499771

research-article2013
AEIXXX10.1177/1534508413499771Assessment for Effective InterventionTheodoridou and Koutsoklenis

International Perspectives
Assessment for Effective Intervention

Functional Behavioral Assessment for a

39(1) 54­–64
© Hammill Institute on Disabilities 2013
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DOI: 10.1177/1534508413499771

and Problem Behavior: A Case Study From aei.sagepub.com

Greece

Zoe Theodoridou, PhD1 and Athanasios Koutsoklenis, PhD1

Abstract
This article focuses on the application of functional behavioral assessment (FBA) to design a positive behavior intervention
(PBI) for a boy with Duchenne muscular dystrophy (DMD) who encounters serious difficulties at the mainstream school
because of behavioral problems and physical limitations. After the definition of problem behavior and its causes, a number of
environmental changes in the context of positive behavior support (PBS) aiming at learning outcome and social engagement
were implemented. The assessment steps and the intervention are thoroughly discussed. This work expands the existing
literature by highlighting the feasibility and applicability of FBA and PBS in a low-incidence population within a Greek
classroom environment.

Keywords
functional behavioral assessment, positive behavior support, Duchenne muscular dystrophy

It has been argued that every behavior serves a specific pur- and instructional and curricular changes. The idea behind
pose or function for a student (Donnellan, LaVigna, Negri- such an intervention is that predictable problem behavior is
Shoultz, & Fassbender, 1988). Understanding the function preventable (Scott, 2003). PBS is considered an important
of problem behaviors is a critical component to developing approach to identifying and organizing effective school
an effective intervention plan (Tasse, 2006). Functional practices, especially for students who present significant
Behavioral Assessment (FBA) has been defined as a set of problem behavior (Sugai et al., 2000).
procedures used for the identification of the causes of a The process of functional assessment has drawn remark-
problematic behavior in a particular context (Horner & able attention in the past few years. This rapid growth is
Carr, 1997; Sugai et al., 2000). Such procedures seek to depicted in the scholarly and professional literature, the
identify the maintaining variables and stimulus conditions profusion of practical handbooks and guidelines, and the
that govern the occurrence of identified behaviors (Dunlap development of relevant materials and tools (Dunlap &
et al., 1993). The results of FBA are consequently used for Kincaid, 2001). The value of PBS and FBA has been dem-
the development of a behavior support plan that will assist onstrated in many cases of individuals with severe and mild
the recipient to reduce the problem behavior (Foster- disabilities in special and general education settings
Johnson & Dunlap, 1993). (Blakeslee, Sugai, & Gruba, 1994; Broussard & Northup,
Positive Behavior Interventions (PBI) are applied to the 1995; Dunlap, Kern-Dunlap, Clarke, & Robbins, 1991;
theoretical framework of Positive Behavior Support (PBS), Lohrman-O’Rourke, Knoster, & Llewellyn, 1999; Repp &
an approach that uses educational and systems change Horner, 1999; Umbreit, 1995).
methods to enhance quality of life and minimize problem In an effort to ensure that schools are conducive to learn-
behavior (Carr et al., 2002; Warren et al., 2003). PBS is a ing, the 2004 Amendments to the Individuals With
team-based, comprehensive, and proactive approach for Disabilities Education Act (IDEA; the law that governs
facilitating and maintaining student success across settings
(Scott, 2003). The Center for Effective Collaboration and 1
St. Luke’s Hospital, Thessaloniki, Greece
Practice (CECP, 1998) recommends that PBS plans include
Corresponding Author:
strategies for supports for teaching more appropriate, alter- Zoe Theodoridou, Department of Special Educational Needs, St. Luke’s
native behaviors; setting event, antecedent, and conse- Hospital, Panorama, Thessaloniki, 55236, Greece.
quence strategies; provisions for positive reinforcement; Email: ztheodoridou@hotmail.com

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Theodoridou and Koutsoklenis 55
special education in the United States) requires schools to
take various steps to address behavior that prevents students
from learning and other inappropriate classroom behavior.
Such actions include the use of FBA, which aims at devel-
oping or revising PBI plans and supports (CECP, 2000).
The paramount impact of such an intervention is evident in
the incorporation of these concepts in the language of a fed-
eral law (Dunlap & Kincaid, 2001).
Nevertheless, PBS is not a well-established practice
around the world. For example, in Greece, PBS is not
implemented systematically within the educational system
and is not supported by legislation or educational policies.
Moreover, general and most special education needs (SEN)
teachers are not familiar with PBS also due to the lack of
appropriate training. As a result, PBS is rarely and unsys-
tematically practiced in Greek educational settings.
Educational policy in Greece is formulated and enforced
by the Ministry of Education, which exercises a rigid con-
trol over school procedures such as staff appointment, cur-
ricula creation and distribution of textbooks, time table
prescriptions, resource allocation, in-service training, and
school organization (Kassotakis & Lambrakis, 1998). At
the same time, individual schools and teachers, compared
with schools of other European countries, are more autono-
mous in certain areas with the state holding a very limited
role over what has been traditionally perceived as “internal
school affairs” such as classroom organization, teacher
accountability, pupil testing, and assessment of school qual-
ity (Vlachou, 2006).
Special education is compulsory and functions as part of
the public and free education system. It includes special
schools, appropriate buildings, programs of educational
integration, and home tuition, as well as necessary diagnos-
tic and assessment services (Syriopoulou-Delli, 2010).
According to the Act 3699/2008 on the “Special Education
and the Education of the Individuals With Disability or
Special Educational Needs,” the Ministry of National
Education and Religious Affairs is responsible for the
assessment and development of teaching programs for these
students.
The aforementioned law (3699/2008) defines that handi-
capped students or students with SEN can attend a main-
stream school, a special education school, or home-based
tutoring, depending on the nature of their difficulties. A stu-
dent who attends a mainstream school might have the addi-
tional support of a special education teacher either into the
classroom or into an independent unit of the school called
“integration class.” Students who attend such classes follow
the core curriculum inside the general education classroom
and an individualized education plan (IEP) that is imple-
mented by the special education teacher. Special schools are
chosen when the attendance is particularly difficult in main-
stream schools. Last, home-based interventions are imple-
mented in the existence of long-term health problems,
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which inhibit mobility and school attendance. In line with
international trends, special education services are based on
IEPs. The public diagnostic services called Center for
Differential Diagnosis, Diagnosis and Support (CDDDS) in
cooperation with the school’s educational and special staff
(e.g., occupational therapist) is responsible for the develop-
ment of an IEP for every student. However, the IEPs are
usually generic and their implementation is not subjected to
any kind of formal assessment. Thus, one may encounter a
remarkable amount of improvisation from teachers.
In effect, this situation means that often teachers without
or with limited knowledge on SEN, specifically emotional
and behavioral difficulties, are called to face challenging
behaviors. In a Greek study, almost four out of five teachers
(79.2%) were found to have at least one student with emo-
tional and behavioral difficulties in their classroom, a fact
that elicited their greatest concern (Poulou & Norwich,
2000). It has been stated (Wheldall & Merrett, 1988) that
children’s troublesome behaviors are hardly crimes. They
are time-wasting, exhausting, and stressful for teachers; yet,
they respond well to simple, positive, behavioral methods
(Poulou & Norwich, 2000). In Greece, however, general
education teachers rarely carry in their arsenal a variety of
such methods because universities do not provide a rigid
education in behavioral methods either at the undergraduate
or the postgraduate level. This affects not only teachers but
educational and social student gains as well. Therefore, the
implementation of an FBA apart from the development of a
preventative intervention is of critical importance.
Given the widely acknowledged value of PBS, it was
decided to adopt such an intervention and portray the imple-
mentation of a PBI based on FBA aiming at coping with the
behavioral problems of a boy with Duchenne muscular dys-
trophy (DMD) attending a general education classroom in
Greece. DMD is a progressive, hereditary, X-linked muscu-
lar disorder, characterized by muscle wasting and weakness
affecting 1 in 4,000 males (Emery, 2001).
Children with DMD first present with a proximal muscle
weakness that emerges before the age of 5 years (Hoffman,
Brown, & Kunkel, 1987), and they usually become con-
fined to a wheelchair by the age of 12 years (Emery, 2003).
DMD is frequently associated with poor academic achieve-
ment (Hinton, De Vivo, Fee, Goldstein, & Stern, 2004), dif-
ficulties in social integration (Donders & Taneja, 2009;
Hinton, Nereo, Fee, & Cyrulnik, 2006), and interpersonal
skills (Achenbach, 2001).
Purpose of the Study
The overall purpose of this study was to provide a thorough
description of the feasibility and applicability of FBA and
PBS within a general education classroom in Greece. To our
knowledge, the use of FBA and PBS in a Greek school con-
text has not been previously studied. Furthermore, DMD
56 Assessment for Effective Intervention 39(1)
entails a complex learning and psychosocial profile that
seriously threatens inclusion in a mainstream school. Still,
probably due to its low frequency and conceivably due to
the prioritization of needs (i.e., serious health issues),
behavioral problems of pupils with DMD have received
little attention. For the aforementioned reasons, we chose to
conduct a FBA and implement a PBS for Philip (pseud-
onym), a 9-year-old boy diagnosed with DMD.
Case study methodology was used as a framework for the
design of this research project. Case study is a well-estab-
lished research strategy that focuses on a case in its own right
by taking its context into consideration (Robson, 2002). Case
studies have been used extensively in the social sciences
because they can provide the scientific rigor and the type of
detail that practitioners require in implementing strategies
effectively (Hartley, 2004). Such methodology is suitable for
research that is concentrated on specific instances of educa-
tional experience and has as an aim to gain knowledge from
a full documentation of those instances (Freebody, 2003).
Methods
Participant
Philip lives with his parents and older brother in a support-
ive environment. His ability to walk is already affected by
the muscle weakness that characterizes DMD. His poor bal-
ance contributes to frequent falls. Moreover, he faces prob-
lems with his motor coordination and functional writing
difficulties. His overall academic achievement is poor as
reflected on assessments carried out by his SEN teacher and
on his low marks in the two first years in school. In addi-
tion, Philip is passively and uneventfully participating in
the regular schedule. His participation is hindered by barri-
ers coming from his physical disability and from emotional
and behavioral difficulties.
Philip experiences a general inability to cope with the
routine of daily tasks. His socio-emotional functioning is
seriously disturbed and he always seems angry. In particular,
he shows aggressive and antisocial behavior in class and
during breaks. In class, he does not respect the rules, inter-
rupts the lesson speaking out of turn, and moves place with-
out permission showing disobedience. According to the
information that was gathered from the interviews, the most
serious of Philip’s problem behaviors in the classroom is that
he leaves his seat without permission. This is followed by
his teacher’s attempt to seat him again, which usually ends
up with Philip falling, crying, and refusing to stand up.
While on the ground, Philip exhibits physical and verbal
aggression. In particular, he often tries to throw objects to
hurt anyone who is nearby and insults his classmates and the
teacher. Philip’s teacher complains that he exhibits such
behaviors every day, during almost all activities, irrespective
of the time of the day. Every time this behavior occurs, the
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teacher interrupts the lesson and she, along with Philip’s
classmates who are gathered around him, tries to raise him
from the ground. The English language teacher described
similar incidents, whereas his mother confirmed that the
falls accompanied by crying and aggression were among the
repertoire of Philip’s everyday behaviors. During breaks he
cannot initiate and keep social interaction with peers.
Instead, he intrudes on their games and annoys them seem-
ing to seek attention.
The general education teacher experiences frustration
and helplessness, while Philip’s classmates are indignant
over his behavior. At the same time, his classmates’ parents
make complaints to the head of the school about Philip’s
behavior. For these reasons, Philip’s family and school
environment are primarily preoccupied with his behavioral
problems and especially with his disruptive behavior.
Setting
Phillip is enrolled in a small elementary school in an urban
location in Greece. The school personnel consisted from the
head of the school, a general education teacher with purely
administrative role, general education teachers, second lan-
guage teachers, a physical education teacher, and an art
teacher. None of them had ever had any formal training con-
cerning special educational needs. However, several meet-
ings had been organized since the new SEN teacher’s
recruitment. During the FBA, Philip’s teachers had been
interviewed by the SEN teacher. In the phase of PBI, each
one of them undertook certain responsibilities and commit-
ments that were described in Philip’s IEP.
Philip’s family was asked to adhere to the school’s
approach. In particular, his mother was given an active role
to consequence manipulation and reinforcement. The SEN
teacher and Philip’s mother were communicating on a daily
basis and feedback was regularly given.
Before Philip’s admission to the school, the local
CDDDS suggested the provision of learning support in the
classroom by a SEN teacher. When Philip was attending the
third grade of the elementary school, this SEN teacher was
transferred to another school for personal reasons and a
SEN teacher who holds a master of arts degree in SEN and
has considerable experience in working with individuals
with behavioral difficulties was subsequently recruited to
replace her. The new SEN teacher provided PBS after
implementing an FBA tripartite strategy. The procedures
took place at Philip’s general education classroom across all
lessons as well as at the schoolyard during breaks.
Procedures
This case study included three phases: (a) data collection
through indirect and direct assessment, (b) the implementa-
tion of the PBI, and (c) the evaluation of its impact on target
Theodoridou and Koutsoklenis 57
behavior. First, a FBA was conducted by the SEN teacher.
The FBA included indirect assessment (examination of the
student’s portfolio and structured interviews with his
mother, the general education teacher, and the English lan-
guage teacher) as well as direct observation, with the use of
an individualized observation form and antecedent-behavior-
consequence (ABC) forms. The results of the FBA suggest
that the child’s behavior was maintained by negative rein-
forcement in the form of escape from demands and positive
reinforcement in the form of access to peer and teacher
attention. Based on these results, a behavior intervention
plan was developed that included antecedent manipulation,
teaching replacement behaviors, and noncontingent access
to attention coupled with attention extinction for challeng-
ing behavior.
Phase 1: FBA data collection. Data were collected at three
time periods: (a) baseline, (b) during the implementation of
PBS, and (c) the following month with the school keeping
the same support plan. A number of indirect and direct
assessment procedures were used in an attempt to collect
information relevant to the student’s behavior.
Indirect assessment. Indirect procedures included the
examination of the student’s portfolio and structured inter-
views with his mother, the general education teacher, and
the English language teacher. Portfolios are considered
the principal way for exhibiting student work and perfor-
mance data (Arter & Spandel, 1992). Portfolio assessment
is designed to present a broader and more genuine picture
of student’s learning and progress over time (De Fina,
1992). The examination of Philip’s portfolio provided valu-
able data regarding his overall academic achievement as
reflected on his low marks in the first two years in school.
Further assessments carried out by his SEN teacher shed
light on specific strengths and vulnerabilities concerning
his cognitive profile. Interviews are considered an appro-
priate complement to observation (Robson, 2002). Using a
structured functional assessment interview form developed
by the CECP (1998), answers regarding the topography, the
duration, and the intensity of the problem behavior as well
as certain factors that shape the classroom environment
were obtained. The participants’ answers were recorded
and fully transcribed by the authors. The analysis of inter-
view data provided useful information for Philip’s behav-
ioral profile. Given the limitations of indirect measures of
assessment, best practice dictates never relying solely on
such procedures (Sterling-Turner, Robinson, & Wilczynski,
2001). For that reason, the second step of the procedure
involved direct observation.
Direct assessment.  Direct assessment procedures
entailed direct observation with the use of an individualized
observation form and ABC forms. After the interviews that
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facilitated the concentration on specific settings, an indi-
vidualized observation form was designed. An observation
form that included a scatter plot was used because such an
approach is designed to contribute in identifying patterns
of response in natural settings (Touchette, MacDonald, &
Langer, 1985). Speculating on the reasons for the occur-
rence of the problem behavior, an observation form that
contained time intervals corresponding to activities was
created. That was further justified by the fact that Philip’s
school schedule changes from day to day, which means that
the sequence of classes is not the same every day.
The analysis of data derived from the observation form
revealed that Philip exhibited problem behavior more fre-
quently during language and English language lessons as
well as during breaks (see Figure 1). For example, on
Wednesday, October 7, Philip exhibited problem behavior
five times. To be more precise, the incidents occurred once
during a language lesson, twice during an English language
lesson, and during two out of three breaks. To our surprise,
Philip, despite his movement difficulties, never showed
such behaviors during the physical education lesson. At this
point, we should underline that the physical education
instructor had already made a number of adjustments and
modifications to the social and physical environment to
ensure Philip’s participation.
Based on information gained through indirect and direct
assessment procedures, observations were conducted using
an ABC form. At this phase, it was decided to focus on
activities that were more often related to Philip’s problem
behaviors. Therefore, evidence observing Philip in the
classroom during language and English language lessons
and in the schoolyard during breaks was collected. Five
such observations were conducted in various settings. The
ABC forms were completed by the SEN teacher. Three
examples of ABC observations are presented in Figure 2.
The observations led to the development of a hypothesis
concerning the probable function of Philip’s behavior. This
step of the procedure carried special weight because well-
developed hypotheses provide the foundation for effective
PBI plans.
Phase 2: PBI planning and implementation.  A data triangula-
tion chart, which is considered to enhance the rigor of the
research (Robson, 2002), was used for the generation of a
hypothesis (see Figure 3). To analyze patterns of problem
behavior, we gathered information from interviews, an indi-
vidualized scatter plot, and ABC observations. According to
the interview, whenever Philip left his seat, he drew his
teacher’s and classmates’ attention. Such behaviors were
more frequent during language and English language les-
sons as well as during breaks. ABC observations revealed
that either too demanding or restrictive tasks often preceded
Philip’s behaviors. Thus, the hypothesis statement was for-
mulated as follows:
58 Assessment for Effective Intervention 39(1)

Time intervals Monday 05/10 Tuesday 06/10 Wednesday 07/10 Thursday 08/10 Friday 09/10

8:00 Arrival Arrival (1) Arrival Arrival Arrival (1)

8:15
8:16 Language Language (1) Language Mathematics Language (1)
8:30
8:45
9:00
9:01 Language (1) Language (1) Language (1) History Language (1)
9:15
9:30
9:45
9:46 Break Break Break Break Break (1)
10:00
10:01 Mathematics (2) Physical Education English Language (2) Religious Education Mathematics (1)
10:15
10:30
10:45
10:46 Environmental Mathematics Environmental English Language (1) Art
11:00 Education Education
11:01  
11:15
11:30
11:31 Break (1) Break Break (1) Break (1) Break
11:45
11:46 Music Flexible Zone Physical Education Environmental Flexible Zone
12:00 Education
12:01  
12:15
12:30
12:31 Break (1) Break (1) Break (1) Break (1) Break (1)
12:45
12:46 History Flexible Zone Religious Education Art English
13:00 Language (1)
13:01  
13:15
13:30
13:31 Departure Departure Departure Departure Departure

Figure 1.  Scatter plot showing the occurrence of target behavior in each time interval (arrival, lessons, breaks, and departure).
Note. The target behavior is that “Philip falls on the ground and cries.” Numbers in brackets indicate the frequency of occurrence in a time interval.

Whenever a too demanding task is presented that does not
permit Philip to engage in common activities with his
classmates—either academic or having to do with his social
interactions (play in the schoolyard)—he falls on the ground
and cries in order to avoid what seems to him a task which
is difficult to complete and to obtain peer and teacher
attention.
The target behavior was considered Philip’s falls and
remaining on the ground crying. The PBI did not aim to
control and suppress the problem behavior; it aimed at mod-
ifying the physical and social environment to create an
atmosphere conducive for learning and social engagements
and further provided him with a set of alternative, func-
tional, socially acceptable behaviors equivalent to the prob-
lem behaviors. Therefore, the intervention focused on the
axons presented below.
The manipulation of antecedent events.  Among the ante-
cedent events that triggered the problem behavior, one
could find difficult tasks assigned by Philip’s teachers
during the lesson. The difficulty could be related to the
advanced academic level of an exercise and/or by Phil-
ip’s muscular weakness. The latter could happen in cases
where Philip was asked to complete a writing task. More-
over, the fact that Philip’s classmates were playing soccer
or other games he could not participate in could trigger
violent reactions. The implementation of curricular and
instructional modifications was decided for the manipu-
lation of the antecedents. At first, Philip’s teachers were
asked to modify the exercises that they assigned to Philip
to keep up with Philip’s level of academic competence.
They were further advised to prefer oral rather than writ-
ten responses when possible. Moreover, a computer was

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Theodoridou and Koutsoklenis 59

ABC RECORDING FORM (Example 1)

Date: 10/05/2010 Time begin: 11:30 Time end: 11:38

Student: Philip Setting: Schoolyard Observer: Sp. Ed. Teacher

Antecedent Behavior Consequence

“When the ring bells for break Philip’s “Philip falls on the ground yelling at his “Children and teachers are gathered
classmates take a ball and run to the classmates for not inviting him to play with around Philip and try to calm him
school yard to play soccer”. them and cries”. down”.

ABC RECORDING FORM (Example 2)

Date: 10/07/2010 Time begin: 11:10 Time end: 11:26

Student: Philip Setting: English class Observer: Sp. Ed. Teacher

Antecedent Behavior Consequence

“The English language teacher
asks the students to read their
homework”.
“Philip leaves his seat and runs around the
classroom while he is singing. He finally
falls on the ground at his attempt to escape
from the teacher who tries to drive him to
his seat and cries”.
“English language teacher tries to raise
him from the ground with the help of
two of Philip’s classmates while the
whole classroom is gathered around
them”.

ABC RECORDING FORM (Example 3)

Date: 10/09/2010 Time begin: 08:51 Time end: 08:59

Student: Philip Setting: Language class Observer: Sp. Ed. Teacher

Antecedent Behavior Consequence

“Philip’s teacher asks from the
students to write a language
exercise”.
“Philip leaves his seat and wanders around “Philip’s teacher tries to raise him
the classroom annoying his classmates. He from the ground with two of Philip’s
finally falls on the ground at his attempt to classmates help while the whole
escape from the teacher who tries to drive classroom is gathered around
him to his seat and cries”. them”.

Figure 2.  Three examples of ABC observations conducted in different settings (schoolyard, English class, and Language class).

placed in Philip’s classroom to facilitate his completion of
written exercises (Philip was familiar with computer use).
In this way, the elimination of the need to avoid a task or
escape from it in an inappropriate manner was achievable.
Endeavors were also made to underline the importance of
gaining enough attention by his teachers who were asked
to ensure that they offered him enough opportunities to
equally participate in the lesson. The manipulation of
antecedents related to Philip’s interactions at playtime was
based on the teaching of replacement behaviors.
Replacement behaviors. To cope with the inappropriate
behaviors that occurred in the classroom during language
and English language lessons, apart from the instructional
modifications, Philip was taught replacement behaviors,
such as asking for help from his teachers whenever he
encountered difficulty in accomplishing a given task. The
desirable behavior was taught through a multicomponent
approach that included incidental teaching, discussion
strategies and skill autopsy, verbal prompts, feedback, and
reinforcement. Eventual fading of procedures was gradually

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60 Assessment for Effective Intervention 39(1)

Source 1: Interview Source 2: Scatterplot Source 3: ABC form

  Philip often leaves his seat without permission. When the Philip exhibited problem Whenever a too demanding and
teacher attempts to seat him again Philip falls on the ground behavior more restricting task is presented,
crying, refusing to stand up and exhibiting physical and frequently during Philip falls on the ground and
verbal aggression. Every time this behavior occurs, the language and English cries. He avoids the task and
lesson is interrupted and Philip’s classmates are gathered language lessons as he gains peers’ and teacher’s
around him. well as during breaks. attention.

Interpretation

1.  Antecedent: A demanding task is presented and Philip is excluded from a group activity.

2.  Consequence: Philip falls on the ground crying and getting aggressive.

3.  Function: Avoidance of demanding tasks and gain of peer and teacher attention.

Figure 3.  A data triangulation chart was used for the generation of a hypothesis.

applied and Philip independently exhibited the skill taught.
To the same end, Philip learned specific skills that would
enable him to gain peer attention and approval through
positive social initiations. The strategies that were used to
enhance such social skills included modeling with video,
preparing peer partners, verbal prompts, feedback, rein-
forcement, and fading. Within this framework, an active,
but tailor-made, role was given to Philip during play time.
An agreement was made with Philip and his classmates to
take over the role of the goal keeper whenever they played
soccer. Since then Phillip proudly wore his gloves and tried
to save goals sitting on the ground, exhibiting such a behav-
ior independently.
Consequence manipulation and reinforcement.  A variety of
consequence strategies were implemented. Philip was pro-
vided noncontingent attention throughout the day and the
problem behaviors that functioned to gain attention were
ignored. Regarding reinforcement, a behavioral contract
was signed by Philip, his teachers, and his mother defining
the kind of praise he would get for using desirable behaviors
instead of the problem ones. It was clearly stated that Philip
should show the following replacement behaviors: (a) to
ask for help from his teacher by raising his hand whenever
he encounters a difficult task instead of escaping and leav-
ing his seat and (b) to kindly ask his friends to participate in
their games during break.
It was agreed that Philip would gain a smiley face sticker
at the end of every 45-min time period either if he com-
pleted his assignments on his own or if he asked for help by
raising his hand. If he managed to gain a sticker for every
45-min period, his mother would take him to play soccer
after school for 20 min. For exhibiting desirable behavior
during breaks, he would be reinforced with a sticker of his
favorite soccer team on a daily basis. To be more specific,
Philip had to gain one tick for each break on a daily record-
ing form to gain the sticker. However, more than this, his
reinforcement would be the very participation in the game.
If not so, he would lose these privileges. In the case Philip
failed to gain five stickers, one for each 45-min period, he
could not play soccer after school. Moreover, if he gathered
fewer than three ticks, one for each break, he could not gain
the sticker with his favorite soccer team for his collection.
Crisis management. PBS systems render additional
classroom and individual student support strategies most
effective and reduce the necessity for more individualized,
intensive, or crisis supports (Hieneman, Dunlap, & Kin-
caid, 2005). Yet, given that planning and implementation
may take some time, it may be necessary to use crisis pro-
cedures in the interim (Florida Department of Education,
1999). Thus, if a student’s behavior poses considerable risk
to the self or others, the behavioral support plan may also
need to include strategies to ensure safe and rapid de-esca-
lation of the crisis. A crisis is defined as “a situation that
requires an immediate, intrusive, or restrictive intervention
to: 1) protect the student or others from serious injury; 2)
safeguard physical property; and/or 3) deal with an acute
disturbance of the teaching/learning process” (CECP, 2000,
p. 16). Every crisis plan should be monitored closely to be
revised if its necessity fails to diminish over time or pro-
vokes emotional reactions from the student (Florida Depart-
ment of Education, 1999).
Given that Philip could exhibit extreme behaviors (e.g.,
throwing objects such as scissors), a crisis management
plan was designed. According to this plan, when Philip falls
down on the ground and cries, the teacher should approach
him, try to calm him down, and have him sit up. The teacher
should make sure that Philip’s classmates do not leave their
activities to gather around him and give him attention. In

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Theodoridou and Koutsoklenis 61
this way, the plan was consistent with the aim of attention
extinction. However, if the crisis lasts more than 2 min, the
general education teacher should call the SEN teacher to
walk Philip outside the classroom, as Philip’s and his class-
mates’ protection was considered the highest priority. Philip
would not be allowed to rejoin the group until he was calm.
Meanwhile, Philip would have the chance to work on self-
management skills with the SEN teacher. The crisis man-
agement plan was designed as a tentative and emergency
solution, which would hopefully withdraw.
Phase 3: Results—Evaluation of the PBI.  The evaluation of the
PBI plan is a critical process because it counts the results of
the intervention and further allows the optimization of the
support provided. The evaluation of the PBI plan focused
on the following targets: (a) to decrease the frequency of the
problem behavior, (b) to decrease the intensity of the prob-
lem behavior, (c) to decrease the duration of the problem
behavior, and (d) to increase the use of socially acceptable
behaviors conducive to Philip’s social integration.
The changes in Philip’s behavior were monitored using
the baseline information as a standard. To be more specific,
frequency was measured by using the same observation
form thrice in a period of 1 month. The intensity and the
duration of the behavior were monitored with the use of
ABC charts by the general education teacher whenever
Philip exhibited problem behavior. The general education
teacher was given precise and concise guidelines by the
SEN teacher to keep record of Philip’s behavior. According
to the Behavior Rating Scale (BRS), intensity refers to
the magnitude, strength, amplitude, force, or effort of a
response (Bayley, 1993). This method of measurement
involves a description of the heightened impact of the
behavior (Wright, Cafferata, Keller, & Saren, 2009). To
measure the intensity of Philip’s challenging behavior, a
qualitative analysis of the data was made. Different phras-
ings corresponded to different degrees of intensity. For
example, sometimes Philip was screaming out loud, other
times he was crying, whereas in some cases he was just
complaining. The general education teacher was provided
with plenty of ABC observation form copies to use them
whenever a problem behavior was exhibited. The adoption
of desirable, replacement behaviors was evaluated using
direct observation of his behavior during lessons and
breaks.
The PBI plan applied in Philip’s case had a number of
beneficial outcomes. First, there was a remarkable reduc-
tion in the occurrence of the target behaviors inside the
classroom and in the schoolyard. The average number of
incidents dropped from 25 to 2 per week (see Figure 4).
Moreover, the duration and the intensity of the incidents
gradually diminished.
Second, Philip’s academic performance improved con-
siderably as measured by the assessments conducted by his
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general teacher and his SEN teacher. At the same time,
Philip’s participation increased during the lessons. Third,
Philip’s engagement in play with his classmates during
breaks increased because he was given an active, motivat-
ing, and rewarding role. These outcomes indicated that the
hypothesis of task avoidance and seeking attention as pri-
mary functions of Philip’s behavior were sound. Last,
Philip’s parents and teachers were very pleased with the
effectiveness of the PBI. This is vividly portrayed by their
comments on Philip’s behavior after the intervention:
Philip participates more in my lessons after the intervention . . .
he rarely exhibits the problem behaviors and seems to enjoy
more day-to-day classroom activities. (General education
teacher)
I think that my child looks happier now. I feel calmer because
apart from all the other academic benefits, Philip seems to
enjoy his interactions with classmates more than ever. (Philip’s
mother)
Implications for Practice
DMD is a muscular disorder frequently accompanied by
behavioral and cognitive difficulties. As a consequence of
emphasis often placed on health-related problems and espe-
cially on physical limitations, the educational needs of
pupils with DMD are at risk of being overlooked. However,
school interventions can promote learning and social
engagement and enhance the quality of life of pupils with
DMD. This article draws attention to the treatment of
behavioral difficulties of pupils with DMD within the
school environment in an attempt to abolish the barriers to
their successful participation.
Because problem behavior is often a comorbid condi-
tion in DMD that along with learning difficulties unavoid-
ably threatens successful participation in school, this study
covers a gap in the literature related to school-based assess-
ments for effective interventions for the management of
DMD. In particular, the presented work enhances the liter-
ature concerning the use of FBA procedures to develop
hypothesis-based interventions demonstrating its effective-
ness within a low-incidence population. Furthermore, the
fact that this case study was conducted in the student’s
natural educational environment adds validity in the use of
such a process in an educational setting. Overall, the results
of our study highlight the feasibility and applicability of
FBA and PBS within a general education classroom in
Greece. Our intervention (a) decreased the frequency of the
problem behavior, (b) decreased the intensity of the prob-
lem behavior, (c) decreased the duration of the problem
behavior, and (d) increased the use of socially acceptable
behaviors conducive to Philip’s social integration. Such
progress had a very beneficial effect on Philip’s family. In
addition, the personnel of the school became familiar with
62 Assessment for Effective Intervention 39(1)

Figure 4.  Figures showing frequency of incidents per week during “Language class,” “English Language class,” and “breaks.”

the procedures of FBA and PBS, thereby enhancing their
potential to face the highly frequent issue of challenging
behavior.
Related case studies had indicated the decrease of prob-
lem behaviors after the implementation of FBA-based inter-
ventions stressing the necessity of additional research on
the use of replacement behaviors (McLaren & Nelson,
2009). Observation data from Carter and Horner’s (2007)
case study demonstrated a functional relation between the
addition of function-based supports and decreases in prob-
lem behavior and increases in academic engagement.
Furthermore, teacher perceptions of student behavior and
academic competence show increases in social skills and
academic competence and decreases in problem behavior
following intervention.
Nevertheless, PBS is not a well-established practice
around the world. For example, in Greece, PBS is not
implemented systematically within the educational system
and is not supported by legislation or educational policies.
Moreover, general and most SEN teachers are not familiar
with PBS because of the lack of appropriate training. The
results of the study presented here reveal the necessity for
proper training of general and special education teachers
that will expand their teaching repertoire by adding an
approach that can effectively meet the needs of pupils with
behavioral problems. Given the financial crisis that induced
a reduction of personnel in Greek schools, such a need
seems now more pronounced than ever.
The lack of resources (e.g., special education consulta-
tion, paraprofessional support, specialized assessments,
and planning) and appropriate training often constitute
barriers to effectiveness in general education settings
(Hieneman et al., 2005). The PBS process shares a com-
mon denominator with some existing procedures within
schools used by existing disciplines, such as the IEP pro-
cess. In this article, the practicality of implementing PBS
by the available personnel in a general education school
was highlighted. Our study opened up a new pathway for
the Greek educational system, which unfortunately has not
embraced such procedures so far.

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Theodoridou and Koutsoklenis 63
Limitations
Certain cautions and limitations exist in considering the
results of this study. An important consideration for the case
study methodology is that of generalization because
researchers cannot conclude general schemes from the find-
ings (Grosvenor & Rose, 2001). Nevertheless, Flyvbjerg
(2006) states that the difficulty of generalizing from case
studies is often due to the “properties of the reality studied
than to the case study as a research method” (p. 241). This
case study does demonstrate a general process of functional
assessment that leads to the generation of an effective inter-
vention issued from the information gathered during func-
tional assessment, strengthening the belief that school
personnel can apply such procedures.
Suggestions for Future Research
Future investigations should examine the existence of pat-
terns of problem behaviors that are related to DMD.
Longitudinal data from children with DMD would hope-
fully reveal the trajectory of behavioral difficulties and
their potential association with the progressive deteriora-
tion of symptoms. Given the biological substrate of the
behavioral difficulties (i.e., the lack of dystrophin), medi-
cal therapies aimed at remediation might be helpful. Thus,
future studies should be steered into the direction of phar-
macological treatments. In any case, research should
further focus on school-based interventions for the man-
agement of problem behaviors that are exhibited by chil-
dren with DMD, aiming at the optimum support in
academic and social aspects of school life. It is also hoped
that future studies will investigate the effectiveness of FBA
and PBI in other low-incidence disabilities. The applica-
tion of FBA and behavior intervention in diverse popula-
tions that appear with behavioral problems attending either
mainstream or special education schools within the Greek
educational system should constitute a new line of research
in the future.
Declaration of Conflicting Interests
The author(s) declared no potential conflicts of interest with respect
to the research, authorship, and/or publication of this article.
Funding
The author(s) received no financial support for the research,
authorship, and/or publication of this article.
References
Achenbach, T. (2001). Child behavior checklist for ages 6–18.
Burlington, VT: University of Vermont.
Arter, J. A., & Spandel, V. (1992). Using portfolios of student work
in instruction and assessment. Educational Measurement:
Issues and Practice, 11, 36–44.
Downloaded from aei.sagepub.com at UCSF LIBRARY & CKM on April 19, 2015
Bayley, N. (1993). Bayley scales of infant development (2nd ed.).
San Antonio, TX: Psychological Corporation.
Blakeslee, T., Sugai, G., & Gruba, J. (1994). A review of func-
tional assessment use in data-based intervention studies.
Journal of Behavioral Education, 4, 397–414.
Broussard, C. D., & Northup, J. (1995). An approach to func-
tional assessment and analysis of disruptive behavior in regu-
lar education classrooms. School Psychology Quarterly, 10,
151–164.
Carr, E. G., Dunlap, G., Horner, R. H., Koegel, R. L., Turnbull, A.
P., Sailor, W., & Fox, L. (2002). Positive behavior support:
Evolution of an applied science. Journal of Positive Behavior
Interventions, 4, 4–16.
Carter, D. R., & Horner, R. H. (2007). Adding functional behav-
ioral assessment to First Step to success: A case study. Journal
of Positive Behavior Interventions, 9, 229–238.
Center for Effective Collaboration and Practice. (1998). Addressing
student problem behavior: An IEP’s team introduction to
functional behavioral assessment and behavior intervention
plans. Washington, DC: U.S. Department of Education.
Center for Effective Collaboration and Practice. (2000). Addressing
student problem behavior—Part III: Creating positive behav-
ioral intervention plans and support. Washington, DC: U.S.
Department of Education.
De Fina, A. A. (1992). Portfolio assessment. New York, NY:
Scholastic Professional Books.
Donders, J., & Taneja, C. (2009). Neurobehavioral characteris-
tics of children with Duchenne muscular dystrophy. Child
Neuropsychology: A Journal on Normal and Abnormal
Development in Childhood and Adolescence, 15, 295–304.
Donnellan, A. M., LaVigna, G. W., Negri-Shoultz, N., &
Fassbender, L. L. (1988). Progress without punishment:
Effective approaches for learners with behavior problems.
New York, NY: Teacher’s College Press.
Dunlap, G., Kern, L., dePerczel, M., Clarke, S., Wilson, D.,
Childs, K. E., & Falk, G. D. (1993). Functional analysis of
classroom variables for students with emotional and behav-
ioral disorders. Behavioral Disorders, 18, 275–291.
Dunlap, G., Kern-Dunlap, L., Clarke, S., & Robbins, F. R. (1991).
Functional assessment, curricular revision, and severe behavior
problems. Journal of Applied Behavior Analysis, 24, 387–397.
Dunlap, G., & Kincaid, D. (2001). The widening world of func-
tional assessment: Comments on four manuals and beyond.
Journal of Applied Behavior Analysis, 34, 365–377.
Emery, A. E. H. (2001). The muscular dystrophies. New York,
NY: Oxford University Press.
Emery, A. E. H. (2003). Duchenne muscular dystrophy (3rd ed.).
Oxford, UK: Oxford University Press.
Florida Department of Education. (1999). Facilitator’s guide,
positive behavioral support. Tallahassee: Florida Department
of Education, Division of Public Schools and Community
Education, Bureau of Instructional Support and Community
Services.
Flyvbjerg, B. (2006). Five misunderstandings about case study
research. Qualitative Inquiry, 12, 219–245.
Foster-Johnson, L., & Dunlap, G. (1993). Using functional assess-
ment to develop effective, individualized interventions for
challenging behaviors. Teaching Exceptional Children, 25,
44–50.
64 Assessment for Effective Intervention 39(1)
Freebody, P. (2003). Qualitative research in education: Interaction
and practice. Thousand Oaks, CA: SAGE.
Greek Official Governmental Gazette. Law 3699 2/10/2008 199
[In Greek].
Grosvenor, I., & Rose, R. (2001). Case study. In R. Rose &
I. Grosvenor (Eds.), Doing research in special education:
Ideas into practice (pp. 70–74). London, England: David
Fulton Publishers.
Hartley, J. (2004). Case study research. In C. Cassell, & G. Symon,
(Eds.), Essential guide to qualitative methods in organ-
isational research (pp. 323–333). Thousand Oaks, CA:
SAGE.
Hieneman, M., Dunlap, G., & Kincaid, D. (2005). Positive support
strategies for students with behavioral disorders in general
education settings. Psychology in the Schools, 42, 779–794.
Hinton, V. J., De Vivo, D. C., Fee, R., Goldstein, E., & Stern,
Y. (2004). Investigation of poor academic achievement
in children with Duchenne muscular dystrophy. Learning
Disabilities Research & Practice, 19, 146–154.
Hinton, V. J., Nereo, N. E., Fee, R. J., & Cyrulnik, S. E. (2006).
Social behavior problems in boys with Duchenne muscu-
lar dystrophy. Journal of Developmental & Behavioral
Pediatrics, 27, 470–476.
Hoffman, E. P., Brown, R. H. J., & Kunkel, L. M. (1987).
Dystrophin: The protein product of the Duchenne muscular
dystrophy locus. Cell, 51, 919–928.
Horner, R. H., & Carr, E. G. (1997). Behavioral support for stu-
dents with severe disabilities: Functional assessment and
comprehensive intervention. Journal of Special Education,
31, 84–104.
Kassotakis, M., & Lambrakis, P. A. (1998). Greek education and
its legislative framework. In W. Tulasiewicz & G. Strowbridge
(Eds.), Education and the law: International perspectives
(pp. 112–126). Thousand Oaks, CA: Routledge.
Lohrman-O’Rourke, S., Knoster, T., & Llewellyn, G. (1999).
Screening for understanding: An initial line of inquiry
for school-based settings. Journal of Positive Behavioral
Interventions, 1, 35–42.
McLaren, E. M., & Nelson, C. M. (2009). Using functional behav-
ior assessment to develop behavior interventions for students
in Head Start. Journal of Positive Behavior Interventions, 11,
3–21.
Poulou, M., & Norwich, B. (2000). Teachers’ causal attributions,
cognitive, emotional and behavioural responses to students
with emotional and behavioral difficulties. The British Journal
of Educational Psychology, 70, 559–581.
Downloaded from aei.sagepub.com at UCSF LIBRARY & CKM on April 19, 2015
Repp, A., & Horner, R. H. (Eds.). (1999). Functional analysis of
problem behavior: From effective assessment to effective sup-
port. Belmont, CA: Wadsworth.
Robson, C. (2002). Real world research: A resource for social sci-
entists and practitioner-researchers (2nd ed.). Oxford, UK:
Blackwell.
Scott, T. M. (2003). A schoolwide example of positive behavior
support. Journal of Positive Behavior Interventions, 3, 88–94.
Sterling-Turner, H. E., Robinson, S. L., & Wilczynski, S. M.
(2001). Functional assessment of distracting and disruptive
behaviors in the school setting. School Psychology Review,
30, 211–226.
Sugai, G., Horner, R., Dunlap, G., Hieneman, M., Lewis, T.,
Nelson, C., & Ruef, M. (2000). Applying positive behavior
support and functional behavioral assessment in schools.
Journal of Positive Behavior Interventions, 2, 131–143.
Syriopoulou-Delli, C. K. (2010). A historical review of educa-
tional policy in Greece for children with pervasive devel-
opmental disorders, behavioral difficulties and other special
educational needs. Review of European Studies, 2, 2–14.
Tasse, M. J. (2006). Functional behavioural assessment in people
with intellectual disabilities. Current Opinion in Psychiatry,
19, 475–480.
Touchette, P. E., MacDonald, R. F., & Langer, S. N. (1985). A
scatter plot for identifying stimulus control of problem behav-
ior. Journal of Applied Behavior Analysis, 18, 343–351.
Umbreit, J. (1995). Functional assessment and intervention in a
regular classroom setting for the disruptive behavior of a stu-
dent with attention deficit hyperactivity disorder. Behavioral
Disorders, 20, 267–278.
Vlachou, A. (2006). Role of special/support teachers in Greek
primary schools: A counterproductive effect of ‘inclusion’
practices. International Journal of Inclusive Education, 10,
39–58.
Warren, J. S., Edmonson, H. M., Griggs, P., Lassen, S. R., McCart,
A., Turnbull, A., & Sailor, W. (2003). Urban applications of
schoolwide positive behavior support: Critical issues and lessons
learned. Journal of Positive Behavior Interventions, 5, 80–91.
Wheldall, K., & Merrett, F. (1988). Which classroom behaviors
do primary school teachers say they find most troublesome?
Educational Review, 40, 13–27.
Wright, D. B., Cafferata, G., Keller, D., & Saren, D. (2009). The
BSP desk reference: A teacher and behavior support team’s
guide to developing and evaluating behavior support plans
for behaviors that interfere with the learning of student and/
or peers. Retrieved from www.pent.ca.gov