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2020
Assessing Preferences for Montessori-Based Activities in
Assessing Preferences for Montessori-Based Activities in
Persons with Memory Impairment
Persons with Memory Impairment
Katelyn Danielle Smith
Minnesota State University, Mankato
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Recommended Citation
Smith, K. D. (2020). Assessing preferences for Montessori-based activities in persons with memory
impairment [Master’s thesis, Minnesota State University, Mankato]. Cornerstone: A Collection of Scholarly
and Creative Works for Minnesota State University, Mankato. https://cornerstone.lib.mnsu.edu/etds/
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Assessing Preferences for Montessori-based Activities in Persons with Memory
Impairment
By
Katelyn D. Smith
A Thesis Submitted in Partial Fulfillment of the
Requirements for the Degree of
Master of Arts
In
Clinical Psychology
Minnesota State University, Mankato
Mankato, Minnesota
i
May 3, 2020
Assessing Preferences for Montessori-based Activities in Persons with Memory Impairment
Katelyn D. Smith
This Master’s thesis has been examined and approved by the following members of the
student’s committee.
________________________________________________
Chairperson
Jeffrey Buchanan, Ph.D.
________________________________________________
Committee Member
Angelica Aguirre, Ph.D.
________________________________________________
Committee Member
Kevin Filter, Ph.D.
ii
Acknowledgments
I am profoundly thankful for the support and guidance provided by my advisor, Dr. Jeff
Buchanan. Throughout this process, he has provided me with sincere and constructive guidance
along with endless encouragement.
I would like to thank the members of my thesis committee, Dr. Angelica Aguirre and Dr. Kevin
Filter for taking time from their own projects and duties to review and provide feedback for my
work. I would like to thank members of my research team, Paige Shoutz, Kaylee Enevold, and
Maddison Hajek, for making data collection possible.
Lastly, I would like to thank my mother, my father, and my fiancé. I could not be who I am or
where I am without you.
iii
Table of Contents
Introduction……………………………………………………………………………………………………………………………….1
Background and Significance ……………………………………………………………………………………….. 1
Importance of Engagement …………………………………………………………………………………………… 2
Distinguishing Preference
…………………………………………………………………………………………….. 3
Matching Activities and Capabilities
……………………………………………………………………………… 4
The Montessori Approach…………………………………………………………………………………………….. 4
Literature review
…………………………………………………………………………………………………………. 5
Method ………………………………………………………………………………………………………………………….. 9
Participants and Settings ………………………………………………………………………………………………. 9
Materials ………………………………………………………………………………………………………………….. 10
Dependent Variables
………………………………………………………………………………………………….. 11
Interobserver Agreement ……………………………………………………………………………………………. 11
Procedures
………………………………………………………………………………………………………………… 11
Results …………………………………………………………………………………………………………………………. 13
Ben ………………………………………………………………………………………………………………………….. 13
Stan …………………………………………………………………………………………………………………………. 14
Figure 1 ………………………………………………………………………………………………………………… 15
iv
Figure 2. ……………………………………………………………………………………………………………….. 16
Figure 3 ………………………………………………………………………………………………………………… 17
Discussion ……………………………………………………………………………………………………………………. 18
Limitations and Future Directions ……………………………………………………………………………….. 19
Conclusions
………………………………………………………………………………………………………………. 20
References ……………………………………………………………………………………………………………………. 22
v
Abstract
The population of older adults in the U.S is continuously increasing. With this comes an increased
number of individuals with Alzheimer’s or other dementia related disease (ADRD), along with the
need for quality care for these individuals. The use of activities to increase engagement has been
shown to have a number of psychological benefits, especially when these activities are tailored to
the abilities and preferences of the individual. However, individualizing activity programming is
not always feasible for activity and care staff. The purpose of this study was to use a stimulus
preference assessment to identify Montessori-based activities that persons with cognitive
impairment can do independently. An engagement-based stimulus preference assessment was used
to identify preferred activities for two older adults with ADRD with severe cognitive impairment.
The most and least preferred items were validated by measuring length of time engaging in the
materials. The results indicated both participants spent more time with the most preferred activity
compared to the least preferred activity, as well as the ability to engage independently with the
activity.
vi
1
Assessing Preferences for Montessori-based Activities in Persons with Memory
Impairment
Background and Significance
It has become widely publicized that the number of older adults in the U.S. is growing at
a historic rate. Currently, individuals over the age of 65 make up nearly 10% of the population,
and by 2020 older adults are expected to outnumber children under the age of five for the first
time in recorded history (He et al., 2016). Due to medical advances decreasing mortality rates,
and the Baby Boomer generation getting older, a large number of people are living longer. Along
with this influx of older adults, there is an expected increase in the prevalence of mental and
physical health disorders. Specifically, Alzheimer’s disease and related diseases (ADRD) is one
of the most permeating issues this population faces. Globally, there are 50 million individuals
with ADRD and in the next ten years, this number is projected to reach 82 million (WHO, 2019).
ADRDs are characterized as the rapid deterioration of multiple cognitive domains (APA, 2013).
This manifests as a gradual decline in memory, language skills, behavioral repertoires, and motor
functioning. As a neurodegenerative disease progresses, the severity of these deficits increases.
For most, the ability to effectively communicate needs or preferences is lost, therein creating a
challenge both for the individual and their caregivers. This necessitates a greater amount of
support from mental health and medical professionals, including the investigation of empirically
supported mechanisms of increasing access to preferred stimuli.
From a functionally analytic perspective, all behaviors serve a function and changes in
behavior by individuals with ADRD are ways of communicating needs in lieu of a declining
behavioral repertoire and the context of their environment (Fisher et al., 2008). Reduced abilities
2
result in reduced access to reinforcers (extinction), and variable novel behaviors can occur.
Consistent with this theory, Hancock et al. (2006) investigated unmet needs across two-hundred
and thirty-eight individuals with ADRD living in residential facilities and found that unmet
needs, such as social interaction and daytime activities, were associated with higher rates of
behavioral problems. Partly in response to this information, the past few decades have witnessed
what is known as a “Culture Change” in long-term care facilities (Grabowski et. al., 2014).
Individualized treatment and better meeting the needs of residents has become a central focus,
with the overall goal of improvement in the quality of life. One way this was done was by
implementing regularly scheduled activities. Increased engagement in daily activities is
correlated with a better quality of life, as well as mental and physical health (Harowitz &
Vanner, 2010).
Importance of Engagement
While many long-term care facilities boast a person-centered care approach and
legislation requires the provision of activity programs, staff-to-resident ratios continue to make it
difficult to provide individualized care and activities (Omnibus Budget Reconciliation Act, 1987;
Harrington et al., 2016). Common activities seen in nursing homes include bingo, movie
viewing, music events, art projects, card games, and current events. Unfortunately, individuals
with ADRD may not have the ability to participate in these group-based activities due to their
varied skill levels and declining abilities, resulting in missed opportunities for engagement and
social interaction (Orsulic-Jeras et al., 2000; Jøranson et al. 2016). Voelkl et al., (1995) observed
in one week that almost 40% of nursing home residents with severe cognitive impairment did not
participate in any activities. Ice (2002) observed that even in a facility with high standard care
and an activities department, residents spent more than half of their days alone in their rooms
3
doing little to nothing. Additionally, not all activities are enjoyed by the same people, and
individual preference may contribute to levels of engagement as well. In all, complex and unique
factors such as personal interests, mental and physical abilities, and availability of the activities
may influence preference (Kracker et al., 2011).
Distinguishing Preference
While the importance of identifying preference has been established, persons with more
severe dementia often lack the ability to explicitly communicate their needs, which can pose
challenges for caregivers. Accordingly, a limited but continuously growing body of literature has
demonstrated that stimulus preference assessments are an effective and efficient means of
identifying preference for older adults with ADRD. Stimulus preference assessments (SPA)
provide the opportunity of choice for an individual with limited verbal and cognitive abilities by
measuring objective selection or engagement (Fisher, 1992). In turn, these stimuli can be
incorporated into care plans, oftentimes as an antecedent intervention designed to prevent
disruptive behaviors (Buchanan & Fisher, 2002; Feliciano et al., 2009). Studies utilizing SPAs
with individuals with ADRD have successfully identified preferred activities, increased
engagement, and produced positive behavioral changes (LeBlanc et al., 2006; Feliciano et al.,
2009). While trial and error methods or indirect interviews can be conducted, these are not the
most effective or accurate means for identifying preferences. Mesman et al. (2011) investigated
the accuracy of staff and family identified preferred activities and found no positive correlations
between SPA rankings and family and staff rankings. When working with a population of
individuals that experience a gradual loss in independence, there is inherent value in increasing
the ability to choose.
4
Matching Activities and Capabilities
In addition to preference, research has revealed there are multiple benefits to modifying
activities to the unique abilities and skills level of persons with ADRD. Often, activities are
viewed as being meaningless or juvenile (Camp, 1999). Along with increased engagement in
pleasurable activities, matching activities to an individual’s unique capabilities can decrease
challenging behaviors such as agitation and disruptive vocalizations as well as reduce apathy
(Buettner et al., 2006; Gitlen et al., 2008). While the reduction of challenging behaviors is
beneficial to both caregivers and individuals exhibiting them, it should remain a priority to select
activities that are not only pleasurable, but promote the maintenance of existing abilities (Fisher,
2008). That is to say, we may be doing this population a disservice by focusing all of our energy
on decreasing behaviors (challenging or not) when their behavioral repertoire is continuously
diminishing.
The Montessori Approach
Malone and Camp (2007) describe that, in the early 20th century, Maria Montessori
developed the Montessori system in response to the misconception that some children were
unteachable. Montessori understood that individuals do not always learn in the same ways or at
the same rates, and by adapting the environment individuals would be able to learn (Malone &
Camp, 2007). Using the same constructive approach, the Myers Research Institute adapted these
principles to the needs of older adults with ADRD (Malone & Camp, 2007). The authors add that
Montessori-based Dementia Programming (MBPD) activities are designed to engage individuals
based on their individual skill level, as well as their personal interests. These activities have since
been prepared in multiple manuals in order to systematically incorporate these activities into the
5
lives of individuals with ADRD, particularly in long-term care settings (Camp, 1999; Camp et
al., 2006).
There are a few notable features that exemplify MBPD. First, is the activities include the
use of personally relevant, age-appropriate materials. Everyday materials can have reminiscent
qualities that make an activity more enjoyable (Jarrott, 2008). Secondly, activities begin with a
demonstration. By demonstrating the activity, individuals can understand how an activity is
performed and that it can be done (Camp, 1999). A third feature of MBPD is that independence
is encouraged. The goal is increasing or maintaining skill level, and this cannot be accomplished
unless individuals are given the opportunity to perform a task on their own (Camp, 1999).
Finally, these activities are provided with extensions that allow activities to be performed at
higher or lower skill levels, as well as new ways to practice the same skill at the same level to
encourage maintenance (Camp, 1999).
Literature review
Mahendra et al. (2006) determined in their systematic review of MBPD that, though
relatively limited, the existing literature is promising and supports the utility of this approach.
Judge et al. (2000) hoped to build upon the literature by investigating the effects of both
individual and group based MBPD activities compared to regularly scheduled activities on four
types of engagement. Eleven individuals with ADRD were assigned to either the treatment (n=9)
or the control group (n=10). Those in the intervention group participated in MBPD activities
twice a day, in the morning and afternoon; at the same time, those in the control group
participated in regularly scheduled activities (e.g. watching a movie or playing cards). An
engagement scale was developed to assess constructive engagement, defined as motor activity in
response to the activity; passive engagement, defined as listening or looking in response to the
6
activity; non-engagement, defined as sleeping, looking away, or motor behavior in response to
something else; and self-engagement, defined as motor behavior exhibited when the activity was
not present or the individual chose not to participate. Observations took place at baseline as well
as four and eight months after baseline. During baseline, all participants engaged in regularly
scheduled activities. At eight months, the intervention group participated in both regular and
MBPD activities. The results revealed that those in the MBPD group exhibited more constructive
engagement and less passive engagement compared to the control group.
In a similar study, Orsulic-Jeras et al. (2000) examined the effects of MBPD activities on
different types of engagement for sixteen individuals with ADRD. Participants served as their
own controls, participating in both regularly scheduled activities and MBPD. MBPD activities
occurred in both individual and group formats twice a week for 15 to 30 minutes. Regular
activities ranged from large group to individual and involved activities such as trivia and movies
or puzzles and one-on-one visits, respectively. Similar to Judge et al. (2000), engagement was
measured as constructive, passive, non-engagement, or self-engagement; however, affect was
also measured in this study. Affect was categorized by pleasure, anxiety/fear, and anger/sadness.
Observations took place at baseline, as well as three and six months after baseline. The results
showed that when participating in MBPD activities, participants demonstrated more constructive
and less passive engagement, while engagement during regular activities did not change
significantly from baseline to six months. Higher pleasure scores and lower anxiety scores were
seen during MBPD activities, however, these scores reduced from the three-month to the six-
month observation in both conditions.
Another study utilized MBPD activities in small parallel groups and observed levels of
social interaction and different types of engagement (Jarrott et al., 2008). Ten individuals with
7
ADRD were divided into three groups and each group was delivered one MBPD activity a week
for 10 weeks. These individuals served as their own control, as they continued to participate in
regularly scheduled activities. The term “parallel” meant that, though the activities were done in
groups, each individual was given their own materials and worked at their own pace. The
purpose of the parallel groups was to reflect typical staff-to-resident ratios found in long-term
care facilities. Like Orsulic-Jeras et al. (2000), affect and engagement were measured.
Observations took place during the first two weeks, around the fifth week, and the final week.
Constructive engagement was significantly higher while non-engagement and self-engagement
was significantly lower during MBPD activities; however, passive engagement did not differ
significantly between conditions. Additionally, though no significant differences in affect were
found, the large effect sizes for depression (d= .91) and interest (d= .86) suggest the clinical
utility of MBPD activities.
Lastly, Giroux et al. (2010) investigated the effects of MBPD activities on affect,
behavior, and engagement in fourteen individuals with ADRD living in a nursing home for
veterans. Using a quasi-experimental design, participants were compared to themselves during
MBPD activities, regularly scheduled activities, and without any activity. MBPD had no specific
structure, other than each individual was given their own activities. Regularly scheduled
activities included music activities, group games, and bingo. In the inactivity condition,
participants were alone either in their room or somewhere on the unit with no involvement in any
activity. Conditions were separated by two-week periods. Affect was measured via direct
observation and video recording, as well as through a participant rating scale delivered after the
activity. Participant mood, disruptive behavior, participation, and the intensity of stimulation
required to stimulate participation were measured by video recording. While no statistical
8
differences in mood were found between the regular and MBPD activities, the results indicated
higher overall participation, higher active participation and significantly longer times spent with
the MBPD activities. MBPD also demonstrated significantly higher (more positive) ratings of
affect.
While this review of literature is not exhaustive, it is a good example of the empirical
evidence available today the demonstrates the effects of MBPD activities compared to activities
commonly seen in long-term care. Overall, MBPD is a method of increasing engagement that
provides the possibility of skill maintenance and reminiscence while increasing positive affect.
When compared to regular activities, MBPD activities resulted in more engagement, as well as
longer periods of time engaged. Camp (1999) urges caregivers to allow individuals to select the
MBPD activities whenever possible; yet, to date, no research has demonstrated the use of
stimulus preference assessments to identify preferred MBPD activities among individuals with
limited communicative abilities.
Additionally, though a key component of MBPD is independent functioning, one-on-one
activity planning is not feasible for many long-term care facilities (Jarrott et al., 2008). One
reason being staffing ratios and time constraints make giving all residents individualized
attention incredibly challenging (Abbott et al., 2016; Engle et al., 2017). Voelkl et al. (1995)
found that across 89 long-term care facilities, the average time activity staff had per resident was
12 minutes a week. Another reason is that residents’ time engaging in activities varies for a
multitude of personal and environmental reasons (Voelkl et al., 1995). Thus the goal of the
present study was to (a) add to the growing body of literature investigating the utility of stimulus
preference assessments with individuals with ADRD, and (b) identify and validate MBPD
activities that individuals will engage in with minimal assistance or aid from staff.
9
Method
Participants and Settings
Five individuals with a diagnosis of dementia with mild to severe cognitive impairment
were recruited from three long-term living facilities in southern Minnesota. Consent was
obtained from the participants’ guardian, and assent was obtained from the participants before
data collection began. Demographic information was obtained from staff records at the
respective facilities, or from the participants’ guardian. Inclusion criteria for this study included:
a diagnosis of dementia and a Brief Interview of Mental Status (BIMS) score below 12,
indicating moderate to severe cognitive impairment. Three participants did not participate in the
preference assessment due to refusal, excessive sleepiness, and nonengagement resulting in two
participants completing the study. These participants were given pseudonyms to maintain
confidentiality.
Ben was an 87-year-old white male with a BIMS score of 3. Ben lived at a long-term care
facility for veterans, in a locked memory care unit. Staff reported that Ben attended group and
staff-assisted activities, but rarely engaged in activities independently. Ben’s spouse indicated
that Ben had begun packing items and removing photos from the walls when left alone in his
room.
Stan was a 71-year-old white male with a BIMS score of 0. Stan lived in a memory care
facility. Staff reported that Stan had difficulty attending to most group or individual activities.
Sessions were conducted at their respective facility, in either a small conference room or a small
sitting area with tables and chairs. All sessions were recorded with pencil and paper, and were
conducted at relatively the same time of day. This study was approved by the University’s
Institutional Review Board.
10
Materials
Brief Interview of Mental Status (BIMS)
The BIMS assesses the cognitive domains of memory and orientation (Chodosh et al.,
2008). The BIMS includes seven items and scores range from 0 to 15. A score of 15 to 13
indicates intact cognition, 8 to 12 indicates moderately impaired cognition, and 7 to 0 indicates
severely impaired cognition. Individuals scoring below a 12 were eligible for this study.
Montessori-Based Activities
Eight Montessori-based activities were chosen from Montessori activity manuals and
used to assess preference (Camp, 1999; Camp et al., 2006). These activities are developed for
persons with dementia with the aim of utilizing remaining abilities and maximizing engagement.
For example, the volume one manual includes a section titled Fine Motor activities, the first
activity of which involves stringing beads onto cord (Camp, 1999). Extensions are provided that
increase or decrease the difficulty of the activity (i.e., vertical programming) as well as giving
new ways to practice the same skill (i.e., horizontal programming). This activity provides an
opportunity to practice fine motor skills, hand-eye coordination, and gives an individual the
opportunity to demonstrate an area of independence by completing a task on their own. Another
example is the pillow stuff-n-fluff activity in the volume two manual (Camp, 2006). This
involves stuffing pillow fluff into an empty pillowcase to create a pillow, and then fluffing the
pillow. This activity is intended to hand-eye coordination and gross motor skills, while also
practicing the self-care skill of fluffing your pillow.
The activities included in this study were: a puzzle, pillow stuff’n’fluff, organizing rubber
band colors, ice cube/cotton ball, photo album, stenciling, beading, and matching lids.
11
Dependent Variables
Engagement
Engagement in activities was operationally defined as touching or manipulating the
materials. Researchers recorded the duration of engagement in seconds during the preference
assessment trials and the validation procedure.
Interobserver Agreement
Interobserver agreement (IOA) data were recorded during 20% of the preference
assessments and 64% of validation sessions. Secondary observers were trained by the primary
observer by reviewing the protocol and behavior definition, modeling the scoring procedures,
and allowing the secondary observers to practice the scoring procedure. Observations were
conducted during sessions, and observers were positioned on opposite sides of the room behind
the participant to minimize intrusion on the session. Total IOA was calculated at 94.3% for the
preference assessments and 99.8% for the validation procedure.
Procedures
Once consent was obtained, the researcher assessed the degree of cognitive impairment
by administering the BIMS. The researcher then carried out the remainder of the study in two
phases:
Stimulus Preference Assessment. An engagement-based stimulus preference assessment
procedure was conducted that combined elements of free operant and paired stimulus preference
assessment (Roane et al, 1998; Fisher et al., 1992). The preference assessment was used to
determine preferences among eight Montessori activities. When the preference assessment
began, the researcher invited the participant to engage in activities that were brought for them. If
the participant agreed, the preference assessment began. Two activities were used during each
12
trial, with one being placed to the left of the participant and one placed on the right side of the
participant. Activities were placed roughly two feet apart. The researcher described and
demonstrated how each activity could be done, and then asked the participant to engage in the
activity they prefer. The participant was given 30 seconds to try the activities. A second
experimenter, located out of the participants sight, recorded the amount of time the participant
engaged in each activity during the 30-second interval. After 30 seconds, the two activities were
removed, followed by the presentation of a new pair of activities, and the procedure was
repeated. This continued until every combination of activities were presented, totaling 28
pairings. Activities were presented equally on both left and right sides to prevent biases based on
positioning of the activities. Two preference assessments were conducted with each participant,
resulting in a rank-ordered list based on the amount of time the participant spent engaging with
each activity. Based on these rankings, the most and least preferred items to be used in the
validation sessions were identified.
Validation Assessment. The purpose of the validation procedure was to demonstrate that
the preference assessment was successful at identifying an activity in which the individual would
spend more time engaging. During the validation procedure, the participant was presented either
the most- or least-preferred activity from the stimulus preference assessment. Prior to starting the
validation session, the researcher described and demonstrated the activity as was done during the
preference assessment. The researcher then invited the participant to engage in the activity as
long as they would like, moved to another part of the room, and recorded the duration of
engagement in the activity. When the participant was no longer engaging in the activity for 5
consecutive seconds, the activity was removed. A 5-minute break was given, and then the same
procedures were conducted with the remaining activity. The order in which activities were
13
presented was determined by flipping a coin. Originally, six sessions were to be completed with
each participant; however, seven sessions were ultimately completed for both participants.
During the fourth session with Ben, he completed his least preferred activity very quickly. To
ensure Ben did not spend less time with the least preferred activity due to it being simpler, the
activity was extended using the Montessori Manual by adding more pillows for Ben to make
(Camp et al., 2006). Stan showed nonengagement for one or both activities during multiple
sessions, so the researcher felt it was necessary to extend data collection in order to get a clearer
picture of Stan’s engagement.
Results
Ben
Stimulus Preference Assessment. The results of Ben’s stimulus preference assessment
were as follows in order of most to least preferred: puzzle, stencil, matching lids, beading, ice
cube/cotton ball, rubber bands, photo album, and pillow stuff-n-fluff (see in Figure 1). Ben spent
more total time engaged with the puzzle and the least time engaged with the pillow activity.
Validation Procedure. Data are presented as mean number of seconds engaged per
presentation (see in Figure 2). Ben spent more time engaged in the most preferred activity (M=
2003.57 seconds) than the least preferred activity (M= 494.71 seconds). After the eight
presentation, the least preferred activity was extended by having the participant stuff different
sizes of pillows (Camp et al., 2006). Ben continued to spend more time engaged in the most
preferred activity (M= 2471.33 seconds) than the least preferred activity (M= 926.33 seconds).
The Nonoverlap of All Pairs (NAP) statistic was used to calculate effect size (Parker & Vannest,
2009). This statistic provides a more precise and less biased estimate of treatment effects than
visual analysis. NAP was 86%, indicating a moderate effect size. These results indicate the
14
engagement-based stimulus preference assessment was moderately effective at identifying least
and most preferred activities for Ben and that the most-preferred activity produced greater
engagement.
Stan
Stimulus Preference Assessment. The results of Stan’s stimulus preference assessment
were as follows in order of most to least preferred: photo album, stencil, pillow stuff-n-fluff,
puzzle, matching lids, beading, rubber bands, and ice cube/cotton ball (see in Figure 1. Stan
spent more total time engaged with the photo album and the least time engaged with the ice
cube/cotton ball.
Validation Procedure. Stan spent more time engaged in the most preferred activity (M=
216.14 seconds) than the least preferred activity (M= 29.71 seconds; see Figure 3). NAP was
66%, indicating a moderate effect size. These results indicate the engagement-based stimulus
preference assessment was moderately effective at identifying least and most preferred activities
for Ben and that the most-preferred activity produced greater engagement.
15
Figure 1
Total Engagement in MBPD Activities
Ben
Stan
Item
Total Seconds Engaged
Item
Total Seconds Engaged
Puzzle
360
Photo Album
215
Stencil
330
Stencil
195
Matching lids
250
Pillow stuff-n-fluff
162
Beading
217
Puzzle
153
Ice cube/cotton ball
180
Matching lids
116
Rubber bands
176
Beading
102
Photo album
133
Rubber bands
76
Pillow stuff-n-fluff
121
Ice cube/cotton ball
43
Note. This table details the ranked order of MBPD activities by seconds engaged.
16
Figure 2.
Ben’s Validation Procedure
Note. Results of Ben’s validation of the stimulus preference assessment
0
500
1000
1500
2000
2500
3000Time 1Time 2Time 3Time 4Time 5Time 6Time 7Time 8Time 9Time 10Time 11Time 12Time 13Time 14
Seconds Engaged in Activity
Presentations
Most Preferred: Puzzle
Least Preferred: Pillow
17
Figure 3
Stan’s Validation Procedure
Note. Results of Stan’s validation of the stimulus preference assessment.
0
100
200
300
400
500
600
700
800
900Time 1Time 2Time 3Time 4Time 5Time 6Time 7Time 8Time 9Time 10Time 11Time 12Time 13Time 14
Seconds Engaged in Activity
Presentations
Most Preferred
Least Preferred
