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Exercise is just a small factor in a bigger problem that university students and the young adult population do not get sufficient exercise (Reed & Phillips, 2005) due to a number of reasons that include lack of time management skills, lack of knowledge on health education and lack of support or motivation (Miser & McKenna, 2000). To counter this inactive behavior, studies have shown to implement behavioral interventions such as token economies in order to increase patient’s activity – mainly exercise.
In a study done by Bernard, Cohen & Movement (2009), a token economy system was implemented to increase exercise adherence for three patients with cystic fibrosis, a lethal respiratory disease affecting the lungs and pancreas. Using an ABA single subject study design, the experimenter trained the parents to implement a token economy system in the home in which the target was for the child to exercise approximately four times per week for 20 minutes and receive a small immediate reward following the session.
Points were also awarded for each 10 minutes of exercise that could be exchanged for a larger prize (Bernard et al. , 2009). The results showed that implementing a token economy system to increase exercise is an effective technique -? all three participants showed an increase in exercise during treatment phase (Bernard et al. , 2009). The 1 month and 3 month follow-up indicated long-term maintenance – all three participants were exercising above baseline levels (Bernard et al. , 2009).
This study demonstrates the effective technique in using a token economy intervention to increase exercise and that a combination of gradually fading out tokens with social reinforcement and self-reinforcement can promote a “long-term lifestyle change in exercise behavior” (Bernard et al. , 2009). Other studies demonstrate similar results with the use of a token economy system, not specifically with the goal to increase exercise but for the reduction of destructive behaviors such as violence and apathy in institutionalized patients (Hinkler, 1970).
In a 1970 study done by Hinkler, a token economy system was designed to reduce excessive violence on patients diagnosed mainly with schizophrenia. The results showed that the system not only reduced undesirable behaviors but without exception improved every type Of behavior that was reinforced (Hinkler, 1970). These behaviors included making the bed, attendance at morning exercise and gnashing morning exercise. Problem solving training is also very effective for student populations due to research suggesting that students who demonstrate effective time management techniques have better academic performance (Miser & McKenna, 2000).
Many students do not know how to effectively time manage their studies (Miser & McKenna, 2000) and problem solving training can be an effective tool in helping them learn. A literature review of students and time management revealed that how a student structures their leisure time and work time played a key role in reducing academic stress (Miser & McKenna, 2000). The study also revealed that student’s who engage more ‘frequently in time management behaviors will report fewer physical and psychological symptoms of stress” (Miser & McKenna, 2000).
Based on these studies, a combination of a token economy system aimed at the acceleration of exercise and problem solving training on effective time management skills and health education can be beneficial for students. The focus of this study is John Smith, a university student who decided to seek the help of a therapist in order to combat his inactivity. John’s issue is that he is too busy too exercise, is tired after a long day, cannot find titivation to exercise on the weekend and is generally inactive.
Since exercise is necessary for maintaining good physical and psychological health (Reed & Phillips, 2005), the target behavior will focus around exercise adherence – specifically increasing exercise. The purpose of this study was to examine if token economy and problem solving training can help John become more active. During the intake, the therapist learned that John is a second year Honors in Psychology major at York University, which comes with a strenuous workload.
In addition to his full course load, he dedicates 8 hours a week to irking in the university bookstore to make money to pay off his loans, is living on residence at school and has difficulty with time management. John stressed that pressure and stress slow him down rather than motivate him and this leads him to eat unhealthy foods (i. E. Junk food) and stay up on the computer or watching TV as his method to De-stress. John also states that he is a morning person, prefers the outdoors for performing physical exercise and can have bouts of laziness.
After clarifying John’s problem, both the therapist and John focus on the gradual increase of exercise in Johns weekly Monday to Friday routine. With the help of the therapist, John’s initial goals were specific – to exercise 3 to 4 times a week -? and unambiguous – to jog around the neighborhood – and it was made measurable with the goal being for John to be able to jog for 60 minutes near the end of therapy. The target behavior that was chosen was increasing run inning individually for John.
Choosing a target behavior – running individually – that allowed for acceleration allowed John to be active right away rather than focusing on decreasing his other unhealthy behaviors such as an unhealthy diet or poor leaping habits. Furthermore, the target behavior was narrow in scope – it was a cardiac workout consisting of running individually – and it was unambiguous – the participant was running around the York University campus where he was currently presiding. The map of his exercise routes can be seen in Appendix B.
To make the target behavior measurable, the therapist and John worked considerably on the frequency, duration, intensity and amount of byproduct. The frequency was made to be 3 to 4 times a week, which was done purposely to take into consideration Johns busy schedule and tendency for laziness. This way if the participant missed one of his days, he had an additional scheduled exercise to make up for it; therefore, in reality the frequency was 3 times per week of individual running. Taking the clients personality into consideration, the weekly running sessions were scheduled for 3 mornings and 1 afternoon.
Appendix A demonstrates John’s weekly schedule with the target behavior incorporated. The duration was set for a gradual increase in exercise to avoid injury; Appendix C demonstrates the breakdown for the weekly duration of the running session beginning with walking for 15 minutes in week 1 and running or 15-30 minutes in weeks 2 and 3. The duration works its way up to 45-60 minutes in week 6 in which the participant is expected to maintain this duration for the final two weeks of therapy.
The graph in Appendix C also lists the intensity of the participants running session beginning with fast-paced walking to moderate jogging detailing that the participant should not be able to keep up a conversation if he is performing the activity correctly. John then self-records the amount of by-product in the form of fatigue and perspiration. These goals were believed to be adaptable and appropriate for the client’s Laos and therefore easily incorporated into his schedule.
Before the start of treatment, the client was asked to record his overt behaviors, cognitions and emotions for one week using a behavioral assessment procedure. Self-recording was chosen as the assessment procedure and John recorded any exercise he engaged in (overt behaviors) during the baseline week and his cognitions and emotions before during and after he engages or did not engage in the exercise. The daily (Monday-Friday) self-recording diary contain due throughout the course of the 9-week therapy to evaluate John’s target behavior on a weekly basis.
The week 1 baseline recording was used to identify John’s maintaining conditions for his inactive behavior. Using the baseline assessment, John’s maintaining antecedents were identified as a lack of time, feeling stressed and tired from his academic workload – which resulted in a lack of energy – and a tendency to be lazy. He tended to create excuses for himself such as “It won’t make a difference to exercise for one day anyway” and his lack Of problem solving and time management skills did not allow him to figure out a more effective routine.
The consequences of his maintaining antecedents included John feeling pressed, having low self-esteem and engaging in unhealthy behavior such as staying up to watch TV or eating junk food. He continued to create excuses for himself, such as, “If exercise I am going to be more tired”. Conducting a chain analysis revealed that John’s day included coming home from school or work and feeling exhausted. He would sit and watch TV to relax and find that he had no energy for exercise afterwards.
John would then try to motivate himself by looking in the mirror, which did not give him motivation, but only led to feelings of low self-esteem which led him not to exercise. To take his mind off of these negative feelings John would watch more TV late into the night and feel tired the next morning. The studies reviewed earlier demonstrated that a token ecology system can be used to increase adaptive behaviors while reducing maladaptive behaviors and is particularly effective in increasing exercise behaviors (Bernard et al. , 2009).
The majority of student populations do not demonstrate effective time management skills (Miser & McKenna, 2000), however, problem solving training can be an effective technique to teach these skills. While a token economy system and problem solving training have en researched separately, there is no research using both techniques to increase exercise behaviors in students. The purpose of this study is to evaluate the effectiveness of a combined token economy and problem solving training intervention on an average university student.
Methods Participant As described earlier, the participant is a second year Honors student majoring in psychology. He lives on residence at his school, York University, and reveals to the therapist during his intake that he loves to spend time in front of the TV, has a tendency to be lazy and is a morning person. The artificial was not active at the time of intake but prefers outdoor activities to indoor exercising. Due to his heavy workload and part time job at the bookstore, he has difficult¶y’ managing his time effectively and finding time to be active, and feels unmotivated towards performing exercise.
Design Losing an outcome research study design, a case study was conducted of the participant throughout the sessions. Being the only participant in this study, a case study was most appropriate because a detailed description of what transpires during treatment was necessary to monitor his progress. Due to the novel application of this intervention, using a case study was good for doc meeting the success of therapy and allows the researcher to demonstrate the feasibility of the delivery of the therapy technique, which can lay the groundwork for further empirical testing.
The study included weekly sessions over a 9-week treatment plan including a baseline assessment during the first week. The token economy was terminated during week 6 of treatment and natural reinforces were slowly incorporated instead. The last two weeks of therapy consisted of the participant learning robber solving training skills to allow him to maintain his target behavior after the end of therapy without token reinforcements.
Procedure Using a daily self-recording behavioral assessment, the participant measured his target behavior (exercise) only from Monday through Friday since no exercise sessions were scheduled for the weekend. Before, during and after performing his target behavior, the participant kept detailed notes of his cognitions, emotions, overt behavior (whether he exercised or did not exercise) and physiological responses; for the latter, his heart rate was measured after each running session.
Appendix D is an excerpt from the participant’s daily diary during week 4 of treatment, and includes his thoughts and the emotions he experienced during his exercise session. It also includes whether he performed the target behavior and his heart rate after the target behavior was performed. The daily self-recording was continued until the end of therapy to allow both the participant and the therapist to track changes in the target behavior. As previously mentioned, a token economy and problem solving training intervention was used, with the latter focusing on time management skills and health education.
The underlying principles involved in these techniques include operant conditioning for token economy, specifically positive reinforcement of adaptive behaviors. The participant is positively reinforced by the addition of tokens every time he completes his target behavior, which then motivates him to perform the behavior again. If he missed an exercise session or chose not to complete it, points would be taken away. The token economy also allowed for a competing response for maladaptive behaviors, I. . If John was exercising it would be impossible for him to be inactive and watch TV at home. The problem solving training allowed him to learn coping skills for stress through learning effective time management skills and the health education he received gave him knowledge on the benefits and consequences of exercise and maintaining good health. It also gave him the skills for long-term maintenance of the target behavior and helped him prepare for termination of therapy.
The token economy system was individualized for John and consisted of four basic elements. This included the use of a point system to allow John to visually see his success in performing the target behavior. If the target behavior is performed then points would be given, and if it is not performed, points would be taken away. When the target behavior was performed, 10 points would be awarded; however, if the participant engaged in any other activity during the allotted time for exercise then ID points would be taken away.
The therapist worked with the participant to make a list of backup reinforces which included the following: archery for 25 points, reading for 50 points, cooking for 35 points, nature photography for 30 points and TV/ movies for 60 points. The less physically active the activity was, the more mints the participant had to collect to use the backup reinforce. Symbolic tokens were chosen – rather than tangible token such as poker chips – to allow the participant to evaluate himself on a chart or a calendar, both of which he frequently used daily for school.
The chart or calendar was then brought to the therapy session at the end of the week along with the daily diary to assess whether he completed his target behavior for the week. The therapist would then sign off on his points by looking at his daily diary for each running session. The rules for the token economy system included that the therapist must verse it and it is the therapist who ultimately awards the points to the participant by signing off on them. The participant was also allowed to carry over his points to the following week if he did not want to exchange them for backup reinforces.
Before termination of therapy, the transfer of token reinforces to natural reinforces slowly took place. Natural reinforces included social reinforces (praise from his friends and family on his healthy behaviors and appearance) and internal reinforces such as feeling good. This ‘feeling good’ maintains the participants healthy behaviors even after hereby is terminated. With the withdrawal of token reinforces at week 6, problem solving training was incorporated as a general coping strategy for dealing with problems that may arise in the course of the participants daily life.
Studies have shown that problem solving training is often incorporated into regular classroom curriculums and that the strongest empirical support for a maintenance strategy is following behavioral weight-control programs (Tannic, Smith, Bank & Penciled, 2006). In this study, problem solving training was used because of the positive client-therapist relationship it generates and that the reoccurred can be individualized for each client. Given that this was a case study, it was necessary to adapt the problem solving training to the participant’s specific needs, which include health education and learning appropriate time management skills.
The therapist also acted as a model for different problem solving skills and gave the participant homework assignments including practical examples of time management and how he would implement the skills he learned in each example. John learned a variety of methods to cope with stress; he also placed importance on good time management skills and how that corresponds to DOD health. The study lasted 9-weeks in total including a 3-month follow-up after the termination of therapy and a booster session to assess whether the target behavior was maintained.
Rest Its During the course of the 9-weeks Of treatment, the participant was required to self-record himself daily, beginning with the baseline assessment in the first week. Looking at figure 1 . 1, the graph reveals that the participant was not physically active before the treatment other than walking to and from class or work. He increased his exercise, as recommended by his therapist, gradually o avoid injury and by 1 5-minute intervals until he reached his goal of maintaining 60 minute jogging sessions. Figure 1. 1. Weekly running and duration, in minutes, during each week of treatment.
The graph demonstrates the weekly increases of the participants target behavior and shows the token economy system to have been effective for him as a reinforce for exercise adherence. John started off by 1 5 minutes of fast-paced walking in week 2 and gradually increased to 30 minutes in week 3 and 4, 45 minutes in week 5 and 6 and 60 minutes for the final two weeks. The final two weeks, which consisted of termination of the token economy yester and implementation of problem solving training, showed taxation was able to use the techniques he learned to maintain his target behavior and the results were significant.
Discussion This study examined the effects of a 9-week intervention program combining a token economy system with problem solving training to increase exercise adherence for a 20-year-old male university student. The results indicated that the intervention was effective in increasing exercise and teaching effective time management skills for long-term maintenance of the target behavior post-treatment. Limitations It is important to consider the limitations of the study when presenting these findings.
One limitation is that the sample of the study was one individual and is too small to generalize to the larger student population. While a study by Bernard et al. (2009) demonstrated that a single subject design could provide a “fine-grained examination of the effectiveness of interventions on target behaviors and variability in individuals, which is lost in group design studies”, it is still important to be able to generalize the intervention to a larger population. Future studies can include a larger sample u to determine its generalization to a larger student population.
The participant was a male university student, which limits making conclusions to a female population undertaking a similar intervention due to gender differences in exercising. These differences include motivation for exercise which research shows to be greater in males (Reed & Phillips, 2005). Additional research is required to apply the intervention to both genders equally. The participant was also in charge Of self-monitoring his target behavior and awarding himself appropriate points, and so possible participant bias Anton be ignored.
It is possible for the participant to credit himself with extra points or award himself points when he did not engage in the target behavior. This presents a limitation on self-monitoring as a reliable source ii measurement and whether the results found in this study were reliable as well.. Future research can look into the possibility of the use of technology as a behavioral assessment such as the use of cell phones to monitor self- recording or similar such applications.
Confounds in the study include the participants diet and school workload wrought the treatment. Diet or school workload was not monitored pre, during or post treatment. A change in diet to healthier meals is a potential factor in the participants increase in motivation to exercise. Workload was not assessed to compare the participant’s current workload to his workload in the previous term. There is the possibility of having a lighter workload than the previous term, which allowed him more free time to exercise.
Additional research is required to control for dietary, environmental and social factors to determine the effectiveness of the intervention. Additional research can also account for students with disabilities to be able to generalize to a greater student population. Implications The results of the study and similar research indicate that a token economy system, along with problem-solving training in the areas of time management and health education, should be applied to a larger student population for future research.
The York University play exchange – Canada’s active living challenge that asks Canadians to submit ideas of how they can be more active – is one example where this study can be applied. The play exchange states hat to maintain good health all individuals need to get stuffiest exercise, however, many students do not. Applying this token economy case study, the submission to York university would include a credit system in place of the symbolic point system used in this study; students would receive 3. 0 credits for a yearlong course in an exercise Of their choice. This system is already in place at York University with the ‘PKZIP’ courses offered to students majoring in Sinology; PKZIP courses are a broad range 01 exercises varying from cardiac classes, swimming, dance and outdoor activities. The submission would include that these PKZIP courses be available to all faculties and majors, with students having the option of a letter grade or a pass or fail grade.
The first two weeks of the fall and winter terms would include a crash course in problem solving training; this allows the students to individualize the time management skills they learn to each term. This system would allow students to maintain good health and exercise and get credit for it as well. The results from this study suggest that there is a strong relationship between increasing exercise using a token economy system and long-term maintenance Of exercise using problem solving training.