Communication-Based Intervention

This paper provides an overview of communication-based intervention, which is an alternative method of controlling problem behaviors in individuals with severe disabilities. It is not uncommon for individuals with disabilities to possess problem behaviors. However, it should be noted that communication-based intervention is not a method that can be used exclusively for all problem behaviors. This paper will also provide an overview of functional assessment, designing communication strategies and contexts, and the generalization of the strategies into the everyday environment.

Keywords ABC Assessment; Antecedents; Aversive Actions; Problem Behavior; Communication; Communication-Based Intervention; Consequence; Contexts; Functional Assessment; Functional Equivalence; Observation; Punishment; Self-Injurious Behavior

Overview

Defining Communication

Communication is a process that defines how organisms share ideas. In humans, the sharing of ideas is a complex multisystem process. Haynes, Moran, and Pindzola (1990) proposed that communication is composed of five interconnected systems:

• Biologic,

• Access to a language model,

• Cognitive development,

• Intent to communicate, and

• Social development.

An effective communicator must have an intact auditory-vocal channel as well as access to a language model that provides opportunities for interaction. In terms of cognitive development, the individual must be able to use a symbol system to share concepts and knowledge (Haynes, Moran, & Pindzola, 1990). The use of the symbol system must be paired with intent to communicate with others in the environment to be an effective communicator. Finally, an effective communicator must socially engage and interact with his or her environment to develop communicative competence (Haynes, Moran, & Pindzola, 1990).

In contrast, language is a component of communication. In comparison to communication, language is a complex shared rule-governed symbol system. Bloom and Lahey (1978) described language in terms of form (phonology, syntax, morphology), content (semantics), and use (pragmatics). Each area overlaps the other at some point and therefore is dependent on the others (Bloom & Lahey, 1978). In other words, difficulties in any one area (form, content, use) can have an effect on the use of the other area(s).

The primary purpose of communication is to allow purposeful interaction between an individual and his or her family and community. Communication allows an individual to influence people and events in his or her environment through social interaction. For many children with severe disabilities and/or autism, social interaction is not considered to be appropriate and is often times replaced by inappropriate behaviors (tantrums, biting, yelling, etc).

This paper will address the replacing of problem behaviors with communication using communication-based intervention.

The Beginnings of Communication-Based Intervention

Communication-based intervention is a technique often used to control problem behaviors. The belief is that inappropriate behaviors may serve as a mechanism for communication, as all humans communicate in some way (Carr, Levin, McConnachie, Carlson, Kemp, & Smith, 1997; Wacker, Berg, Harding, Barretto, Rankin, & Ganzer, 2005). Typically, one uses communication-based intervention to replace the long-standing practice of eliminating behaviors (Durand & Carr, 1991). Communication-based intervention is designed for understanding why the problem behavior occurs by determining its function and/or purpose (Carr, et al., 1997; Durand & Carr, 1991).

Carr, Levin, McConnachie, Carlson, Kemp, and Smith (1997) stated that Carr's 1977 seminal article, "The Motivation for Self-Injurious Behavior: A Review of Some Hypotheses" proposed that problem behavior can be a purposeful form of communication by serving a communicative purpose for the individual who initiates the act. This was a thought provoking paper that led to many studies and a refinement of Carr's hypothesis (Carr, et al., 1997; Goldstein, 2002). Carr's continued research in this area proposed that problem behaviors might serve as a form of communication for an individual with limited expressive abilities (Carr, et al., 1997; Goldstein, 2002). This hypothesis has led to research which has investigated the understanding that an inappropriate behavior can serve a purposeful function versus a way in which to decrease social interaction (Beukelman, & Mirenda, 1992; Day, Horner, & O'Neill, 1994; Haynes, Moran, & Pindzola, 1990).

Carr, et al. (1997) defined communication- based intervention as "an approach that reduces or eliminates problem behavior by teaching an individual specific forms of communication" (p.3). There is a distinction between communication training and communication-based intervention (Carr, et al., 1997). Communication training addresses specific speech and/or language deficits. Communication-based intervention replaces problem behaviors with appropriate communication.

Problem Behavior as a Form of Communication

In terms of communication-based intervention, problem behavior includes a variety of verbal and nonverbal behaviors that are considered socially unacceptable. Problem behaviors include acts of aggression (hitting, kicking, biting, etc.); self-injurious behaviors (head banging, self biting, etc.); property destruction (throwing objects, punching walls, etc.); and tantrums (crying, screaming, etc.) (Carr, et al, 1997, p. 3).

By proposing that problem behaviors (i.e., tantrums, aggression, self-injurious behavior) serve as a form of communication, an individual is advancing the thought that language allows one to control his or her environment (Goldstein, 2002). Therefore, this type of intervention is used with individuals who typically have severe behavior disorders or developmental disabilities (Carr, et al., 1997; Day, Horner, & O'Neill, 1994; Goldstein, 2002).

Educational Importance of Communication-Based Intervention

Society views education as an area through which an individual gains the necessary skills and knowledge to become a productive citizen. Learning the basic skills of reading, writing, and arithmetic is the foundation of academic success. However, for individuals with severe developmental disabilities learning to communicate becomes the priority, in many cases. Without simple or basic communication skills, an individual is not able to effectively and appropriately interact in the academic or social environments of everyday life. Thus, for children with developmental disabilities communication is the first basic skill that has to be learned. As a whole, society is not accepting of individuals who do not know how to appropriately interact with others. Thus, exhibiting problem behaviors can lead to isolation for individuals who engage in them.

Premises of Communication-Based Intervention

Regardless of the source, communication-based intervention operates on six distinctive premises. Each will be briefly discussed in the discussion to follow.

• The primary premise of communication-based intervention is that problem behaviors exist because they typically serve a purpose for the individual (Carr, et al, 1997). For example, each time a child throws his or her cup and cries the caregiver fills the cup with milk and returns the cup to the child. Thus, the child learns to request "more milk" by throwing his or her cup and crying.

• A functional assessment must occur to determine what purpose the problem behavior serves. A problem behavior may temporarily be altered through aversive actions such as punishment. However, should the original function of the behavior not be determined then the behavior will continue and possibly become more problematic. For example, over time, the caregiver withholds the drink in an attempt to punish the behavior of throwing the cup. In response, the child adds the problem behavior of biting his or her hand along with throwing the cup and crying.

• In educating children with significant disabilities (i.e., mental retardation, autism), one must keep in mind that the goal is to teach the individual that alternative means (i.e., communication) exist to influence the behavior of others rather than an inappropriate behavior (Carr, et al., 1997). Prior to the idea that the behavior could be a form of communication, intervention primarily focused on immediate elimination of the behavior.

• Carr, Levin, McConnachie, Carlson, Kemp, and Smith (1997) stated that another theme in communication-based intervention is that a problem behavior can exist in different contexts and serve different purposes. Thus, intervention that is successful in one context may not be successful in another.

• To be effective, interventionists must understand the goal is to change the social contexts and not the individual (Durand, & Carr, 1991). For communication to occur a dyad must exist between a speaker and a listener (Bloom, & Lahey, 1978; Haynes, Moran, & Pindzola, 1990). Whether the mode of communication is verbal or nonverbal, a message must be communicated between at least two people. Thus, for an individual with a problem behavior the social context must cause enough of an interest that the individual wants to socially interact.

• For life to have meaning or some type of quality, the reduction of the problem behavior should attempt to increase the social interaction of the individual with his or her environment. The intent of communication-based intervention is to assist the individual with problem behaviors; from a passive participant in society to an active participant.

While the advantages of communication-based intervention are evident, one cannot assume that a behavior can be haphazardly observed and intervention initiated. Therefore, prior to the beginning of communication-based intervention, all stakeholders must engage in a systematic functional assessment to determine the function or purpose of the problem behavior.

The Functional Assessment

Functional assessment uses behavioral observation and analysis to determine the purpose or function of the behavior (Carr, et al., 1997; Haynes, Moran, & Pindzola, 1990). Events that occur before a behavior are considered to be antecedents and events that occur after an occurrence are the consequences (Carr, et al., 1997). For example, a child throws his or her cup at the teacher at the same time each day. Once the cup is thrown, the teacher fills it with juice and gives it to the child. Observations may reveal that the child has learned to request a drink by engaging in this behavior. The research literature (Carr, et al., 1997) refers to this as an "ABC" assessment which determines the antecedent (A), behavior (B), and consequence (C).

One of the disadvantages of an ABC assessment is that it is very time consuming due to the systematic collection of data. Additionally, the behavior should be observed across environments to determine if the behavior is occurring in other environments and has the same meaning. The task of observation can become grueling for parents, stakeholders, and teachers not trained in observational assessment techniques. Thus, Carr, Levin, McConnachie, Carlson, Kemp, and Smith (1997) proposed a variation to ABC assessment termed as describing, categorizing, and verifying. A brief overview of the process will be provided to enhance understanding of communication-based intervention.

The first stage is to directly observe and interview individuals in the contexts the problem behavior is occurring. Direct observations allow the evaluator to confirm or deny the interview description of the behavior or identify a new problem that was not previously described (Carr, et al., 1997).

The second stage is to categorize the problem behaviors. This step is crucial in identifying the purpose of the behavior. The assessor must formulate a hypothesis about the purpose of the behavior, then group the purpose of the behavior into categories and determine the themes within the categories (Carr, et al., 1997).

The final stage of functional assessment is to verify the findings of the behavior through experimental manipulation. Manipulation of the data allows the evaluator to determine or deny the accuracy of the observations and interviews or to identify additional factors which may be occurring on a day to day basis (Carr, et al., 1997).

Disciplines Involved in Functional Assessments

Any discipline that has formal and technical training in observation, interviewing, and data collection is qualified to perform a functional assessment (Carr, et al., 1997). Disciplines may include psychologists, educational specialists, speech-language pathologists, and/or vocational specialists. In addition, parents and/or caregivers could collect data as well under the direction of an evaluator.

Carr, Levin, McConnachie, Carlson, Kemp, and Smith (1997) caution against using individuals who are in contact with the individual on a daily basis. The primary reason for this exclusion is that primary service providers (i.e., classroom teacher, therapists) are limited in the amount of time in which to observe and collect data in addition to daily responsibilities. Another reason to use an independent assessor is the high probability of bias in collecting and interpreting the data. Finally, the familiar person may not observe subtle intentions of the individual with the problem behavior (Carr, et al., 1997).

Applications

Uses for Communication Based Intervention

As with any type of intervention method, communication-based intervention may not be an effective intervention method with all children. The technique should be used only after an assessment has determined the function of the behavior. This is because not all problem behaviors serve a purpose to communicate. In some instances, the behavior is just a behavior.

Carr, et al. (1997) discussed three types of behavior for which a communication-based intervention model is not the appropriate choice. The first is what is described as sensory factors. In this instance the individual gains stimulation through the engagement of self-injurious behavior. The second is homestatic and refers to too much or too little stimulation from the environment. In this instance, the individual either creates stimulation or reacts to stimulation in the environment. Finally, organic behavior is when the individual is influenced by something internal or biological. There is some research to indicate that for some individuals the problem behavior is an addictive behavior (Carr, et al., 1997).

Communication Forms

Carr, et al. (1997) stated that problem behavior is not a random act but something that is useful to the individual in communicating his or her needs, thoughts, and/or ideas (p. 125). Since the problem behavior serves as a useful tool, it can be difficult to eliminate and/or replace with the more socially accepted form of interaction. Carr, et al. further stated that to replace a problem behavior with a form of communication it must be "functionally equivalent" (p. 125). Thus, both must achieve the same result.

In addition to "functionally equivalent" analysis, the new form of communication must be more efficient than the problem behavior (Carr, et al. 1997, p. 131). Factors that must be considered are the ease with which the person can use the new form of communication and the ease in which another person can interpret the form of communication (p. 132). For example, an individual uses screaming to gain attention. If the problem behavior (screaming) gains attention, instead of asking for help, each time it is used it is considered to be easy for the person to apply. However, this function is not easy for each possible interaction partner to understand. Therefore to employ ease of use and ease of understanding the communication method (I want to talk) must be as efficient as the screaming.

In communication-based intervention, the communication modality of choice is, of course, speech. Speech is a highly efficient communication system that allows the rapid transmission of thoughts, ideas, and needs (Haynes, Moran, & Pindzola, 1990). However, it should never be considered the only mode of communication (Beukelman, & Mirenda, 1992; Haynes, Moran, & Pindzola, 1990). Communication can occur through augmentative and/or alternative means such as writing, using sign language, or voice output systems (Beukelman, & Mirenda, 1992; Haynes, Moran, & Pindzola, 1990).

In choosing communication, one must also determine the communication contexts in which the form of communication is used (Beukelman, & Mirenda, 1992; Carr, et al 1997). For communication to be successful, the individual must be able to use the communication in multiple contexts with multiple individuals. If this does not occur, then the communication-based intervention is limited in its effectiveness in replacing the problem behavior.

Generalization & Maintenance of the Communication-Based Intervention

For any procedure to be considered useful, the individual must be able to generalize and maintain the use of the procedure. This is particularly true for individuals with special needs. In other words, intervention cannot be considered successful if it only occurs in certain situations with certain people. Intervention must allow the individual with special needs to integrate his or her skills into the school and community environment. Therefore, the new form of communication must be generalized and maintained in other social situations. Wacker, Berg, Harding, Barretto, Rankin, and Ganzer (2005) demonstrated that functional communication training could generalize into different social contexts (person, setting) and have long-term effects.

Generalizing and maintaining the new skill also requires additional training for the individual. In teaching the individual to replace the problem behavior with a more acceptable form of communication, the individual has learned that an immediate response will occur to the behavior. However, in society, individuals often have a delay in response before a need is met. Therefore, the individual must also learn that not all needs are met immediately.

For example, an individual has learned to ask for a drink. Communication-based intervention has taught the individual to use the phrase "want drink" instead of throwing a cup to indicate this need. In society, when an individual asks for a drink in a restaurant the server must leave to prepare the drink and then return to the table to meet the request. Hopefully, the server is able to do this in a short period of time. However, the reality is that many servers are waiting on more than one customer and most times a delay in response happens before the requested need is met.

The importance of teaching generalization of skills in multiple contexts is critical for changing the quality of life for an individual with special needs. By generalizing the skill into many different contexts and across communication partners, the maintenance of the skill increases. Maintaining a skill occurs when an individual is able to self-monitor his or her behavior in response to the environment. Therefore, independence in controlling an individual's environment is integrated into everyday life activities.

Viewpoints

Evidence Based Research

Goldstein (2002) reported that the literature has documented that use of communication-based intervention has been effective in replacing problem behaviors with communication alternatives. Much of the research to date has focused on individuals with autism and the reduction of inappropriate behaviors with communication-based intervention. There is variation in the techniques used and researched but each remain some type of extension of Carr's (1977) seminal work.

Functional Communication Training

It is important to know that another term being used in the literature is based on the same hypothesis of communication-based intervention. The term is functional communication training (FCT) and basically requires the same type of assessment procedures in determining an individual's current abilities, skills, and behaviors in the environment (Beukelman & Mirenda, 1992). During the assessment, determinations are made as to what inappropriate behaviors are being used for in terms of communication. Once that determination is made, then the individual is provided a new form of communication that is positively reinforced through interaction within the environment. For instance, if an individual wants a break from an activity he or she must signal rather than just escaping from the activity by using problem behaviors.

Conclusions

Many discussions have been held over the years about the most effective way to intervene with individuals who have problem behaviors. This paper has discussed contemporary viewpoints on the use of the communication-based intervention. This paper has explained that the use of communication-based intervention should not be used to eliminate a behavior but to replace a behavior with communication.

The reader should investigate the information provided in the suggested readings to develop a deeper understanding of the current viewpoints of using communication-based intervention with individuals with disabilities. The information provided in this paper does not represent a comprehensive summary of the information available in literature. However, the general overview of communication-based intervention offers the reader an introduction and alternative to managing challenging behavior.

Terms & Concepts

ABC Assessment: "ABC" assessment determines the antecedent (A), behavior (B), and consequence (C) of a problem behavior.

Antecedents: Antecedents are events that occur before a problem behavior.

Aversive Actions: An aversive action is an action that shows a dislike or a way to avoid a task.

Communication: Communication is a verbal or nonverbal way to exchange information or influence the actions of others.

Communication-Based Intervention: Communication-based intervention can be defined as decreasing inappropriate behaviors by teaching an individual with challenging behaviors appropriate ways to express thoughts, emotions, and want/needs (Carr, et al., 1997).

Consequence: Consequent is what is observed after the problem behavior occurs.

Functionally Equivalent: In terms of communication-based intervention, functionally equivalent is new form of communication must be more efficient than the problem behavior.

Morphology: Morphology is the elements of meaning at the level of the word.

Phonology: Phonology is the study of how sounds are organized and used in language.

Pragmatics: Pragmatics is the verbal and nonverbal aspects of language. Pragmatics allows the user to effectively communicate with his or her environment.

Problem Behavior: Problem behavior is a behavior that is culturally unacceptable. Problem behaviors can be harmful to the person or to other individuals.

Punishment: Punishment is causing something unpleasant to happen to an individual in response to an inappropriate action.

Self-injurious Behavior: Self-injurious behavior is behavior that causes bodily harm to the individual or to another person.

Semantics: Semantics is the meaning of language.

Syntax: Syntax is the rules that govern the structure of language.

Bibliography

Bloom, L., & Lahey, M. (1978). Language development and language disorders. New York: Wiley.

Beukelman, D., & Mirenda, P. (1992). Augmentative and alternative communication: Management of severe communication disorders in children and youth. Baltimore, MD: Paul H. Brookes.

Carr, E. Levin, L., McConnachie, G., Carlson, J., Kemp, D., & Smith, C. (1997). Communication-based intervention for problem behavior: A user's guide for producing positive change. Baltimore: Paul H. Brookes Publishing.

Day, H.M., Horner, R.H., & O'Neill, R.E. (1994). Multiple functions of problem behaviors: Assessment and intervention. Journal of Applied Behavior Analysis, 27, 279-289. Retrieved December 7, 2007 from EBSCO online database, Academic Search Premier http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=9408051373&site=ehost-live

Dodd, J. L., & Gorey, M. (2014). AAC intervention as an immersion model. Communication Disorders Quarterly, 35, 103-107. Retrieved December 15, 2013, from EBSCO Online Database Education Research Complete. http://search.ebscohost.com/login.aspx?direct=true&db=ehh&AN=93280062&site=ehost-live

Durand, V. M., & Carr, E. G. (1991). Functional communication training to reduce challenging behavior: Maintenance and application in new settings. Journal of Applied Behavior Analysis, 24, 251-264.

Goldstein, H. (2002). Communication intervention for children with Autism: A review of treatment efficacy. Journal of Autism and Developmental Disorders, 32 , 373-396, Retrieved December 7, 2007 from EBSCO online database, Academic Search Premier, http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=11305705&site=ehost-live

Gordon, K., McElduff, F., Wade, A., Charman, T., Pasco, G., & Howlin, P. (2011). A communication-based intervention for nonverbal children with autism: What changes? Who benefits?. Journal of Consulting & Clinical Psychology, 79, 447-457. Retrieved December 15, 2013, from EBSCO Online Database Education Research Complete. http://search.ebscohost.com/login.aspx?direct=true&db=ehh&AN=63895648&site=ehost-live

Haynes, W., Moran, M., & Pindzola, R. (1990). Communication disorders in the classroom. Dubuque, IA: Kendall/Hunt.

Fisher, W., & Piazza, C. (1993). Functional communication training with and without extinction and punishment. Journal of Applied Behavior Analysis, 26 , 23-36. Retrieved December 7, 2007 from EBSCO online database, Academic Search Premier http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=9305145401&site=ehost-live

Ogletree, B. T., Bruce, S. M., Finch, A., Fahey, R., & McLean, L. (2011). Recommended communication-based interventions for individuals with severe intellectual disabilities. Communication Disorders Quarterly, 32, 164-175. Retrieved December 15, 2013, from EBSCO Online Database Education Research Complete. http://search.ebscohost.com/login.aspx?direct=true&db=ehh&AN=63248670&site=ehost-live

Wacker, D., Berg, W., Harding, J., Barretto, A., Rankin, B., & Ganzer, J. (2005). Treatment effectiveness, stimulus generalization, and acceptability to parents of functional communication training, Educational Psychology, 25 (2/3), 233-256, Retrieved December 7, 2007 from EBSCO online database, Academic Search Premier http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=15545140&site=ehost-live

Suggested Reading

Bird, F., Dores, P.A., Moniz, D., & Robinson, J. (1989). Reducing severe aggressive and self-injurious behaviors with functional communication training. American Journal on Mental Retardation, 94, 37-48. Retrieved December 7, 2007 from EBSCO online database, Education Research Complete http://search.ebscohost.com/login.aspx?direct=true&db=ehh&AN=18824249&site=ehost-live

Brady, N. C., Saunders, K. J., & Spradlin, J. E. (1994). A conceptual analysis of request teaching procedures for individuals with severely limited verbal repertoires. The Analysis of Verbal Behavior, 12, 43-52.

Carr, E. & Blakeley-Smith, A. (2006). Classroom intervention for illness-related problem behavior in children with developmental disabilities, Behavior Modification, 30 ,901-924, Retrieved December 7, 2007 from EBSCO online database, Academic Search Premier http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=22854065&site=ehost-live

Carr, E. G., & Durand, V. M. (1985). Reducing behavior problems through functional communication training. Journal of Applied Behavior Analysis, 18, 111-126.

Durand, V. M., Berotti, & Weiner, J. S. (1993). Functional communication training: Factors affecting effectiveness, generalization, and maintenance. In J. Reichle & D. P. Wacker (Eds.), Communicative alternatives to challenging behavior (pp. 317-340). Baltimore: Paul H. Brookes.

Durand, V.M. (1990). Severe behavior problems: A functional communication training approach. New York: Guilford Press.

Ford, J (2007). Educational supports for students with disabilities and significant behavioural challenges: Teacher perceptions. Australasian Journal of Special Education, 31 , 109-127, Retrieved December 7, 2007 from EBSCO online database, Education Research Complete http://search.ebscohost.com/login.aspx?direct=true&db=ehh&AN=27601301&site=ehost-live

Jones, E. & Carr, E. (2004). Joint attention in children with autism: Theory and intervention, Focus on Autism & Other Developmental Disabilities, 19 , 13-26,

Retrieved December 7, 2007 from EBSCO online database, Academic Search Premier http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=12329692&site=ehost-live

Kahng, S., Iwata, B. A., DeLeon, I. G., & Worsdell, A. S. (1997). Evaluation of the "control over reinforcement" component in functional communication training. Journal of Applied Behavior Analysis, 30 , 267-277. Retrieved December 7, 2007 from EBSCO online database, Academic Search Premier http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=9708111705&site=ehost-live

Lalli, J. S., Casey, S., & Kates, K. (1995). Reducing escape behavior and increasing task completion with functional communication training, extinction, and response chaining. Journal of Applied Behavior Analysis, 28 , 261-268. Retrieved December 7, 2007 from EBSCO online database, Academic Search Premier http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=9510305415&site=ehost-live

Orelove, F. & Sobsey, D. (1987). Educating children with multiple disabilities: A transdisciplinary approach. Baltimore: Paul Brookes Publishing.

Rainforth, B., York, J., & Macdonald, C. (1992). Collaborative teams for students with severe disabilities: Integrating therapy and educational services. Baltimore, MD: Paul H. Brookes.

Reid, D. H., & Hurlbut, B. (1977). Teaching nonvocal communication skills to multihandicapped retarded adults. Journal of Applied Behavior Analysis, 10, 591- 603.

Shirley, M. J., Iwata, B. A., Kahng, S., Mazaleski, J. L., & Lerman, D. C. (1997). Does functional communication training compete with ongoing contingencies of reinforcement? An analysis during response acquisition and maintenance. Journal of Applied Behavior Analysis, 30 , 93-104. Retrieved December 7, 2007 from EBSCO online database, Academic Search Premier, http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=9705296550&site=ehost-live

Shukla, S., & Albin, R. W. (1996). Effects of extinction alone and extinction plus functional communication training on covariation of problem behaviors. Journal of Applied Behavior Analysis, 29 , 565-568. Retrieved December 7, 2007 from EBSCO online database, Academic Search Premier, http://search.ebscohost.com/login.aspx?direct=true&db=aph&AN=9708102698&site=ehost-live