Research Synopsis: Token‐economy‐based contingency management increases daily steps in adults with developmental disabilities

Nastasi, J. A., Sheppard, R. D., & Raiff, B. R. (2020). Token‐economy‐based contingency management increases daily steps in adults with developmental disabilities. Behavioral Interventions, 35(2), 315-324. https://doi.org/10.1002/bin.1711

Reviewed by
Molly Joyce-Trainor, MSEd, MS, BCBA, LBA
New York City Public Schools

Why research this topic?

Research Synopses - Psuchological, Educational and Therapeutic Interventions In 2020, only 24.2% of Americans met the guidelines for minimum physical activity (Elgaddal et al., 2022); additionally, adults with a developmental disability such as autism spectrum disorder (ASD) or intellectual disability (ID) are less likely to meet these guidelines (Nastasi et al., 2020). Individuals who do not meet recommended guidelines are at a greater risk of medical conditions that include obesity, type 2 diabetes, heart disease, and premature death (DHHS, 2008). These risks decrease when physical activity guidelines are met. One recommendation that can help individuals meet these guidelines is to increase moderate-intensity activities, such as walking approximately 10,000 steps per day. Alternative guidelines have been identified to promote physical activity for adults that include aerobic (e.g., aquatic therapy, ballroom dancing, brisk walking, cross-country and downhill skiing, hand-crank bicycling, hiking, horseback riding, Nordic walking, rowing, seated volleyball, swimming laps, water aerobics, wheeling oneself in wheelchair, wheelchair basketball, tennis, football, or softball) and muscle-strengthening that vary from moderate to vigorous intensity (CDC, 2024). Although alternative activities have been identified, there is no modification to the total number of steps to accommodate individuals with disabilities or those who are unable to meet the 10,000-step criteria. One successful behavioral intervention that has been used to increase physical activity, such as steps, is contingency management; this intervention uses incentives such as prizes contingent on meeting predetermined goals. Contingency management has been shown to be an effective behavioral intervention on increasing steps by members in a day program and autistic students enrolled school settings; resulting in more steps taken incentivized by prizes or small sums of money (Krentz et al., 2016; LaLonde et al., 2014; Valbuena et al., 2018). Prior to this research study, contingency management had not been used as an intervention to track an entire day for sedentary adults with developmental disabilities residing in a group home or community residence.

What did the researchers do?

Nastasi et al. (2020) designed, implemented, and monitored an intervention to increase physical activity among adults living in a residential group home. Three adults (Casey, Scott, and Nick) with developmental disabilities and one adult (Megan) with autism participated in this study. The inclusion criteria for participants were basic math skills, self-reported sedentary lifestyle, and willingness to wear a Fitbit Flex™ device. The intervention lasted 8 weeks and consisted of a changing criterion design, with a gradual increase in physical activity that culminated in 10,000 steps. The criterion was adjusted by 1,000 steps after participants met their previous goal on 3 of 5 days (Monday through Friday).

Participants were asked to wear their Fitbit Flex™ for 24 hours per day, Monday through Friday, not including when the device was charging. The participants received daily updates that included a step goal for the day, if they met the goal from the previous day (paired with a token delivered by staff), and when they were to earn a prize; no additional coaching or instruction was provided to participants. Tokens (star-shaped stickers) were earned when their daily step goal was met; they were able to exchange tokens for a reward on Friday. Tokens were “spent” on rewards or activities delivered during Saturday program hours or after hours (3:00 pm) during the week. Informal interviews were conducted with participants to identify activities for rewards, and some activities included arts and crafts materials, puzzle books, and outings with preferred staff. Two tokens resulted in a prize exchange; Megan was switched to a one sticker exchange schedule due to limited results with the two sticker exchange.

What did the researchers find?

Scott, Nick, and Casey increased their daily steps compared to pre-intervention; however, only one participant (Casey) met the 10,000 daily step goal consistent with CDC guidelines. The study supports contingency management interventions to increase daily steps of sedentary adults living in group residence. An increase in steps from baseline for Scott, Nick, and Casey was 168% (baseline, M = 3,255; final 5-day block, M = 8,720), 106% baseline, M = 3,602; final 5-day block, M = 7,430), and 88% (baseline, M = 5,678; final 5 day block, M = 10,672) respectively. Megan, the sole participant with an autism spectrum disorder diagnosis, had no observed increase in steps during intervention. It should be noted that Megan’s data collection was inconsistent as she did not wear her Fitbit Flex ™ or it was not charged, and she went on a family vacation during the intervention phase.

What are the strengths and limitations of the study?

The current study highlights the effect of external reinforcement on physical activity, as well as emphasizes the value in providing choice to participants when selecting rewards. Rewards in this study were relatively inexpensive, totaling approximately $277 across 8 weeks. Furthermore, results from informal evaluations completed by participants and staff indicated the intervention was viewed favorably; the authors suggest that a favorable intervention is more likely to be used again in the future.

Limitations included reliability of data; for example, Fitbit Flex ™ collects data on movements other than steps, such as shaking the device; although all participants and staff reported that the devices were not shaken during intervention, this may be a concern in falsifying data in future interventions. A second limitation to the study is that the researchers did not account for human error with data transfer from device to file; one way to mitigate error is by having a second researcher transfer data on at least 30% of sessions. A third limitation is the duration of the study, as most participants did not meet their end goal due to the intervention only taking place across 8 weeks.

What do the results mean?

Although only one participant met the CDC guidelines for physical activity, 75% of participants’ physical activity increased as a result of the intervention. This indicates that incentivizing physical activity is one way to help promote more active lifestyles in sedentary adults. Participants and staff viewed the intervention favorably; however, further studies should be conducted to compare the effect of monetary reward vs. activity-aligned reward (i.e., extra community outing). Additional research is recommended to assess the benefits of a more robust intervention, to explore the effect of feedback on performance, as well as to incorporate a social component to the intervention. Greater participation by autistic adults in group homes will elucidate whether this intervention is applicable to this specific population.

References:

Centers for Disease Control and Prevention. (2024). Increasing physical activity among adults with disabilities. Centers for Disease Control and Prevention. https://www.cdc.gov/disability-and-health/conditions/physical-activity.html

Elgaddal, N., Kramarow, E., & Reuben, C. (2022). Physical Activity among Adults Aged 18 and over: United States, 2020. https://doi.org/10.15620/cdc:120046

Krentz, H., Miltenberger, R., & Valbuena, D. (2016). Using token reinforcement to increase walking for adults with intellectual disabilities. Journal of Applied Behavior Analysis, 49(4), 745-750. https://doi.org/10.1002/jaba.326

LaLonde, K. B., MacNeill, B. R., Eversole, L. W., Ragotzy, S. P., & Poling, A. (2014). Increasing physical activity in young adults with autism spectrum disorders. Research in Autism Spectrum Disorders, 8(12), 1679-1684. https://doi.org/10.1016/j.rasd.2014.09.001

U.S. Department of Health and Human Services. (2008). 2008 Physical activity guidelines for Americans. Retrieved from http://www.health.gov/paguidelines/pdf/paguide.pdf

Valbuena, D., Miltenberger, R., Livingston, C., & Slattery, L. (2018). Self-monitoring and monetary reinforcement increases rate of walking in adults with intellectual disabilities. Journal of Developmental and Physical Disabilities, 31(2), 189-203. https://doi.org/10.1007/s10882-018-9627-8

Reference for this article:

Joyce-Trainor, M. (2025). Research synopsis: Token‐economy‐based contingency management increases daily steps in adults with developmental disabilities. Science in Autism Treatment, 22(3).

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Token‐economy‐based Contingency Management Increases Daily Steps in Adults with Developmental Disabilities