A quarterly publication of the Autism Research Institute

The Autism Research Review International is quarterly publication of the Autism Research Institute

Summer, 2018 | Number 3, Volume 32

Simple positive intervention leads to better compliance with toenail and fingernail clipping

A simple reinforcement procedure can reduce the resistance of individuals with autism spectrum disorders (ASD) to having their fingernails and toenails cut, according to a small new study. 

Art Dowdy and colleagues note that “escape extinction” (preventing an individual from escaping a demand) is a common approach used during grooming tasks. However, they point out that this can be dangerous when these tasks involve sharp objects such as nail clippers. In addition, escape extinction can temporarily cause a behavior to escalate. 

In their study, Dowdy and colleagues tested an approach involving positive reinforcers but not escape extinction. Participants were two nonverbal male teenagers with ASD, attention deficit hyperactivity disorder, and intellectual disability. 

During baseline testing, a therapist told each participant, “I am going to cut your nails,” and moved the clippers toward a nail. The therapist allowed five seconds of escape response (for instance, pulling the hand away) before re-presenting the nail clippers. 

During the intervention, the therapist told each participant, “For each nail I cut, you will earn a snack.” The therapist placed preferred snacks in view and provided immediate access to them following each successful nail trimming. As during baseline, the therapist allowed five seconds of escape response before re-presenting the clippers. The researchers clipped the toenails of one child (“Jackson”) and the fingernails of the other (“Steven”). 

During baseline sessions, Jackson engaged in a mean of 5.4 escape responses per minute, and the therapist was unable to cut any of his toenails. Steven engaged in a mean of 4.5 escape responses per minute, and the therapist was able to cut an average of only 31% of his nails. During intervention sessions, the therapist was able to cut a mean percentage of 91% of Jackson’s toenails (and succeeded in cutting 100% during the final three sessions), and he engaged in only 1.7 escape responses per minute. In follow-ups at one and two months, the therapist was able to cut all of his toenails. 

In Steven’s case, the therapist was able to cut a mean percentage of 92% of his fingernails during the intervention sessions, and his escape responses dropped to 1.1 per minute. (Because he left the residential treatment facility, the researchers could not conduct follow-up visits.) 

Dowdy and colleagues cite other research showing that an intervention using reinforcers without escape extinction can be effective in increasing compliance with toothbrushing, haircuts, and blood glucose monitoring. They conclude that “when compared to escape-extinction procedures, which may initially increase problem behavior and create potentially unsafe situations, treatments that do not require escape extinction are more practical for caregivers to implement and are likely to be less prone to producing untoward side effects.”


“Effects of reinforcement without extinction on increasing compliance with nail cutting: a systematic replication,” Art Dowdy, Matt Tincani, Timothy Nipe, and Mary Jane Weiss, Journal of Applied Behavior Analysis, June 17, 2018 (epub prior to print publication). Address: Art Dowdy, Melmark Pennsylvania, 2600 Wayland Rd.,  Berwyn, PA 19312, [email protected].