Token-economy-based contingency management increases daily steps in adults with developmental disabilities

Abstract

• Objective: Investigate the effectiveness of a token economy within a contingency management (CM) intervention to increase physical activity (daily steps) in adults with developmental disabilities.

• Participants: 4 adults diagnosed with developmental disabilities in a residential group home.

• Method: Implemented a changing criterion design over 8 weeks, with step goals tracked by Fitbit Flex™.

• Results: Significant increase in daily steps for three participants, with implications for sustainable health improvement in residential settings.

Introduction

• Background:

  • 80% of Americans don't meet physical activity guidelines (CDC, 2014).

  • Recommended: 2.5 hours of moderate or 1.25 hours of vigorous aerobic activity per week (approx. 10,000 steps/day).

  • Health consequences of inactivity: obesity, type 2 diabetes, heart disease, and high costs in healthcare ($131 billion annually, 2014).

• Focus on Developmental Disabilities:

  • Individuals with developmental disabilities (e.g., ASD, ID) are less likely to meet physical activity guidelines.

  • Need for effective interventions to increase daily steps in this demographic (CDC, 2007; Hsieh et al., 2015; McCoy et al., 2016).

• Contingency Management (CM):

  • Incentives are provided based on achieving specific goals.

  • Previous studies showed effectiveness (e.g., Miltenberger et al., 2018, using financial incentives).

• Research Gap:

  • Lack of studies on token economies to increase physical activity in adults with developmental disabilities in residential settings.

• Study Purpose: Evaluate feasibility and effectiveness of a token economy within a CM intervention to increase physical activity in sedentary adults in a residential group home.

Methodology

Participants and Setting

• Participants: Four adults from a residential group home for individuals with developmental disabilities; eligibility criteria include ability to perform basic math, self-reported inactivity, and consent to wear Fitbit.

• Exclusion: Individuals unable to engage in physical activity due to medical conditions or disabilities.

• Demographics:

  • Casey (26): schizophrenia, bipolar, mild ID.

  • Scott (44): mild ID, depression, borderline obesity.

  • Nick (55): mood disorders, borderline personality disorder, borderline intellectual functioning.

  • Megan (23): ASD, bipolar, obesity.

Materials

• Fitbit Flex™:

  • Tracks physical activity accurately, with a five-light display indicating recorded steps.

  • Continuous monitoring of daily steps throughout the study.

Target Behaviors and Data Collection

• Dependent Measure: Total daily steps recorded by Fitbit Flex™.

• 3-axis accelerometer provides step counts using an algorithm; calories burned and distance traveled were not analyzed.

• Data was uploaded daily for analysis; no inter-observer agreement was measured due to automated data collection.

Experimental Design and Procedure

• Design: Changing criterion design over 8 weeks, addressing physical activity incrementally until a goal of 10,000 steps/day achieved.

• Baseline Phase: 7-day baseline for participant acclimatization, without goal setting.

• Intervention Phase:

  • Step goals set with increments of 1,000 steps contingent upon meeting prior goals over blocks of 5 days (Monday-Friday).

  • Token economy in place: tokens exchanged for desired backup reinforcers.

Interventions and Procedures

• Changing Criterion Implementation:

  • Participants wear Fitbit continuously (24/7, barring charging).

  • Personal goals recalibrated every five weekdays based on prior performance (greater adherence leads to increased goals).

  • Data extraction was automated post-researcher verification of daily activities.

• Token Economy:

  • Participants earned star-shaped stickers for meeting goals, which could be exchanged for prizes at week's end.

  • Reinforcements included preferred activities and items identified through participant interviews.

Results

• Outcomes:

  • Significant increase in daily steps for three participants:

  • Scott: 168% increase (Baseline: 3,255; Final Block: 8,720)

  • Nick: 106% increase (Baseline: 3,602; Final Block: 7,430)

  • Casey: 88% increase (Baseline: 5,678; Final Block: 10,672)

  • Megan: 15% decrease observed, with factors influencing data reliability (device usage, absence).

• Cost Analysis:

  • Total incentive cost: $277 for four participants over study duration; average $69/participant.

  • Feedback indicated positive views on intervention but highlighted the need to ensure robust participant monitoring and support.

Discussion

• Findings:

  • CM via token economies effectively increased physical activity among participants.

  • Reinforcement based on behavior adaptation may enhance health outcomes for individuals with developmental disabilities.

• Future Research Directions:

  • Assess long-term sustainability and social acceptability of token strategies in residential settings.

  • Explore the integration of social support factors in exercise interventions.

  • Measure the impact of using varying levels of feedback and goal-setting methodologies on physical activity uptake.

• Limitations:

  • Potential for data falsification through misuse of wearable technology.

  • Absence of treatment integrity checks and inter-observer agreement considerations.

Ethical Compliance

• Standards:

  • Study approved by relevant Ethical Committees, with informed consent obtained from all participants or their guardians.

  • No conflicts of interest reported by authors.

Conclusion

• Advocacy for Intervention:

  • Supports token-economy based CM as a viable method for increasing daily physical activity.

  • Potential to enhance quality of life for adults with developmental disabilities, simultaneously driving public health benefits and reducing related healthcare costs.

• Next Steps: Conduct additional research extending intervention durations and examine frameworks surrounding social comparison in supportive environments.