NADD Bulletin Volume V Number 5 Article 1

Complete listing

Behavioral Relaxation Training (BRT) With Children With Dual Diagnoses

Theodosia R. Paclawskyj, Ph.D.


For several decades, relaxation training has been used as a behavioral intervention for reducing anxiety, agitation, pain, and stress (Bernstein & Borkovec, 1973; Craske, Rapee, & Barlow, 1992; Jacobson, 1938; Poppen, 1998; Turk, Rudy, & Sorkin, 1992). However, Harvey (1979) noted in a review of the literature that relaxation training was underutilized with persons with mental retardation. Since this time there have been several investigations of the efficacy of relaxation in the treatment of stress-related disorders in adults with developmental disabilities (e.g., Morrissey, Franzin, & Karen, 1992; Reese, Sherman, & Sheldon, 1984; Schloss, Smith, Santori, & Bryant, 1989; Wells, Turner, Bellack, & Hersen, 1978). Yet minimal work has been done to extend this technique to the treatment of behaviors exhibited by children with developmental disabilities.

The most researched relaxation procedure in the developmental disabilities literature is an abbreviated form of Progressive Relaxation (PR) (Lindsay & Baty, 1989; Luiselli, 1980). With PR it is assumed that through a series of tense-release muscle exercises, an individual will become aware of the sensations that their body experiences in tensed and relaxed states (Bernstein & Borkovec, 1973). Thus, when the person is anxious, they can implement PR after identifying tense sensations. However, a limitation of this procedure is that it involves subjective interpretation of internal states, which may be difficult for some individuals with developmental disabilities (Lindsay, Baty, Michie, & Richardon, 1989; Michulka, Poppen, & Blanchard, 1988; Poppen, 1998).

A potential alternative to PR is Behavior Relaxation Training (BRT) (Poppen, 1998; Schilling & Poppen, 1983). BRT focuses on the training of overt behaviors through which a relaxed state can be objectively assessed by an observer, making it very amenable to applied behavior analytic methodology. The procedures of BRT involve modeling both relaxed and unrelaxed behaviors in 10 areas of the body (head, mouth, hands, feet, body, breathing, throat, eyes, shoulders, and vocalizations). After observing relaxed and unrelaxed postures, the person is encouraged to model the appropriate behaviors. The rationale behind BRT is that engaging in the motoric responses that are associated with relaxation produces the relaxation response (Poppen, 1998). Scoring of relaxed behaviors can be accomplished through the Behavioral Relaxation Scale (BRS), a reliable and valid measure for recording the presence of relaxed motoric responses (Poppen & Maurer, 1982; Schilling & Poppen, 1983).


BRT acquisition typically is conducted using a multiple-baseline design across relaxed behaviors (Poppen, 1998). Behaviors may be taught individually, or more typically, in clusters of 3-4 responses. Teaching sessions can be accomplished in a distraction-free environment using a comfortable chair with sufficient head and back support. A footrest is optional and depends on the size of the client. During the session, each behavior is practiced until there are 2-3 consecutive sessions of at least 80% relaxed responding for the target behaviors.

However, there is little description available of effective prompting sequences. This author has adapted prompting sequences based on instructional methods currently used with the child. These have ranged from prompt hierarchies to didactic instruction in the form of storybook presentation. Use of such prompting sequences has resulted in acquisition of BRT responses in an average of three hours of clinic time for the three cases presented. In the first case example, a 6-year old boy diagnosed with moderate mental retardation presented with self-injury in the form of head slapping. Despite a history of self-injury in novel demand situations, this child was able to learn BRT within a 3-hour session period following presentation through the storybook format. His data demonstrate generalization across settings and therapists.

This author has used BRT as an adjunct to behavioral treatment of skin-picking, aggression, self-injury, and anxiety. In the second case example, a 14-year old girl with diagnosed with Obsessive-Compulsive Disorder and Mild-Moderate Mental Retardation presented with skin-picking and physical aggression. Skin-picking was successfully treated using BRT as an augmentative component to simplified habit reversal. Aggression, which tended to occur when particular rituals were interrupted, decreased following BRT use prior to the interruption of the ritual. Both behaviors remained low at 6-month follow-up.

In the third case example, a 10-year old boy diagnosed with Bipolar Disorder, ADHD, Tic Disorder, and Moderate Mental Retardation presented with aggression preceded by agitation. Specific precursor behaviors associated with agitation were identified and the child was instructed to engage in BRT upon occurrence of precursor behaviors, leading to a subsequent reduction in physical aggression.


BRT has potential utility as both a primary treatment intervention and as an augmentation to current behavioral treatments. Behavior therapy with persons with developmental disabilities is in need of expansion into areas addressed with typically-functioning individuals; Behavioral Relaxation Training is one area where there is great potential for both clinical and research innovation.


Bernstein, D. A., & Borkovec, T. D. (1973). Progressive relaxation training. Champaign, IL: Research Press.

Craske, M. G., Rapee, R. M., & Barlow, D. H. (1992). Cognitive-behavioral treatment of panic disorder, agoraphobia, and generalized anxiety disorder. In S. M. Turner, K. S. Calhoun, & H. E. Adams (Eds.), Handbook of clinical behavior therapy (2nd ed.), (pp. 39-66). New York: John Wiley & Sons, Inc.

Harvey, J. R. (1979). The potential of relaxation training for the mentally retarded. Mental Retardation, 17, 71-76.

Jacobson, E. (1938). Progressive relaxation. Chicago: University of Chicago Press.

Lindsay, W. R., & Baty, F. J. (1989). Group relaxation training with adults who are mentally handicapped. Behavioural Psychotherapy, 17, 43-51.

Lindsay, W. R., Baty, F. J., Michie, A. M., & Richardson, I. (1989). A comparison of anxiety treatments with adults who have moderate and severe retardation. Research in Developmental Disabilities, 10, 129-140.

Luiselli, J. K. (1980). Relaxation training with the developmentally disabled: A reappraisal. Behavior Research of Severe Developmental Disabilities, 1, 191-213.

Michulka, D. M., Poppen, R. L., & Blanchard, E. B. (1988). Relaxation training as a treatment for chronic headaches in an individual having severe developmental disabilities. Biofeedback and Self Regulation, 13, 257-266.

Morrissey, P. A., Franzini, L. R., & Karen, R. L. (1992). The salutary effects of light calisthenics and relaxation training on self-stimulation in the developmentally disabled. Behavioral Residential Treatment, 7, 373-389.

Poppen, R. (1998). Behavioral relaxation training and assessment (2nd ed.), Thousand Oaks, CA: SAGE Publications.

Poppen, R., & Maurer, J. (1982). Electromyographic analysis of relaxed postures. Biofeedback and Self-Regulation, 7, 491-498.

Reese, R. M., Sherman, J. A., & Sheldon, J. (1984). Reducing agitated disruptive behavior of mentally retarded residents of community group homes: The role of self-recording and peer-prompted self-recording. Analysis and Intervention in Developmental Disabilities, 4, 91-107.

Schilling, D., & Poppen, R. (1983). Behavioral relaxation training and assessment. Journal of Behavior Therapy and Experimental Psychiatry, 14, 99-107.

Schloss, P. J., Smith, M., Santora, C., & Bryant, R. (1989). A respondent conditioning approach to reducing anger responses of a dually diagnosed man with mild mental retardation. Behavior Therapy, 20, 459-464.

Turk, D. C., Rudy, T. E., & Sorkin, B. A. (1992). Chronic pain: Behavioral conceptualizations and interventions. In S. M. Turner, K. S. Calhoun, & H. E. Adams (Eds.), Handbook of clinical behavior therapy (2nd ed.), (pp. 373-396). New York: John Wiley & Sons, Inc.

Wells, K. C., Turner, S. M., Bellack, A. S., & Hersen, M. (1978). Effects of cue-controlled relaxation on psychomotor seizures: An experimental analysis. Behaviour Research and Therapy, 16, 51-53.

For further information:

Theodosia R. Paclawskyj, Ph.D.
Johns Hopkins University School of Medicine & Kennedy Krieger Institute
707 N. Broadway
Baltimore, MD 21205