stimuli; Mistr and Glenn 1992). Verbal stimuli may be
especially sufficient for individuals with a strong receptive
verbal repertoire.
Finally, token economies vary with respect to the
inclusion of contingencies in which tokens are lost or
removed following inappropriate behaviors (referred to as
response cost). Some token economies rely entirely upon
this arrangement by providing a fixed number of tokens
at set intervals (e.g. each morning), and then removing
one each time challenging behavior occurs. Any tokens
that remain when the exchange-production schedule is met
can then be exchanged for backup reinforcers (Salend and
Henry 1981).
To date, existing reviews of token systems have gen-
erally provided only broad overviews about procedural
aspects of token economies. However, specifics about
each of these variables, such as the exact schedules
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 Scheithauer et al. A consecutive case review of token systems

at the start and end of the token economy as well as Table 1 Demographic characteristics of sample
when the exchange took place, are often not described. Characteristics n %
In addition, Maggin and colleagues (2011) identified Gender
limitations related to research in the field of token Male 17 70.83
Female 7 29.17
economies, including that the majority of studies do Age
not provide demographic information about the sam- 05 4 16.67
ple. Despite the fact that there are many examples of 610 6 25.00
1115 11 45.83
the effective use of tokens in the literature, it remains 1620 3 12.50
unclear how effective they are because of the possibility Ethnicity
African American 14 58.33
of publication bias (Sham and Smith 2014) and signif- Caucasian/White 9 37.50
icant variations in methodology. Asian 1 12.50
The current study expanded on past research related Diagnosis
Autism spectrum disorder 22 91.67
to token economies by providing a consecutive case Conduct disorder 5 20.83
review of all individuals seen in a day-treatment unit Attention deficit hyperactivity disorder 4 16.67
Disruptive behavior disorder 4 16.67
that included tokens in treatment development, elim- Developmental delay 2 8.33
inating the potential for publication bias. Specific Other 3 12.50
descriptive information is provided about the token
systems and participants demographic information,
including the function of their challenging behavior. A Table 2 Characteristics of Problem Behavior and General
broad description of the success of treatments including Treatment
tokens is also presented.
Characteristics n %
Primary concern
Methods Aggression 22 91.67
Participants and setting Disruption 19 79.17
Elopement and/or Dropping 8 33.33
Participants were individuals seen in a day-treatment Inappropriate vocalization 7 29.17
unit for the assessment and treatment of severe chal- Self-Injurious behavior 4 16.67
lenging behavior. Experimenters conducted a consecu- Spitting 2 8.33
Multiple primary concerns 20 83.33
tive case review of all patients admitted from January Function of challenging behavior
2012 to April 2015, which included 94 individuals. Escape 20 83.33
Tangible 15 62.50
Individuals were included if tokens were used at any Attention 10 41.67
point during the admission based on a review of the Automatic 1 4.17
treatment protocols and data, admission summaries, and Multiply maintained 15 62.50
Other treatment components
behavioral recommendations. This review resulted in Extinction 23 95.83
24 individuals who had received some form of token Least-to-most prompting 16 66.67
Functional communication training 12 50.00
treatment, with a mean age of 10.63years (range 318) Visual schedule 10 41.67
and the majority of whom were male (70.83%). All par- Multiple schedule 10 41.67
ticipants were diagnosed with an intellectual and devel- Response reduction 5 20.83
Differential reinforcement 4 16.67
opmental disabilities prior to admission (see Table 1 for Other 5 20.83
additional demographics). Note: Least-to-Most Prompting included vocal, model, and physi-
cal guidance prompts; Miltenberger, 2001.
Challenging behavior and function coding
Upon admission to the day-treatment unit, topographies of
When an analog functional analysis was conducted,
challenging behavior that were of primary concern to the
frequency data were collected on each instance of tar-
caregiver were identified through unstructured interviews
get behavior across a session and were then graphed
and observations. Operational definitions were written
across conditions. For three participants, the functional
for each topography targeted during assessment and/or
analysis was undifferentiated because no challenging
treatment in the participants admission (see Table 2 for
behavior was observed. For the remaining participants,
targeted topographies).
a panel of behavior analysts viewed the functional anal-
Early in the admission, a functional behavioral assess-
ysis graph(s) and came to a consensus on function (sim-
ment was conducted to identify the reinforcer maintaining
ilar to procedures used to identify a consensus by Roane
challenging behavior (i.e. the functional reinforcer). For
et al. (2013)). Any disagreements were discussed, and if
all but two participants, an analog functional analysis was
not resolved through discussion, a vote would have been
conducted following procedures similar to those described
taken with the majority vote being documented. In the
by Iwata et al. (1994), with modifications made based on
present study there were no disagreements, so no voting
idiosyncratic differences.

 International Journal of Developmental Disabilities 2016VOL. 62 NO. 3 159

Scheithauer et al. A consecutive case review of token systems
was required. The panel consisted of five individuals, all
were Board Certified Behavior Analysts who interpreted
functional analysis data on a regular basis.
If an analog functional analysis was not conducted or
if it was undifferentiated, the case manager at the time
of the admission concluded function based on records of
the antecedents and consequences related to challenging
behavior and caregiver report. The case manager recorded
the hypothesized function in the clients behavioral rec-
ommendations and the experimenter pulled information
from this document. This was done for five participants
in this study.
Token system coding
Each participants clinical file was searched to gather infor-
mation about variables related to how tokens were used in
the childs treatment plan. Several variables were common
across all treatments. First, all tokens were exchanged for
backup reinforcers, and if the functional reinforcer was
identified, then this was included as one of the backup
reinforcers. In other words, if the participant engaged in
challenging behavior to get attention, then attention was
one of the backup reinforcers. In addition, the items used
as backup reinforcers were restricted across the day, while
the individual was at the day-treatment unit unless they
were earned by the exchange of tokens. So items used as
backup reinforcers were not freely available outside of
the token system. This system, commonly referred to as
a closed-economy, is likely to result in a better response
to the token system when compared to an open-economy
when reinforcers are available outside of token-exchange
times (Roane et al. 2005). We also coded whether a partici-
pant needed token training or not. We found that 45.83% of
participants went through explicit token training to ensure
that tokens would serve as a conditioned reinforcer and
that the individual mastered the skills of token exchange
and production prior to starting treatment.
We also coded how tokens were produced; that is,
what the participant was required to do to earn a token.
Tokens were contingent on appropriate behaviors (differ-
ential reinforcement of alternative behavior [DRA]), the
absence of challenging behavior (differential reinforce-
ment of other behavior [DRO]), or a combination of the
two (DRA/DRO). In addition, several participants had
different production schedules in different settings (e.g.
a DRA during academic periods and a DRO during lei-
sure periods). The majority of participants started earning
tokens on a dense schedule, but for some participants, this
schedule was gradually thinned to increase social validity
and make the intervention more practical to use. Both the
starting and ending production and exchange values were
coded and reported when thinning occurred.
Participants treatment protocols differed in the
exchange-production schedule (or when tokens could be
exchanged) and how the backup reinforcers were deliv-
ered. Possible exchange times included specific times
160 International Journal of Developmental Disabilities 2016VOL. 62
of day (e.g. at the end of the day), after a pre-specified
number of tokens were earned (e.g. after every fifth token
earned), or continuous schedules (i.e. exchange could
occur after each token earned). In addition, tokens differed
in whether they were exchanged for a specified amount of
time with the item/activity (e.g. one token=30 s of time on
an iPad, two tokens=60 s, etc.), a specified quantity of an
item (e.g. one token=one piece of candy, two tokens=two
pieces of candy, etc.), or whether there was a menu of
items that the individual could select from and purchase
with his/her tokens (e.g. one token=one piece of candy,
two tokens=5min of time on the iPad, 15 tokens=a trip
to a playground, etc.). All of these variations were coded
for each participant. In addition to the token system, other
aspects of treatment that were included in the childs final
treatment plan were also coded.
Interobserver agreement
During all baseline and treatment sessions, an observer
recorded the frequency of each instance of targeted chal-
lenging behavior using either a computerized data-col-
lection system or paper-and-pencil recording. A second
independent observer also collected data for a portion of
sessions for all participants except one for whom percent
reduction was based on injuries. Interobserver agree-
ment (IOA) was collected for 34.58% sessions across the
remaining participants (range 19.4057.03%). Agreement
was calculated using one of two methods. When data were
collected using a computerized system, IOA was calcu-
lated by dividing the session into 10 s bins. The observers
record with the smallest frequency or duration of challeng-
ing behavior was divided by the other observers record
and multiplied by 100 to reach a percentage. When paper-
and-pencil data were collected, the observers record with
the smallest frequency or duration across the entire session
was divided by the other observers record, and also con-
verted to a percentage. We summarized mean IOA across
both types of calculations. Average IOA across participants
was 96.67% (range 84.8899.92%).
Effectiveness
Effectiveness of the treatment that included a token system
was determined using a percentage reduction calculation.
The rate of challenging behavior during the initial baseline
was compared to the rate observed on the last three days
that the token treatment was in place on the day-treatment
unit. The rate in treatment was subtracted from the rate
in baseline, divided by the baseline rates, and converted
to a percentage. The percentage reduction was calculated
for all participants, with the exception of two who did not
exhibit challenging behavior in baseline. One participant
had a different calculation because she engaged in covert
self-injurious behavior that was not observed while she
was at the clinic. Skin-checks were conducted daily and
the number of new injuries caused by her self-injurious
behavior was recorded; thus, percentage reduction was
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 Scheithauer et al. A consecutive case review of token systems

calculated using these values. For another participant, Table 3 Components of Token Treatments
in-seat behavior served as the primary target. A percentage Characteristics n %
increase in latency from the start of session to the time he Context
left his seat was calculated from baseline to the last three Demands 18 75.00
Non demands (e.g. Leisure) 1 4.17
days of treatment. Demands & non demands 5 20.83
Percentage reduction in challenging behavior was com- Token training
Yes 11 45.83
pared across participants with different components of the No 13 54.17
token economy including, how reinforcement was earned Response cost
(DRO or DRO/DRA), how reinforcement schedules were Yes 7 29.17
No 17 70.83
thinned (production-exchange schedule thinned; both pro- Target behaviors
duction-exchange and production schedules thinned; or no DRO 7 29.17
DRO & DRA 17 70.83
thinning), whether a response cost was included, whether Schedule thinning
token training was conducted, and variables related to the Exchange-production 5 20.83
cost of backup reinforcers (constant, varied, or the use Production & exchange-production 11 45.83
No thinning 8 33.33
of a menu). Unit price
In addition to percentage reduction, the type of experi- Fixed 13 54.17
Varied 9 37.50
mental design used with each participant was also coded. Menu 2 8.33
For several participants, experimental control was demon-
strated by delivering reinforcement immediately following
compliance or the absence of challenging behavior, with When tokens were delivered based on compliance, all
tokens added in at a later generalization step as reinforce- participants began with a FR 1 schedule of reinforcement
ment schedules were thinned. For these individuals, the (i.e. one instance of compliance resulted in one token).
initial design was coded in addition to when tokens were Similarly, when tokens were delivered based on time
added into treatment. without challenging behavior, the schedule was initially
relatively brief (e.g. 60 s or less for 63.63% of participants
Results with a time-based schedule). Schedule thinning occurred
Challenging behavior and function for the majority of participants (66.67%).
The most common topographies among participants A menu of reinforcers was used for 8.33% of partic-
whose treatment packages included tokens were aggres- ipants. These participants were given a reinforcer menu
sion and disruptive behavior (see Table 2). The majority with several items/activities listed and the number of
of participants treatments targeted multiple topographies tokens that had to be exchanged for each. During the token
of challenging behavior. Regarding the function of the exchange, the participant vocally stated which item he/she
behavior treated with token systems, we found that an would like to purchase. Both of these individuals had
analog functional analysis was conducted with 91.67% of a vocal repertoire that allowed for reliable requests. For
cases. The most common function was escape (83.33%), participants not using a menu, the unit price was either
followed by tangible and attention (see Table 2). Only one constant (meaning one token always resulted in the same
participant engaged in challenging behavior (specifically backup reinforcer) or varied (cost gradually increased
disruption) maintained by automatic reinforcement, other based on when tokens could be exchanged). The most
topographies were maintained by escape. For most par- frequent backup reinforcer used was a break (83.33% of
ticipants, challenging behavior was multiply maintained. participants).
A functional analysis was not conducted for two partic- Finally, only 29.17% of token systems included a
ipants because their treatment goals were completion of response cost, and all participants but one were able to
academic work. Results from the functional analysis were re-earn removed tokens. See Appendix A for individual
undifferentiated for an additional three participants. Thus, participant information related to the token treatments.
a function was hypothesized for these five participants
based on their FBA which is reported in Table 2. Treatment effectiveness
Token systems were included in the final treatment pack-
Common token system components age for all but two of the participants because simpler
All but two participants earned tokens in a demand con- interventions worked just as well for these individuals. The
text. For all participants, tokens were earned for the mean percent reduction across participants was 70.18%
absence, or low rates, of challenging behavior. Procedural with a median of 92.94% (see Table 4). We also com-
differences were present based on whether the participants pared percentage reduction across participants based on
earned tokens for the passage of time without challenging a variety of variables. These included the type of backup
behavior (DRO) or whether they were required to comply reinforcers used (menu, unit price constant, or unit price
with demands (DRA and DRO; see Table 3). varied); how the reinforcement schedule was thinned

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Scheithauer et al. A consecutive case review of token systems

Table 4 Results of Treatment Plans the targeted behavior for earning reinforcement, with the
Outcome n % DRO/DRA resulting in a slightly higher percentage reduc-
Tokens used in final treatment tion (M=73.22%) than a DRO alone (M=62.80%). There
Yes 22 91.67 were no differences based on the thinning method (mean
No 2 8.33
Experimental design reductions of 82.20 and 81.89%); however, both were
ABAB generalization 14 58.33 superior to times when reinforcement was not thinned
AB 6 25.00
Multiple baseline 3 12.50
(M=46.57%). Lastly, there was negligible difference for
ABAB 1 4.17 whether or not token training was conducted (average
Change in problem behavior reductions of 74.12 and 66.84%, respectively). None
Increase 2 8.33
150% Decrease 3 12.50 of these comparisons resulted in statistically significant
5075% Decrease 2 8.33 differences.
75100% Decrease 17 70.83
For 75% of participants, experimental control was
Note: A=Baseline, B=Treatment, ABAB-Generalization=tokens achieved through either a reversal (ABAB) or multiple
added after the reversal.
baseline design (see Table 4). However, for most partici-
pants, the tokens were added in later in treatment, using an
(exchange-production schedule, exchange-production and ABAB design with tokens added in during generalization
production schedule thinning, or no thinning); how tokens (see Appendix B for individual participant information).
were earned (passage of time without challenging behav-
ior only [DRO] or whether compliance was also required Discussion
[DRO/DRA]); whether token training was conducted; and The current report suggests that interventionists may select
whether response cost was included (see Fig. 1). Results from a wide range of potential components to include in
from each of these analyses are incorporated below. a token system. Specifically, our sample included vari-
Based on visual analysis of the mean percentage reduc- ations in token production, exchange, and the use of
tion of challenging behavior, inclusion of a response-cost backup reinforcers; which clinicians may alter based on
resulted in higher reductions in challenging behavior individual need or the presenting problem. Some of the
(M=84.56%) than when a response-cost was not included consistent aspects of the token systems used were that
(M=64.26%). There was also an advantage in using a clinicians (a) restricted reinforcement outside of the token
menu of reinforcers compared to using a constant unit- system while participants were at the treatment center, (b)
price, which resulted in moderately higher reductions delivered tokens on a predetermined and consistent sched-
than when a constant reinforcer was utilized with a varied ule, (c) clearly defined exchange time, (d) made backup
unit price (mean reductions of 85.17, 74.09, and 61.20%, reinforcers consistently available at exchange times, and
respectively). Similar differences were found based on (e) utilized assessment tools (i.e. functional analysis or

Figure 1 Between-group comparison of token system components. Gray bars represent the mean percentage reduction in
challenging behavior for each group and the error bars represent one standard deviation (.5 SD above and .5 SD below the mean).

162 International Journal of Developmental Disabilities 2016VOL. 62 NO. 3


preference assessment) to guide the selection of backup
reinforcers. Given the success of the majority of the treat-
ment packages in this case review, these basic components
may be important to include in token systems.
In the current case review, clinicians generally deliv-
ered tokens either contingent on a specific behavior or for
the passage of time without challenging behavior. This
decision was often matched to the setting, with tokens
delivered for a specific behavior common in demand con-
texts where there is a socially appropriate behavior that is
often incompatible with challenging behavior (i.e. com-
pliance). Contrarily, token delivery based on the passage
of time without challenging behavior was common in lei-
sure contexts, where there may be a variety of alternative
appropriate behaviors that could be the target for a DRA
intervention. When challenging behavior served multiple
functions and tokens were used to address multiple sce-
narios, clinicians often used different contingencies based
on the setting. For example, a DRA in work settings (for
challenging behavior maintained by escape) and a DRO
in a leisure context (for challenging behavior maintained
by access to attention or tangible items). Our results sug-
gest a slight difference in treatment effectiveness based
on how tokens were delivered, with an advantage to use
a combination of DRA and DRO procedures as opposed
to a DRO alone.
For several participants, tokens were initially delivered
and exchanged on a dense schedule of reinforcement that
was later thinned. This thinning procedure is important
in that it allows for token delivery on a leaner schedule,
requiring less effort from the caregiver during general-
ization, which may increase caregiver fidelity (Stocco
and Thompson 2015). In addition, providing tokens on
an intermittent schedule may promote generalization
and maintenance if integrity errors do occur (Kazdin and
Polster 1973; Stokes and Baer 1977). The results from
the current study demonstrate that treatment remained
effective even when the schedule of reinforcement was
reduced or thinned over time. Treatment was substantially
less effective when no schedule thinning took place. It
is somewhat difficult to interpret these results, however,
because the criteria to thin reinforcement were a series of
consecutive sessions with low rates of challenging behav-
ior, preventing thinning when criteria were not met at early
stages of treatment development. Despite this, the results
demonstrate a compelling argument that schedule thinning
was helpful for the majority of participants.
There were also variations in whether the unit price for
reinforcement was held constant (e.g. where one token
was always exchanged for one piece of food) compared
to participants for whom the unit price varied based on
the exchange-production schedule (e.g. one piece of food
delivered whenever the exchange-production schedule
was met). Past research has suggested that keeping the
unit price constant is adventitious when schedule thinning
(Roane et al. 2007). Results from the current study support
 International Journal of Developmental Disabilities 2016VOL. 62
Scheithauer et al. A consecutive case review of token systems
this recommendation in that a fixed unit-price was superior
to a unit-price that changed across the study. However,
including a menu of reinforcers was superior to both of
these options.
It is interesting to note that challenging behavior was
maintained by escape for 83.33% of participants. This per-
centage is higher than reviews on published functional
analyses conducted prior to a variety of function-based
interventions (32.2%; Beavers et al. 2013). Token sys-
tems may fit easily into treatments for escape maintained
challenging behavior because reinforcement may be pro-
vided for a discrete behavior in the form of compliance
or task completion. In addition, token systems allow for
the delivery of intermittent reinforcement and signal the
amount of work required to earn the backup reinforcer
while still allowing for uninterrupted work. Further, the
delivery of a token is likely less disruptive than stopping
work to consume a backup reinforcer. This finding aligns
with DeLeon and colleagues (1996) description regarding
accumulated vs. distributed reinforcement arrangements,
as well as research related to fluent vs. disfluent work
schedules (Fienup et al. 2011). This explanation likely
contributes to the frequent use of token systems in school
settings (Boegli and Wasik 1978; Filcheck et al. 2004;
McCullagh and Vaal 1975).
The current study found that the majority of partic-
ipants challenging behavior served multiple functions
(62.50% of participants compared to 18.9% identified by
Beavers et al. 2013). In addition, despite multiple itera-
tions and modifications to the analog functional analysis,
results were still undifferentiated for three participants.
This could be a facet of publication bias in that functional
analyses demonstrating challenging behavior that is mul-
tiply maintained or with inconclusive results may be less
likely to be included in reviews of published work (Sham
and Smith 2014), or clinicians working with individuals
presenting with multiply maintained challenging behavior
may be more likely to utilize token systems. The latter
is likely, given that token systems are particularly useful
intervention for individuals with an undifferentiated or
unclear function for challenging behavior as clinicians can
include a variety of potential backup reinforcers in a menu
format. This is supported by the superior results in the cur-
rent study for treatment plans using a menu of reinforers.
Another interesting finding is only one participant
engaged in challenging behavior maintained by access
to automatic reinforcement, possibly because tokens are
most easily exchanged for social and tangible forms of
reinforcement. Commonly recommended interventions for
automatically maintained challenging behavior (including
response interruption and redirection, competing items,
and sensory extinction; Vollmer 1994) are not easily con-
verted to a token system.
Another important outcome from this study is that treat-
ment plans including response-cost components were more
effective than treatment plans without a response-cost,
NO. 3 163
Scheithauer et al. A consecutive case review of token systems
but there are some aspects to consider when including a
response-cost. In this review, all but one participant was
able to re-earn tokens after they were lost. When includ-
ing a response-cost contingency in a token economy, it is
important to ensure that the individual does not lose all
opportunity to access the backup reinforcer. If the child
is unable to earn tokens back, there are no contingencies
in place for appropriate behavior after all tokens are lost.
Therefore, it is important that he/she can earn the tokens
back or that another strategy is in place to promote appro-
priate behavior in this scenario. In addition, using response
cost token systems alone may not promote appropriate
behavior. In several of the examples discussed in this case
review, a DRA system was used to reinforce appropriate
behavior. However, if a response cost system were to be
used in isolation, we would expect reductions in chal-
lenging behavior without promoting alternative behavior
unless the two are incompatible (e.g. losing a token for
noncompliance would promote compliance given that
these are incompatible responses). So while response cost
appears to make a token system more effective, it is crucial
to take these issues into consideration.
Although token systems were used in the vast majority
of participants final treatment packages and these final
treatment packages resulted in reductions in challenging
behavior, these results should be interpreted with caution
due to a few limitations. First, token economies were not
implemented exclusively; other treatment components
were also included and varied across participants, mak-
ing it impossible to ascertain the specific contribution
that token systems alone had to reductions in challenging
behavior. Future research should conduct component anal-
yses to determine the direct effect of the tokens themselves
on challenging behavior with and without other treatment
components. It is important to note that the results of the
comparisons of percentage reductions across different
components of the token system were not statistically sig-
nificant. However, given our sample size, the differences
create an interesting area for future research and should
be further studied.
In addition, while the reinforcement contingencies were
implemented in a manner that allowed for single-subject
experimental control for most participants, tokens were
often added in later in treatment. In other words, an ABAB
design demonstrated the effectiveness of delivering rein-
forcement immediately without using tokens, and tokens
were added in to assist with thinning the schedule of rein-
forcement. Modifying treatment to promote schedule thin-
ning after experimental control has been demonstrated with
a more dense and immediate schedule of reinforcement is
not uncommon (e.g. Fisher et al. 2000; Hanley et al. 2001),
but it creates a limitation in interpreting the effectiveness
of the token system itself. Conclusions drawn from this
review create an informative guideline of different ways
in which token systems may be implemented, as well as a
review of the characteristics of children for which tokens
164 International Journal of Developmental Disabilities 2016VOL. 62
are used. However, the effectiveness outcomes should
be evaluated as exploratory or preliminary findings that
require verification. In addition, although no statistically
significant differences were found between groups based
on aspects of the token systems, this study was not ade-
quately powered to identify minor differences between
groups. Future studies should replicate these comparisons
with more participants.
Finally, the participants in this study were selected
based on a retrospective analysis of clinical case series
and the reason a token system was selected varied
across participants. While this allows for a compre-
hensive evaluation of how token systems were used
in a naturalistic clinic context, it creates difficulties in
corroborating the data for the purpose of evaluating
effectiveness. Future research should expand on this
by creating guidelines or manualizing the interventions
to guide development of token systems in a consistent
way. This would also allow for token systems to be
evaluated using designs with more experimental rigor
(e.g. random control trials) and lend further support to
the use of token systems in clinical work.
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Appendix A. Information about individual participants token systems

Production schedule Exchange-production schedule
Token Response Backup
# training Cost Context Target behavior Start End Start End reinforcer
1 No No Demands Absence of PB 60 s 60 s 1 Token (T) 1 T 30 s break
2 Yes Yes Demands Compliance & No PB 1 step of 1 full task 1 T 10 T 1=2min break
dem
3 No No Demands No PB 60 s 60 s 1T 1T 1=1 piece of
food
4 No No Demands No PB 60 s 60 s 1T 1T 1=1min break
5 No No Life Skills Compliance & No PB 1 dem 1 dem 1T 4T 30 s break
Academic Compliance & No PB 1 dem 1 dem 1T 10 T 30 s break
6 No No Demands Compliance & No PB 1 dem 1 dem 1T 10 T 30 s break
7 Yes No Leisure No PB 5min 515min 1T Specific times Menu
Demands Compliance & No PB 1 dem 13 dem 1T Specific times Menu
8 No No Demands No PB 5min 4min 2T 8T 1=15 s break
Breaks from No PB & Restarting Duration Duration Based on Based on Item Item Selected
Demands Work of Break of Break Item after Previous
Exchange
9 Yes No Demands Compliance & No PB 1 dem 1 dem 12 T 515 T 1=1min break
10 No No Demands Compliance & No PB 1 dem 12 dem 1T 15 T 30min break
11 No No All Contexts Low rates of PB All Day All Day 1T 1T Activities on a
menu
12 Yes Yes Academic Compliance & No PB 1 dem 1 dem 2T 5T 1=30 s break
Life Skills Compliance & No PB 1 dem 3 dem 2T 5T 1=30 s break
13 Yes Yes Demands Compliance & No PB 1 dem 1 dem 1T 5T 1=30 s break
14 No No Car Rides No PB 10min 10min End of Car End of Car Ride 1=piece of
Ride food
15 No Yes Demands Compliance & No PB 1 dem 1 dem 520 T 520 T variable time
break
16 No No Demands Compliance & No PB 1 dem 2 dem 1T 10 T 2min break
17 No No Demands Compliance & No PB 1 dem 2 dem 1T 30 T 5min break
18 Yes No Demands Compliance & No PB 1dem 4 dem 1T 6T 1=20 s break
Leisure No PB 30 s 2min 1T 6T 1=20 s break
19 Yes Yes Demands On-Task & No PB 1015 s 1015 s 5T 5T 1=25 s break
20 Yes No Demands Compliance & No PB 1 dem 1 dem 1T 1T 1=30 s break
21 No Yes Demands In Seat Checked Checked 1T 10 T 2min break
at 60 s at 60 s
22 Yes No Demands Compliance & No PB 1 dem 2 dem 1T 5T 1=4min break
23 Yes No Demands Compliance & No PB 1 dem 3 dem 2T 10 T 3min break
24 Yes Yes Demands Compliance & No PB 1 dem 10 dem 1T 10 T 1=30 s break
Leisure No PB 30 s 30 s 1T 10 T 1=30 s break

Appendix B. Results of treatment plans for individual participants

Type of Experimental Control and Percentage Reduction Values

Included in final Percentage
# treatment Experimental design First baseline Last 3 days change
1 Yes AB .07 .12 (+) 71.78
2 Yes AB .04 .00 () 90.69
3 Yes ABAB Generalization 1.73 .23 () 86.71
4 No ABAB Generalization 1.85 .65 () 64.86
5 Yes ABAB Generalization 5.10 .15 () 97.06
6 Yes ABAB Generalization 2.63 .00 () 99.87
7 Yes N/A 1.40 new injuries per day .00 new injuries per day () 100
8 Yes AB .05 .00 () 100
9 Yes MBL 1.90 .00 () 100
10 Yes ABAB Generalization 2.70 2.26 () 16.30
11 Yes ABAB Generalization 1.18 .35 () 70.34
12 Yes ABAB Generalization 1.91 .07 () 96.34
13 Yes ABAB Generalization 1.85 1.59 () 14.05
14 Yes ABAB Generalization .19 .00 () 89.47
15 Yes ABAB Generalization .76 .00 () 100
16 Yes MBL .43 .03 () 30.23
17 Yes ABAB Generalization .92 .13 () 85.87
18 Yes AB 2.56 .13 () 94.92
19 Yes ABAB Generalization 1.86 .17 () 90.86
20 No AB .19 .30 (+)57.89
21 Yes ABAB 25.56 s latency to leave seat 417.27 s latency to leave seat (+)1532.51
22 Yes ABAB Generalization .87 .06 () 93.10
23 Yes ABAB Generalization 2.68 .18 () 93.28
24 Yes ABAB & MBL 1.15 .00 () 100

Note: Unless otherwise denoted, challenging behavior in baseline and treatment are reported in responses per minute.

166 International Journal of Developmental Disabilities 2016VOL. 62 NO. 3

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