The purpose of this study was to examine if the participants’ level of understanding was related to the cause of her severe self-injurious behavior. We wondered if her problem behavior was due to frustration because she did not fully understand instructions and what she was expected to do. To evaluate this, clinic staff performed one step instructions using vocal cues only or vocal plus visual cues. When instructions were prompted using vocal cues only, the participant responded correctly to one out of four trials. However when vocal cues plus visual cues were presented the participant responded correctly to three out of four trials. The participant had the most difficulty following one step directions when instructed with the propositions “besides” and “under”. The participant was praised after each trial even when she responded incorrectly. No problem behavior was observed. When presented with instructions, results suggest the participant will benefit from visual cues paired along with vocal cues to better understand directions given to her.