Naturalistic Developmental Behavioral Interventions for Autism Spectrum Disorder [1 ed.] 168125204X, 9781681252049

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Naturalistic Developmental Behavioral Interventions for Autism Spectrum Disorder edited by

Yvonne Bruinsma, Ph.D., BCBA-D In STEPPS and In STEPPS Academy Irvine, CA Mendy B. Minjarez, Ph.D. Seattle Children’s Hospital Autism Center and University of Washington School of Medicine Seattle, WA Laura Schreibman, Ph.D. University of California, San Diego La Jolla, CA and

Aubyn C. Stahmer, Ph.D., BCBA-D University of California, Davis MIND Institute Sacramento, CA

Baltimore • London • Sydney

Paul H. Brookes Publishing Co. Post Office Box 10624 Baltimore, Maryland 21285-0624 USA www.brookespublishing.com Copyright © 2020 by Paul H. Brookes Publishing Co., Inc. All rights reserved. “Paul H. Brookes Publishing Co.” is a registered trademark of Paul H. Brookes Publishing Co., Inc. Typeset by Absolute Service, Inc., Towson, Maryland. Manufactured in the United States of America by Sheridan Books, Inc., Chelsea, Michigan. The information provided in this book is in no way meant to substitute for a medical or mental health practitioner’s advice or expert opinion. Readers should consult a health or mental health professional if they are interested in more information. This book is sold without warranties of any kind, express or implied, and the publisher and authors disclaim any liability, loss, or damage caused by the contents of this book. The individuals described in this book are composites or real people whose situations are masked and are based on the authors’ experiences. In all instances, names and identifying details have been changed to protect confidentiality. Purchasers of Naturalistic Developmental Behavioral Interventions for Autism Spectrum Disorder are granted permission to download, print, and photocopy the forms in the text for clinical and educational purposes. Faculty may download, print, and photocopy the sample syllabi, test bank, and PowerPoint slides for educational use. These materials are available at http://downloads.brookes publishing.com. The forms, sample syllabi, test bank, and PowerPoint slides may not be reproduced to generate revenue for any program or individual. Photocopies may only be made from an original book. Unauthorized use beyond this privilege may be prosecutable under federal law. You will see the copyright protection notice at the bottom of each photocopiable page. Library of Congress Cataloging-in-Publication Data Names: Bruinsma, Yvonne, editor. Title: Naturalistic developmental behavioral interventions for autism  spectrum disorder / edited by Yvonne Bruinsma, Ph.D., BCBA-D, In STEPPS  Academy, Irvine, CA, Mendy B. Minjarez, Ph.D., Seattle Children’s Hospital Autism Center and University of Washington School of Medicine, Seattle, WA, Laura Schreibman, Ph.D., University of California, San Diego, CA, and Aubyn C. Stahmer, Ph.D., University of California, Davis MIND Institute, Sacramento, CA. Description: Baltimore, Maryland: Paul H. Brookes Publishing Co., [2020] |  Includes bibliographical references and index. Identifiers: LCCN 2019001591 (print) | LCCN 2019011481 (ebook) | ISBN  9781681253398 (epub) | ISBN 9781681253404 (pdf) | ISBN 9781681252049  (paperback) Subjects: LCSH: Autistic children—Behavior modification. | Autistic  children—Education. | BISAC: EDUCATION / Special Education / Mental  Disabilities. | EDUCATION / Special Education / Social Disabilities. Classification: LCC RJ506.A9 (ebook) | LCC RJ506.A9 N38 2019 (print) | DDC  618.92/85882—dc23 LC record available at https://lccn.loc.gov/2019001591 British Library Cataloguing in Publication data are available from the British Library. Version 1.0

Contents About the Editors � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � ix About the Contributors� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � xi Foreword � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � xvii Acknowledgments � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �xxiii About the Online Materials � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � xxv SECTION I

Overview

Chapter 1

Understanding NDBI. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3 Laura Schreibman, Allison B. Jobin, and Geraldine Dawson ASD Defined � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 4 History of ASD Intervention � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 5 Developmental Science and Its Influence in ASD Early Intervention � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 7 Integration of Behavioral and Developmental Sciences � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 8 Examples of NDBI � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �10 Common Elements of Empirically Validated NDBI � � � � � � � � � � � � � �10

Chapter 2

Considering NDBI Models . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21 Mendy B. Minjarez, Yvonne Bruinsma, and Aubyn C. Stahmer Early Start Denver Model � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �21 Enhanced Milieu Teaching� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 23 Incidental Teaching/Walden Toddler Program � � � � � � � � � � � � � � � � � 25 Joint Attention, Symbolic Play, Engagement, and Regulation � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 27 Pivotal Response Treatment � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 30 Project ImPACT � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �32

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Contents

SECTION II Core Concepts and Foundational Principles Chapter 3

Selecting Meaningful Skills for Teaching in the Natural Environment . . . . . . . . . . . . . . . . . . . . . . . 45 Grace W. Gengoux, Erin McNerney, and Mendy B. Minjarez Goodness of Fit of NDBI Approaches� � � � � � � � � � � � � � � � � � � � � � � � � Functional Skills � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � The Natural Environment � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � Case Example: Jin � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �

Chapter 4

46 49 56 66

Empowering Parents Through Parent Training and Coaching. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 77 Mendy B. Minjarez, Elizabeth A. Karp, Aubyn C. Stahmer, and Lauren Brookman-Frazee Parent-Mediated Interventions and NDBI � � � � � � � � � � � � � � � � � � � � � 77 Psychological Functioning in Parents of Children With ASD � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 79 Effective Parent Coaching Practices � � � � � � � � � � � � � � � � � � � � � � � � � � 82 Case Example: Gabe � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �91

Chapter 5

Fostering Inclusion With Peers and in the Community . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 99 Aubyn C. Stahmer, Connie Wong, Matthew J. Segall, and Jennifer Reinehr The Importance of Inclusion � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 99 Inclusion in Practice� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �100 Use of NDBI in Inclusive Settings � � � � � � � � � � � � � � � � � � � � � � � � � � � �102 Practical Suggestions for Incorporating NDBI Strategies Into Community Programs� � � � � � � � � � � � � � � � � � �106 Common Challenges to Inclusion � � � � � � � � � � � � � � � � � � � � � � � � � � � �111 Case Example: Preschool Program � � � � � � � � � � � � � � � � � � � � � � � � � � �112 Case Example: Adult Program� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �114

SECTION III NDBI Strategies Chapter 6

Implementing Motivational Strategies . . . . . . . . . . . . . . . . . . . . . 123 Mendy B. Minjarez and Yvonne Bruinsma NDBI and Motivation � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �124 Measuring Motivation� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 125 Strategies That Enhance Motivation � � � � � � � � � � � � � � � � � � � � � � � � � �126

Chapter 7

Applying Antecedent Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . 151 Jennifer B. Symon, Yvonne Bruinsma, and Erin McNerney Preparing to Teach � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �153 Setting Up Opportunities in NDBI � � � � � � � � � � � � � � � � � � � � � � � � � � �164 Case Example: Ty � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �171

Contents

Chapter 8

v

Implementing Instructional Cues and Prompting Strategies . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 175 Kyle M. Frost, Brooke Ingersoll, Yvonne Bruinsma, and Mendy B. Minjarez Definitions � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �175 Learning Opportunities Across NDBI Models � � � � � � � � � � � � � � � � �177 Prompting Strategies � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �182 Prompt Fading � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �187 Examples of Prompts for Specific Skills � � � � � � � � � � � � � � � � � � � � � � �187 Case Example: Leah � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �190

Chapter 9

Using Consequence Strategies. . . . . . . . . . . . . . . . . . . . . . . . . . . . . 193 Allison B. Jobin and Laura Schreibman Increasing the Strength of a Behavior � � � � � � � � � � � � � � � � � � � � � � � �194 Decreasing the Strength of a Behavior � � � � � � � � � � � � � � � � � � � � � � � �195 Applying the Premack Principle � � � � � � � � � � � � � � � � � � � � � � � � � � � � �196 Promoting Consequence Effectiveness � � � � � � � � � � � � � � � � � � � � � � �196 Using Consequences to Maintain Behavior Change � � � � � � � � � � � �199 Shaping and Chaining � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �201 Using Natural Consequences� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 202 Reinforcing Attempts � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 205 Modeling and Expanding on Child’s Response � � � � � � � � � � � � � � � 205 Imitating the Child’s Response � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 206 Troubleshooting NDBI Consequence Strategies � � � � � � � � � � � � � � � 206

Chapter 10

Guiding Meaningful Goal Development . . . . . . . . . . . . . . . . . . . 213 Grace W. Gengoux, Erin E. Soares, and Yvonne Bruinsma Formulating Goals � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �214 Assessment � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �218 Case Example: José� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �221 Considerations for Goal Selection � � � � � � � � � � � � � � � � � � � � � � � � � � � 224 Case Example: Jenna � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 226 Case Example: Kaleb � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 227 Case Example: Ashir � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 227 Developmental Considerations � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 228 Case Example: Alex � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 229 Case Example: Cole � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 229 Case Example: Josephine � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 230 Case Example: Marco � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 230

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SECTION IV Applications of NDBI Strategies Chapter 11

Targeting Communication Skills . . . . . . . . . . . . . . . . . . . . . . . . . . 237 Mendy B. Minjarez, Rachel K. Earl, Yvonne Bruinsma, and Amy L. Donaldson Communication Profile of Children With ASD � � � � � � � � � � � � � � � �237 Communication Development in Typically Developing Children � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 238 Use of NDBI for Targeting Communication � � � � � � � � � � � � � � � � � � �240 Teaching Communication Across Developmental Levels Using NDBI Strategies � � � � � � � � � � � � � � � � �249

Chapter 12

Improving Social Skills and Play . . . . . . . . . . . . . . . . . . . . . . . . . . 277 Yvonne Bruinsma and Grace W. Gengoux Social Initiations � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �278 Imitation Skills � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 284 Play � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 286 Teaching Play With Friends � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �297

Chapter 13

Supporting Behavior, Self-Regulation, and Adaptive Skills . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 309 Mendy B. Minjarez, Yvonne Bruinsma, and Rosy Matos Bucio NDBI and Challenging Behavior � � � � � � � � � � � � � � � � � � � � � � � � � � � �310 Relevant Applied Behavior Analysis Interventions � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �311 NDBI Strategies for Teaching Self-Regulation and Adaptive Skills � � � � � � � � � � � � � � � � � � � � � � � � � 322 Promoting Self-Regulation in Individuals With ASD � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �326 Teaching Adaptive Skills � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �332 Tips for Teaching Self-Regulation and Adaptive Skills � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 339 Case Example: Jonas � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 341

Chapter 14

Implementing NDBI in Schools . . . . . . . . . . . . . . . . . . . . . . . . . . . 347 Aubyn C. Stahmer, Jessica Suhrheinrich, and Laura J. Hall Including NDBI Components in Group or Academic Settings � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 348 School-Based Activities Most Suited for NDBI � � � � � � � � � � � � � � � � 355 Examples of Activities and Lessons � � � � � � � � � � � � � � � � � � � � � � � � � �357

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Collecting Data in NDBI . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 361 Mendy B. Minjarez, Melina Melgarejo, and Yvonne Bruinsma General Framework for Data Collection � � � � � � � � � � � � � � � � � � � � � �362 Data Collection Across NDBI Models� � � � � � � � � � � � � � � � � � � � � � � � 363 When and Why Data Are Collected � � � � � � � � � � � � � � � � � � � � � � � � � �369 Types of Data and Measurement Systems � � � � � � � � � � � � � � � � � � � � �375 Data Collection in the Natural Environment � � � � � � � � � � � � � � � � � 383

Chapter 16

Identifying Quality Indicators of NDBI Programs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 391 Aubyn C. Stahmer, Sarah R. Rieth, Brooke Ingersoll, Yvonne Bruinsma, and Aritz Aranbarri Quality Indicators Versus Common Features � � � � � � � � � � � � � � � � � �391 Specific Program Elements to Look for in a Quality NDBI Program � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �391

Chapter 17

Considering Future Directions in NDBI . . . . . . . . . . . . . . . . . . . . 407 Laura Schreibman, Mendy B. Minjarez, and Yvonne Bruinsma Research Future Directions � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 408 Dissemination and Implementation: Future Directions � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �410

Glossary� � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � �415 Index � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � � 423

About the Editors Yvonne Bruinsma, Ph.D., BCBA-D, In STEPPS and In STEPPS Academy, Irvine, CA. Dr. Bruinsma is CEO and founder of In STEPPS and In STEPPS Academy, a behavioral health agency and a nonprofit private school for children with autism in California. She is a Board Certified Behavior Analyst and received her doctorate in special education, developmental disabilities, and risk studies in 2004. She has been working with families and teaching others how to work with families by using Naturalistic Developmental Behavioral Interventions (NDBI) strategies for over 20 years. Yvonne’s focus is to blend research and reality in the highest quality treatment in a community setting. Mendy B. Minjarez, Ph.D., Seattle Children’s Hospital Autism Center and University of Washington School of Medicine, Seattle, WA. Dr. Minjarez is a licensed psychologist with a background in Applied Behavior Analysis and NDBI. She is an assistant professor in psychiatry and behavioral sciences at the University of Washington, the Clinical Director of the Seattle Children’s Hospital Autism Center, and the Program Director of the Applied Behavior Analysis Early Intervention Program at Seattle Children’s Hospital Autism Center. Dr. Minjarez’s clinical work is focused on diagnosis and treatment of autism spectrum disorder, with a particular interest in NDBI, parent training, and early childhood. Her research is focused on dissemination of parent-mediated NDBI, particularly through innovative models, such as group parent training. Laura Schreibman, Ph.D., Department of Psychology, University of California, San Diego, La Jolla, CA. Dr. Schreibman served as Director and Principal Investigator of the Autism Intervention Research Program at the University of California at San Diego from 1984 until 2012. She is Distinguished Professor Emeritus of Psychology and Research Professor at the University of California, San Diego. Her most recent research interests have focused on the development and dissemination of NDBI strategies, the development of individualized treatment protocols, translation of empirically based treatments into community settings, analysis of language and attentional deficits, generalization of behavior change, parent training, and issues of assessment. She is the author of four books and more than 160 research reports, articles, and book chapters.

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Aubyn C. Stahmer, Ph.D., BCBA-D, University of California, Davis MIND Institute, Sacramento, CA. Dr. Stahmer has been using and studying NDBI strategies with children with autism spectrum disorder and their families in research and community settings for 30 years. She is an expert in the translation of evidencebased autism research to community-based practice and delivery. The main goals of her research include developing ways to help community providers, such as teachers and therapists, and helping children with autism and their families by providing high-quality care. She is widely published and a frequent presenter at annual professional meetings in the field of services to children with autism.

About the Contributors Aritz Aranbarri, Ph.D., The MIND Institute, University of California (UC) Davis Medical Center, Sacramento, CA. Dr. Aranbarri is a clinical licensed psychologist specialized as a developmental neuropsychologist (Early Start Denver Model certified therapist) and holds a Ph.D. in environmental epidemiology and early neurodevelopment. He received postdoctoral training in Autism Early Intervention Community Research at the UC Davis MIND Institute mentored by Dr. Aubyn C. Stahmer and now coordinates autism research at the SJD Barcelona Children’s Hospital. Lauren Brookman-Frazee, Ph.D., San Diego Department of Psychiatry, University of California, La Jolla, CA. Dr. Brookman-Frazee is Professor of Psychiatry at the University of California, San Diego, Associate Director of the Child and Adolescent Services Research Center, and Research Director at the Autism Discovery Institute at Rady Children’s Hospital–San Diego. She specializes in parent-mediated interventions for children with autism spectrum disorder (ASD) and other developmental and mental health problems. Dr. Brookman-Frazee’s research involves partnering with mental health and education system leaders, providers, and families to develop, test, and implement evidence-based interventions in community and school-based settings. Geraldine Dawson, Ph.D., Departments of Psychiatry and Behavioral Sciences, Pediatrics, and Psychology & Neuroscience, Duke University, Durham, NC. Dr. Dawson is Professor in the Departments of Psychiatry and Behavioral Sciences, Pediatrics, and Psychology & Neuroscience at Duke University. She is Past-President of the International Society for Autism Research and a member of the Interagency Autism Coordinating Committee. She is Director of the Duke Center for Autism and Brain Development, an interdisciplinary autism research and treatment center, and Chair of the Faculty Governance Committee for the Duke Institute for Brain Sciences. Dr. Dawson is Director of a National Institutes of Health Autism Center of Excellence Award at Duke focused on understanding early detection, neural bases, and treatment of autism and attention-deficit/hyperactivity disorder. Dr. Dawson has published extensively on early detection, brain function, and treatment of autism. With Sally Rogers, she developed the Early Start Denver Model, a comprehensive early behavioral intervention for young children with autism. She completed a Ph.D. in developmental/child clinical psychology from University of Washington and clinical internship at the University of California, Los Angeles. xi

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Amy L. Donaldson, Ph.D., CCC-SLP, Department of Speech and Hearing Sciences, Portland State University, Portland, OR. Dr. Donaldson is an associate professor in the Department of Speech & Hearing Sciences at Portland State University. Her research focuses broadly on social-communication and perception of social competence in individuals on the autism spectrum and neurotypical individuals. Dr. Donaldson examines intervention efficacy, pre- and postprofessional development, the influence of context on performance, and the experiences of neurodivergent individuals in different contexts. Rachel K. Earl, Ph.D., Seattle Children’s Hospital, Seattle, WA. Dr. Earl earned her Ph.D. in school psychology at the University of Washington. She is currently a postdoctoral fellow at Seattle Children’s Hospital–Autism Center, specializing in diagnosis and treatment of ASD. Kyle M. Frost, M.A., Department of Psychology, Michigan State University (MSU), East Lansing, MI. Mrs. Frost is a doctoral candidate in clinical psychology at MSU and a member of the MSU Autism Research Lab. Her research focuses on measuring intervention response and implementation, as well as understanding the common elements of Naturalistic Developmental Behavioral Interventions (NDBI). Erin E. Soares, B.S., Palo Alto University, Palo Alto, CA. Ms. Soares is a third-year Ph.D. student at Palo Alto University (PAU) in the clinical psychology program, with an emphasis in child and family studies. Prior to attending PAU, Ms. Soares graduated from Santa Clara University with a B.S. in psychology and child studies. Grace W. Gengoux, Ph.D., BCBA-D, Division of Child and Adolescent Psychiatry, Department of Psychiatry, Stanford University School of Medicine, Stanford, CA. Dr. Gengoux is a clinical psychologist and Board Certified Behavior Analyst who directs the Autism Intervention Program within the Stanford Autism Center at Lucile Packard Children’s Hospital. Dr. Gengoux received her Ph.D. in Clinical Psychology from the University of California Santa Barbara and completed her clinical internship and postdoctoral fellowship at the Yale Child Study Center. Her research specifically focuses on the development and evaluation of NDBI for young children with ASD. Dr. Gengoux’s previous publications have focused on models for enhancing functional communication and social development and for providing effective parent training. Laura J. Hall, Ph.D., Department of Special Education, San Diego State University, San Diego, CA. Dr. Hall is Professor and Chair of Special Education at San Diego State University. She has been working with individuals with ASD and their families for over 35 years. The focus of her research and teaching has been on the transfer of research into practice, or facilitating the implementation of evidencebased practices by supporting educators and paraeducators. She is the author of the widely used textbook, Autism Spectrum Disorders: From Theory to Practice (2009, Pearson).

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Brooke Ingersoll, Ph.D., BCBA-D, Michigan State University (MSU), East Lansing, MI. Dr. Ingersoll is an associate professor of clinical psychology at MSU, where she is the director of the MSU Autism Research Lab. She is also a licensed psychologist and Board Certified Behavior Analyst. Dr. Ingersoll’s research focuses on the development, evaluation, and dissemination of social-communication interventions for individuals with ASD. She has published multiple peer-reviewed journal articles and book chapters on ASD and is the coauthor of Teaching Social Communication to Children with Autism (with A. Dvortcsak; 2010, Guilford Press), an NDBI parent training curriculum for children with ASD. Allison B. Jobin, Ph.D., BCBA-D, Child and Adolescent Services Research Center, Department of Psychiatry, University of California, San Diego, Rady Children’s Hospital San Diego, San Diego, CA. Dr. Jobin is a licensed clinical psychologist and Board Certified Behavior Analyst at the Autism Discovery Institute of Rady Children’s Hospital San Diego and study manager in the Department of Psychiatry of the University of California, San Diego, and Child and Adolescent Services Research Center. Dr. Jobin has over 15 years of experience in the delivery, supervision, and evaluation of evidence-based interventions for children with ASD and their families. She specializes in parent-mediated treatment models and NDBI. Her research focus includes evaluating and improving treatment for children with ASD, as well as methods for effective implementation in community settings. Elizabeth A. Karp, M.S., Department of Psychology, University of Washington, Seattle, WA. Ms. Karp is a doctoral candidate in child psychology at the University of Washington. She is passionate about identifying ways to provide family-centered care for families with a child with ASD. She is particularly interested in caregivers’ experiences as they implement interventions with their young children. Rosy Matos Bucio, Ph.D., BCBA-D, Santa Barbara SELPA, Santa Barbara, CA� Dr. Matos Bucio is a Board Certified Behavior Analyst who completed her doctoral training in 2005 at the University of California, Santa Barbara. For over 20 years, her research and professional practice has focused on using the motivational strategies of NDBI to support individuals with ASD across the life span and disseminate best practices to families and professionals. Erin McNerney, Ph.D., BCBA-D, In STEPPS and McNerney & Associates, Irvine, CA. Dr. McNerney is a licensed clinical psychologist and Board Certified Behavior Analyst Doctoral specializing in ASD, developmental disabilities, and behavior challenges. She has spent the past 2 decades teaching and implementing Pivotal Response Treatment (PRT) and providing behavior-based parent training. She currently provides psychological assessment and therapy to support the mental health needs of individuals with ASD and their families. Melina Melgarejo, Ph.D., San Diego State University, San Diego, CA. Dr. Melgarejo received her Ph.D. in education with an emphasis in special education, disabilities,

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and risk studies from the University of California, Santa Barbara. She is a postdoctoral scholar at San Diego State University and the Child and Adolescent Services Research Center. She is currently involved in research on the multi-level factors affecting the use of evidence-based practices for children with ASD within schools. Jennifer Reinehr, Psy.D., TEACCH Center, University of North Carolina at Chapel Hill, Chapel Hill, NC. Dr. Reinehr is a clinical assistant professor and staff psychologist at the TEACCH Center with the University of North Carolina at Chapel Hill. She is specialized in diagnostic and developmental assessment of young children with ASD. For over 10 years, she has provided clinical oversight for an integrated preschool program for young children with and without ASD. Dr. Reinehr continues to work toward practical application of evidence-based practices in an individual’s natural settings. Sarah R. Rieth, Ph.D., BCBA-D, Child and Adolescent Services Research Center, Department of Child and Family Development, San Diego State University, San Diego, CA. Dr. Rieth is Assistant Professor of Child and Family Development at San Diego State University and an investigator at the Child and Adolescent Services Research Center. She received her Ph.D. from the Psychology Department at UCSD in 2012. Her research focuses on intervention for children with ASD and their families and the delivery of high-quality intervention in community settings. Dr. Rieth is a licensed clinical psychologist and specializes in training others and delivering intervention for children with ASD, ages 12 months to 10 years. Her current work involves training community providers to deliver parent-mediated interventions and examining student outcomes from community-based trials of evidence-based treatment models. Matthew J. Segall, Ph.D., Emory Autism Center, Emory University School of Medicine, Atlanta, GA. Dr. Segall is Program Director for Education and Transition Services at the Emory Autism Center, as well as Assistant Professor of Psychiatry and Behavioral Sciences in the Emory University School of Medicine. He is a licensed psychologist in the State of Georgia. Dr. Segall completed his bachelor’s degree in psychology at the University of Virginia and his doctoral degree in school psychology at the University of Georgia. His predoctoral internship and postdoctoral fellowship were both completed at the Emory Autism Center, while also completing a fellowship at Georgia State University in the Georgia LEND (Leadership Education in Neurodevelopmental Disabilities) program. Dr. Segall’s professional interests include educator and professional training, supporting students in inclusive educational settings, and transition planning. Jessica Suhrheinrich, Ph.D., Department of Special Education, San Diego State University, San Diego, CA. Dr. Suhrheinrich is an assistant professor of special education at San Diego State University and an investigator with the Child and Adolescent Services Research Center. Broadly, her research aims to improve community-based services for children with ASD.

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Jennifer B. Symon, Ph.D., BCBA, Special Education and Counseling, California State University Los Angeles, Los Angeles, CA. Dr. Symon is a professor in the Division of Special Education and Counseling at California State University, Los Angeles. She coordinates the programs in ASD and is a Board Certified Behavior Analyst. Her research interests include interventions for parents, teachers, paraprofessionals, and peers who support students with ASD. Connie Wong, Ph.D., Frank Porter Graham Child Development Institute, University of North Carolina at Chapel Hill, Chapel Hill, NC. Dr. Wong is a research scientist at the Frank Porter Graham Development Institute at the University of North Carolina at Chapel Hill and Adjunct Professor in Early Intervention and Early Childhood Special Education at California State University, Los Angeles. Her research focuses on young children with or at risk for autism and other developmental delays and their families.

Foreword The outcomes of children with autism spectrum disorder (ASD) may be about to change radically for the better in the next decade. If so, a world of promise, rather than a world of challenges, may open to the approximately 66,000 children who are born every year in the United States alone who will have autism. This possibility is within the grasp of this coming generation of autism investigators and clinicians to attain, in deep collaboration with parents and community providers. Yet, if we are to succeed in optimizing developmental potential and quality of life of the next generations of children with ASD, three priority goals need to be achieved. We need to identify ASD early; we need to translate early detection into access to evidence-based, effective early treatments; and we need to provide ongoing high-quality supports and solutions to children and families affected by ASD. The challenges in these domains are considerable but not insurmountable. Why is early detection critical? By the time we celebrate a baby’s first birthday, his or her brain has doubled, and synaptic density has quadrupled. Brain maturation guides a baby’s experiences, which in turn deeply influences brain organization and continued specialization. By the end of their second year of life, babies have undergone their period of maximal lifetime neuroplasticity. By 18–24 months, there may be an emergence of autism symptoms, making possible reliable diagnosis by expert clinicians. For treatment to have optimal benefits, there is a need to capitalize on this early brain malleability, before speech-language and communication development is severely derailed and problem behaviors become entrenched. Yet, the median age of autism diagnosis has not changed in consecutive cohorts followed by Centers for Disease Control and Prevention surveillance efforts. Fifty percent of children with autism are diagnosed after the age of 4–5 years, and children from underserved populations—minorities, low income, rural—are diagnosed later still. What is the solution? Despite some controversy on this topic in the past 5 years, most investigators, as well as science, policy, and advocacy organizations, believe that populationwide surveillance programs can effectively deploy universal screening for ASD and related developmental delays and that the screening process can be made actionable via increased access to diagnostic services. The promise of early detection can only be delivered if screening programs are shown to increase access to effective early intervention services. Most studies of early treatment in autism have shown major benefits in learning and language acquisition. Yet, it is likely that the potential benefits of early treatment have xvii

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been grossly underestimated. One reason may be the fact that most investigations have focused on children age 3 years old and older; another reason may be the fact that most studies have reported on relatively small studies conducted by research groups rather than on population trends resulting from federally mandated birth-to-3 services. More studies are needed of early treatment involving toddlers if we are to take neuroplasticity seriously, and more “big data” studies of state-by-state indicators of service access and outcomes are needed if we are to judge the populationwide effects of the Program for Infants and Toddlers with Disabilities (Part C) of the Individuals with Disabilities Education Act (IDEA), and of the now 11-year-old recommendations of the American Academy of Pediatrics. The promise is clear: Optimize development and learning potential by age 3 years, and the child’s lifetime prospects are likely to change dramatically; make highquality early treatment accessible, and the longtime, financial equation burdens are alleviated for individual families and for the entire health care and education systems. Yet, a large number of children with ASD receiving special education in their school years have not benefited from early treatment, and some who receive services before the age of 3 may obtain treatments that vary in quality and intensity, indeed services that may fail to maximize what might be achieved otherwise. What is the solution? You are holding it in your hands. This book compiles the best promise we have of treatments that work, that leverage the best science we currently have, and that are scalable to meet the demands of the community at large. The authors on these pages are some of the leading innovators and experts in this field. Their commitment to evidence-based practice, to individualized and personalized treatments, and to the wedding of quality and access is second to none. Most of all, their commitment is to the families of children with autism and to the providers who are in the trenches: They need to navigate a labyrinth of information, some of which is questionable or even predatory, in order to identify and secure what is best for children. The authors of this book make this task easy and straightforward. Unhelpful arguments that verge on ideological fights are left behind; acronyms that create differences when there are none, and that confuse rather than illuminate, are sidestepped in order to focus instead on principles that work and have been proven via scientific rigor and on active ingredients that can be easily identified, studied, and promoted. This book is a victory of common sense: a consensual framework that will serve as the basis for improvements of treatment efficacy, effectiveness, and community uptake in what is now the highest priority, with potentially the highest gains in the field. Why is the provision of supports and solutions to children and families affected by ASD so critical? Although early detection and intervention promise life-changing opportunities for the next generations of children with autism, those affected by ASD now cannot wait. Families, community providers, and schools can deploy treatments that work in fostering communication and adaptive skills and that decrease the risk of problem behavior. Communication skills facilitate meaningful inclusion and make possible friendships and other relationships, as well as a world of vocational opportunities. Adaptive skills promote independence, self-reliance, and self-determination. The management of challenging behavior decreases the risk of isolation, enhances quality of life, and makes it possible for a child to learn and adapt to environmental demands. Yet, families are often confused and frustrated with the lack of direction, integration, and helpful navigation

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through the struggles of the day; providers are often overwhelmed at the very sight of the plethora of titles sitting on their book shelves that do not necessarily translate into a concrete plan and approach for their day of therapy and teaching. How are we to distill from this chaotic state the straightforward principles of treatment and supports that work, the roadmap to generate learning that generalizes, and the strategies to promote communication skills that are self-driven and effective across environments? The solution, again, is in your hands. This book describes ways to leverage children’s daily lives as the stage for their learning. Teach skills in isolation, and the road from skill acquisition to spontaneous skill deployment is a much longer and winding road. The importance of developmental considerations is extended to all ages: Not only are the children with ASD growing up, but so are their peers. And with the passage of developmental stages comes the unfolding of increasingly more challenging environmental demands. Remove therapy and supports from the developmental context in which they need to work, and one may witness further isolation, prompt dependency, and reduced adaptation. Similarly, the reader will learn about environmental controls and reinforcement management techniques that foster habit formation, accelerate skill learning, and promote self-motivation and self-regulation. Fail to consider that, and you may find yourself struggling with continued disruption, lack of engagement, despondency, and heightened anxiety. These are principles of treatment and intervention that should guide our work with children of all ages, from infancy through adolescence and beyond. How does this book achieve the sorely needed synthesis? First and foremost, it represents the culmination of some 50 years of science in early treatment of autism, a process that has greatly accelerated in the past 10 years. Facts matter, and science has produced a great body of evidence justifying the integrative approach taken by the authors. In this approach, there is great respect for a clinical principle, enshrined in the language of educational law, that treatments and intervention programs should be individualized to a child’s profile, addressing the child’s needs while capitalizing on the child’s assets. This principle unravels many of the ideological debates. A treatment devised to promote communication skill acquisition in a nonverbal 6-year-old at risk of never speaking is unlikely to be beneficial in the case of a 2-year-old who vocalizes and shows intent to communicate with others, albeit inconsistently, and vice versa. There is no need to train a child to display a complex behavior by chaining discrete and disconnected behaviors if the child has the ability to learn how to learn in more naturalistic settings. In this way, generalization challenges are reduced; prompts and consequences are inherent in the real world; and pivotal skills generate more learning, in more settings, and in more contexts. The authors also leverage behavioral science in ways that do not turn it into a stereotype. The science of Applied Behavior Analysis (ABA) has generated some of the most critical advances in the care of individuals with developmental disabilities. Anyone who has worked in a residential facility for individuals with severe disabilities is quick to appreciate this fact. But ABA is not synonymous to narrow applications that may have its place for some children but not for others. ABA is a vast body of science that painstakingly assesses and changes human behavior. At its core is learning theory with its focus on an individual’s behavior acquisition and display as a function of environmental conditions. For primates in general, but certainly for humans, that environment consists of people and their referents in the

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surroundings. Making these connections is central to the acquisition of speech, language, and communication. We fail to follow ABA principles at our peril; indeed, we are all behaviorists in real life, but unfortunately most of us are bad behaviorists, often pre-empting the very result we seek to achieve. By advancing individualized, naturalistic approaches and the basic scientific tenets of learning theory, there should be no surprise that the individual child, his or her style of learning, and his or her perceived environment take center stage in any effective program of treatment and intervention. In between an antecedent and a response, there is a single child with a specific age and stage of development, assets and needs, emotional state, capacity for self-regulation, motivations, social relatedness, interests, fears, and personalized environment. For too long, learning theorists proceeded in their scientific endeavors by pretending to ignore a child’s individualized agency: The brain is no black box! Similarly, for too long, developmental scientists proceeded in their scientific endeavors by focusing on sweeping generalities that were not easily translatable into manualized treatments capable of singling out active ingredients and of achieving greater fidelity. Why these two currents of human ideas forged parallel paths for so many decades is as infuriating as it is counterproductive to any evidence-based synthesis of effective treatment for young vulnerable children. Thankfully, the authors of this book leave this anachronistic notion behind us all. The behaviorists versus developmentalist confrontation should be relegated to the history of the field, thus erased and eradicated from its future science and its future scientists. By moving the nonsensical aside, and by leveraging the best science from within, this book generates a consensual synthesis, whose name includes the very words that generated this unsatisfactory state of artificial conflagration in our past: Naturalistic Developmental Behavioral Interventions. The very name is our best assurance that research on early treatments will continue to thrive on healthy scientific grounds. This book is more than a compilation of evidence-based treatment principles; it is also a recipe for viability and for increased access. In an early intervention world of scarce resources, to state that a 40-hour regimen of treatment delivered by an expert clinician is aspired standard of care, as we have learned to believe over the past 2 decades, is a recipe for frustration. With few exceptions in the country, most states, where maybe 1–2 hours a week is the reality of treatment, need more viable solutions. Children need to access effective services when they need them and where they are. For that to happen, a number of stakeholders need to be involved. It is the responsibility of investigators and clinicians to use the best implementation science to generate innovations that can be deployed in the real world, advancing quality as well as accessibility. Parents need to be engaged in the most important role in their lives: to promote the development of their children. Parent-mediated interventions are emerging as both viable and effective: Professional interventionists can use their limited availability to train parents to turn every waking moment of the child’s life into a learning moment, using routine daily activities as naturalistic platforms for treatment, with the intensity and emotional engagement needed to achieve lasting results. Similarly, generalist child development providers and teachers can promote similar principles in group settings. In this fashion, a new ecosystem of care becomes possible, in which divisions across contexts and settings can dissolve thanks to common goals and strategies.

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Most important, the involvement of parents and child care providers allows treatments to be downward extended into toddlerhood and maybe even infancy: There is no reason to wait until a diagnosis is attained to turn surveillance and parent education into strategies that promote development—of all children. All vulnerable children, and certainly those with autism, are likely to benefit from a robust dosage of facilitation of social and communication engagement. This is already the approach taken by those trying to counter the effects of intergenerational poverty on a child’s language acquisition. And therein lies one of the greatest promises in the field: the beneficial effects of child development surveillance and parental engagement on the outcomes of all children. Perhaps if we were to deploy these generalist strategies systemically in a communitywide fashion, children would reach the age of more individualized and intensive treatments at a much higher level of readiness to learn. These may seem like lofty aspirations. Yet, after the publication of this book, we, as a field, are closer to these goals than ever before. The authors have made a terrific contribution in our effort to ensure that every child with ASD is afforded what they need in order to fulfill their promise. Ami Klin, Ph.D. Director, Marcus Autism Center Children’s Healthcare of Atlanta and Emory University School of Medicine

Acknowledgments This book is the result of the persistence and resolve of a small group of people. I believe this book may advance our field, and I sincerely hope it is the cohesive and comprehensive book that we set out to write when we started. It is our passionate desire for this book to create the start of the resources we need for broader dissemination and implementation of Naturalistic Developmental Behavioral Interventions (NDBI). This book could not have been written without the support and collaboration from the authors of the different NDBI models. I am grateful for their collaboration and willingness to come together under one name to help advance our field. I am incredibly proud to be a part of that movement. While the book covers many NDBI, it is important to note the book editors were all initially trained in Pivotal Response Treatment (PRT). Our hope is that by including experts from many methods in various book chapters and asking additional experts to review our descriptions of their model, we have represented all of the NDBI respectfully and accurately. I would like to acknowledge my mentors and teachers who supported me along the way and helped me grow clinically and academically. I especially thank my teachers Robert and Lynn Koegel, Paul Smeets, Paul Touchette, and Harry Boelens. I thank all my friends and the staff at In STEPPS and In STEPPS Academy for supporting me through this process. I would especially like to thank Danny Openden for putting me in touch with Brookes Publishing Co. and, of course, Mendy Minjarez. Her incredible task-master and organizational skills as well as her clinical expertise and writing skills brought the book to a new level. Gratitude is also deserved for Grace Gengoux, who went above and beyond in helping us write some of the chapters. Finally, I would like to thank my family. My husband, Robert, and my “poor” kids Niels, Sander, and Fenna Rose, who were so sick of yet another writing retreat. I have good news for you: No more writing retreats. It is done. Yvonne Bruinsma, Ph.D., BCBA-D

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I would like to acknowledge those who have supported me and my career personally, and those who have made this work possible through their contributions to the field. Personally, I could not have asked for a better colleague, coauthor, and friend than Yvonne Bruinsma. I am also grateful to my mentors and colleagues for the knowledge and opportunities they have provided, including Marji Charlop, Ami Klin, Bob and Lynn Koegel, Tara O’Connor, Bryan King, and Maddie Parsons. The body of work that has preceded the NDBI framework must be fully acknowledged because it is the foundation for the content of this book, which we believe will propel the field forward. I have also learned so much from the children and families that I work with, which I anticipate will continue lifelong; however, my greatest teachers are my own children, who have taught me that life is messy and hard but full of humor and joy, which I hope carries over to the rest of my career and life as well. Mendy B. Minjarez, Ph.D. Over many years, I have had the good fortune to work with amazing students, colleagues, researchers, teachers, and community members of all kinds. Most important, I have had the good fortune to work with wonderful children and families who have taught me so much and have showed me the real power of what we do and what we can accomplish. I want to acknowledge the efforts of all these people who have worked so hard at getting us to where we are today. I see the development of NDBI as the fruit of these efforts. Laura Schreibman, Ph.D. Many people have devoted their time and expertise to make this project a reality. First, thank you to all the amazing NDBI developers willing to support the integration of their individual evidence-based interventions into a coherent model. Each reviewed the descriptions of their respective interventions in this book and supported the concept of NDBI through the original article. Second, thank you to all my colleagues who helped shape my understanding of NDBI across contexts. Third, thanks to my research and treatment teams in San Diego and Sacramento, who bring it all to life. Finally, thank you to all the children, families, teachers, therapists, and advocates who have supported this work. Aubyn C. Stahmer, Ph.D., BCBA-D

About the Online Materials Online materials are available to supplement the knowledge, approaches, and strategies discussed in Naturalistic Developmental Behavioral Interventions for Autism Spectrum Disorder� All readers can access downloadable versions of the datasheets and other forms for use in clinical settings and the classroom. To access the forms: 1. Visit the Brookes Publishing Download Hub: http://downloads.brookes publishing.com 2. Register to create an account, or log in with an existing account. 3. Filter or search for the book title. Course materials are also available to help faculty and instructors integrate Naturalistic Developmental Behavioral Interventions for Autism Spectrum Disorder into their course. These resources include: • Sample syllabi for various disciplines to guide instructors on how this book can be integrated into their course • Customizable PowerPoints that summarize Chapters 1–16, for use in lecture • A test bank with 160 multiple-choice questions for instructors to use and adapt in course exams To access the course materials for this book: 1. Visit the Brookes Publishing Download Hub: http://downloads.brookes publishing.com 2. Register to create an account with your university email, or log in with an existing account. 3. Filter or search for the book title.

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I Overview

1 Understanding NDBI Laura Schreibman, Allison B. Jobin, and Geraldine Dawson

A

utism spectrum disorder (ASD) affects as many as 1 in 59 children (Baio et al., 2018). Although this statistic certainly has an impact across service systems, the impact is far greater for those individuals and families affected. While ASD may have been considered a dire prognosis for these children and families from the 1950s through the 1980s and beyond, the state of affairs is much brighter today. Research since the 1960s conducted across multiple academic disciplines has led to the identification and development of treatments for ASD that are both highly effective and efficient. The development of these effective intervention strategies, coupled with an ability to diagnose ASD at earlier ages, has broadened and strengthened the positive effect of treatment efforts. Early intervention by using empirically based treatments has proven to have a substantial impact on the future functioning of children with ASD, changing the outlook for these individuals and their families (e.g., Dawson, 2008; Dawson et al., 2012; Rogers & Dawson, 2010). Although early intervention using these newer strategies has certainly improved the prognosis for young children with ASD, treatments based on these same principles have also proven to be effective for individuals throughout the life span, as well as for individuals with related disorders that share some of the same features of ASD (e.g., language acquisition delays, behavior problems, cognitive impairment). Our goal in writing this book was to describe a scientifically validated set of interventions, derived primarily from the fields of Applied Behavior Analysis (ABA) and developmental psychology. These interventions are called Naturalistic Developmental Behavioral Interventions (NDBI) to reflect the essential combined contributions of these two disciplines. As described in later chapters, there are several established NDBI utilized with children with ASD and related disorders; although specific NDBI have differences, they all have general concepts and procedures in common. This book describes the development of NDBI, identifies and describes 3

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Overview

the concepts and procedures that unite them, and provides an implementation guide for practitioners and others who wish to use NDBI with children with ASD. Section I introduces NDBI and key NDBI models. Section II explains core concepts and foundational principles common to all NDBI, highlighting topics such as the selection of meaningful skills, parent empowerment, and inclusion. Section III dives deeper into specific NDBI strategies, and Section IV offers an implementationfocused look at NDBI in practice. This book is a resource for practitioners, educators, and other professionals who make treatment decisions for children with ASD. Those searching for ASD treatment are often confused and overwhelmed because there is so much information available. Much of what is available via the web or other sources is not likely to be helpful and can even be harmful. Some proposed treatments have proven to be dangerous (e.g., certain drug regimens or chelation). Other treatment approaches elevated through celebrity advocacy, although perhaps the most visible, often lack evidence for effectiveness. Furthermore, even if a child receives a relatively benign but not scientifically validated treatment (e.g., equine or dolphin therapy), it still can be harmful if it is costly or results in the child spending less time in effective treatment. There are so many treatments and claims of effectiveness (often patently false) that the process of identifying effective interventions for a child with ASD too often becomes a burden for parents and treatment providers. This book offers a solution by not only identifying proven treatments but also by describing the basic, important concepts that characterize such treatments to help parents, teachers, and practitioners decide if interventions meet the standards of established NDBI. Although specific NDBI may have different names, such as Pivotal Response Treatment (or Training) (PRT), Early Start Denver Model, and Project ImPACT, they all involve the same important core concepts discussed in this book. Our hope is that by helping parents, teachers, and practitioners determine whether a treatment meets the standard of research-based practice, we will make the initially unmanageable, manageable.

ASD DEFINED Before diving in to the more complicated topics that follow in this book, perhaps it is best to establish a common understanding of what we mean by autism spectrum disorder (ASD). Autism was first identified as a specific disorder by Leo Kanner in 1943. Kanner described a group of children who exhibited a set of features unlike those of any other known pediatric disorder. These features included severe social deficits, such as failure to bond with parents, social avoidance of others, failure to establish eye contact, failure to acquire language or particular pathological features of language if it did develop, lack of appropriate interaction or interest in toys or other features of the environment, and the presence of repetitive, nonpurposeful behaviors. He also believed that these children possessed normal or above-normal intelligence. Kanner named this disorder early infantile autism to describe the fact that the symptoms were exhibited very early in life and involved a severe withdrawal. Since 1943, much has changed in terms of understanding of the disorder, including requisite diagnostic features (Schreibman, 2005).

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According to the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5; American Psychiatric Association, 2013), the following diagnostic criteria for ASD have been established: 1. Persistent deficits in social-communication and social interaction such as abnormal social approach, reduced sharing of emotions or affect, and failure to initiate or respond to the social initiations of others 2. Persistent deficits in verbal and nonverbal behaviors used for social interaction, such as failure to develop speech, inadequate eye contact, failure to use or understand gestures for social purposes, failure to develop and maintain social relationships, and absence of interest in, or sharing with, peers 3. Presence of restricted, repetitive patterns of behavior, interest, or activities (including stereotyped or repetitive motor movements or use of objects; inflexibility to changes in routines; and highly restricted, fixated interests that are abnormal in intensity of focus) 4. Hyper- or hyporeactivity of the sensory environment Also, whereas Kanner did not associate autism with cognitive impairment, a significant number of these individuals do experience cognitive impairment. (See the DSM-5 and Autism Speaks at http://www.autismspeaks.org for a more detailed and comprehensive description of ASD.)

HISTORY OF ASD INTERVENTION To fully appreciate where the field of ASD intervention is now, it is important to look back at where the field began and how it has progressed. Prior to the early 1960s, educators widely assumed that children with ASD could not learn. The early work of Charles Ferster and Marian DeMyer (1961, 1962) demonstrated that children with ASD could learn a simple task if their responses reliably resulted in a positive effect. The task was pressing a lever for candy in the presence of a stimulus, and the positive effect was delivery of candy. Although this was not a particularly functional curriculum, it did demonstrate that the principles of learning could be used effectively to teach children with ASD. This early work was followed by a substantial increase in the study of operant learning approaches to teach a variety of skills. Examples of these skills include language (Lovaas, Berberich, Perloff, & Schaeffer, 1996; Risley & Wolf, 1967), social skills (Ragland, Kerr, & Strain, 1978; Strain, Kerr, & Ragland, 1979), play (Koegel, Firestone, Kramme, & Dunlap, 1974; Lifter, SulzerAzaroff, Anderson, & Cowdery, 1993; Stahmer, 1999; Stahmer & Schreibman, 1992), adaptive skills (Ayllon & Azrin, 1968; Baker, 2004), and academic skills (McGee, Krantz, & McClannahan, 1986; McGee & McCoy, 1981), as well as skills to reduce the occurrence of interfering or challenging behaviors (Carr & Durand, 1985; Iwata, Dorsey, Slifer, Bauman, & Richman, 1982; Schreibman & Carr, 1978). This work reflected the new field of ABA, which studies the laws governing how the environment affects behavior. Once researchers had determined these laws, they began to study how to alter the environment to change others’ behavior for the better. For example, the principle of positive reinforcement (i.e., a behavior followed by a positive event will become stronger) is not only well established but is used by everyone (e.g., saying “please” to request a treat will become a stronger

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Overview

response if the treat follows saying the word). The field of ABA has established many of these laws and continues to refine understanding of how to improve the life of others. It offers specific experimental methodologies to investigate and prove the effects of procedures aimed at changing behavior. The application of behavioral principles to teach new skills and reduce behavioral challenges for children with ASD took a huge leap forward through the work of Ivar Lovaas; Lovaas and his colleagues developed an intensive and comprehensive intervention program that focused on many of these skills (Lovaas, 1987, 2002). Although Lovaas’s successes, and those of other behavioral researchers, propelled behavioral treatment into the forefront, his 1987 treatment study had the most profound impact. In that study, Lovaas provided intensive (i.e., up to 40 hours per week) behavioral intervention to a group of young children with ASD. In contrast to a control group of children who did not receive the treatment at such intensity, the children in the experimental group showed significant gains in IQ score and success in typical school placements. This work greatly altered the expectations of treatment, especially early treatment, for ASD. The field began to realize that tremendous progress, potentially leading to limited ongoing need for services and supports, might be possible for almost half of children with ASD if they receive excellent treatment early enough and with enough intensity. This work, and subsequent studies demonstrating efficacy of early intervention, led to two main trends in ASD treatment. First, parents, understandably very encouraged by these findings, began advocating for their children to receive early intensive behavioral intervention, which led to changes in educational practices and policies. Second, discrete trial training (DTT), the behavioral approach used in Lovaas’s (1987) study, became increasingly popular. In brief, DTT involves one system of implementation of operant methodology. In this type of intervention, teaching is conducted via successive discrete trials, with each trial consisting of an antecedent (a cue to indicate when a response should be emitted), a response or behavior, and a consequence (an event following the response). We call this the three-term contingency and abbreviate it A-B-C. In DTT, educators break skills down into smaller, separate components and teach them one at a time using discrete training trials until the complete skill is acquired. For example, if a teacher wanted to teach a child to put on a pair of pants when told to put on pants, he or she might first teach the child to point to a pair of pants when told to put on pants. Once the child reliably points to the pants, the teacher would teach the next component of the skill by requiring the child to point to and then pick up the pants. Once that is mastered, the child would be required to put one leg in the pants and so forth until the child could perform the entire skill when told to put on pants. Thus, the teacher broke the complex skill of putting on pants down into smaller steps and taught them separately. Although DTT became increasingly popular with parents and other treatment providers, intervention research in the late 1980s found that highly structured intervention such as DTT had some limitations (Schreibman, 2005). These limitations included 1) failure to generalize newly learned skills across multiple contexts, 2) occurrence of escape/avoidance-motivated challenging behaviors, 3) lack of spontaneity in responding, and 4) overdependence on prompts. These limitations, plus the successes of behavioral interventions, led many ASD treatment researchers from different disciplines to focus their efforts on addressing these identified

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limitations and otherwise improving and expanding treatment effectiveness. Advances in the developmental sciences—particularly those in the area of promoting early communication skills, social engagement, and affective engagement—set the stage for advancing early intervention methods beyond the highly structured format of DTT. The marriage of ABA principles and principles derived from developmental science has proven to be particularly important and relevant because the ability to diagnose ASD in children at earlier ages has led to an increased number of children receiving early intervention.

DEVELOPMENTAL SCIENCE AND ITS INFLUENCE IN ASD EARLY INTERVENTION In the late 1980s and 1990s, researchers started to think that ASD could be best understood by explaining how the developmental trajectory of children with the diagnosis deviated from that of typically developing children. This perspective was fueled by the emergence of the field of developmental psychopathology (Cicchetti, 1989), which allowed for the scientific study of atypical development. Researchers realized that typical and atypical development are mutually informative and that their understanding of ASD would be enhanced by studying the basic processes that caused development to diverge from typical pathways. This led to a search for the earliest fundamental developmental processes that could explain the core symptoms of ASD. At this time, there was also greater emphasis on longitudinal studies and perspectives. The result was formative work that helped define the core distinguishing early characteristics of ASD. Studies comparing preschool-age children with and without ASD were especially useful in shedding light on some of the early deficits that distinguished children with ASD. Such deficits were found in the areas of social orienting (Dawson, Meltzoff, Osterling, Rinaldi, & Brown, 1998), imitation (Dawson & Adams, 1984; Rogers, Bennetto, McEvoy, & Pennington, 1996), joint attention (Mundy, Sigman, Ungerer, & Sherman, 1986), affective reciprocity (Dawson, Hill, Spencer, Galpert, & Watson, 1990; Yirmiya, Kasari, Sigman, & Mundy, 1989), and responses to emotional cues (Sigman, Kasari, Kwon, & Yirmiya, 1992). Studies of home videotapes showed that young infants who later developed ASD did not orient to name, point, show, or make eye contact, demonstrating the earliest symptoms of ASD by 10–12 months of age (Werner, Dawson, Osterling, & Dinno, 2000). These findings began to shape both the strategies used in early intervention and the targets of intervention. For example, theories of typical development emphasized the active role of the child in constructing both the social and nonsocial world. Researchers found that even young infants learn by forming ideas or hypotheses and then testing these ideas through playing with objects, interacting with people, and using social interaction to test those hypotheses (Saffran, Aslin, & Newport, 1996). Thus, researchers focused intervention methods more on children’s initiation and spontaneity rather than on their response to cues and prompts. Likewise, research on typically developing infants and young children showed that learning is promoted when that learning occurs in the context of an affectively rich social environment, such as social play involving smiling and eye contact (Kuhl, 2007). Research on young children with ASD demonstrated that the disorder is associated with deficits in affective sharing and social motivation

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Overview

(Dawson et al., 1990). Thus, ASD treatments began using strategies to promote affective engagement (e.g., Prizant et al., 2003; Rogers & DiLalla, 1991), or using social emotion to act on and respond to the world. Studies of typically developing infants found that early emerging skills, such as joint attention and imitation, were critical for setting the stage for a wide range of later skills. As a result, early intervention began targeting skills that were fundamental precursors to the development of language, including joint attention (Mundy, Sigman, & Kasari, 1990). As the theoretical frameworks and research findings from the fields of developmental psychology and developmental psychopathology were incorporated into early intervention models, it became clear that they could be readily integrated with the strategies of ABA. This integrated approach improved children’s motivation to learn, speed of acquisition of skills, and ability to generalize newly acquired skills to novel environments. NDBI were the result of this integration of developmental and ABA principles.

INTEGRATION OF BEHAVIORAL AND DEVELOPMENTAL SCIENCES Despite their distinct theoretical foundations, methodologies, and implications for intervention, the fields of behavioral and developmental science came together with the emergence of NDBI (see Schreibman et al., 2015). These interventions incorporated components of both fields, demonstrating that integrating behavioral and developmental sciences had a profound effect. The merging of these two fields led to interventions that are informed by the strengths of each perspective and that better serve the younger ASD population in particular. NDBI essentially are research-based interventions that incorporate well-established behavioral interventions to affect developmentally important and appropriate behavior change. Thus, NDBI ensure that the treatment strategies employed remain guided by understanding of child development. The core elements of NDBI fall into three general areas: the nature of the teaching targets, contexts in which the interventions are delivered, and instructional strategies (see Schreibman et al., 2015). Nature of Teaching Targets The teaching targets selected in NDBI typically come from a broad range of developmental domains, including language and communication, play, social interaction, cognition, and motor skills. The skills are selected based on the cascading effect (i.e., flow or progression from lower level skills toward higher level skills) and the foundational role they play in later development, especially in regard to the core social deficits of ASD. These skills include imitation; shared and reciprocal engagement; joint attention; and functional communication via the use of gestures, facial expressions, and words, among others. Moreover, various domains are targeted concurrently during learning episodes, in contrast to more highly structured methods that may teach each domain separately. This distinction reflects a developmental systems approach, whereby different skills are integrated from the start to promote generalization. Generalization is the use of skills across various people, places, and materials with the ultimate goal of promoting long-lasting and functional use of learned skills in real-world settings. For example, a young child who learns new words while playing kitchen with a therapist would also practice those

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same words during dinnertime at home or during another daily routine. During these activities, the therapist or parent would also incorporate other developmental skills, such as gesture use, imitation, shared engagement, or joint attention. Contexts of Treatment Delivery The empirical literature has provided evidence that children’s experiences affect neurobiological development (Dawson et al., 2012; Knudsen, 2004) and that experiences have a cascading effect on development (e.g., Thelen & Smith, 1994). The contexts in which early learning occurs need to allow children to experience the natural contingencies of their own behavior (Gibson, 1973). For example, asking an adult for help reaching a toy leads to acquiring the toy. Increasing evidence is emerging that learning is enhanced when it is embedded in activities that contain emotionally meaningful social interactions, compared to situations in which instruction occurs without meaningful social engagement (Topál, Gergely, Miklósi, Erdohegyi, & Csibra, 2008). Spelke, Bernier, and Skerry (2013) argued that providing children the opportunity to learn within a socially engaged context sets the stage for them to learn about the social landscape around them. For example, an educator can teach a child about different pieces of furniture by teaching the labels chair or table separately, but learning is improved if a social partner teaches the child while playing house. The child could sit a doll in the chair or put a dish on the table for his or her mother so that the child learns the pieces of furniture within the context of the natural environment. In NDBI, these concepts are brought to fruition through child-initiated and motivation-based (i.e., following the child’s preferences) interactions. These interventions take place during enjoyable play routines and familiar daily routines using a variety of materials. Teaching usually looks and feels like the everyday interactions that are central to toddler experiences. In fact, first-time observers of these approaches have said they do not look like therapy. Parent and family involvement is also common to NDBI because it broadens the context in which teaching occurs and increases the frequency of learning opportunities. Learning opportunities include imitating facial expressions and actions, identifying body parts during bath time with mom or dad, or building shared engagement and social initiations during a game of Peekaboo or chase with the child’s therapist. Skill acquisition has been shown to be more effective in engaged contexts such as these (Dawson et al., 2010; Delprato, 2001). Thus, specific characteristics of learning contexts, including the activities, materials, and quality and emotional valence of the adult–child interaction, contribute toward optimal learning and generalization of newly developing skills. Instructional Strategies Finally, NDBI have in common the use of development-enhancing strategies, which are described in more detail in other chapters. These strategies promote learning and motivation within ecologically valid contexts and routines. At first, the child may learn through highly predictable and salient response–reinforcer sequences. For example, he or she may get to push a car down a steep ramp after making brief eye contact with the play partner. This might later be expanded to following instructions around the vehicle-based activity or even taking turns and sharing

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Overview

enjoyment around that theme with the therapist. By incorporating behavioral strategies, such as modeling, shaping, chaining, prompting, and differential reinforcement, the therapist, teacher, or parent supports the child throughout these activities in the development of expressive communication, receptive language understanding, early cooperative play, and shared engagement. The rewarding value of these child-centered, everyday activities maximizes motivation. Research has also demonstrated a decrease in maladaptive behaviors as they are replaced with more functional, adaptive skills (e.g., Carr & Durand, 1985). These skills are relevant for older individuals as well. Although this feature of NDBI is most commonly utilized in early intervention, researchers and practitioners realize the importance of skills such as imitation and joint attention as foundations for many more advanced skills. For example, joint attention skills are an important component of successful social interaction. Thus, they are good skills for older individuals learning social skills. These skills need to be taught at any age if the individual has not already acquired them. Another key feature of NDBI is that the components can be adapted for any age and any skill area.

EXAMPLES OF NDBI While developing interventions for ASD, several clinical research laboratories independently realized the need for more naturalistic treatments that would greatly expand on the earlier work of Hart and Risley (1968) and increased focus on strategies that would enhance child motivation and improve generalization of learned skills. Thus, these laboratories established distinct NDBI that had several commonalities. Examples include incidental teaching (IT; Hart & Risley, 1968, 1975; McGee, Morrier, & Daly, 1999), Pivotal Response Treatment (Koegel & Koegel, 2006; Koegel et al., 1989; Schreibman & Koegel, 2005), the Early Start Denver Model (ESDM; Dawson et al., 2012; Dawson et al., 2010; Rogers & Dawson, 2010; Rogers, Dawson, & Vismara, 2012), Enhanced Milieu Teaching (EMT; Kaiser & Hester, 1994), Project ImPACT (Improving Parents as Communication Teachers; Ingersoll & Wainer, 2013a, 2013b), and Joint Attention, Symbolic Play, Engagement, and Regulation (JASPER; Kaale, Fagerland, Martinsen, & Smith, 2014; Kaale, Smith, & Sponheim, 2012; Kasari, Gulsrud, Wong, Kwon, & Locke, 2010; Kasari, Kaiser, et al., 2014; Kasari, Lawton, et al., 2014; Kasari, Paparella, Freeman, & Jahromi, 2008). Although this list is not exhaustive, it includes many of the models with the most research, each of which is discussed in greater detail in Chapter 2. Some of the intervention models are comprehensive (i.e., they target a broad range of functioning across multiple developmental domains), whereas others are focused interventions that address specific areas of behavior or development (e.g., social-communication only). The emphasis throughout this book, however, is on the commonalities among these NDBI.

COMMON ELEMENTS OF EMPIRICALLY VALIDATED NDBI As noted previously, all NDBI share common elements that distinguish them from other forms of intervention (see Schreibman et al., 2015). Thus, when a practitioner or parent wishes to determine whether a specific intervention qualifies as one of the NDBI, he or she can look for these common elements (see Box 1.1). (The common elements are covered in more detail in subsequent sections of this book.)

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Ready, Set, Implement! BOX 1.1: What are the common elements of empirically validated NDBI? Core Components • Are based on the well-established principles developed via the science of ABA • Use developmentally based intervention strategies and sequences to guide goal development that is individualized to each child Common Procedural Elements • Have an intervention manual or manuals that clearly specify the procedures of the intervention • Include procedures for assessing treatment fidelity • Involve ongoing measurement of progress during treatment Common Instructional Strategies • Specify how the environment should be arranged to ensure that the child must initiate or interact with an adult in order to gain access to desired materials, favored activities, or familiar routines • Utilize natural reinforcement and other motivation-enhancing procedures • Use prompting and prompt fading during acquisition of new skills • Use balanced turns within teaching routines • Use modeling • Utilize adult imitation of the child’s language, play, or body movements • Work to broaden the attentional focus of the child • Involve some form of child-initiated teaching episodes

Core Components of NDBI This section discusses foundational tenets underlying all NDBI, presented along a continuum of emphasis/degree across NDBI. • All evidence-based NDBI are based on the well-established principles developed via the science of ABA. As might be expected from ABA-based strategies, NDBI all involve the threepart contingency of antecedent → behavior (response) → consequence, which helps the child understand when to respond and ensures that the intervention provides feedback to the child. Although more recent strategies for ASD intervention, such as NDBI, differ in various forms from earlier behavioral interventions, the basic tenets of NDBI are the same as those of their original ABA roots. For example, Skinner’s (1953) work on motivation and Stokes and Baer’s (1977) seminal work on enhancing generalization of intervention effects are well represented in NDBI strategies. Skinner described the contingent application of rewarding events as seminal to the process of acquiring new behaviors.

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Overview

Motivation to respond is enhanced when rewarding events can be anticipated. NDBI utilize strategies that promise these rewards (reinforcers) for responding and thus increase the child’s motivation to respond. Stokes and Baer (1977) described how generalization of acquired behaviors may be enhanced by utilizing a specific set of teaching strategies. To illustrate, a generalization-enhancing strategy is to use multiple examples of materials during training. Thus, when teaching a child the concept of a car, the teacher would utilize cars of various colors, shapes, and sizes to ensure the child learns the general concept of car instead of learning car means a red object of medium size on a specific table. NDBI employ strategies to ensure that the child’s teaching environment contains a variety of stimuli. • Having a base in developmental science, NDBI use developmentally based intervention strategies and sequences to guide goal development that is individualized to each child. Some NDBI are associated with a specific developmental assessment and curriculum (e.g., ESDM; Rogers & Dawson, 2010). In almost all NDBI, goals are developed with the use of standardized assessment, observation, and developmental checklists, which serve to guide the clinician in determining individualized treatment targets across behavior domains. Strategies for assessment and goal development are outlined in detail in later chapters. Common Procedural Elements Common procedural elements are procedures that consistently accompany use of NDBI and should be incorporated throughout implementation of the intervention approaches. Those elements are as follows: • NDBI have an intervention manual or manuals that clearly specify the procedures of the intervention. Research has shown that accurate implementation of an intervention requires adherence to clearly stated procedures (Durlak & DuPre, 2008; Fixsen, Naoom, Blasé, Friedman, & Wallace, 2005; Greenberg, Domitrovich, Graczyk, & Zins, 2005). Manualization helps with consistency of implementation and with training of treatment providers (e.g., clinicians, parents). Some manuals for NDBI are published and thus readily available to the public, whereas others are available primarily in research settings. Of course, clearly described procedures and manualization of intervention are important in ensuring accuracy of implementation, but manuals alone are unlikely to lead to proficiency. Additional training, including coaching and feedback, will be required (Bush, 1984; Cornett & Knight, 2009). • NDBI include procedures for treatment fidelity. Treatment fidelity refers to the degree to which an intervention is being applied correctly, as it was designed (i.e., Gresham, 1989; Rabin, Brownson, Haire-Joshu, Kreuter, & Weaver, 2008; Schoenwald et al., 2011). That is, it indicates that treatment providers are implementing NDBI accurately. This is essential because the evidence base shows that the intervention is effective when implemented according to the manual, but it is unknown how effective the intervention might

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be if it is not accurately applied. Thus, the accuracy of treatment implementation is likely a mediating factor in child outcome, with better outcome likely associated with more accurate treatment implementation (Durlak & DuPre, 2008; Gresham, MacMillan, Beebe-Frankenberger, & Bocian, 2000; Stahmer & Gist, 2001). NDBI provide specific assessment procedures and mastery criteria to allow trainers to assess the level of implementation accuracy by practitioners. • Ongoing measurement of progress during treatment is an essential feature of good treatment and thus a feature of all NDBI. Effective practice must be systematically and objectively verified through appropriate data collection (Simpson, 2005a, 2005b). Data must be collected to track child progress not only to ensure overall treatment effectiveness but also to allow for alterations in treatment procedures or treatment targets if necessary. Although all NDBI have specified procedures for tracking treatment progress, different NDBI emphasize different methods appropriate for their intervention. Data collection methods may include trial-by-trial recording of child responses to each learning opportunity, interval recording of progress during a treatment session, probes of specific behavior, or the use of curriculum-based assessments to examine progress at specific time periods (e.g., monthly, quarterly). Data collection is an essential feature of any intervention based on ABA and should be linked to the child’s treatment goals. If necessary, it should be used to alter intervention to better serve the child’s needs. Common Instructional Strategies Although NDBI vary in terminology and emphasis on each of these strategies, all NDBI share common instructional strategies that comprise the intervention application itself. These strategies are the individual component parts that make up the interventions. • NDBI specify how the environment should be arranged to ensure that the child must initiate or interact with an adult in order to gain access to desired materials, favored activities, or familiar routines. Environmental arrangement refers to how the adult structures the environment to facilitate and encourage child initiation of skills and learning of new target skills. Preferred materials may be visible but placed out of reach to encourage the child to initiate a request for the material (e.g., incidental teaching); in other interventions, a variety of toys or activities are placed in a room and the child is asked what he or she wants (e.g., PRT). Other types of environmental arrangement 1) control access to materials until the child initiates; 2) playfully obstruct where the child initiates to continue the activity; 3) introduce materials that require assistance so that the child must interact with the adult; 4) create expectant waiting, in which the adult looks at the child and waits for an initiative response; or 5) violate a routine, in which the adult changes a familiar sequence of events so that the child must correct the sequence. Some NDBI are quite specific on methods to structure the environment to promote child initiation, whereas others are less specific, dictating that the adult simply must gain the child’s attention while controlling toy access. Adults do not need to arrange the child’s environment in specific ways in NDBI. The variety of ways to promote

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interaction with the child can be used extensively in the child’s natural environment. Thus, if the child is playing in a community park where different objects are present, the treatment provider can use NDBI to promote initiation and interaction, allowing all of the child’s environments to be potentially therapeutic. • NDBI utilize natural reinforcement and other motivation-enhancing procedures. NDBI give the child a good deal of control over a teaching episode, and the child’s choice of stimuli or activities allows for the use of natural reinforcement as a consequence. Reinforcement refers to the strengthening of a behavior and making that behavior more likely to occur, as a result of what happens immediately following that behavior. A natural reinforcer is one that is directly related to the child’s response. For example, if the child wishes to play with a car, access to the car would be contingent on a related response from the child, such as saying “car.” This is in contrast to an indirect or unrelated reinforcer, which is not related to the response. The previous example would exhibit an indirect reinforcer if the child says “car” and the adult reinforces the child with a piece of candy. Candy and saying “car” are not related, whereas saying “car” and gaining access to a car are related. A related motivation-enhancing procedure involves the use of loose reinforcement contingencies, also referred to as reinforcing attempts or loose shaping. This strategy involves allowing for more variability around a correct response such that the child may receive reinforcement for reasonable attempts to respond correctly. Thus, the child receives reinforcement for trying. Overall this procedure typically leads to more reinforcement and thus higher motivation. Different NDBI vary in terms of how closely the child’s response must be to the target response in order for a reinforcer to be delivered. Another strategy used to keep the overall reinforcement level, and thus the child’s motivation, high is interspersal of maintenance tasks. A maintenance task is a skill the child has already mastered (i.e., an easy task). When teaching a new skill, the adult will expect some maintenance (i.e., easier) tasks among acquisition (i.e., new, more difficult) tasks. To illustrate, a child is learning to say the phrase “I want the ball” (i.e., acquisition task). It is new, so it may be challenging at times. To increase the child’s motivation while decreasing frustration, the adult would intersperse trials where the child is asked only to label the ball, a skill already mastered (i.e., maintenance task). This practice also serves to maintain learned skills through presentation of mastered skills while helping the child acquire more advanced skills. Several NDBI specifically require this strategy, whereas others achieve this effect via loose shaping by reinforcing a mastered or maintenance task as an attempt. Some NDBI also require the use of both procedures (e.g., PRT). • All NDBI use prompting and prompt fading during acquisition of new skills. Prompting involves presenting a cue (i.e., visual, verbal, auditory, physical) between an instruction (also referred to as a discriminative stimulus [SD]) and the target behavior being taught in order to evoke the desired response and thus set the context for reinforcement. Prompt stimuli are used to support behaviors not yet in the child’s repertoire or not yet under the control of the SD so they can occur and be reinforced. Again, some NDBI are very specific about how prompts should be used, whereas others are less specific. However, all NDBI require the systematic use of adult prompts to promote new skills.

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• NDBI use balanced turns within teaching routines. This strategy (also known as turn taking, shared control, or reciprocal interactions) involves back-and-forth exchanges in activities or with objects between the child and the adult. Such interactions serve to increase and support the social reciprocity found in many typical social interactions. In addition, this strategy increases maintenance of social interactions as well as allows the adult to control access to materials. Because turn taking involves the back-andforth structure that has been associated with early learning (Harris & Waugh, 2002), its inclusion in NDBI has intuitive merit. However, despite its inclusion in NDBI, its empirical validation as an individual component awaits more research. Not all NDBI emphasize turn taking to the same degree. Some require it as a specific, programmed component of their NDBI, and others emphasize that turn taking occurs within the context of building longer interactions and thus is not specifically programmed. • NDBI use modeling. In modeling, the adult demonstrates a behavior that follows the child’s focus of interest and typically demonstrates the target skill the child should perform. Modeling is often used as a prompt strategy, specifically by the adult to evoke and support the child’s imitation of a modeled action or language. Across NDBI, modeling is used in various ways. Some NDBI use it primarily as a prompt strategy, and others also incorporate it as a general strategy for promoting engagement and enhancing the learning environment outside of specific embedded teaching trials. • NDBI utilize adult imitation of the child’s language, play, or body movements. This strategy is used to increase the child’s responsivity to, and imitation of, an adult, as well as to promote continuation of the interaction. Research indicates that children with or without ASD respond with increased attentiveness when being systematically imitated by the adult (Dawson & Adams, 1984; Ingersoll 2010; Ingersoll & Schreibman, 2006). Again, different NDBI place different emphasis on reciprocal imitation as a specific component strategy, with some models using this strategy to systematically generate a context for embedding teaching trials (as in reciprocal imitation training) and others using it as a general strategy to enhance engagement and enrich the learning environment. • NDBI work to broaden the attentional focus of the child. Early research identified an attentional deficit in many children with ASD, wherein a child’s behavior might only be affected by a small portion of a compound stimulus (e.g., Lovaas, Schreibman, Koegel, & Rehm, 1971). This attention phenomenon is called stimulus overselectivity to denote that the level of selective attention is excessive. For example, one child whose father wore glasses could not identify his father when the father removed the glasses. The child used only a very small portion (glasses) of the compound stimulus (father, made up of many component features) to identify him. It is easy to see how such restricted stimulus control might interfere with learning. More recent research has shown that overselectivity is highly related to developmental level and is not specific to ASD (Ploog, 2010; Reed, Stahmer, Suhrheinrich, &

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Schreibman, 2013). In many cases, it can be modified (e.g., Koegel & Schreibman, 1977), and teaching with multiple examples seems to be key. Because NDBI emphasize teaching in natural and varied contexts with a variety of materials, this natural occurrence of multiple examples may likely help broaden, or normalize, the child’s attentional focus (Dawson et al., 2012; Rieth, Stahmer, Suhrheinrich, & Schreibman, 2014). • One of the most critical features of NDBI is that all NDBI involve some form of child-initiated teaching episodes. This strategy may be called child choice or following the child’s lead. It seeks to take advantage of increased motivation by presenting something highly desired to a child or providing an instruction or opportunity to respond within the context of a child-preferred activity or familiar routine. The child indicates interest in an object or activity by speaking, pointing to, reaching for, or spontaneously engaging in the desired activity, and the clinician provides a teaching opportunity within the activity. Because the child chooses the object or activity involved in the teaching interaction, the child’s successful achievement of his or her goal is the positive consequence for the child’s use of the target skill set up by the adult. The degree to which the child must initiate a teaching episode varies across NDBI, with some models focusing primarily on child initiations (e.g., incidental teaching) and other models balancing child initiations with adultinitiated teaching episodes (e.g., PRT, Project ImPACT).

CONCLUSION ASD has historically been the focus of intense interest and intervention strategies. The development of treatments based on the science of ABA provided the first successful treatment for ASD. These behavioral interventions initially focused on a discrete trial model of implementation wherein skills were broken down into smaller components and taught via a successive series of discrete trials. Although effective, and indeed a substantial change for ASD intervention, subsequent research identified some important limitations of DTT treatments. In response to these limitations, behavioral treatments expanded and became more naturalistic. This included teaching in the child’s everyday environments, teaching skills likely to be maintained in the child’s everyday environment, and using the child’s motivation. In addition, the ASD field changed as younger children began being diagnosed and the importance of developmental science became apparent when early social and other behavioral deficits became the focus of treatment. Thus, the fields of behavioral psychology and developmental psychology have joined to inform a set of interventions called NDBI. NDBI are composed of a number of specific interventions that include required components and procedures. Thus, the concept of NDBI provides for parsimony of distinct intervention models (e.g., PRT, ESDM, JASPER) and allows for a clearer appreciation and understanding by families, professionals, insurance carriers, and others. It is essential that researchers and clinicians self-identify their particular intervention as one of the NDBI. To be identified as such, however, requires that the intervention has strong empirical support and incorporates the requirements described in this chapter.

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Chapter 2 provides a short overview of NDBI models. Sections II–IV offer more specifics of NDBI concepts, requirements, and intervention procedures. This book focuses in detail on how NDBI are implemented and evaluated as treatment strategies for individuals with ASD and other developmental disabilities.

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2 Considering NDBI Models Mendy B. Minjarez, Yvonne Bruinsma, and Aubyn C. Stahmer

C

hapter 1 clarifies what constitutes Naturalistic Developmental Behavioral Interventions (NDBI) and provides conceptual history and background. This chapter presents key NDBI models with a condensed synopsis of the empirical support and a short overview of the characteristics of each model. Each included NDBI model meets two criteria: 1) a manual or enough literature was available to adequately describe the model, and 2) the model itself or its core components were considered evidence-based practices (Wong et al., 2015) or established interventions (National Autism Center, 2015) or they had other strong evidence (e.g., Kasari, Gulsrud, Paparella, Hellemann, & Berry, 2015). This chapter is not necessarily an exhaustive review of all NDBI models or all models that use NDBI components; rather, it is a representative sample of models that met the two criteria. Indeed, there are a number of additional models that use strategies consistent with NDBI; for example, the Social Communication, Emotional Regulation, and Transactional Support (SCERTS) Model (Prizant, Wetherby, Rubin, Laurent, & Rydell, 2006; Rubin, Prizant, Laurent, & Wetherby, 2013); Developmentally Appropriate Treatment for Autism (Project DATA; Sandall et al., 2011; Schwartz, Ashmun, McBride, Scott, & Sandall, 2017; Schwartz, Thomas, McBride, & Sandall, 2013); Social ABCs (Brian, Smith, Zwaigenbaum, Roberts, & Bryson, 2016; Brian, Smith, Zwaigenbaum, & Bryson, 2017); and Learning Experiences: An Alternative Program for Preschoolers and Parents (LEAP; Strain & Bovey, 2011; Strain & Hoyson, 2000). The example models included here are presented in alphabetical order.

EARLY START DENVER MODEL A key NBDI model meeting the criteria is the Early Start Denver Model (ESDM). ESDM is a comprehensive treatment model for children with autism spectrum disorder (ASD) younger than age 5 and their families. Developed in the 1980s, the

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original Denver model (Rogers, Herbison, Lewis, Pantone, & Reis, 1986) continues to shape the current model in several important ways. These include the multidisciplinary team approach, the use of sensory social routines, the involvement of parents as stakeholders, and the use of a developmental curriculum to identify skill deficits. The Denver model also includes the idea of interpersonal development in ASD (Rogers & Pennington, 1991), which describes the ASD skill deficits in a developmental framework and emphasizes the lack of affective sharing and imitation in children with ASD. Some of the same theories inform the social motivation hypothesis of ASD (Dawson et al., 2004; Dawson et al., 2002), which is also important to ESDM. This hypothesis suggests that the social reward system in the brain is compromised, resulting in children with ASD receiving limited reinforcement from social engagement. The focus on this idea leads ESDM to specifically target social engagement and motivation and to continually increase the salience of social rewards within interactions. These ideas were integrated with the science of learning via the incorporation of Pivotal Response Treatment (PRT; e.g., Koegel et al., 1999). PRT principles, discussed in greater detail later in the chapter, support initiative, spontaneity, and social motivation through an emphasis on natural reinforcers within social interactions. The resulting NDBI model was coined the ESDM in recognition of the extension of the work down to toddler-age children. Empirical Support The ESDM is supported by a number of empirical studies that demonstrate efficacy. In 2010, Dawson and colleagues conducted a randomized controlled trial, which provided the most methodologically rigorous support of ESDM. This study followed 48 toddlers (age range 10–30 months at intake) over 2 years. The children were randomly assigned to the intervention or control group. Families received training and delivered 5 or more hours of intervention per week. In addition, each child in the ESDM treatment group received 20 hours of ESDM from a clinician. Data from this study indicated that children in the treatment condition demonstrated significant gains in IQ score, adaptive behavior, and communication skills and experienced reductions in ASD symptoms. These treatment gains were also correlated with more normalized electroencephalogram (EEG) activity (Dawson et al., 2012), suggesting that ESDM did in fact change neural pathways in ways that affected social attention and engagement. Furthermore, data from a follow-up study assessing the same groups of children 2 years post treatment suggested that the ESDM treatment group not only maintained initial treatment gains in multiple domains of functioning but also improved core ASD symptoms (Estes et al., 2015). This finding is especially interesting because the ESDM treatment group did not demonstrate reduced core ASD symptoms immediately following treatment, thus indicating a possible long-term benefit to this type of early intervention. A number of additional studies reported strong outcomes for ESDM as a parentmediated intervention. These include outcomes for a short-term, low-intensity parent education program for toddlers (Rogers et al., 2012) and infants (Rogers et al., 2014), outcomes of ESDM implementation in a child care setting (Vivanti et al., 2014), and outcomes following an intensive 4-day workshop in ESDM for community practitioners (Vismara, Young, & Rogers, 2013). Please see Ryberg (2015) for a comprehensive review and discussion of research related to the ESDM model.

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Core Components As outlined previously, ESDM is a multidisciplinary intervention that draws strategies and frameworks from multiple models. The core teaching strategies are a combination of general Applied Behavior Analysis (ABA), PRT, and the original Denver model. These strategies complement each other because they address different facets of a comprehensive model. ABA teaching strategies include using the antecedentbehavior-consequence (A-B-C) format for teaching, prompting, shaping, and chaining. Challenging behaviors that do not decrease as communication increases are addressed using functional behavioral assessment and teaching replacement behaviors. PRT techniques address the social motivation component by reinforcing attempts, alternating easy and difficult tasks (i.e., interspersal of maintenance and acquisition tasks), using natural reinforcers, using turn taking, using clear prompts, incorporating child-selected activities, and following the child’s lead. Teaching strategies from the original Denver model add the relationship component, focusing on affective sharing and relationship building. These strategies include adults providing sensitive and responsive interaction; using positive affect; and regulating and optimizing the child’s readiness for learning in terms of affect, attention, and arousal. Teaching is conducted within joint activity routines that include following a child into an activity, setting up a theme or action with the child, varying the theme, and finally, closing the activity together (e.g., putting away the toys) and making the transition to a new one. In addition, the interdisciplinary focus leads to incorporation of specific communication teaching strategies, often used by licensed speech and language therapists. These strategies include providing many and varied language and play opportunities and supporting transitions. Teaching goals are derived from the ESDM curriculum tool, which guides the developmentally appropriate content of the intervention. Relationship to Other NDBI The ESDM is an excellent example of a comprehensive treatment model that truly balances the behavioral and developmental principles that are the hallmark of NDBI. The ESDM has published a manual, and highly qualified trainers provide ongoing workshops to promote high-quality community implementation as much as possible. It has methods for measuring treatment fidelity, as well as parent coaching methods, and includes methods for collecting ongoing data to evaluate and monitor child progress. In addition, a curriculum checklist is used to identify developmentally appropriate goals across areas of development. It uses all of the teaching strategies identified as central to NDBI models.

ENHANCED MILIEU TEACHING Initially developed as an intervention program for young children with intellectual disability and language delays (Hancock & Kaiser, 2006; Kaiser, Hancock, & Trent, 2007), Enhanced Milieu Teaching (EMT) has also been applied extensively to children with ASD who are preverbal (Kasari, Kaiser, et al., 2014) or have some foundational language skills (Hancock & Kaiser, 2002; Kaiser & Robert, 2013). Like other NDBI, EMT is a blended approach that combines strategies from ABA (incidental teaching [IT], natural language paradigm, and milieu teaching; Hancock & Kaiser, 2012)

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with developmentally based strategies such as responsiveness, modeling, and expansions (Kaiser & Hampton, 2017). It has been described in the literature as a contemporary ABA model (Corsello, 2005; Ogletree, Oren, & Fischer, 2007; Prizant, Wetherby, & Rydell, 2000) as well as a developmental pragmatic communication approach (Hancock & Kaiser, 2012). EMT strategies are infused into daily routines, including play and daily living sequences, with a special focus on teaching the child to initiate communication and play skills. EMT can be implemented by therapists (Hancock & Kaiser, 2002), parents (Kaiser, Hancock, & Nietfeld, 2000; Roberts & Kaiser, 2012; Wright & Kaiser, 2016), and educators (Kaiser & Hester, 1994) in a range of settings, including classrooms (Kaiser & Hester, 1994). Although the intervention may be less intensive compared to traditional ASD treatment programs, the parent education emphasis ensures a high number of overall treatment hours and provides parents with skills that they can continue to implement over time. EMT research has explored a combination of interventions by therapists and parents at the same time (Kaiser & Roberts, 2013; Roberts & Kaiser, 2012, 2015). This approach was the result of research suggesting that, although the use of trained therapists resulted in faster language acquisition for some children, parent implementation of EMT resulted in better generalization to the home environment (Kaiser et al., 2000). In general, communication interventions implemented by therapists and parents show the largest effects on spoken language (Hampton & Kaiser, 2016). Empirical Support A substantial body of literature suggests strong evidence for the effectiveness of EMT with a variety of providers, populations, ages, and skill levels (Hampton, Kaiser, & Roberts, 2017; Hancock & Kaiser, 2006, 2012; Kaiser, Hancock, et al., 2007; Kaiser & Roberts, 2013; Kaiser, Scherer, Frey, & Roberts, 2017; Roberts & Kaiser, 2015; Wright & Kaiser, 2016). In addition, several studies have demonstrated that skills acquired during EMT generalize to other settings and communicative partners (Hancock & Kaiser, 2002; Kaiser et al., 2000; Kaiser & Roberts, 2013). Research also supports reductions in problem behaviors associated with communication gains in the context of EMT intervention for preschoolers (Curtis, Roberts, Estabrook, & Kaiser, 2017; Hancock, Kaiser, & Delaney, 2002). EMT has also been combined with Joint Attention, Symbolic Play, Engagement, and Regulation (JASPER) and speech-generating devices (Almirall et al., 2016; Kasari et al., 2014; Olive et al., 2007) to specifically support the development of joint attention, communication, and play skills of children who are preverbal. In addition, specific EMT components enjoy strong empirical support from a variety of sources. These include, but are not limited to, following the child’s lead (e.g., Kern et al., 1998), turn taking (Ingersoll & Dvortcsak, 2010), imitation (Ingersoll & Dvortcsak, 2010; Rogers, Dawson, & Vismara, 2012), contingent responsiveness (e.g., Tamis-LeMonda & Bornstein, 2002), expansions or recasts of child language (e.g., Camarata, Nelson, & Camarata, 1994; Cleave, Becker, Curran, Van Horne, & Fey, 2015), reinforcement, time delays (Halle, Marshall, & Spradlin, 1979), and prompting. Core Components EMT consists of four components: environmental arrangements, responsive interaction, specific language modeling and expansions, and milieu teaching prompts

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(Hampton & Kaiser, 2016). Environmental arrangements are ways in which adults optimize the child’s surroundings to create learning opportunities. Adults may give children choices between or among play materials that provide opportunities for interaction and learning. They typically exclude from the environment materials that invite independent play. They preselect materials that can easily be adapted into routines and use them to establish and then extend play schemes. Responsive interaction in EMT refers to the ability of the parent or therapist to connect with the child emotionally. Following the child’s lead, mirroring nonverbal actions (sometimes referred to as synchronization; Harrist & Waugh, 2002), and turn taking are examples of responsive interactions that provide the context and the interaction in which teaching is optimized. Communication skills are a core focus of EMT. Adults model and expand on language and use specific prompting to reinforce and shape verbal behavior. They sometimes use visual supports to assist children with ASD and echolalia. Finally, EMT takes special care to ensure children can develop independent language and do not become prompt dependent or prompt resistant (Hancock & Kaiser, 2012). Relationship to Other NDBI EMT is a packaged intervention similar to other NDBI, firmly rooted in ABA and developmental frameworks. EMT is primarily used in the research setting and has been adequately described in book chapters; however, an instructional manual is not yet available to the wider public. In an environment optimized for learning, therapists implementing EMT use reinforcement contingencies, prompting and fading strategies, and shared control strategies. Therapists model appropriate language targets and mirror child actions and behaviors to ensure synchronous interactions and affective engagement. Data are collected throughout the program, both on child target behaviors and treatment fidelity. Parents learn EMT strategies and are stakeholders in the treatment.

INCIDENTAL TEACHING/WALDEN TODDLER PROGRAM The original pioneering work on IT was conducted by Todd Risley and Betty Hart (Hart & Risley, 1968, 1975). The initial focus of IT was on reducing language delays in preschoolers from disadvantaged backgrounds and preschoolers who experienced delays (e.g., Hart & Risley, 1975) but was quickly expanded to other skill deficits and populations. Gail McGee and colleagues (McGee, Morrier, & Daly, 1999) subsequently utilized IT as the foundation for their Walden Toddler Program at Emory University. We use the Walden Toddler Program to illustrate IT as an NDBI model because it is a comprehensive and well-described example. However, IT is a more general group of teaching strategies that is not synonymous with the Walden Toddler Program only. The Walden Toddler Program is a full inclusion preschool program for students with ASD. Students receive instruction for 4 hours per day. In addition, families receive weekly parent training (up to 4 hours) and commit to at least 10 hours per week of home implementation. At school, IT episodes are interspersed throughout all activities, and the environment is arranged to optimize the possibility of child initiations, a core feature of IT. Although IT is often generally described as an intervention focused on the development of verbal communication, the Walden Toddler

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Program specifically notes targeting a variety of developmentally appropriate skills (e.g., toy play, daily living skills, gross motor skills) (McGee et al., 1999). In addition, like other NDBI, it places a particular emphasis on the social connection between the child with ASD and others: social responsiveness to adults, social tolerance of peers, and peer imitation and (parallel) play. Empirical Support IT as a general strategy has broad and substantial empirical support, especially in the improvement of expressive and receptive communication. IT has been successfully used to target early language development (Haring, Neetz, Lovinger, & Peck, 1987; McGee et al., 1999), as well as specific language abilities, such as use of adjectives (Hart & Risley, 1968), preposition use (McGee, Krantz, & McClannahan, 1985), and receptive labeling (McGee, Krantz, Mason, & McClannahan, 1983). IT has also shown success for increasing spontaneous speech (Charlop-Christy & Carpenter, 2000) and has been used to address social pragmatic skills, such as social phrases (McGee & Daly, 2007) and child initiations (Ryan, Hemmes, Sturmey, Jacobs, & Grommet, 2008). Research has also addressed the use of IT to target broader social behaviors, such as reciprocal interactions with peers (McGee, Almeida, SulzerAzaroff, & Feldman, 1992) and assertiveness (McGee, Krantz, & McClannahan, 1984). Research on IT has also been extended to academic skills, such as sight reading, with good success (McGee, Krantz, & McClannahan, 1986). The Walden Toddler Program, developed by McGee and colleagues at Emory University, was originally funded as a model demonstration grant by the U.S. Department of Education. Although much empirical support exists for IT, only one study reported empirical support for the Walden Toddler Model specifically. In this seminal study, 28 children with ASD received an average of 30 hours per week of IT through a combination of center-based and in-home intervention (McGee et al., 1999). Prior to starting the Walden Toddler Program, 36% of the participating children had some form of expressive communication, which was primarily stereotyped. After participating in the Walden Toddler Program, 82% of the children were functionally using meaningful expressive verbalizations. Core Components The Walden Toddler Program has a number of core principles that drive decision making in the design and implementation of intervention. These principles are aligned with best practices in intervention for children with ASD and are shared with other NDBI. Some examples include focus on parent involvement, inclusion with typically developing peers, and use of specific strategies to increase child motivation and engagement (McGee et al., 1999). In addition, the Walden Toddler Model developed a distinctive curriculum with input from professionals from a variety of disciplines. Another unique component to this program is the organization of the preschool classroom into specific teaching zones that are conducive to ongoing learning related to specific sets of goals per zone. Teachers are deployed by zone and ensure opportunities for learning are presented when the child shows interest. In addition to this initiation-based learning, children receive short bursts of more intensive one-on-one teaching, thus ensuring enough trials are completed to maintain intervention intensity.

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The Walden Toddler Program employs core IT strategies that focus on remediating the lack of initiations in children with ASD. During all teachable moments, IT specifies the following steps: 1) the adult establishes the environmental arrangement, 2) the adult waits for the child to initiate engagement for the teachable moment, 3) the adult prompts the response if necessary, 4) the adult reinforces the child’s correct response with access to the desired item or activity, and 5) the adult fades the prompting level or support as the child gains mastery. McGee and colleagues referred to these steps as “wait-ask-say-show-do.” In addition, IT incorporates a variety of ABA teaching strategies, some of which were mentioned previously, including the use of natural reinforcement, errorless learning, shaping, prompting sequences, and modeling. Relationship to Other NDBI Consistent with other NDBI models, IT is firmly rooted in the principles of ABA while delivering intervention in the natural environment using a developmental framework. The Walden Toddler Model has been replicated several times, but a published instructional manual is not yet available, hindering broader implementation. IT models, such as the Walden Toddler Model, utilize data for ongoing clinical evaluation, have methods for assessing treatment integrity, and use most of the NDBI teaching strategies, with somewhat more focus on behavioral strategies. IT was one of the earliest interventions to emerge with a focus on enhancing motivation and skill generalization through teaching in the natural environment using natural reinforcers. The most unique feature of IT in comparison to its fellow NDBI models is its emphasis on child-initiated teaching interactions.

JOINT ATTENTION, SYMBOLIC PLAY, ENGAGEMENT, AND REGULATION JASPER is a targeted social-communication intervention for very young children with ASD and older prelinguistic individuals with ASD (Kasrai, Freeman, & Paparella, 2006; Kasari, Paparella, Freeman, & Jahromi, 2008). Developed by Connie Kasari at the University of California, Los Angeles, JASPER is likely the NDBI model most firmly rooted in developmental strategies. JASPER focuses particularly on the foundations of social-communication, especially joint attention and play (Kasari et al., 2008). JASPER targets increasing all social-communication behaviors but especially the spontaneous use of joint attention initiation (e.g., coordinated joint looking, showing and giving objects to share interest, and pointing to show or request). It utilizes toy play not only as a context for teaching but also as an important intervention goal. In addition, JASPER highlights the need for regulation as an important prerequisite for learning. JASPER uses a combination of active strategies to promote engagement (e.g., imitating and modeling language, play and affect) and matches the child’s skill level and frequency of communication behaviors, strategies that leave room for child spontaneous initiation of social, communication, and play behaviors. Empirical Support A series of randomized controlled trials have emerged in the literature supporting the use of JASPER with very young children with ASD (Kasari et al., 2006;

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Kasari et al., 2005; Kasari, Gulsrud, Wong, Kwon, & Locke, 2010). To date, empirical evidence supports that JASPER is useful for teaching joint attention, symbolic play, language, and engagement to children ranging from 12 months to 8 years of age (Kasari et al., 2006; Kasari et al., 2015; Kasari, Kaiser, et al., 2014). Its application extends beyond clinicians, to parents, teachers, paraprofessionals, and other primary caregivers (Gulsrud, Hellemann, Shire, & Kasari, 2015; Kasari et al., 2010). Randomized controlled trials of JASPER have demonstrated its effects across several areas of development. For example, in an early randomized controlled trial, Kasari, Freeman, and Paparella (2006) demonstrated that children who received a joint attention–focused intervention had significant increases in showing behaviors, initiation, and response to joint attention compared to controls and that children who received a symbolic play intervention had more diverse symbolic play and higher play levels than controls. These findings have been replicated (Kasari et al., 2010) and also extended to demonstrate increases in expressive language skills following joint attention and symbolic play interventions (Kasari et al., 2008). JASPER has also used speech-generating devices in conjunction with other treatments, such as EMT to target communication skills in minimally verbal children with ASD (Kasari et al., 2014). These findings support the use of this combination of interventions with older children (ages 5–8 years) who are minimally verbal because participants gained spontaneous communicative utterances, novel words, and comments. Several studies have also examined the effectiveness of teaching caregivers to implement JASPER with good success (Kasari et al., 2015), including with families who were considered “low-resourced,” such as those living in poverty (Kasari, Lawton, et al., 2014). Another study evaluated implementation of JASPER in a preschool program and demonstrated that play diversity improved and also generalized from the treatment setting to the classroom (Goods, Ishijimi, Chang, & Kasari, 2013). These studies suggest strong potential for successful dissemination of JASPER to settings and populations that have been traditionally harder to reach, such as classroom settings and families who are low-resourced. Core Components JASPER places a primary emphasis on remediating the foundational socialcommunicative behaviors that are absent or severely compromised in children with ASD. To accomplish this, JASPER focuses on four interrelated core components: 1) joint attention, 2) symbolic play, 3) engagement, and 4) regulation (Kasari et al., 2015). Joint attention (i.e., the coordination of attention between objects and people for purposes of sharing) can manifest in many ways (e.g., coordinating eye contact between a person and object, pointing to share, commenting; Kasari et al., 2010; Kasari et al., 2008). The techniques of JASPER not only emphasize bids of joint attention through modeling but also directly teach children how to demonstrate joint attention behaviors during play routines. Consistent with research in neurotypical children, as children with ASD learn to engage in joint attention, their engagement, communication, and learning improve (Charman et al., 2005; Mundy, Sigman, & Kasari, 1990). In terms of symbolic play, JASPER emphasizes improving the diversity and complexity of each child’s play abilities, using functional play to build up to symbolic exchanges. The play aspect of JASPER is formulaic. Although it may

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appear like simple play on the surface, the intervention taking place to target play includes a range of complex strategies and targets. Although the main focus in the intervention is object play, sometimes play without toys is recommended. Described as person-engaged play, this skill can be targeted with children who lack object play skills and can also be alternated with object play to provide periods of less demanding play that can be alternated with more difficult toy play. The focus on play has a twofold purpose in the JASPER model. The intervention targets play as the venue for learning socialization and language, but it also targets teaching play skills. Language and verbal communication goals are not targeted with the same intensity and core focus in JASPER as they are in other NDBI models; however, language is nonetheless directly and indirectly targeted during play interactions. Techniques used to scaffold language development in JASPER include the adult responding to all of the child’s functional communication attempts, the adult modeling language at the child’s level plus one step above (similar to ESDM), and the adult providing some direct prompting for language, although this is used sparingly. Language goals are typically focused on requesting and use of language for joint attention. JASPER targets engagement by using scaffolding to help the child move from inattentive and/or solitary focus on objects to states of sustained joint engagement with others. Related to this is regulation, which emphasizes techniques to reduce self-stimulatory behaviors that interfere with the direct development of the other three core components. Indispensable to JASPER is the inclusion of caregiver training (e.g., parents, teachers) to ensure generalization and maintenance. The key caregivers or interventionists implementing JASPER must learn how to effectively use environmental arrangements to promote engagement, effectively use modeling and imitation, and expand language and play behaviors. Basic elements of each intervention session include adults 1) adjusting the environment (i.e., activities, routines, toy choices) to match the child’s interests 2) responding to the child’s communication bids (all are treated as functional); 3) modeling joint attention, expressive communication, and symbolic play; 3) expanding the child’s joint attention, language, and play behaviors; 4) pacing adult language and play behavior to mirror the child’s; and 5) using prompting procedures (using the least-to-most method) to evoke episodes of joint attention, language, and play. The therapist uses general strategies common with other NDBI, including environmental arrangements, following the child’s lead, imitation of the child’s actions on toys and language, and prompting strategies to scaffold targeted behaviors. JASPER is promoted as complimentary to other behaviorally based ASD interventions (e.g., Kasari et al., 2014), as well as easily incorporated into inclusive and special education classroom settings (e.g., Goods et al., 2013). JASPER also emphasizes parent involvement and implementation across daily routines and activities. Developmentally appropriate toys and activities must be used during intervention sessions. Relationship to Other NDBI Unlike most NDBIs, JASPER does not identify itself as a comprehensive treatment model but rather a focused intervention specifically designed to improve socialcommunication, play, and engagement. In fact, in several studies, it has been used

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in conjunction with EMT or discrete trial teaching to enhance learning (e.g., Kasari et al., 2014). Gains in these areas are not collateral; they are the direct result of precise intervention implementation. Its evidence base suggests strong support for teaching joint attention and engagement skills early on because it predicts later language use. Project ImPACT (discussed later) is one of the few other models that focuses on specific strategies for teaching joint attention through parent education, making these two models unique from other NDBI. Finally, the fact that JASPER has more than 15 years of research and numerous clinical trials validating its treatment effectiveness merits recognition. JASPER draws on the ABA literature for many of its teaching strategies but clearly has a developmental focus. For example, JASPER’s building blocks include child-centered intervention (i.e., following the child’s lead), teaching in the natural environment with developmentally appropriate toys, natural reinforcement, family involvement, and learning opportunities across daily routines and activities. JASPER uses ongoing data collection to measure child progress and has individualized goals. An internal manual is currently in press for wider dissemination, which will include treatment fidelity measures.

PIVOTAL RESPONSE TREATMENT Pivotal Response Treatment (PRT), also called Pivotal Response Training, is grounded in the same combination of ABA and developmental theory as other NDBI models. It focuses on embedding behaviorally based, contingent teaching trials in natural interactions, activities, and routines rather than working in a structured format, as in discrete trial teaching. In PRT, parents, caregivers, educators, and therapists learn to embed these teaching trials across as many of the child’s waking hours as possible. As such, this model emphasizes ongoing embedded teaching trials, as opposed to targeted therapy sessions. PRT rests on the premise that certain “pivotal” areas can be targeted that will result in widespread gains in untargeted areas (Koegel et al., 1999), such as reductions in challenging behavior (Koegel, Koegel, & Surratt, 1992) and improvements in initiation behaviors (Koegel, Koegel, Shoshan, & McNerney, 1999). The primary pivotal area is motivation, and the PRT principles heavily focus on the application of behavioral teaching principles while maintaining child motivation. Motivation is often cited as a core deficit in ASD (Dawson, Webb, & McPartland, 2005; Rogers & Dawson, 2010); therefore, targeting this area is considered critical in remediating the core deficits and engaging children in meaningful learning opportunities (Rogers & Dawson, 2010). Other pivotal areas discussed in the literature include broadening attentional focus through varied cues and teaching materials (Reith, Stahmer, Suhrheinrich, & Schreibman, 2015; Schreibman & Koegel, 1982, 2005), teaching initiation behaviors, and learning self-management skills (Genc & Vuran, 2013). PRT has seven components, which are designed to target motivation and maintain strong treatment fidelity (e.g., clear prompts, contingent and immediate reinforcement). PRT places equal emphasis on maintaining motivation and engagement and embedding teaching trials such that the pace and difficulty level of teaching are constantly individualized based on a child’s skills and motivation. In addition, instructional cues and materials are varied to help children broaden their attention and generalize learning from the outset (Schreibman & Koegel, 1982, 2005). PRT historically has been taught to parents as the primary agents

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of intervention (e.g., Koegel, Bimbela, & Schreibman, 1996); however, alternative models of PRT have been developed, such as classroom PRT (CPRT; Suhrheinrich, Stahmer, & Schreibman, 2007). Parent education in PRT is typically conducted during sessions with a therapist and parent–child dyad over a number of sessions that has ranged in the literature from 10 sessions to treatment that is ongoing over years. Short-term and group models of PRT have also emerged and are gaining popularity due to their ease of dissemination compared to models that require more clinician support (e.g., Hardan et al., 2015; Minjarez, Williams, Mercier, & Hardan, 2011). Empirical Support PRT is considered an established intervention (National Autism Center, 2015) and an evidence-based practice (Wong et al., 2015). Empirical support for PRT has primarily been derived from single-case design studies demonstrating its efficacy in teaching a range of social, communication, and play behaviors (Cadogan & McCrimmon, 2015). For example, PRT has been associated with improvements in question asking (Koegel, Camarata, Valdez-Menchaca, & Koegel, 1998), increased number and length of utterances (Koegel, Carter, & Koegel, 2003), spontaneous language (Koegel et al., 2003), vocabulary, and functional communicative utterances (Hardan et al., 2015; Minjarez et al., 2011; Symon, 2005). In the social realm, PRT has demonstrated efficacy in targeting peer interactions (Boudreau, Corkum, Meko, & Smith, 2015; Koegel, Kuriakose, Singh, & Koegel, 2012), social initiations (Koegel et al., 1999; Pierce & Schreibman, 1997), conversation skills (Genc & Vuran, 2013), and engagement. Play skills have also been successfully targeted (e.g., Stahmer, 1995; Stahmer, Ingersoll, & Carter, 2003). PRT also has support as an intervention for reducing challenging behaviors (Koegel et al., 1992; Koegel, Stiebel, & Koegel, 1998) and repetitive behaviors (Koegel & Koegel, 1990). This is primarily done through a combination of functional communication training using PRT strategies and other behavior analytic methods, such as manipulation of antecedents and extinction. Various individuals have learned to implement PRT techniques. The majority of PRT studies have focused on parent education models and have demonstrated that parents can successfully learn these strategies and have a positive impact on their child’s treatment goals (Hardan et al., 2015; Koegel et al., 1996; Koegel, Symon, & Kern Koegel, 2002; Minjarez et al., 2011). Research has also supported that parents experience positive impact as a result of this training, including improvements in stress and empowerment (e.g., Minjarez et al., 2013). Paraprofessionals, including those who work in schools and in-home child care providers, have also been trained successfully (Kim, Koegel, & Koegel, 2017; Koegel, Kim, & Koegel, 2014; Symon, 2005). One study even demonstrated that parents who were trained by PRT clinicians could then successfully train their own paraprofessionals, such as child care providers (Symon, 2005). Classroom PRT has increasing empirical support as well for targeting a range of social, communication, and academic skills (Stahmer, Suhrheinrich, & Rieth, 2016; Suhrheinrich, 2015; Suhrheinrich, Stahmer, & Schreibman, 2007) by training teachers to embed PRT strategies in the classroom. Peers have also successfully learned PRT, primarily to target social-communication and play behaviors, often in classroom settings (e.g., Harper, Symon, & Frea, 2008; Pierce & Schreibman, 1997).

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Brief and group-based models of PRT have also emerged. Several studies have demonstrated efficacy of short-terms models, including workshops (e.g., Bryson et al., 2007) and short courses of therapy (e.g., Coolican, Smith, & Bryson, 2010; Smith et al., 2010). A short-term group model of PRT has also emerged in the literature, showing efficacy of this model, which was associated with parent acquisition of PRT skills and meaningful changes in child verbal communication skills (Gengoux et al., 2015; Hardan et al., 2015; Minjarez et al., 2011). Core Components In PRT, the adult providing the intervention is encouraged to embed as many teaching trials as possible in his or her natural interactions with the child while also balancing the need to maintain motivation and engagement. A teaching trial consists of a four-part sequence, in which the adult 1) follows the child’s lead and gains shared control over the identified reinforcer, 2) gives a cue and/or prompt to evoke the target behavior, 3) waits until a behavior is evoked, and 4) provides reinforcement contingent on the behavior. This sequence follows the typical behavior analytic A-B-C format. There are seven core components of PRT, which are primarily behavior analytic in nature but also focus on enhancing motivation during teaching interactions: 1) child attention and clear prompts, 2) task variation (interspersal of maintenance and acquisition tasks), 3) following the child’s lead and gaining shared control, 4) immediate and contingent reinforcement, 5) natural reinforcement, 6) reinforcing attempts (i.e., a loose shaping contingency), and 7) broadening children’s attention through varying the instructional cue and materials used to teach each goal. Relationship to Other NDBI As with all NDBI, by definition, PRT combines behavior analytic teaching methodology with developmental principles and embeds teaching in the natural context. PRT balances motivation and engagement with embedding of contingent learning trials with about equal focus. When using PRT, the adult must constantly gauge the child’s motivation in order to modify the pacing and difficulty level of demands being placed. Like other NDBI, motivation and engagement are core areas of focus and are considered a prerequisite for embedding trials; however, PRT has more focus on the number of trials and encourages as many trials as possible during the child’s waking hours. In contrast, some NDBI models have decreased emphasis on explicit demands and focus more on sustained engagement (e.g., JASPER).

PROJECT ImPACT Project ImPACT (Improving Parents as Communication Teachers) was developed by Brooke Ingersoll and Anna Dvortcsak as a short-term parent education program focused on teaching social-communication to children with ASD. The program was published in 2010 as a manual and practitioner’s guide and can easily be implemented by most practitioners with a background in ABA and an understanding of developmental principles (Ingersoll & Dvortcsak, 2010). A parent trainer must meet treatment fidelity standards, which are clearly described and included in the published manual. Parent trainers should be able to use the program’s techniques fluently, as well as be able to provide constructive feedback to a parent in the moment.

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This parent training program is appropriate for children with ASD and socialcommunication delays between the ages of 18 months and 6 years. Written by a speech therapist and a psychologist who is also a Board Certified Behavior Analyst (BCBA), Project ImPACT is a practical and user-friendly program. The focus on parents as providers of intervention is well supported by decades of research and is especially important in terms of sustainability of intervention gains. Empirical Support To date, two publications show strong empirical support for this parent education program, and many of its components are supported in literature reviews of targeted behavioral interventions (e.g., Kasari et al., 2006). In a multiple baseline design study across eight participating dyads, all parents improved in their use of the techniques during the parent education intervention and met treatment fidelity after 6 weeks (Ingersoll & Wainer, 2013a). Sessions in this study were once per week. In addition, the data showed a significant positive correlation between parent treatment fidelity and child spontaneous language, suggesting that if the parent improved in his or her use of the techniques, correlated gains in child spontaneous language were observed. In a more methodologically rigorous study (Stadnick, Stahmer, & BrookmanFrazee, 2015), researchers compared child and parent outcomes between intervention and control groups for 30 dyads in community settings. Children in the intervention group showed significantly greater gains in communication when compared to the control group. In addition, as in the first study, a positive relationship was found between parent treatment fidelity and improvement in child communication skills. In contrast, some data suggested that parents with very high stress levels may not benefit from this intervention as much because their children progressed less. Findings of this nature require further study to better understand the nature of these outcomes. Project ImPACT has also been implemented in preschool settings (Ingersoll & Wainer, 2013b), where teachers implemented the intervention with parent–child dyads. Findings demonstrated that parents significantly improved their use of treatment strategies from pre- to postintervention, and children increased their rate of language during a home-based parent–child interaction. Both parents and teachers rated the intervention positively in terms of feasibility and effectiveness, supporting the use of Project ImPACT in preschool settings. Because teachers conducted the parent training, these findings also support that highly trained NDBI therapists are not required to implement intervention. Other methods of training in Project ImPACT have been explored, including a protocol that uses a combination of web-based instruction, brief workshops, and remote consultation to teach community providers (Wainer, Pickard, & Ingersoll, 2017). Results from this study demonstrated feasibility of this protocol for dissemination of Project ImPACT in community settings. Telehealth has also been explored as a dissemination strategy (Ingersoll & Berger, 2015; Ingersoll, Wainer, Berger, Pickard, & Bonter, 2016; Pickard, Wainer, Bailey, & Ingersoll, 2016), with results indicating that parents showed gains in targeted intervention skills and children showed correlated gains in social-communication skills. In one study, selfdirected and therapist-directed online modules were randomly assigned to parents (Ingersoll & Berger, 2015). Although both groups successfully learned the strategies

34

Overview

and reported high levels of satisfaction with treatment, engagement was higher in the therapist-assisted version, suggesting that parents can benefit from a minimal amount of clinician support when receiving services via online training modules. As with several other interventions outlined in this chapter, strong evidence is readily available for the individual teaching strategies used in Project ImPACT. Examples of these include following the child’s lead (e.g., Kern et al., 1998), prompting and reinforcement strategies, environmental arrangements (e.g., McGee et al., 1999), and a focus on joint attention (e.g., Kasari et al., 2006). Core Components Project ImPACT is a short-term parent education program that can be implemented in an individual or group format. The individual format consists of two weekly sessions over 12 weeks, or 24 sessions total. The group format alternates between group sessions (six 2-hour groups) and individual practice sessions (6 hours total). The program has both child and parent goals. Child goals revolve around four core child skill deficits: 1) social engagement, 2) language/communication, 3) social imitation, and 4) play. Parent trainers help parents to identify and select intervention targets and set goals using a brief curriculum checklist. Parents learn specific teaching strategies that build on each other. The early teaching techniques target the parent’s active engagement and general responsiveness to the child, for example, by following the child’s lead, reading the child’s cues (verbal or nonverbal), and responding to the child’s behavior as if it were meaningful. The later teaching techniques include the prompting and reinforcing components that are intentionally embedded to teach specific skills. Examples of these include environmental arrangements, shared control, reinforcement of target behaviors, and communication temptations to evoke joint attention and verbal behaviors. Relationship to Other NDBI Project ImPACT shares many of the same ABA strategies (e.g., environmental arrangements, shared control, natural reinforcement, prompting, turn taking, imitation) and the developmental framework with other NDBI. In fact, the manual indicates that strategies are drawn from several of the NDBI discussed. In addition, it has a well-developed manual, including a parent workbook and teaching material on DVD (Ingersoll & Dvortcsak, 2010). Project ImPACT also meets all of the other procedural NDBI characteristics in that it uses data collection to evaluate ongoing progress and has detailed treatment fidelity procedures for both parent implementation and the parent trainer. Project ImPACT is unique in its singular focus on parent education. Parent training programs such as these may also be a cost-effective addition to other NDBI and could certainly function as an early first step for those children newly diagnosed with ASD.

CONCLUSION NDBI go by many names or brands, but as the summaries of the models demonstrate, they share many core characteristics and all rely on the core combination of ABA and developmental principles. These relationships are also highlighted in Table 2.1, which summarizes the roles that various treatment components play in each model. As emphasized in Chapter 1, the NDBI framework is not another

Table 2.1. Summary of NDBI models and their relationship to the NDBI framework NDBI common elements

IT

JASPER

PRT

EMT

ESDM

Project ImPACT

Yes Implicit

Yes Yes

Yes Implicit

Yes Yes

Yes Yes

Yes Yes

Not publicly available Not publicly available Yes

Not publicly available Not publicly available Yes

Yes

Yes

Yes

Yes

Yes

Yes

Not publicly available Not publicly available Yes

Yes

Yes

Yes Yes Yes

Yes Yes Yes

Yes Yes Yes

Yes Yes Yes

Yes Yes Yes

Yes Yes Yes

Yes Yes Yes No Not specifically Yes

Yes Yes Yes Yes Yes Yes

Yes Yes Yes No Yes Yes

Yes Yes Yes Yes Not specifically Yes

Yes Yes Yes Yes Yes Yes

Yes Yes Yes Yes Yes Yes

McGee, Morrier, and Daly (1999)

Kasari, Paparella, Freeman, and Jahromi (2008)

Koegel and Koegel (2006)

Kaiser and Hampton (2017)

Rogers and Dawson (2010)

Core components ABA Developmental theory Common procedural elements Manualized Treatment fidelity Ongoing measurement

Yes

Instructional strategies Use of three-part contingency Arranging the environment Shared control and natural reinforcement Prompting and prompt fading Balanced turns Modeling Imitation of child Broadening of attentional focus Use of child initiations Literature Manual citation or seminal article describing the model

Ingersoll and Dvortcsak (2010)

Key: ABA, Applied Behavior Analysis; ESDM, Early Start Denver Model; JASPER, Joint Attention, Symbolic Play, Engagement, and Regulation; PRT, Pivotal Response Treatment; IT, Incidental Teaching; EMT, Enhanced Milieu Teaching.

35

36

Overview

rebranding of intervention strategies being used in the treatment of ASD. Rather, the goal is to cut across brands and propose a set of empirically supported practices that treatment providers can draw on to develop individualized treatment plans to target the core deficits in ASD across a broad range of ages. This may be similar to a “technical eclectic” approach to community treatment (Odom, Hume, Boyd, & Stabel, 2012), in which evidence-based intervention strategies are selected purposefully for each program. In a technical eclectic approach, teaching strategies should be empirically supported for targeting specific skills, even if they have not been studied as a package or a comprehensive treatment model (CTM), and should be combined to target a range of developmentally appropriate individualized goals. A set of similar key treatment strategies have been used across different NDBI brands (e.g., ESDM, EMT, PRT), and it may be helpful to think of NDBI generally as a technical eclectic approach that focuses on key evidence-based strategies from principles of ABA and developmental theory. As such, the goal of this book is to describe and define the active ingredients common to NDBI that can be used to select both individualized treatment strategies and appropriate child goals. One challenge of adopting a technical eclectic approach is that manualized materials for selecting intervention strategies and targets are not readily available, whereas the individual treatment “brands” (e.g., ESDM) are more well operationalized. As such, clinicians may be tempted to adopt brands because they have a road map to follow, whereas adopting a technical eclectic approach may require drawing on a range of available materials that may require a higher level of expertise and training. We hope this book will help clinicians develop comprehensive programming knowledge based on a range of NDBI strategies rather than just based on individual brands. Generally speaking, all NDBI share three overarching guiding principles, which are highlighted throughout the remaining chapters in this book: 1) teaching functional skills in the natural environment in developmental order, 2) parents as key stakeholders, and 3) inclusion in the least restrictive environment with typically developing peers in the community. The remainder of this book focuses on the practical use of NDBI principles in developing high-quality intervention programming for children with ASD. Although it considers the models discussed in this chapter where appropriate, it focuses on describing treatment components and their application to specific target behaviors in treatment, as opposed to on what brand the component can be ascribed to. Recommendations and strategies described can be used with any of the branded interventions or as part of a technical eclectic approach. The three guiding principles outlined previously and the 13 characteristics of NDBI interventions outlined in Chapter 1 are integrated into this discussion as well. However, the focus ultimately turns to the practical application: designing and implementing high-quality technical eclectic treatment plans.

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Goods, K. S., Ishijima, E., Chang, Y., & Kasari, C. (2013). Preschool based JASPER intervention in minimally verbal children with autism: Pilot RCT. Journal of Autism and Developmental Disorders, 43(5), 1050–1056. Gulsrud, A. C., Hellemann, G., Shire, S., & Kasari, C. (2015). Isolating active ingredients in a parent-mediated social communication intervention for toddlers with autism spectrum disorder. Journal of Child Psychology and Psychiatry, 57(5), 606–613. Halle, J. W., Marshall, A. M., & Spradlin, J. E. (1979). Time delay: A technique to increase language use and facilitate generalization in retarded children. Journal of Applied Behavior Analysis, 12(3), 431–439. Hampton, L. H., & Kaiser, A. P. (2016). Early intervention effects on spoken-language outcomes or children with autism: A systematic review and meta-analysis. Journal of Intellectual and Developmental Disabilities, 60(5), 444–463. Hampton, L. H., Kaiser, A. P., & Roberts, M. Y. (2017). One-year language outcomes in toddlers with language delays: An RCT follow-up. Pediatrics, 140(5), e20163646. doi:10.1542/ peds.2016-3646 Hancock, T. B., & Kaiser, A. P. (2002). The effects of trainer-implemented enhanced milieu teaching on the social communication of children with autism. Topics in Early Childhood Special Education, 22(1), 39–54. Hancock, T. B., & Kaiser, A. P. (2006). Enhanced milieu teaching. In S. F. Warren & M. E. Fey (Series Eds.) & R. J. McCauley & M. E. Fey (Vol. Eds.), Communication and language intervention series: Treatment of language disorders in children (pp. 203–236). Baltimore, MD: Paul H. Brookes Publishing Co. Hancock, T. B., & Kaiser, A.P. (2012). Implementing enhanced milieu teaching with children who have autism spectrum disorders. In M. E. Fey & A. G. Kamhi (Series Eds.) & P. A. Prelock & R. J. McCauley (Vol. Eds.), Communication and language intervention series: Treatment of autism spectrum disorders: Evidence-based intervention strategies for communication and social interaction (pp. 163–187). Baltimore, MD: Paul H. Brookes Publishing Co. Hancock, T. B., Kaiser, A. P., & Delaney, E. M. (2002). Teaching parents of preschoolers at high risk: Strategies to support language and positive behavior. Topics in Early Childhood Special Education, 22(4), 191–212. Hardan, A. Y., Gengoux, G. W., Berquist, K. L., Libove, R. A., Ardel, C. M., Phillips, J., . . . Minjarez, M. B. (2015). A randomized controlled trial of pivotal response treatment group for parents of children with autism. Journal of Child Psychology and Psychiatry, 56(8), 884–892. Haring, T. G., Neetz, J. A., Lovinger, L., & Peck, C. (1987). Effects of four modified incidental teaching procedures to create opportunities for communication. Journal of The Association for Persons with Severe Handicaps, 12(3), 218–226. Harper, C. B., Symon, J. G., & Frea, W. D. (2008). Recess is time-in: Using peers to improve social skills of children with autism. Journal of Autism and Developmental Disorders, 38(5), 815–826. Harrist, A. W., & Waugh, R. M. (2002). Dyadic synchrony: Its structure and function in children’s development. Developmental Review, 22, 555–592. Hart, B. M., & Risley, T. R. (1968). Establishing use of descriptive adjectives in the spontaneous speech of disadvantaged preschool children. Journal of Applied Behavior Analysis, 1(2), 109–120. Hart, B., & Risley, T. R. (1975). Incidental teaching of language in the preschool. Journal of Applied Behavior Analysis, 8(4), 411–420. Ingersoll, B., & Berger, N. I. (2015). Parent engagement with a telehealth-based parentmediated intervention program for children with autism spectrum disorders: Predictors of program use and parent outcomes. Journal of Medical Internet Research, 17(10), e227. Ingersoll, B., & Dvortcsak, A. (2010). Teaching social communication to children with autism: A manual for parents. New York, NY: Guilford Press. Ingersoll, B., & Wainer, A. (2013a). Initial efficacy of Project ImPACT: A parent-mediated social communication intervention for young children with ASD. Journal of Autism and Developmental Disorders, 43(12), 2943–2952. Ingersoll, B. R., & Wainer, A. L. (2013b). Pilot study of a school-based parent training program for preschoolers with ASD. Autism, 17(4), 434–448. Ingersoll, B., Wainer, A. L., Berger, N. I., Pickard, K. E., & Bonter, N. (2016). Comparison of a self-directed and therapist-assisted telehealth parent-mediated intervention for children with ASD: A pilot RCT. Journal of Autism and Developmental Disorders, 46(7), 2275–2284.

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Pickard, K. E., Wainer, A. L., Bailey, K. M., & Ingersoll, B. R. (2016). A mixed-method evaluation of the feasibility and acceptability of a telehealth-based parent-mediated intervention for children with autism spectrum disorder. Autism, 20(7), 845–855. Pierce, K., & Schreibman, L. (1997). Multiple peer use of pivotal response training social behaviors of classmates with autism: Results from trained and untrained peers. Journal of Applied Behavior Analysis, 30(1), 157–160. Prizant, B. M., Wetherby, A. M., Rubin, E., Laurent, A. C., & Rydell, P. J. (2006). The SCERTS Model: A comprehensive educational approach for children with autism spectrum disorders. Vol. II. Baltimore, MD: Paul H. Brookes Publishing Co. Prizant, B. M., Wetherby, A. M., & Rydell, P. J. (2000). Communication intervention issues for young children with autism spectrum disorders. In S. F. Warren & J. Reichle (Series Eds.) & A. M. Wetherby & B. M. Prizant (Vol. Eds.), Communication and language intervention series: Vol. 9. Autism spectrum disorders: A transactional developmental perspective (pp. 193–224). Baltimore, MD: Paul H. Brookes Publishing Co. Rieth, S. R., Stahmer, A. C., Suhrheinrich, J., & Schreibman, L. (2015). Examination of the prevalence of stimulus overselectivity in children with ASD. Journal of Applied Behavior Analysis, 48(1), 71–84. Roberts, M., & Kaiser, A. (2012). Assessing the effects of a parent-implemented language intervention for children with language impairments using empirical benchmarks: A pilot study. Journal of Speech, Language, and Hearing Research, 55(6), 1655–1670. Roberts, M. Y., & Kaiser, A. P. (2015). Early intervention for toddlers with language delays: A randomized controlled trial. Pediatrics, 134(4), 686–693. doi:10.1542/peds.2014-2134 Rogers, S. J., & Dawson, G. (2010). Early Start Denver Model for young children with autism: Promoting language, learning, and engagement. New York, NY: Guilford Press. Rogers, S. J., Dawson, G., & Vismara, L. A. (2012). An early start for your child with autism: Using everyday activities to help kids connect, communicate, and learn. New York, NY: Guilford Press. Rogers, S. J., Estes, A., Lord, C., Vismara, L., Winter, J., Fitzpatrick, A., . . . Dawson, G. (2012). Effects of a brief Early Start Denver Model (ESDM)–based parent intervention on toddlers at risk for autism spectrum disorders: A randomized controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 51(10), 1052–1065. Rogers, S. J., Herbison, J., Lewis, H., Pantone, J., & Reis, K. (1986). An approach for enhancing the symbolic, communicative and interpersonal functioning of young children with autism and severe emotional handicaps. Journal of the Division of Early Childhood, 10, 135–148. Rogers, S. J., & Pennington, B. F. (1991). A theoretical approach to the deficits in infantile autism. Development and Psychopathology, 3(2), 137–162. Rogers, S. J., Vismara, L., Wagner, A. L., McCormick, C., Young, G., & Ozonoff, S. (2014). Autism treatment in the first year of life: A pilot study of infant start, a parent-implemented intervention for symptomatic infants. Journal of Autism and Developmental Disorders, 44(12), 2981–2995. Rubin, E., Prizant, B. M., Laurent, A. C., & Wetherby, A. M. (2013). Social Communication, Emotional Regulation, and Transactional Support (SCERTS). In S. Goldstein & J. A. Naglieri (Eds.), Interventions for autism spectrum disorders: Translating science into practice (pp. 107–127). New York, NY: Springer. Ryan, C. S., Hemmes, N. S., Sturmey, P., Jacobs, J. D., & Grommet, E. K. (2008). Effects of a brief staff training procedure on instructors’ use of incidental teaching and students’ frequency of initiation toward instructors. Research in Autism Spectrum Disorders, 2(1), 28–45. Ryberg, K. H. (2015). Evidence for the implementation of the Early Start Denver Model for young children with autism spectrum disorder. Journal of the American Psychiatric Nurses Association, 21(5) 327–337. Sandall, S. R., Ashmun, J. W., Schwartz, I. S., Davis, C. A., Williams, P., Leon-Guerrero, R., . . . McBride, B. J. (2011). Differential response to a school-based program for young children with ASD. Topics in Early Childhood Special Education, 31(3), 166–177. Schreibman, L., & Koegel, R. L. (1982). Multiple-cue responding in autistic children. Advances in Child Behavioral Analysis & Therapy, 281–299. Schreibman, L., & Koegel, R. L. (2005). Training for parents of children with autism: Pivotal responses, generalization, and individualization of interventions. In E. D. Hibbs & P. S. Jensen (Eds.), Psychosocial treatments for child and adolescent disorders: Empirically based strategies for clinical practice (pp. 605–631). Washington, DC: American Psychological Association.

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Schwartz, I., Ashmun, J., McBride, B., Scott, C., & Sandall, S. R. (2017). The DATA Model for teaching preschoolers with autism: Blending approaches to meet individual needs. Baltimore, MD: Paul H. Brookes Publishing Co. Schwartz, I., Thomas, C. J., McBride, B., & Sandall, S. (2013). A school-based preschool program for children with ASD: A quasi-experimental assessment of child change in Project DATA. School Mental Health, 5(4), 221–232. Smith, I. M., Koegel, K., Koegel, L. K., Openden, D. A., Fossum, K. L., & Bryson, S. E. (2010). Effectiveness of a novel community-based early intervention model for children with autistic spectrum disorder. American Journal on Intellectual and Developmental Disabilities, 115(6), 504–523. Stadnick, N. A., Stahmer, A., & Brookman-Frazee, L. (2015). Preliminary effectiveness of Project ImPACT: A parent-mediated intervention for children with autism spectrum disorder delivered in a community program. Journal of Autism and Developmental Disorders, 45(7), 2092–2104. Stahmer, A. C. (1995). Teaching symbolic play skills to children with autism using pivotal response training. Journal of Autism and Developmental Disorders, 25(2), 123–141. Stahmer, A. C., Ingersoll, B., & Carter, C. (2003). Behavioral approaches to promoting play. Autism, 7(4), 401–413. Stahmer, A. C., Suhrheinrich, J., & Reith, S. (2016). A pilot examination of the adapted protocol for classroom pivotal response teaching. Journal of the American Academy of Special Education Professionals, 119–139. Strain, P. S., & Bovey, E. H. (2011). Randomized, controlled trial of the LEAP model of early intervention for young children with autism spectrum disorders. Topics in Early Childhood Special Education, 31(3), 133–154. Strain, P. S., & Hoyson, M. (2000). The need for longitudinal, intensive social skill intervention: LEAP follow-up outcomes for children with autism. Topics in Early Childhood Special Education, 20(2), 116–122. Suhrheinrich, J. (2015). A sustainable model for training teachers to use pivotal response training. Autism, 19(6), 713–723. Suhrheinrich, J., Stahmer, A. C., & Schreibman, L. (2007). A preliminary assessment of teachers’ implementation of pivotal response training. The Journal of Speech and Language Pathology—Applied Behavior Analysis, 2(1), 1–13. Symon, J. B. (2005). Expanding interventions for children with autism: Parents as trainers. Journal of Positive Behavior Interventions, 7(3), 159–173. Tamis-LeMonda, C. S., & Bornstein, M. H. (2002). Maternal responsiveness and early language acquisition. Advances in Child Development and Behavior, 29, 89–127. Vismara, L. A., Young, G. S., & Rogers, S. J. (2013). Community dissemination of the Early Start Denver Model: Implications for science and practice. Topics in Early Childhood Special Education, 32(4), 223–233. Vivanti, G., Paynter, J., Duncan, E., Fothergill, H., Dissanayake, C., Rogers, S. J., & The Victorian ASELCC Team. (2014). Effectiveness and feasibility of the Early Start Denver Model implemented in a group-based community childcare setting. Journal of Autism and Developmental Disorders, 44, 3140–3153. Wainer, A. L., Pickard, K., & Ingersoll, B. R. (2017). Using web-based instruction, brief workshops, and remote consultation to teach community-based providers a parent-mediated intervention. Journal of Child and Family Studies, 26(6), 1592–1602. Wright, C. A., & Kaiser, A. P. (2016). Teaching parents enhanced milieu teaching with words and signs using Teach-Model-Coach-Review. Topics in Early Childhood Special Education, 36(4), 192–204. doi:10.1177/0271121415621027 Wong, C., Odom, S. L., Hume, K. A., Cox, A. W., Fettig, A., Kucharczyk, S., . . . Schultz, T. R. (2015). Evidence-based practices for children, youth, and young adults with autism spectrum disorder: A comprehensive review. Journal of Autism and Developmental Disorders, 45(7), 1951–1966.

II Core Concepts and Foundational Principles

3 Selecting Meaningful Skills for Teaching in the Natural Environment Grace W. Gengoux, Erin McNerney, and Mendy B. Minjarez

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he emphasis on teaching meaningful skills in natural contexts is a foundational element of Naturalistic Developmental Behavioral Interventions (NDBI; Schreibman et al., 2015). Given the core social-communication deficits in autism spectrum disorder (ASD), both naturalistic behavioral and developmental approaches have historically emphasized teaching of social-communication skills (Ingersoll, 2010). Furthermore, the National Research Council’s (2001) report asserted that personal independence and social responsibility should be priorities for educating children with ASD, just as they are for all children. Yet, when deciding which skills to prioritize, therapists and families are faced with an exhaustive list of possible target behaviors, which often makes the task daunting. In NDBI treatment planning, skill areas are prioritized based on which skills will have the greatest impact on later independence and quality of life for the individual and family and are taught in a developmentally appropriate sequence. Meaningfulness of the skill is the first important consideration when selecting treatment targets. To determine if a skill is meaningful, therapists should consider the following: Is this skill functional? That is, will it help the child participate more fully in his or her school, home, or community activities? Is this a skill that will improve the child’s and family’s quality of life? Of all potential skills, improvement in functional skills is likely to have the greatest impact on an individual’s long-term independence and self-determination. In fact, research has suggested that an individual’s performance of functional daily living and social skills is a stronger predictor of responsibility and independence with life tasks than the individual’s cognitive ability (Kao, Kramer, Liljenquist, & Coster, 2015). Another important advantage of teaching a functional behavior is that it is more likely to result in immediate natural reinforcement from the environment. This frequent and natural reinforcement means that functional skills are easier to learn, maintain, 45

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and generalize (Koegel & Koegel, 2012; Williams, Koegel, & Egel, 1981). Functional skills are discussed in more detail later in this chapter. Developmental sequence must also be considered when developing treatment goals that are functional. The child’s present level of functioning in a particular domain must be evaluated before choosing a skill that represents the next developmental step (Rogers & Dawson, 2010). All NDBI take developmental sequence of skill acquisition into account and therefore focus on certain foundational abilities known to be precursors to other critical functional skills. In typically developing children, several early-emerging social-communication skills, such as joint attention (Bates, Camaioni, & Volterra, 1975; Baldwin, 1991; Mundy & Crowson, 1997; Mundy & Sigman, 1989; Mundy, Sigman, & Kasari, 1990), play skills (Shore, O’Connell, & Bates, 1984; Sigman & Ruskin, 1999), and imitation (Uzgiris, 1981) have been associated with the later emergence of more advanced social and cognitive skills. Given that these skills are often deficient in children with ASD, they are widely considered to be developmentally sound targets for early intervention efforts (Charman & Stone, 2008). A skill may also be considered foundational if acquisition of that behavior is known to produce a cascading effect across broader developmental domains. For instance, skills such as functional communication and initiations are common intervention priorities because these skills have the potential for widespread effects for the individual and for interactions with important stakeholders (Koegel, Koegel, Harrower, & Carter, 1999). This chapter reviews the NDBI approach to selection of functional skills and suggests several priorities in selecting meaningful treatment targets, such as the importance of considering goodness of fit with family values and routines. It also discusses why the natural environment is the ideal place for teaching to occur and examines how parents and providers can effectively contextualize learning opportunities across settings.

GOODNESS OF FIT OF NDBI APPROACHES When developing treatment plans for targeting functional skills in the natural environment, practitioners must consider the goodness of fit of treatment approaches and specific strategies. Goodness of fit, or contextual fit, means that the treatment plan works well for stakeholders in the natural environment (home, school, community), which improves the likelihood of its long-term use (Albin, Lucyshyn, Horner, & Flannery, 1996). The idea is to avoid the problem of elegantly designed interventions that are minimally effective because they are never actually implemented. NDBI are flexible and designed to adapt to fit the environment. The selected intervention strategies must be viewed as important, useful, acceptable, and feasible by the team members responsible for implementing them in order for the implementation to be delivered consistently and with a high degree of fidelity (Odom, McConnell, & Chandler, 1994; Snell, 2003; Stormont, Lewis, & Smith, 2005). Team members will be motivated to implement strategies when they see the short- and long-term meaning and value in teaching a skill. Parents, too, will be more likely to implement those teaching strategies that are consistent with their values, personality, and daily routines. Understanding family culture and beliefs about effective parenting is therefore critical to providing individualized and ecologically valid treatment (see Box 3.1 for definition) in the natural environment (Guler, de Vries, Seris, Shabalala, & Franz, 2017; Rodriguez & Olswang, 2003).

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BOX 3.1: Ecological validity In research, ecological validity is the extent to which research findings can be generalized to everyday real life. Intervention studies with strong ecological validity are conducted in a fashion that mimics real life as much as possible. In a clinical setting, this term refers to whether interventions are feasible in the natural environment and whether context-specific barriers have been accounted for, such as parental involvement and cultural factors.

Programs with a good fit demonstrate alignment with an individual’s needs, respect values and skills of implementers, recognize environmental constraints, and ultimately are likely to result in higher consumer satisfaction. For instance, a parent who is socially shy may struggle with the task of initiating contact with parents of a potential peer, indicating that particular strategy has poor goodness of fit with parent personality. Yet, that same parent may be willing to sign up on a list of parents requesting to have their children participate in a peer buddy program at school, indicating this approach has a better goodness of fit with parent personality. For a family that rarely eats dinner together, it would be unreasonable for a clinician to suggest practicing social conversation during mealtimes, but he or she could be more successful by suggesting that the practice occur during car rides when the family is together. If a family routinely spends time together watching television or movies, the clinician could suggest spending a few minutes practicing social conversation by having family members share their opinions and ask each other questions about what they watched, practicing turn taking and staying on topic. See Box 3.2 for more on assessing ecological and social validity of programs. Role of Culture in Goodness of Fit of Interventions Clinicians begin to learn about the family’s culture and values as part of the assessment process and should continue to incorporate input from parents regarding

Ready, Set, Implement! BOX 3.2: Assessing validity To assess the ecological and social validity of a program, select a client’s current program. Review with the family members their daily and weekly routines. Confirm their current top three treatment priorities, and ask them in which routines they can most easily implement strategies and which routines they find most challenging. Use this opportunity to make sure your strategies match their needs, values, and skill levels. Brainstorm with family members three ways they can try a particularly challenging strategy throughout their week. Check back in 2 weeks to see how practice is going, and brainstorm modifications as needed.

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treatment priorities throughout the treatment relationship. Therapists can enhance goodness of fit of interventions by empowering parents to take an active role in deciding which intervention strategies to prioritize, based on which will fit best within existing family routines (Brookman-Frazee, 2004). Evidence suggests that acceptability of different types of intervention strategies will vary according to family cultural factors (Mandell & Novak, 2005). When working with culturally diverse families, it is important to keep in mind that values endorsed by European American families may be different from those endorsed in other cultures (Bernier, Mao, & Yen, 2010). For instance, in many collectivist cultures, the involvement of extended family is a core value (Jung, 1998; Schwartz, 1990). When appropriate, incorporating siblings and extended family into treatment can show respect for this cultural priority (Santarelli, Koegel, Casas, & Koegel, 2001). Likewise, social conformity (Daley, 2004) and respect for authority (Rodriguez & Olswang, 2003) are highly important in some cultures. Discipline practices, which might at first seem overly strict to a provider whose culture of origin values individualism, could actually be a sign of parental concern, caring, or involvement in some cultures (Chao, 1994). Although the child-directed nature of many NDBI is likely to appeal to families from cultures that value individual autonomy, it may appear to conflict with the value of respect for authority. A clinician who recognizes the validity of multiple perspectives can respond to family preferences in a respectful and collaborative manner. For instance, a therapist might prioritize teaching the child how to use polite language with his or her grandparents and how to comply with adult instructions, knowing that these behaviors are important to the family. Role of Culture in Parent–Professional Collaboration When considering goodness of fit of treatment approaches, practitioners should keep in mind that the relationship between professionals and parents will vary according to several important cultural factors (Bernier et al., 2010). Cultural sensitivity plays an important role in the parent–clinician partnership (Brookman-Frazee, 2004). For instance, some families place high value on expert input. These families may expect therapists and educators to be primary providers of care and may feel that treatment is most useful if clear guidance and recommendations are provided early in the treatment relationship. In contrast, other families may appreciate an egalitarian relationship with professionals, may expect to participate actively in treatment decisions, and may respond best to a less directive partnership model of care. Regardless of cultural norms, parents from diverse backgrounds will be more likely to obtain care if they perceive providers to be culturally competent (Bernier et al., 2010). Practitioners should demonstrate curiosity in learning about each family’s cultural background and values and should work collaboratively to balance implementation of evidence-based practices in a way that is congruent with family values. The more practitioners take the time to learn about a parent’s perspective, the more effective the collaboration can be. When practitioners incorporate family values and preferences in treatment decisions and the overall parent training approach, the resulting treatment plan will be acceptable to these critical stakeholders and is more likely to be sustained. Effective strategies for parent–professional collaboration to enhance parent empowerment are discussed in detail in Chapter 4.

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Goodness of fit of treatment approaches should not be confused with social validity of goals and target behaviors, which is discussed in detail next. Both must be considered in order to develop NDBI treatment plans that will function optimally in the natural environment.

FUNCTIONAL SKILLS A functional skill is one that, by its very name, is necessary for daily living. A functional skill is useful to the particular individual within his or her routines, advances the individual toward a more typical developmental trajectory, and ultimately serves as a building block toward independence. Furthermore, functional skills should be meaningful for the individual and should lead to self-determination through ability to meet one’s own needs. A functional skill should also have social validity (Schwartz & Baer, 1991) (see Box 3.3 for definition), fit within the family’s routine, and be consistent with family cultural values. All NDBI focus on functional skills (Schreibman et al., 2015), ensuring children or adults learn skills they will use on a frequent basis and that are meaningful to them, promote their independence, and improve their social functioning in the community (National Research Council, 2001; Rogers & Dawson, 2010). The rationale for prioritizing functional skills is consistent with developmental theory, which emphasizes the importance of building skills that are consistent with an individual’s current developmental functioning and that improve prognosis by forming a foundation for the development of more complex skills. The emphasis on skills that are socially valid, are relevant to long-term independence, and enhance personal responsibility also has strong historical support from the behavioral treatment literature (Bosch & Fuqua, 2001; Rosales-Ruiz & Baer, 1997). By prioritizing functional skills, clinicians ensure that the same skills that are useful in daily routines are also useful in community contexts. For instance, prioritize teaching communication behaviors that will be widely understood in the broader community (e.g., words and conventional gestures rather than specialized sign language; Ingersoll & Dvortcsak, 2010). That is not to say that clinicians will not teach specific signs; however, they should consider the context and environment of each individual to ensure that the individual will be understood by those around him or her. It would similarly be preferable to teach asking for or labeling actual preferred objects and activities rather than teaching naming of flashcards (Koegel & Koegel, 2012; Rogers & Dawson, 2010) because a child is more likely to use this skill in real-life settings to interact with individuals in his or her environment.

BOX 3.3: Social validity Social validity refers to the social importance and acceptability of treatment goals or target behaviors, intervention procedures, and treatment outcomes (Hayes, Barlow, & Nelson-Gray, 1999; Wolf, 1978). A well-rounded view of social validity takes into account the acceptability from the perspective of the client, the treatment provider, and the community or society; however, the client and family views are often most emphasized.

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Functional Skills Lead to Increased Independence A skill can be considered functional for a few key reasons. First, functional skills are useful to the individual in daily life, and demonstration of these skills allows the individual to be more independent. Functional communication has long been a priority in treatment research for this reason. The better a child’s functional communication skills, the more he or she will be able to gain access to typical learning environments and function independently. For example, a parent or provider could teach a 2-year-old child with ASD to say “please” and “thank you” because many typically developing children this age learn these words, and these words are often culturally appropriate and important to parents. However, if the child with ASD shows delayed expressive language development, more meaningful (functional) goals might include labeling common objects in the environment that are used in family routines and that the child may want to obtain or comment on. Although a 2-year-old who says “please” and “thank you” is definitely polite, he or she may continue to lack meaningful skills for making more specific requests, which will also interfere with gaining natural reinforcement. In a similar way, consistent performance of adaptive or daily living skills, such as self-feeding, dressing, toileting, cooking, using public transportation, and so forth, contributes directly to increased independence. Even individuals with ASD who are intellectually able often have substantial deficits in adaptive skills; therefore, the overall goal of many intervention programs is to increase individual selfsufficiency (Kanne et al., 2011). In a longitudinal study of individuals with average cognitive ability, adaptive daily living and social skills were more strongly associated with positive outcome and adult independence than intelligence (Farley et al., 2009). That is, adaptive and social skills may be even more critical for long-term positive outcomes in ASD than academic progress and should be emphasized in treatment across the life span. For instance, for a school-age child with ASD, it could be appropriate to prioritize self-care routines (e.g., brushing teeth, dressing, bathing), which allow that individual a more typical level of personal privacy and self-sufficiency. For a teen with ASD, it could be appropriate to prioritize safety skills (e.g., crossing a street, dialing 911, appropriate Internet use), which might open opportunities for greater independence in the community. Likewise, prioritizing meaningful and functional social skills (e.g., how to enter a social situation, appropriate social behavior for the lunchroom at work) increases access to developmentally appropriate social opportunities and decreases the likelihood of stigma and social isolation. Functional Skills Can Be Pivotal A skill may also be considered functional because of its foundational role as a precursor to the development of other critical skills. When selecting a skill to target, consider the cascading effects it may have on other skill areas, as well as how its emergence may affect the systems (e.g., family, classroom, community) in which the individual participates (Dunlap & Fox, 1996). This concept is similar to that of pivotal behaviors from Pivotal Response Treatment (PRT; Koegel et al., 1999). In this way, functional communication skills are not only important for independence but are also another one of the most important predictors of positive

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long-term outcome in ASD (Fossum, Williams, Garon, Bryson, & Smith, 2018). Furthermore, several other prelinguistic behaviors, such as joint attention (Bates, Camaioni, & Volterra, 1975), play skills (Sigman & McGovern, 2005; Sigman & Ruskin, 1999), and imitation (Uzgiris, 1981), have been identified as key precursors to language acquisition in both typically developing children and children with ASD (Baldwin, 1991; Mundy & Crowson, 1997; Mundy & Sigman, 1989; Mundy, Sigman, & Kasari, 1990; Sigman & McGovern, 2005). Therefore, before moving to teaching spoken language, clinicians should choose treatment targets that provide children with a solid foundation for social-communication. As an example, joint attention is widely acknowledged to play a critical role in social-communication development because so many skills are learned from interactions with others. In the area of language, when a child is learning a new word, the ability to follow another person’s gaze or gesture gives critical information about which item in the environment corresponds with the word spoken. Embedding the teaching of joint attention within naturally reinforcing activities can make this skill more functional for a child with ASD who shows initial impairment in this skill. For instance, a clinician could arrange the teaching environment so that when the child shifts his or her gaze in response to an adult’s pointing gesture, he or she experiences clear natural reinforcement (e.g., seeing something exciting, finding a desired item that had been missing). Understanding how to follow joint attention can facilitate learning many new skills that involve interaction with others. Functional Skills Emphasized Across NDBI Models Due to the pivotal nature of this skill, the NDBI model JASPER (Joint Attention, Symbolic Play, Engagement, and Regulation) was designed to target joint attention; other NDBI approaches have also emphasized it (e.g., Bruinsma, 2004; Whalen & Schreibman, 2003). Interventions systematically targeting joint attention skills have demonstrated important downstream effects on untargeted language (Kasari, Paparella, Freeman, & Jahromi, 2008), as well as play and imitation skills (Whalen, Schreibman, & Ingersoll, 2006). The JASPER approach also emphasizes the importance of symbolic play, which has been a priority in other NDBI as well (Stahmer, 1995), due to its similar association with social-cognitive development (Shore, O’Connell, & Bates, 1984). Imitation is another skill prioritized by several NDBI approaches, including the Early Start Denver Model (ESDM) and Project ImPACT (Improving Parents as Communication Teachers; Ingersoll & Schreibman, 2006; Ingersoll, Lewis, & Kroman, 2007). Treatments targeting symbolic play (Kasari et al., 2008) and imitation (Ingersoll, 2008) have been similarly shown to result in greater gains in expressive language compared to control groups. These studies all support the idea that teaching within a developmental framework can lead to widespread developmental improvements in key skill areas. Although all NDBI take a functional and developmental approach, each model may focus on different skills. For example, PRT typically places initial focus on (social) communication and language, especially requesting behaviors (Koegel & Koegel, 2012), although PRT may be used to focus on other areas such as social and play skills (Schreibman, Stahmer, & Pierce, 2006). Enhanced Milieu Teaching (EMT) targets new language skills, with emphasis on initiations (Kaiser & Trent, 2007). JASPER places less focus on requesting and more on teaching symbolic play

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and joint attention, as described previously (Kasari, Freeman, & Paparella, 2006). ESDM typically focuses on a wide range of social-communication and play skills within the context of dyadic engagement (Rogers & Dawson, 2010). Project ImPACT similarly focuses on social and communication behaviors, including imitation and play (Ingersoll & Wainer, 2013; Stadnick, Stahmer, & Brookman-Frazee, 2015). Assessment of Functional Skills for Goal Setting Clear understanding of a child’s current developmental level and typical performance across skill domains is essential to developing individualized treatment goals; therefore, assessment of functional skills is a critical first step in any treatment planning process. In addition to published books and manuals, many helpful treatment planning and implementation resources are now available online, including tools for conducting assessments, data collection sheets, tutorials, webinars, instructional software programs, and lesson plans developed by a variety of practitioners and researchers. Selecting what is most appropriate, however, can remain a challenge. This topic is discussed in more detail in Chapter 10 on goal development; however, some assessment strategies for assisting with this process are discussed here. Standardized Assessments Standardized testing can be a useful way to get a general idea of where to begin. An advantage of standardized tests for identification of target skills is the availability of norms for comparison, including ageequivalent information across developmental areas. Clinicians can consider several categories of standardized assessments, each with their own advantages. For instance, developmental tests such as the Mullen Scales of Early Learning (Mullen, 1995) or Bayley Scales of Infant and Toddler Development (Bayley, 2006) can be used to evaluate a child’s performance level across global developmental domains, such as expressive and receptive language, early nonverbal cognitive abilities, and gross and fine motor skills. For older children, cognitive tests (e.g., Wechsler Intelligence Scale for Children [Wechsler, 2014], Stanford-Binet Intelligence Scales [Roid, 2003], Kaufman Assessment Battery for Children [Kaufman & Kaufman, 2004]) can be used to identify global cognitive strengths and weaknesses, as well as specific aspects of a child’s mental processing abilities or learning style. Other specialized tests evaluate social-communication skills specifically, such as the Communication and Symbolic Behavior Scales (CSBS; Wetherby & Prizant, 2003), and can provide detailed information about other prelinguistic communication skills, early language, as well as both functional and symbolic play skills. Language tests, such as the Comprehensive Assessment of Spoken Language (CASL; Carrow-Woolfolk, 2016), can identify aspects of speech syntax and pragmatics to be addressed in treatment. Finally, there are several standardized parent interviews or checklists regarding adaptive behavior, such as the Vineland Adaptive Behavior Scales (Vineland; Sparrow, Cicchetti, & Saulnier, 2016) or Adaptive Behavior Assessment System (ABAS; Harrison & Oakland, 2015), which can identify broad adaptive domains to address in treatment (e.g., personal hygiene, community safety skills, leisure skills). Adaptive measures have the advantage of characterizing actual performance in natural environments and during daily routines. Because they focus on such practical skills, item-level analysis of these measures can also yield helpful ideas about

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specific skills for direct teaching. Although standardized assessments are helpful in giving a general idea of where to begin, they generally do not provide enough detail for goal writing and are typically not useful for tracking progress toward goals in a way that can guide treatment planning. Behavioral Observation Methods Behavioral observation is also routinely used in NDBI programs. These observations typically consist of a clinician watching and recording the behavior of a child in one or more contexts (e.g., alone, with a caregiver, with a peer, at home, at school) in order to collect data relevant to developing program goals or monitoring of progress. Behavior observations can be structured or unstructured, depending on the information desired. Following a structured protocol with a standard set of prompts and materials is helpful when the goal is to track progress over time or compare behaviors across children. For instance, research on PRT has routinely included data from Structured Laboratory Observations (SLO; Hardan et al., 2015), whereas research on JASPER has routinely included data from a Structured Play Assessment (Ungerer & Sigman, 1984). As an alternative, unstructured observations are helpful for assessment of how children typically function in a particular environment of interest and the extent to which they show generalization of skills. These assessment methods may be time consuming if observational data are not collected in vivo, as video recordings must then be evaluated for target behaviors at a later date. In clinical settings, formats and goals of behavioral observation can vary widely, and the clinician is ultimately responsible for selecting the most appropriate context for conducting the observation, the types of supports that may or may not be provided during the observation, and which target behaviors will be measured. Unlike standardized assessment protocols, which provide clear guidance on administration and norms for interpreting results, the validity and usefulness of behavioral observation data depend on the clinician’s judgment and expertise. For instance, data regarding the child’s performance must be interpreted in the context of the clinician’s broader understanding of relevant developmental milestones. Measures such as the Early Social Communication Scale (ESCS; Mundy et al., 2013) can be useful because they provide standardized methods for assessing and recording skills such as joint attention, although this measure is not norm-referenced. In addition, it is not uncommon for clinicians to develop sets of semi-structured tasks that are introduced as a way to probe for various skills. Observations from such interactions can then be recorded using developmental checklists or curricula, such as those discussed previously. Use of Published Curricula in Goal Development In order to gain more detailed information and make the process of assessment and goal selection more systematic, numerous curricula have been created and published for practitioners and parents to use when creating an NDBI program. For instance, the ESDM approach uses a curriculum assessment checklist for identification of goals (Rogers & Dawson, 2010). Project ImPACT also utilizes a social-communication skills checklist (Ingersol & Dvortcsak, 2010). Other NDBI models provide general guidance regarding the recommended developmental sequence for targeting progressively more complex language (Koegel & Koegel, 2006) or play skills (Ungerer & Sigman, 1984).

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In the absence of more available NDBI-specific curricular materials, clinicians are encouraged to use materials from the fields of special education and ABA, many of which have the advantage of systematically evaluating skills and directly linking identified deficits to treatment goals. For example, the recently published Project DATA (Developmentally Appropriate Treatment for Autism) manual (Schwartz et al., 2017) is a helpful source for curricular materials relevant to young children with ASD. In addition, curricular and goal-development materials have been published for early childhood education that are relevant to both typically developing children and children with special needs (e.g., Assessment Evaluation and Programming System for Infants and Children [AEPS®], Second Edition; Bricker et al., 2002) or are specifically for children with disabilities (e.g., The Carolina Curriculum for Infants and Toddlers with Special Needs; Johnson-Martin, Attermeier, & Hacker, 2004). Progress on curricular assessments has been shown to correlate with progress on standardized measures (Bacon et al., 2014) and can be used at more frequent intervals to help guide treatment planning. Additional materials from the ABA field may also be useful, especially when systematic information about cognitive and language targets is appropriate. For instance, assessment tools have been developed specifically for identifying goals for ABA programs (e.g., Assessment of Basic Language and Learning Skills–Revised; Partington, 2006; Verbal Behavior Milestones Assessment and Placement Program; Sundberg, 2008), and a number of manuals have been published to guide ABA treatment implementation (e.g., A Work in Progress; Leaf, McEachin, & Harsh, 1999). Given that most of these curricular materials have not been standardized and are designed primarily for young children, a combination of assessment methods is likely the best approach to developing individualized programming and understanding long-term outcomes. Furthermore, as part of the assessment process, gathering information about the child’s existing preferences and natural environments (Rogers & Dawson, 2010; Winton, 1990) can aid in individualizing the treatment plan, as discussed next. Individualization of Functional Treatment Goals As the field of behavior analysis has begun to incorporate increased understanding of human development, emphasis on individualization of target skills has risen to the forefront of focus for many treatment models, especially NDBI. Though it may initially seem easier to apply the same teaching curriculum to all children, each child presents with a unique set of strengths and weaknesses, and each family presents with a unique set of routines, values, and priorities. Without individualization, progress may be less meaningful to the child and family. Because all individuals with ASD are just that—individuals—treatment programs must be designed specifically to meet each person’s needs. Clinicians must prioritize skills that will be most functional at a given point in time, taking into consideration that this may vary by individual (Anderson, 2013). Child, family, and practitioner variables should all be considered in selecting individualized goals (Stahmer, Schreibman, & Cunningham, 2011). By using specific child and family characteristics to select target behaviors, clinicians can improve their effectiveness. Children with ASD often have difficulty demonstrating age-appropriate skills, and it may therefore be tempting to pick individualized goals based on expectations for their chronological age. Because children with ASD often show

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delayed social-communication skills rather than deviant patterns of behavior (Morgan, Cutrer, Coplin, & Rodrigue, 1989; Snow, Hertzig, & Shapiro, 1987), teaching should instead occur in developmental sequence (Anderson & Romanczyk, 1999). Children may actually acquire skills more readily when they are selected based on appropriate developmental sequence, rather than chronological agebased expectations (Lifter, Sulzer-Azaroff, Anderson, & Cowdery, 1993). Providers can also build on skills already in the child’s existing repertoire. For instance, when teaching first words, a provider might select the word cup to teach a child already saying a /k/ sound and might teach the word milk to a child already saying the /m/ sound. Individualization based on child characteristics can include modifications in what to teach. Teaching an adolescent to tie his or her shoes may seem like a useful and functional self-help skill; however, it fails to be functional if the child dislikes and never wears shoes with laces. Person-centered planning (e.g., Coyne & Fullerton, 2014) is an ongoing collaborative process in which stakeholders (e.g., treatment providers, parents, caregivers, school personnel) partner with the individual with ASD (or any developmental or medical condition) to develop and actualize that person’s vision for his or her life and future. Person-centered planning is another important area of focus when individualizing treatment goals, especially with teens and adults with ASD. In this approach, the team works together to identify opportunities and implement strategies focused on development of personal relationships, participation in the community, increased autonomy, and development of skills needed to attain these goals. Several key principles of person-centered care include valuing individuals, autonomy, valuing the life experience of the individual, understanding relationships, and focusing on necessary environmental supports. As many more individuals with ASD advance to treatment in various community settings, NDBI will need to continue to adapt to addressing their needs. Self-determination and autonomy are important principles to incorporate into treatment planning, even when individuals require a high level of support. Selecting treatment targets that are meaningful to the individual must be addressed as another way to individualize treatment goals. At times, there may be disagreement between treatment or care providers and individuals with ASD about appropriateness of a behavior. For example, if an individual with ASD wants to eat pizza three times per day due to rigid eating patterns but is becoming unhealthy and overweight, it may be more important to set goals to expand eating habits, rather than if the individual eats pizza a few times per week and his or her parents feel this is unhealthy. Like all human beings, individuals with ASD have the right to self-determination and autonomy. These rights must be balanced with promoting optimal functioning and decreasing risks to well-being that the individual may not recognize. The use of person-centered planning strategies is one important way to address these key factors in selecting functional intervention targets. Individualized goal planning has been shown to be a promising way to enhance treatment effectiveness (Schreibman & Koegel, 2005; Sherer & Schreibman, 2005). One way to both individualize programs and increase efficiency is by using a decision tree. Decision trees are typically visual models that break down a course of action (plan) and guide next steps based on an individual’s performance over time. Decision trees are useful because they account for numerous possibilities and provide a framework

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for assessing the likelihood of different outcomes. For instance, ESDM uses decision trees to guide providers in deciding how to address nonresponse to initial treatment efforts, often by targeting alternative skills (Rogers & Dawson, 2010). For example, if a child is not learning to make word approximations after 3–6 months of treatment, the decision tree may guide providers to augment the treatment approach by introducing a Picture Exchange Communication System (PECS) or signs paired with speech. Likewise, research on the effects of combining JASPER and EMT has suggested that addition of a speech-generating device may be helpful for children who are nonverbal and initially unresponsive to intervention (Kasari et al., 2014). Advances in the understanding of specific factors that predict response to NDBI procedures suggest that personalized treatment selection based on child characteristics may soon be possible (Stahmer, Schreibman, et al., 2011). In an early study of predictors, Sherer and Schreibman (2005) conducted a retrospective analysis to identify potential behavioral profiles for predicting response to PRT. They identified several child characteristics (interest in toys, verbal self-stimulatory behavior, minimal nonverbal self-stimulatory behavior, and tolerating another person in proximity) that indeed predicted positive response to PRT in a subsequent prospective study of six children. A follow-up study suggested that toy interest may be particularly important for positive response to PRT but did not predict response to a discrete trial treatment (Schreibman, Stahmer, Barlett, & Dufek, 2009). Fossum and colleagues (2018) found a similar profile, including child cognitive ability, positive affect, and levels of appropriate toy contact, predicted response to PRT in their larger community-based sample. Hardan and colleagues (2015) reported greater improvement from PRT in children with stronger visual reception skills at baseline, whereas Vivanti and colleagues (2016) demonstrated that verbal ability at treatment entry moderated treatment response in young children receiving ESDM. Yang and colleagues (2016) completed an uncontrolled trial that found association between functional magnetic resonance imaging (fMRI) brain response to biological motion and positive response to PRT. Other studies have suggested that parent involvement is a significant predictor of treatment response to NDBI, and high levels of parent stress at baseline may be associated with poor child response to treatment (Stadnick et al., 2015). A study of Project ImPACT showed an association between parent use of treatment strategies and child progress on language measures (Ingersoll & Wainer, 2013). In a study of JASPER, parent involvement, buy-in, and use of strategies were related to child joint engagement (Gulsrud, Hellemann, Shire, & Kasari, 2016). As is clear from this growing body of research, identifying predictors of response to NDBI is a critical area for future study and will allow for greater individualization of goal selection and treatment approach. Considerable progress has been made in identifying child and family factors associated with positive response to treatment. It is expected that treatment selection will soon be guided by more sophisticated understanding of factors predicting treatment response so that eventually treatments can be selected based on child characteristics indicating high likelihood of a favorable response.

THE NATURAL ENVIRONMENT The decision about where to teach functional skills provides another opportunity to individualize treatment and maximize the focus on meaningful goals.

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Clinicians should consider a wide range of potential teaching settings; different contexts may convey distinct advantages depending on the child and family needs. When performance in real-life settings is the ultimate goal of any intervention program, it makes sense to prioritize teaching in environments that are naturally a part of the child’s daily routine. Although “natural” often means home or community—and “unnatural” might mean segregated, clinic, or office settings— many clinic settings can function as a natural environment if planned accordingly (e.g., classroom-based NDBI programs that are conducted in clinic settings). In some circumstances, a child’s rate of learning new skills may be enhanced by teaching specific skills in a setting that provides additional structure or fewer distractions. In this case, incorporating naturalistic components into the setting will be critical to enhance generalization of skills to natural environments as well. Clinicians should consider how to maximize the effectiveness of the available teaching settings, as well as the likelihood that teaching in those settings will help the child function across contexts that really matter to the child and family. On some occasions, teaching in a more structured and decontextualized format may be warranted, at least temporarily, due to individual needs or particularly slow rate of learning. For some individuals, learning proceeds at a faster rate in a highly structured approach than with a completely contextualized and naturalistic approach. The individual can more readily focus on the salient learning cue(s) and access reinforcement immediately. Skills can also be broken down into smaller components, and focus can be placed on teaching systematically and incrementally toward the whole. This approach can also be beneficial for teaching some skills where natural reinforcement is more difficult to provide, when it may not actually be reinforcing yet, or when skill fluency is required in order to obtain natural reinforcement. The ultimate goal is to work toward a more naturalistic and contextualized framework if possible so that each individual can benefit from its advantages, particularly maintenance and generalization of skills (see Box 3.4 for definition). There are a number of reasons, both common sense and empirically supported, why NDBI emphasize teaching skills in the natural environment. There is even some evidence that children may present different behaviors in natural settings than they do in clinics (Stronach & Wetherby, 2014), and because performance in the natural environment is the ultimate goal, targeting skills in that setting often makes the most sense. Although behavioral treatments were first applied in structured settings with few similarities with the natural environment (LeBlanc, Esch, Sidener, & Firth, 2006), the earliest studies of naturalistic behavioral treatments employed teaching in the natural environment as a strategy to increase

BOX 3.4: Skill maintenance and generalization Skill maintenance: A skill is maintained when the child continues to demonstrate the skill after additional reinforcement from the teaching phase is faded. Skill generalization: The transfer of a skill learned under one set of conditions to another set of conditions. Typically thought of as transfer across people, settings, and behaviors.

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generalization and spontaneous use of skills (e.g., Hart & Risley, 1968). Subsequent researchers were heavily influenced by Stokes and Baer (1977) and their seminal work on generalization, which inspired the development of a range of treatment approaches for implementation in natural settings and by caregivers and teachers (i.e., natural change agents). Several decades of research now support the effectiveness of teaching in natural settings, not just for skill acquisition but also in terms of collateral effects on untargeted behaviors (Hart & Risley, 1980). Rate of skill acquisition, maintenance, and generalization of skills are important features to consider in any treatment. Naturalistic teaching strategies have been shown to have considerable advantage; they are quite effective at promoting skill acquisition (Delprato, 2001), and when skills are taught in the natural environment, they often maintain longer and generalize more quickly (Dufek & Schreibman, 2014; Ingersoll & Dvortcsak, 2010; Rogers & Dawson, 2010). Natural environment teaching also allows for practice and feedback in the setting where the skills occur, and the resulting natural reinforcement helps the learned skills generalize more quickly and maintain over time. The use of natural maintaining contingencies has long been recognized as a key way to promote generalization (Stokes & Baer, 1977). For instance, one study demonstrated that children made greater improvement in the intelligibility of their speech when teaching occurred in natural contexts (Koegel, Camarata, Koegel, Ben-Tall, & Smith, 1998). Parent training, which can be more practical and accepted in natural settings, also enhances maintenance and generalization (Kaiser, Hancock, & Nietfeld, 2000; Kasari, Gulsrud, Paparella, Hellemann, & Berry, 2015; Koegel, Koegel, Kellegrew, & Mullen, 1996). Intervention in a natural setting lends itself to more engagement and involvement with the parent, caregiver, siblings, peers, or other individuals who frequently interact with the individual with ASD. This means that targeting skills in the natural environment can increase the dosage and intensity of the treatment via involvement of key stakeholders. For example, if a skill is practiced in the natural environment with the relevant caregivers, those individuals will be more likely to support the individual with ASD when a clinician is not present, thus increasing the dosage (Ingersoll & Dvortcsak, 2010; Vismara, Colombi, & Rogers, 2009). Another way to facilitate increased dosage and practice in the natural environment is to directly teach intervention strategies to parents and other caregivers. Research on PRT, for example, supports that teaching parents this NDBI approach in groups is associated with parent acquisition of PRT skills, increased parent empowerment, and child language gains (Hardan et al., 2015; Minjarez, Mercier, Williams, & Harden, 2013; Minjarez, Williams, Mercier, & Hardan, 2011). This innovative approach simultaneously increases treatment dosage across numerous children and results in intervention being implemented in their natural environments. Thus, the environment matters. Parents and providers should consider teaching across a wide variety of settings for optimal generalization and maintenance of meaningful skills. Although not every skill must be taught exactly where it will be used, and not every person in the individual’s life must be involved, a concept shared by NDBI is that the more natural the setting, and the more stakeholders who participate and learn support strategies, the better the skill will generalize to where it must be used, and the more fluidly reinforcement will be obtained to promote skill maintenance. See Box 3.5 for more on planning for generalization.

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Ready, Set, Implement! BOX 3.5: Planning for generalization To plan for generalization from the start, select a current client’s program. Take a look at each goal and how you have written mastery criteria. How many people should the client practice the skill with? Should the goal include both adults and peers? How many settings apply to this goal? How many sessions, days, or weeks do you want to see the client demonstrate this skill independently before you consider it mastered? By looking at each goal individually to answer these questions, you ensure both individualization as well as increased likelihood the client will generalize (and maintain!) newly learned skills.

Types of Natural Environments A natural environment is the context in which the individual lives, goes to school, works, and/or engages in social or extracurricular activities. The natural environment for a toddler might consist of home, preschool, and any other community settings that are part of his or her family’s routine. As an individual develops, the natural environments may change to involve different settings or individuals. For a teenager, these environments may include home, school, sports practice, community (e.g., buying goods and services), and social settings or events such as activities with peers (e.g., clubs, friends’ houses). For an adult, environments may shift to include the workplace as well as additional social and community settings (e.g., gym, bars or restaurants). Also included in the natural environment are family members, caregivers, and others who may interact with the child in a teaching, mentorship, or supervisory capacity (e.g., teacher, coach, employer). Although perhaps not identified as a traditionally natural environment, therapeutic settings such as a clinic can be included in the natural environment in the event that they have been set up in a manner that imitates the natural environment (e.g., playrooms or classroom settings). Home Settings The home environment is perhaps the most natural of environments and a critical context for practicing and performing many meaningful skills. For example, very young children are more likely to be comfortable at home compared to an unfamiliar clinic (which may also remind them of going to the doctor). At home, they can access familiar caregivers and be surrounded by familiar toys and activities. The home setting also provides access to a wider variety of routines and activities (kitchen, play spaces, outside areas), which allows for targeting more skills in the natural context (Ingersoll & Dvortcsak, 2010). It also allows for frequent switching of activities and the use of daily routines, which is appropriate for young children who are not expected to attend to one activity for more than a few minutes at a time. Teaching at home allows for embedding skills within family routines. Across NDBI approaches, teaching during daily routines is emphasized as an optimal way to ensure frequent practice of functional skills. For example, if a parent wishes to

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increase the frequency of a child’s verbal requests, identification of multiple specific times during the day when the child can practice is often useful (e.g., asking to be picked up in the morning, requesting breakfast items, asking to open the door to go outside, requesting bath toys). With repeated practice, the simple act of engaging in these daily routines can even start to serve as a reminder to practice the communication skills. Home-based intervention also gives providers insight into how suggested treatment approaches actually fit into a family’s day-to-day life. For example, a provider might observe that a parent sometimes has difficulty waiting for the child to make an appropriate verbal request to go outside when the family is late for school. The provider could suggest that this communication skill only be prompted in the afternoon period when the parent has sufficient time to wait for an appropriate response. The social validity of intervention will become quickly clear in the home setting. If modifications to the treatment goals or approach are necessary to improve goodness of fit with family cultural norms and values, an observant professional working in the home setting can help families make these modifications. Some behaviors that may be important targets for intervention may occur only in the home setting. For example, if providers wish to have a meaningful impact on feeding, sleep, dressing, or other personal hygiene behaviors, intervention in the home may be the most efficient and appropriate way to address these skills. Sometimes children exhibit challenging behaviors in the home setting that are not observed in a clinic or school. Intervention to reduce these challenging behaviors is therefore most effective in that context in which it most frequently occurs. Intervention in the home setting can also allow for more natural involvement of family members, and the amount of time they participate can be flexible and match a specific routine or activity. There are some occasions where teaching in the home environment may not be the ideal choice. Parents and providers may find the need to weigh the benefits of teaching at home against practical considerations (shared family space and living arrangements, family schedules, availability of peers and diverse learning materials) and consider whether an alternative setting may be beneficial for at least some of the teaching. Community Settings Treatment in community settings provides a unique opportunity to teach skills that will be meaningful to both the child and to the family. Treatment in community settings may also support inclusion by making other individuals more aware of the needs of individuals with disabilities and promote respect and acceptance. Many families of children with ASD feel isolated due to limited engagement with community activities. Often this can be exacerbated by a child’s unpredictable or disruptive behavior that can feel even more challenging to manage outside the home. If a provider can conduct intervention in this setting, parents can be coached in effective management of these behaviors for future occasions. Helping a family develop behavior supports that allow a successful trip to a grocery store, restaurant, or religious ceremony can greatly enhance quality of life. Expectations for behavior also vary across community settings. Because children are expected to behave differently depending on whether they are playing in a park, visiting a library, crossing a street, or eating at a restaurant, practicing skills across settings allows these nuances to be taught most effectively. For example, the grocery store may be an effective place for teaching walking next to a parent

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and communicating requests to purchase preferred items, as well as tolerating denied access to preferred items, waiting (e.g., in line), and handling aversive sensory input. In the park, there might be increased focus on social-communication and play skills as well as following safety directions and decreasing elopement. At church, the treatment might focus on skills such as waiting prior to being allowed to leave the setting, engaging in quiet activities to promote appropriate behaviors, and conducting context-specific routines such as taking communion. The skills that are appropriate to each context are broader in scope than those that are taught in the home setting, thus expanding both the number of settings in which the individual can function appropriately and the number of skills being targeted. Different types of people are also available in community settings, which provides opportunities for a child to practice a range of social skills and respond to a range of social cues. If some of the targeted skills involve interaction with peers, intervention in a community setting, such as a park, may provide access to those peers with whom the individual can consistently practice skills and receive feedback. Furthermore, for development of safety skills, it is critical that children learn how to interact differently with strangers versus familiar people; these types of skills are ideal for practice in real-world community settings. Group-based activities (e.g., teams, camps, other group extracurricular activities) are settings in which typically developing children commonly participate and, as such, are desirable settings for individuals with ASD as well. Children enrolled in extracurricular activities, sports, summer camps, and clubs also have more opportunities to develop friendships and build social skills, although research indicates that children with disabilities tend, in general, to participate less than their typically developing peers in such activities (Solish, Perry, & Minnes, 2015). When involved, many individuals can show gains in social areas (Brooks, Floyd, Robins, & Chan, 2015), as well as experience long-term academic and social benefits (Ashbaugh, Koegel, & Koegel, 2017; Palmer, Elliott, & Cheatham, 2017). Drawing on the NDBI principles of following the child’s lead and child choice, often the best strategy is to select activities or clubs related to a child’s specific interests to keep him or her engaged and increase the chances of meeting compatible peers. The key is to select an activity the child will enjoy and be able to participate in (with support if necessary). Many children do best in group activities that emphasize individual performance (martial arts, swimming, music lessons) rather than competitive team sports in which the whole group relies on the child’s skills, such as soccer and basketball. Team activities also require a great deal of social judgment, which may be challenging. Self-management (see Chapter 13 on addressing challenging behavior) can also be used to promote independent use of important social skills in group contexts. Camp settings are another natural environment that have been shown to have therapeutic effects when intervention is applied. Summer camps for children with ASD or other special needs initially tended to be segregated (Blas, 2007; Hung & Thelander, 1978). However, intervention has been implemented in inclusive summer camp settings, with gains noted specifically in social skills (Brookman et al., 2003; Maich, Hall, van Rhijn, & Quinlan, 2015). Corbett and colleagues (2014) found that children with ASD who participated in a theater-based inclusive, peer-mediated summer camp demonstrated gains in social areas, such as face perception and social cognition.

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Throughout the life span, participation in group activities can have social and academic benefits. Palmer and colleagues (2017) found a significant association between students with disabilities who participated in extracurricular activity and postsecondary degree completion. Ashbaugh and colleagues (2017) utilized a brief structured social planning approach with adolescents with ASD and found an increase in their number of community-based social events, extracurricular activities, and peer interactions. School Settings The school setting is another core natural environment for all children. Typically developing children spend around 1,000 hours in school each year. Under the Individuals with Disabilities Education Improvement Act of 2004 (PL 108-446), children with disabilities in the United States are entitled to free appropriate public education in school, in the least restrictive environment. This means that children have a fundamental right to be educated appropriately in school. Schools provide many benefits as teaching environments. First, because many children with ASD benefit from familiarity and routine, the predictable structure of the daily schedule often helps children know what behaviors will be expected of them each school day. For instance, the greeting routine or circle time each day can become familiar to children with ASD and support their participation. Consistent behavioral expectations also often help children with ASD learn appropriate behavior. For instance, disruptive noises or high levels of movement may be difficult to accommodate in a school setting, and children may learn to reduce these behaviors in compliance with classroom expectations. Many teachers use multimodal teaching strategies, including visual and tactile supports, which often benefit children with ASD, who may have different learning styles. Furthermore, the fact that many children with ASD enjoy basic academic tasks such letter identification and counting also helps them enjoy early schooling. The group learning format may be challenging for children with ASD, but it can also help children generalize skills learned in an individual context to a more real-life environment. A meta-analysis completed by Bellini and colleagues (2007) and work by Gresham, Sugai, and Horner (2001) indicate that social skills intervention in the natural environment as opposed to pull out settings tends to be more successful. Finally, schools are an ideal context for enhancing social skills and peer interaction given the number of hours children spend at school and the ready availability of peers in this context. Research supports the application of NDBI in school settings, and NDBI approaches can be implemented in school contexts in a variety of ways. For preschool programming, there are a number of inclusive models for serving young children with ASD and typically developing peers using NDBI approaches. For instance, classroom design can be informed by NDBI contextual variables, as in the Walden Toddler Program (McGee et al., 1999), in which classrooms were divided into zones arranged to provide opportunities for incidental teaching. In this context, adults provide instruction and reinforcement in response to childinitiated teaching episodes. In other models, naturalistic developmental behavioral supports are provided within the context of an inclusive preschool program. For example, in the Alexa’s PLAYC (Playful Learning Academy for Young Children) program, all children are provided developmentally appropriate early childhood

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education within a predictable daily routine, and contextual (e.g., visual supports) or behavioral (e.g., prompting and reinforcement) strategies can be provided as needed to support skill acquisition for a child with ASD and can subsequently be faded to promote independence (Stahmer & Ingersoll, 2004). In another model, the Project DATA program provides individualized behavioral treatment and parent training as a supplement to high-quality early childhood education in an inclusive setting (Boulware, Schwartz, Sandall, & McBride, 2006; Schwartz, Sandall, McBride, & Boulware, 2004; Schwartz, Thomas, McBride, & Sandall, 2013). Research on ESDM (Vivanti et al., 2014) and JASPER (Goods, Ishijima, Chang, & Kasari, 2013) also indicates that these approaches can be successfully implemented in preschool settings. The LEAP program (Learning Experiences: An Alternative Program for Preschoolers and Parents; Strain & Bovey, 2011) emphasizes peer-mediated intervention approaches to support children with ASD in inclusive preschool settings. Research is now emerging on application of NDBI strategies in school settings for elementary school children as well. For instance, Mandell and colleagues (2013) documented implementation of Strategies for Teaching Based on Autism Research, a program that combined discrete trial training with PRT and teaching within functional routines. Stahmer and colleagues (2011) also published a manual outlining the application of PRT to classroom settings for children in early elementary school. This research indicated that many teachers can be trained to use evidencebased NDBI approaches in their classrooms (Stahmer, Suhrheinrich, & Rieth, 2016) and also identified a number of challenges to embedding these practices within existing school systems (Suhrheinrich et al., 2013). For instance, direct coaching of teachers may be required to support sustained implementation of these practices (Suhrheinrich, 2011). Another promising approach has been to train individuals with ASD to initiate (Koegel, Kuriakose, Singh, & Koegel, 2012) or use self-management (de Bruin, Deppeler, Moore, & Diamond, 2013) to enhance performance in school settings without the need for intensive intervention in that setting. Chapter 5 reviews additional examples of how NDBI approaches have been embedded in inclusive settings, and Chapter 14 is focused on implementing NDBI in schools. Many children participate in school programs that have ABA treatment embedded in the classroom. Other school programs may contract with ABA agencies to provide ABA to specific children in their school on an as-needed basis. Both types of programs may vary in the degree to which providers use naturalistic behavioral strategies, but parents knowledgeable about NDBI components can often advocate for incorporation of naturalistic procedures. For instance, parents can request specific modifications to the child’s school program to support engagement, motivation, and generalization, such as incorporation of child interests into assignments, use of natural reinforcement, or implementation of a self-management program. A school program that is unwilling to implement evidence-based ABA or NDBI strategies for a child with ASD can be a significant challenge. The first step is to make sure that a child’s educational team is in agreement that the identified deficit areas (e.g., academic skills and/or social behaviors) are important targets for intervention. For social areas, it is often helpful to make sure there are goals related to peer interaction written directly in the child’s individualized education program (IEP). It is also important to identify which adults (teacher, paraprofessional, speech pathologist, behavior therapist) will be directly responsible for treatment implementation in each school context (during class time, lunch, and recess).

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If professionals across multiple public (e.g., school) and private (e.g., therapy clinic) agencies are involved in a child’s care, coordination of goals and intervention strategies across providers is especially critical. Clinic Settings Treatment in a clinic setting will often be a component of a child’s intervention plan. Clinic-based treatment can convey particular advantages, especially as a complement to treatment provided in other natural environments. Clinic settings can be particularly useful when structured practice of skills is necessary because clinicians often have greater control of contextual variables in the clinic setting. In these settings, it can be more feasible to arrange the environment in a manner conducive to the child’s learning or to reduce distractions if necessary. Given the treatment priority of building skills relevant in real-life settings, the addition of naturalistic components in clinic settings may also enhance meaningful generalization of skills. When clinic settings are used, there are specific strategies that can make these settings more natural and appropriate for intervention. For young children, clinic-based programs can be natural if they are designed from a play-based and developmental perspective and set up to mimic the natural environment. Ensuring availability of developmentally appropriate toys and materials and arranging rooms to mimic other important natural learning environments the child currently has access to or is preparing to participate in can be useful. For example, a treatment space for a young child might be set up to mimic a playroom or classroom setting, with spaces for group instruction, individual workspaces, child-sized furniture, toys, and books. When possible, access to an outdoor play area or designated space for gross motor play can be helpful. Environmental arrangements may also be useful in order to provide the child with opportunities to request items that are not readily available, the way he or she would have to do at home or in a classroom. For example, having some materials available just out of reach (e.g., in a cabinet, on a higher shelf) may motivate a child to use spontaneous communication. For older children, inclusion of academic or vocational workspaces is appropriate, along with spaces for learning recreational and leisure skills. For instance, a school-age child might benefit from a desk for completion of academic work; a table for playing board games, puzzles, or block constructions; a comfortable chair or couch for socializing or playing handheld games; and access to an outdoor area or gym for practicing sports. For an individual preparing for a job at a grocery store, shelves for organizing items for purchase might be appropriate. For an individual preparing for a job at a hotel, access to a laundry machine may facilitate learning important housekeeping skills. A treatment space for an adolescent social group might be set up to mimic a school lounge with couches, a speaker for playing music, and snack items. Some clinics may also have access to areas such as a kitchen or can create areas that simulate a bedroom or dining room, which can increase the ability to practice a wide range of skills necessary for independent living. The more the clinic environment mimics other real-life settings relevant to the individual and family, the more readily skills learned in the clinic can be expected to generalize in other meaningful environments. There are some additional factors to consider when providing intervention in a clinic setting. For example, a clinic or office setting may pose limitations on the number of individuals who can be present, as well as the types of situations that can be taught or practiced. Participation in a clinic setting is more difficult

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because someone has to transport the child there and then either drop the child off or remain present throughout the duration of the session. A parent may be able and willing to participate in a 2-hour session; however, the child’s siblings or peers may not be able to do so. For these reasons, treatment programs that provide intervention across a variety of settings have many advantages. When possible, plan both home and community sessions, integrated with clinic-based instruction, to allow a wide range of relevant skills to be taught, practiced, and generalized. Social Validity of the Natural Environment Social validity of treatment context has also been a focus of investigation for NDBI (Ogilvie & McCrudden, 2017; Kim, Koegel, & Koegel, 2017). Evidence indicates that practicing functional skills across a child’s natural environments is a critical way to enhance the social validity of treatment efforts. As previously discussed, social validity should emphasize the client and family’s perspective on the acceptability of treatment. Clinicians should consider the child’s temperament, cognitive profile, interests, learning history, and other individual factors, which may influence how he or she responds to certain teaching contexts. For instance, a therapist might learn that a child responds particularly well to teaching during physical play and could then tailor the treatment to involve outdoor activities and highly physical indoor play. Another child might learn best when his or her surroundings are more calm and quiet, and the therapist could work to minimize distractions and noise to enhance learning. Research has indicated that parents may also prefer more naturalistic interventions (Schreibman, Kaneko, & Koegel, 1991). For an intervention to be socially valid, it should be practical for stakeholders to use (Winett, Moore, & Anderson, 1991). NDBI’s emphasis on parent involvement and embedding treatment within daily routines is consistent with this priority. Treatment providers can be most effective when they seek to help parents integrate teaching into naturally occurring activities rather than suggesting parents find time to practice outside their normal daily lives. For instance, a parent can help teach a child about colors while sorting laundry. In another example, EMT (Hancock & Kaiser, 2002, 2006) enhances goodness of fit by establishing treatment routines within existing daily activities (arranging the environment, teaching to promote language use in functional context). Other NDBI approaches also encourage practicing skills in the context in which they are naturally relevant. A socially valid intervention should also improve family quality of life. When children learn skills and practice them both at home and in important community contexts, it can make a real difference for the family. For instance, parents who teach their child skills that allow them to take the child to a restaurant, grocery store, or church service will likely feel less isolated and less burdened by the child’s disability. Providers should therefore work collaboratively with family members to identify contexts for intervention that may enhance family quality of life. Because the long-term utility of interventions depends on how well they can be integrated in family and community contexts, the continued development of practical systems and tools for enhancing social validity of interventions and enhancing goodness of fit with family values is still urgently needed.

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Case Example: Jin Jin is a 6-year-old Asian American boy who was diagnosed with ASD just before his third birthday. Having recently moved to a new city, Jin’s parents began the process of establishing treatment with a new set of providers. When his parents first discussed their treatment priorities with the supervising clinician, they expressed wanting Jin to learn his numbers, colors, and shapes. When discussing treatment goals further, the supervisor learned that it was also very embarrassing to the family that Jin still was not toilet trained. The supervisor wanted to prioritize this goal because it was important to the family, it would help Jin be more independent, and Jin was showing signs of being developmentally ready (e.g., disliking being dirty, attempting to wipe himself, pulling up his own pants, waking up dry in the morning). After completing an initial assessment, the clinician reviewed treatment priorities and suggested that, given their role in long-term positive prognosis and prevention of challenging behavior, several functional communication skills (e.g., describing desired items and asking for a break) should also be considered a key priority. Together with the family, the clinician developed a plan to integrate teaching of numbers, colors, and shapes into the broader functional communication goals to ensure the family members felt their priorities were being addressed, in addition to those being proposed by the clinician. Although it was not initially on the family’s list of treatment priorities, the clinician also suggested that the parents add several social goals in anticipation of the struggles many children with ASD have during peer interactions. Jin’s parents confessed that they did not have many opportunities to observe him around other children, but they agreed that these additional goals made sense. Jin’s initial goals by domain are listed in Table 3.1. The team considered multiple natural contexts for treatment. They identified home as the best place for practicing toileting skills and as a critical environment for targeting communication and social goals. They identified the school environment for practicing asking for a break, as well as a number of social and preacademic skills. As Jin’s therapists started implementing in-home treatment sessions, the treatment supervisor also started providing parent training during one of the family’s weekly appointments. Knowing from the intake assessment that Jin’s parents held many traditional Asian values, including the importance of family, the supervisor was careful to involve both parents as much as possible and offered to include Jin’s grandparents in sessions when they were visiting the family. Although Jin’s parents at first appeared agreeable to the idea of following Jin’s lead when teaching communication, Table 3.1. Jin’s initial goals Domain

Functional goal priority

Natural environment for practice

Communication

Describe desired items (by number, color, or shape) Ask for a break

Home, school

Daily living skills

Use the toilet independently

Home

Social skills

Imitate peer behavior in a group setting Initiate appropriate requests for play materials Initiate new activity ideas

School, Aikido class Playdates at home, school Park, walks home

School

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they continued to be very directive in their interactions with Jin, even after a month of parent training. The supervisor was worried that Jin might lose motivation to communicate if his parents asked too many questions without reinforcement, but the parents did not agree with this feedback. They wanted Jin to obey their instructions at home but were also uncomfortable directly contradicting the supervisor and continued giving Jin instructions the way they always had. The therapist decided to ask more about the family’s beliefs about effective parenting and learned that Jin’s parents felt strongly that children should show respect to parents’ authority by obeying their directives. The therapist worked to understand the family perspective and find a compromise that allowed the parents to take advantage of Jin’s interests to motivate him to learn while maintaining their role as authority figures within the family. For example, the parents and therapist were able to generate a number of examples of teaching contexts and target behaviors in which they could provide Jin with instructions or ask him questions within motivating activities or his areas of interest. In this way, the parents were able to maintain their expectations while also targeting Jin’s motivation to make social-communication responses and follow directions. As the parents learned more skills, they were able to learn strategies such as interspersal of maintenance and acquisition tasks and shaping in order to give Jin more instructions in adult-directed contexts because these also were important to them. Once the parents and supervisor successfully merged their approaches, the parents learned how to take advantage of incidental opportunities throughout the day for practicing descriptive language. It was tempting to ask Jin to label or describe (e.g., by color) objects all the time, but after the therapists modeled and explained how to use shared control and natural reinforcement strategies to target functional requests instead, the parents could see how much more readily Jin responded when these motivational strategies were incorporated. Jin even started using more complex descriptive language spontaneously. For instance, because Jin loved playing with his train track, his parents learned how to work collaboratively with Jin to build the track together and how to guide him to use words to describe exactly how he wanted to build it (e.g., modeling phrases for him such as “put the curved track next to the bridge” and asking him questions such as “What order should I put the trains in?”) in the context of reciprocal play. Because Jin was attending school, his parents and providers considered how treatment goals could also be addressed in the school setting. His parents advocated in the IEP meeting to have functional goals emphasized on Jin’s IEP. In addition to academic goals, his parents advocated for Jin to learn how to appropriately ask for a break so that he would not be reinforced for using disruptive behavior to escape difficult tasks. They also asked the school team to prompt him to use descriptive language to request desired items, as he was practicing at home. The team agreed to add these goals to his IEP and implemented a plan for coordination between parents and teachers. Jin’s parents initially wanted daily feedback on Jin’s performance in school. After discussing the feasibility of this with the teacher, they agreed that a weekly communication log would be more sustainable for the teacher and would still allow the parents to take Jin on a special outing each weekend to celebrate his consistent appropriate behavior at school. Jin’s parents started including pictures from their weekend in the log, which helped Jin describe recent past events when children shared weekend activity stories during Monday morning circle.

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The team also considered peer interaction opportunities in treatment planning. In talking with Jin’s providers about social goals, his parents realized that school was the main context where Jin had a chance to interact with peers. Jin’s parents were most concerned that Jin was often alone on the playground. They discussed this problem in the IEP meeting and came up with several functional goals related to peer interaction at school, including increasing the duration of peer engagement during recess. The team decided that it would be most functional for Jin to practice the types of tag games children in his class typically played on the playground. Because it was easier for Jin to follow the pace of the game when he was with a buddy (and this gave him an opportunity to work on the goal of imitating peers), the teacher was able to suggest a modification to the rules so that the children played in pairs. Jin’s parents soon realized that Jin’s chances of developing meaningful relationships with peers would be stronger if he had opportunities for peer interaction outside school as well. Because Jin did not have any friends from his neighborhood, his parents started by asking a cousin to come play for a short time on the weekend. Jin’s mother prepared several fun activities that she knew both children would enjoy (making cardboard robots, decorating cookies). Jin practiced the functional skill of initiating to request items from his cousin whenever he needed more materials for his project (e.g., glue for his robot, sprinkles for his cookie). The next week, Jin’s mother set up another playdate by asking a good friend of hers from work who she knew had a boy, Ian, who was about Jin’s age. To make it extra convenient, Jin’s mother offered to pick Ian up after school on a day when she knew her colleague had to stay late for an important meeting. The boys had a good time decorating individual pizzas for dinner and making paper kites to fly in the driveway. Jin practiced making functional social initiations to Ian during the two activities (e.g., “Do you want pepperoni or olives on your pizza?” “How long do you want the string for your kite?”). Ian actually did not want to leave when his mother came to pick him up, but he complied with the instruction, and the parents agreed to let the boys play together again soon. With support from the clinician, Jin’s parents also decided to enroll him in an Aikido class once per week after school. They thought that he would enjoy this activity and that it would be a good way for him to practice following instructions and a class routine. This turned out to be a great activity for Jin to practice imitating peers. Sometimes he did not understand the teacher’s instructions the first time, but his father would remind him to look at what the other children were doing, and that gave Jin clues about what he was supposed to do. The Aikido class was also a place for Jin’s parents to meet other families in their neighborhood. Jin’s parents made sure to arrive a few minutes early for class each week and stay a few minutes after class, making time to chat with the other parents who were there. It turned out that one of the other boys in Jin’s class, Marc, also lived within walking distance of the studio. That made it easy to plan to walk home together after class. Over the next couple of weeks, Jin practiced suggesting new ideas for joint activities during the walk home, such as stopping for a frozen yogurt or playing at the park for a few minutes. Jin’s parents appreciated how hard Jin was working to practice these new skills and, most of the time, Marc’s parents agreed to the plan, and Jin’s social initiation was reinforced. As the families got to know each other, Jin’s mother even suggested the families meet up on a different day to visit a local train museum (Jin’s favorite activity). Marc’s family was thrilled because they had wanted to go to that museum for a while.

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CONCLUSION Treatment teams should consider a variety of factors when selecting and prioritizing treatment targets to ensure that they will be meaningful to the individual and those in his or her environment. Furthermore, it is important to think about how those skills can be taught in the most natural environments in order to maximize treatment effects and increase generalization and maintenance. Meaningfulness of the skill, awareness of contextual features, and goodness of fit of interventions, as well as practicality and logistics regarding where treatment can occur, are all key factors that must be part of planning an individualized program in NDBI.

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4 Empowering Parents Through Parent Training and Coaching Mendy B. Minjarez, Elizabeth A. Karp, Aubyn C. Stahmer, and Lauren Brookman-Frazee

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esearch and clinical guidelines (e.g., National Research Council, 2001; Wong et al., 2013) support the importance of considering family context and involving parents and other caregivers in treatment for children with autism spectrum disorder (ASD). In fact, parents (in this chapter, parents refers to any primary caregiver) increasingly are considered core agents of intervention delivery, especially in Naturalistic Developmental Behavioral Interventions (NDBI; e.g., Early Start Denver Model [ESDM]; Pivotal Response Treatment [PRT]; Joint Attention, Symbolic Play, Engagement, and Regulation [JASPER]). This focus on parent involvement is consistent with the focus in general on involving key stakeholders in order to optimize successful outcomes (Herschell, Calzada, Eyberg, & McNeil, 2002; Kazdin & Weisz, 2003; Patterson, 1982). Families play a central role in creating their children’s social world and have the most intimate knowledge of both their children and the environments in which their children will thrive and grow (Bernheimer, Gallimore, & Weisner, 1990); therefore, considering parent preferences and goals (i.e., goodness of fit, as discussed in Chapter 3) enhances the match between what therapists recommend and the feasibility and/or importance from the family perspective. When therapists consider the family context, families are more likely to implement intervention strategies consistently and with strong treatment fidelity (Brookman-Frazee, 2004).

PARENT-MEDIATED INTERVENTIONS AND NDBI Teaching parents to use NDBI strategies during interactions with their children is one way to provide a cost-effective means of intervention delivery in the natural environment by the individuals who spend the most time with them (e.g., Kasari, Gulsrud, Wong, Kwon, & Locke, 2010; Koegel & Koegel, 2006; Oono, Honey, & 77

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McConachie, 2013). Most, if not all, NDBI models include some form of parentmediated intervention for core ASD symptoms (Schreibman et al., 2015). For some interventions, parents can be the primary intervention agents (e.g., JASPER, PRT, Enhanced Milieu Teaching [EMT]), whereas other models include parent training to enhance clinician-delivered intervention (e.g., Early Start Denver Model [ESDM]). Both are viable forms of parent delivery of NDBI. Children make greater improvements with a combination of clinicianimplemented and parent-implemented intervention because ongoing parent implementation increases the intensity of interventions, whereas clinician involvement can ensure appropriate expertise in program development and maintenance (Nahmias & Mandell, 2014; Rogers et al., 2012). Although parents should always be included in program and goal development, providers must consider the family context, parent resources, stress, and time demands when recommending parentmediated interventions. The goal is both to maximize opportunities for intervention for the child and to support family functioning through collaboration between providers and parents (Stahmer & Pellecchia, 2015). Parent training and education is the primary way in which NDBI models involve parents in treatment. As discussed throughout this book, NDBI highlight intervention in the natural environment and the use of familiar and emotionally connected relationships as a vehicle for intervention delivery. This makes NDBI especially well suited for use by family members in the home and community. For example, strategic arrangement of the environment (e.g., incidental teaching [IT]) is outlined as a key strategy for promoting communication development. Family members can implement this at home by placing toys in hard-to-open see-through containers, giving smaller portions at mealtime to encourage multiple opportunities to request more, or waiting for the child to initiate a request. Providers can teach parents strategies such as the use of natural reinforcement, prompting, balanced turns, modeling, adult imitation of child behavior, and following the child’s lead, and parents can implement these strategies consistently in the context of natural family routines (Hardan et al., 2015; Ingersoll & Wainer, 2013, Kasari et al., 2014; Rogers et al., 2014; Wetherby et al., 2014). Although most parents of children with ASD are not professional interventionists, they can teach their children skills through NDBI, sometimes even with a relatively small amount of training (Coolican et al., 2010; Hardan et al., 2015; Minjarez, Williams, Mercier, & Hardan, 2011; Vismara, Colombi, & Rogers, 2009). Research supports that parents can successfully learn to implement NDBI strategies in the natural environment, and their children show correlated gains in skills (Coolican et al., 2010; Hardan et al., 2015; Ingersoll & Wainer, 2013; Kasari et al., 2010; Kasari et al., 2014; Rogers et al., 2014; Stadnick, Stahmer, & Brookman-Frazee, 2015; Wetherby et al., 2014). When parents are included in their children’s intervention, their children improve in targeted areas, for example, joint attention, communication, and engagement with their parents (Estes et al., 2015; Hardan et al., 2015; Kasari et al., 2010). Because parents can learn to implement interventions effectively, they should be involved in servicedelivery either as primary or complementary agents of intervention. Involving parents in ASD interventions is also critically important for helping children generalize and maintain newly learned skills. Because generalization of skills can be particularly challenging for children with ASD (Mesibov, Shea, & Schopler, 2005), involving parents or primary caregivers promotes opportunities for generalization to other contexts and individuals outside of treatment sessions.

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When parents implement NDBI strategies throughout their daily routines, they enhance opportunities for generalization of skills and continued learning (Lucyshyn, Dunlap, & Albin, 2002). Parent training can occur in a variety of contexts, including in a group (Hardan et al., 2015; McIntyre, 2008; Minjarez et al., 2011), individually, and through telemedicine and other Internet-based platforms (Brookman-Frazee, Vismara, Drahota, Stahmer, & Openden, 2009; Vismara, Young, & Rogers, 2012; Wainer & Ingersoll, 2013). There are certain benefits to conducting parent training in each of these formats. Group Parent Education In group formats, parents can gain support from one another, which has been shown to decrease parent stress and increase empowerment (Minjarez, Mercier, Williams, & Hardan, 2013). One of the most effective ways to reduce parents’ stress is to increase their informal social support, which is likely to be inherent in group training models (Benson, 2006; Weiss, 2002). Group formats are beneficial because they provide a more ecologically valid way to teach important content to a large group of parents. Group formats have been found to be effective, and parents can learn interventions with high levels of treatment fidelity from participating (Hardan et al., 2015; Minjarez et al., 2011). Individual Parent Education Parents can also participate in individual parent coaching, which is how most parent training programs that have been studied are delivered (e.g., Steiner, Koegel, Koegel, & Ence, 2012). When parents learn how to apply a range of skills to teach a range of behaviors during coaching sessions, they can continue to apply what they have learned to different situations across their child’s life span, minimizing dependence on experts or therapists to give them the information. Individual sessions, combined with group parent support, are another way to offer both training and support (Hardan et al., 2015; Stahmer & Gist, 2001). In both group and individual parent training, sustainment of the intervention can be improved when NDBI are individualized to focus on the family’s needs (Murray, Ackerman-Spain, Williams, & Ryley, 2011). Technology-Based Parent-Mediated Intervention Furthermore, depending on geographic location, parents may be the primary means of service delivery for their children (Kasari et al., 2010). In fact, an increasing number of NDBI models have begun exploring telemedicine and Internet-based training for families who live in locations with limited access to services, with initial evidence in support of these models (e.g., Ingersoll, Wainer, Berger, Pickard, & Bonter, 2016; Pickard, Wainer, Bailey, & Ingersoll, 2016; Vismara et al., 2009).

PSYCHOLOGICAL FUNCTIONING IN PARENTS OF CHILDREN WITH ASD Parent psychological functioning is an important consideration when selecting parent-mediated interventions or involving parents in treatment. Research supports that parent functioning can affect treatment outcomes and can also be

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influenced by involvement in treatment. Although the research in this area is still growing, some research has begun to focus on incorporating strategies that may enhance parent functioning and response to treatment. Parent Stress Parents of children with ASD are known to experience high levels of stress—higher than parents of children who are typically developing and higher than parents of children with other developmental disorders (Baker-Ericzen, Brookman-Frazee, & Stahmer, 2006; Dunn, Burbine, Bowers, & Tantleff-Dunn, 2001). Some studies have also documented that this stress actually increases with time (Dale, Jahoda, & Knott, 2006) and is chronic (Seltzer et al., 2010). These heightened levels of stress can have negative effects on parental physical and mental health, putting them at increased risk for heart disease, sleep disturbances, autoimmune diseases, obesity, and depression (Motzer & Hertig, 2004). Once a child is enrolled in treatment, parent stress can, in fact, influence child outcomes, with lower stress being associated with better outcomes (Plienis, Robbins, & Dunlap, 1988; Robbins, Dunlap, & Plienis, 1991). The relationship between parent stress and child growth and development highlights the importance of addressing parent psychological needs, including stress. One strategy for addressing this need is through parent involvement in intervention. Parent Empowerment Incorporating strategies to promote parent empowerment into parent-implemented intervention may be one way to mediate or address the stress that parents of children with ASD face. Family empowerment promotes the development of confidence in advocating for the family’s needs and acquiring necessary resources and opportunities for the family (Murray, Handyside, Straka, & Arton-Titus, 2013). As such, empowerment may be particularly important to consider in parents of children with ASD because acquiring appropriate resources (i.e., services) can be extremely challenging, given the various service systems parents must navigate (e.g., school districts, health insurance, state resources). Parents may also face challenges with understanding the many types of available interventions and their research support (Berquist & Charlop, 2014). The empowered parent is likely to feel more confident navigating the system and discerning which interventions are likely to be most helpful and effective. Research also supports that parent empowerment is associated with increased successful interactions with service providers and more positive coping with daily challenges (Garland, Haine-Schlagel, Accurso, Baker-Ericzén, & Brookman-Frazee, 2012; Koren, DeChillo, & Friesen, 1992). Furthermore, when parents perceive their goals as attainable, they have a stronger sense of hope and a sense that they themselves can be the agent of that change (Lloyd & Hastings, 2009). Box 4.1 outlines several benefits to being empowered, which lend support for conducting parent training and parentmediated interventions using strategies that promote parent empowerment. When taking an empowerment approach, coaching focuses on family strengths rather than deficits, creating an atmosphere of collaboration with a therapist, and helping both the therapist and the parent to see parents as effective agents of change in the child’s life (Minjarez et al., 2013; Steiner, 2011). When parents participate in empowerment-focused interventions, they demonstrate greater

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BOX 4.1: Benefits of empowerment Empowered parents are more likely to do the following: • Receive access to resources • Take an active part in making decisions about their child’s services • Make changes in their lives • Have strong feelings of self-efficacy • Feel as if they are part of a group • Feel hopeful about their lives and their children’s lives • Learn to change their own perspectives and think critically about a range of issues Sources: Carpenter (1997); Dunst (2002); Lloyd & Hastings (2009); Murray & Curran (2008); Murray, Curran, & Zellers (2008).

resilience to negative life events, increased confidence, more positive interactions with their children, and lower levels of depression and stress when compared to less empowered parents (Brookman-Frazee, 2004; Weiss, Cappadocia, MacMullin, Viecili, & Lunsky, 2012). In fact, parents have reported that the aspect of NDBI that they enjoy the most is their participation (Ingersoll & Dvortcsak, 2006). Furthermore, children’s engagement, responsiveness, and affect also improve when empowerment-focused interventions are used (Brookman-Frazee, 2004), suggesting that treatment approaches that use strategies to enhance parent empowerment may also have a positive impact on child outcomes. Parents who learn behavioral strategies report that they feel confident in their ability to prevent their child’s challenging behaviors and that once these behaviors begin, they feel confident in their ability to stop them (Feldman & Werner, 2002). Furthermore, parents of children with ASD who perceive that they can change their child’s behavior report that they use intervention strategies outside of treatment settings (Moore & Symons, 2011). Because so much of the context for implementation of NDBI relies on the relationships between children and adults, it naturally follows that focusing on parent empowerment may be an important intervention goal. Implementation of NDBI during play and daily routines using motivational procedures (e.g., following the child’s lead) relies heavily on the presence of positive adult–child interactions; therefore, strategies to target adult ability to do so are warranted. Impact of Parent Involvement on Parental Functioning In addition to enhancing intensity of treatment for their children and generalization of treatment gains, parent involvement may have additional positive implications for the parent and family. Although the literature on parent stress has been inconclusive to date, there is some evidence that involvement in intervention for children with ASD may reduce parent stress, specifically related to parent–child interactions (Minjarez et al., 2013). Parents who participate in NDBI demonstrated increases in positive interactions with their children (Koegel, Bimbela, & Schreibman, 1996;

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McConachie & Diggle, 2006). For example, one study demonstrated that during interactions, parents were more interested in their children, appeared objectively happier and less stressed, and used more effective communication styles (Koegel et al., 1996). Another found that parent involvement in intervention was associated with improvements in the parent–child relationship, as well as lower levels of depression (McConachie & Diggle, 2006). These findings support parent involvement in intervention because it may have beneficial effects on parents themselves, as well as child progress in treatment. Although a majority of findings support this, there is a subset of parents (perhaps up to one-third) who may not benefit from parent training if they currently have extremely high levels of stress (Robbins et al., 1991; Singer, 2002; Stern, 2000; Webster-Stratton & Reid, 2003). Therefore, parent involvement needs to be individualized based on a family’s needs and capacities at the time of intervention.

EFFECTIVE PARENT COACHING PRACTICES High-quality parent participation in treatment, including treatment fidelity, treatment enthusiasm, and confidence in using the intervention, influences child gains (Gulsrud, Hellemann, Shire, & Kasari, 2015; Kasari et al., 2010). As explored previously, when parents believe that they can enact change in their child, they will be more involved in interventions and, as a consequence, their children may make greater gains (Solish & Perry, 2008). As such, clinicians should know how to help parents feel engaged and empowered in the treatment process. Yet, as Ingersoll and Dvortcsak (2010) noted in their Project ImPACT (Improving Parents as Communication Teachers) parent coaching manual, most clinicians who deliver intervention to children with ASD are trained to work with children but do not necessarily have formal training in teaching adults. Therefore, clinicians as parent coaches require training in both how to provide excellent coaching, including knowledge of adult learning principles, and methods for increasing parent empowerment. This chapter outlines effective parent training and coaching practices, as described in the NDBI literature. In recognition of this problem, there has been increasing emphasis in how to provide effective coaching, including models specific to ASD and developmental delays (e.g., Amsbary & AFIRM Team, 2017; Hardan et al., 2015; Rush & Sheldon, 2011; Steiner et al., 2012). Some NDBI (e.g., Project ImPACT, ESDM) offer specific training for clinicians in how to coach parents. The sections that follow summarize successful strategies and include procedures designed to increase parent collaboration and empowerment. There is growing support for collaborative and responsive coaching interactions with parents (Barnett, Niec, & Acevedo-Polakovich, 2014; Brookman-Frazee, 2004). In comparison with directive coaching (i.e., telling the parent what to do), responsive coaching practices (i.e., reinforcing parent’s use of a specific strategy) has been associated with parent behavior change in subsequent sessions (Barnett, Niec, & Acevedo-Polakovich, 2014), quicker mastery of skills, and higher treatment completion (Barnett et al., 2015). Responsive coaching practices also have more positive effects on measures of observed parent–child interactions and child responding and engagement (Brookman-Frazee, 2004). Haine-Schlagel and colleagues (Haine-Schlagel & Bustos, 2013; HaineSchlagel, Martinez, Roesch, Bustos, & Janicki, 2016) developed a set of strategies interventionists can use to facilitate family engagement in child treatment. These strategies emphasize delivering the intervention in an empowerment-focused

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Table 4.1. Examples of Parent and Caregiver Active Participation Toolkit (PACT) engagement strategies incorporated into NDBI Engagement strategy domain Alliance Goal: To facilitate an open, honest dialogue with the caregiver Collaboration Goal: To share decision making with the caregiver to increase buy-in and a positive experience Empowerment Goal: To help caregivers develop skills and confidence to change their behavior

Strategies

Examples of application to Project ImPACT for toddlers

Actively listen to the caregiver. Convey a sense of caregiver– therapist partnership. Communicate positive regard toward the caregiver. Give suggestions, not directions. Ask for caregiver input. Collaboratively plan for home practice.

Use partnership language, such as we and us. Talk explicitly about how you will be working together, for example, “Let’s work together on. . . .”

Recognize and acknowledge caregiver strengths and effort. Jointly identify and problemsolve barriers.

Comment on the caregiver’s expertise on his or her child as a valued partner. Identify the caregiver’s strengths as a caregiver. Recognize the caregiver’s efforts to attend and speak up in sessions and to try out new techniques in sessions and at home. Ask, “What will be hard about X?” Ask, “What’s one idea for how to handle that?” Say, “Let’s think about a solution to that challenge.”

Ask, “What questions do you have about using this strategy at home?” Ask, “What routines do you think you could use these strategies in?” Ask, “What goals would you most like to work on at home?”

Key: Project ImPACT (Improving Parents as Communication Teachers). Source: Haine-Schlagel, Martinez, Roesch, Bustos, & Janicki (2016).

way; rather than therapists acting as the experts imparting knowledge on parents, parents are considered key partners in the intervention (Brookman-Frazee, 2004). The Parent and Caregiver Active Participation Toolkit (PACT; Haine-Schlagel & Bustos, 2013; Haine-Schlagel et al., 2016) includes a coordinated set of tools targeting three related domains: Alliance, Collaboration, and Empowerment. These strategies have recently been incorporated into NDBI, such as Project ImPACT, for delivery with infants and toddlers at risk for ASD (Brookman-Frazee, Stahmer, Lewis, Feder, & Reed, 2012; Stahmer et al., 2017). Please see Table 4.1 for a description of the application of the Alliance, Collaboration, and Empowerment strategies for Project ImPACT for Toddlers. Setting the Stage for Effective Parent Coaching The first step in parent coaching is for the parent and therapist to develop a strong relationship. Rapport between parent and therapist can influence parents’ learning of treatment strategies and potentially their use of these strategies with their children outside clinic sessions. As such, focusing on building strong parent–clinician partnerships is an important aspect of delivering parent-mediated interventions, particularly in a community setting when it may be challenging for parents to meet the competing demands of raising a child with ASD (e.g., employment, attending

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treatment sessions, caring for siblings). Rapport building can be achieved through the respect of each family’s ethnic and cultural background, effective communication, shared decision making, and development of trust in relationships (McGrath, 2005). All parents have valuable and unique perspectives about their children, and professionals should consider these as such, rather than attempting to classify children in a particular way by a label or diagnosis, which may prevent more personalized care (Hodge & Runswich-Cole, 2008). A number of strategies can be used to promote collaboration and empowerment when working with parents, including the following: • Asking parents what goals they would like to see the child work on. • Frequently asking parents if they have questions about the treatment plan, goals, or strategies being taught. • Asking parents for feedback on the treatment plan, goals, and strategies being taught. • Asking parents if they foresee any barriers to implementing the treatment plan, goals, and strategies they are being asked to use. • Asking parents to brainstorm examples of how they can implement the treatment plan, goals, and treatment strategies at home, rather than making suggestions to them. • Asking parents to brainstorm examples of how they can implement the goals and treatment strategies at home, with a focus on the materials and activities that are available in the home setting. Because several of these strategies are focused on brainstorming with parents, clinicians can develop written materials that parents can use to document their ideas. For instance, as suggested in the final bullet, if a clinician and parent were brainstorming how to target three goals—verbal requesting, imitation, and following directions at home—they might create a grid, noting ideas; see Table 4.2 for an example. Helping parents to think explicitly about how they will target goals using the toys and activities available in the home setting can be very useful.

Table 4.2. Brainstorming with parents about how to target goals at home Use a grid like this one to help parents write down their ideas about how to target goals at home with the materials they have available. Toys available at home Trains

Goal 1: Verbal requesting Requesting pieces while building the tracks Requesting pieces while building

Goal 2: Imitation Imitating driving the train fast or slow

Goal 3: Following directions

Following directions related to where the train should go Blocks Imitating actions, such as Following directions putting a block on or about what to do under with the blocks Mr. Potato Head Requesting the body Imitating funny actions with Following directions parts while building the body parts before about where to put putting them on the toy the body parts

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Key Components of Parent Coaching The following are components to consider when coaching parents and other caregivers to work with children with ASD. Similar steps have been outlined in several parent training programs for children with ASD (Brookman-Frazee et al., 2012; Ingersoll & Dvortcsak, 2010; Steiner et al., 2012), as well as in early intervention parent coaching (e.g., Rush & Sheldon, 2011). The steps in Behavioral Skills Training (e.g., Clayton & Headley, 2019), a standard set of training procedures outlined in the Applied Behavior Analysis (ABA) literature, are embedded here; however, additional strategies are added to enhance empowerment and parent-professional collaboration. The PACT strategies discussed previously can be incorporated into each step. When coaching parents, clinicians should do the following: • Provide manualized or written content • Begin each session with a check-in or reflection • Describe and discuss the technique being taught in the session • Relate the technique to the child’s individual treatment goals • Demonstrate or model the technique during direct work with the child— narrate use of the technique • Have the parent practice the technique with live coaching • Engage the parent in reflective discussion of the interaction • Encourage home practice of the intervention techniques Each of these components is described in detail in the sections that follow. Provide Manualized or Written Content  Clinicians should provide parents with written content that they can review before they are taught a given treatment strategy. Although not all NDBI models have manualized parent training programs, some do, including ESDM, Project ImPACT, PRT, and JASPER. The Project ImPACT manual, for example, contains short chapters on each intervention strategy being taught. Parents have the opportunity to read information before receiving coaching on each technique in session. If parents do not complete the reading, the provider can review it with them during the session. Of course, clinicians should consider the family’s literacy level and English proficiency when providing material. Many NDBI have short handouts (e.g., the refrigerator lists in ESDM) that can support families’ understanding of the topics. For NDBI that do not have manualized parent training content, clinicians may wish to explore how content from related models might apply. For example, the content in ESDM or Project ImPACT contains information about IT that could be provided to parents if IT is the primary model being used. Content may need to be adapted in such cases, which requires clinical expertise. Clinicians who do not feel comfortable with such adaptations may wish to focus on an NDBI model that does have manualized content for parents when conducting parent training. Begin Each Session With a Check In or Reflection  At the beginning of each coaching session, clinicians should schedule time for a check in or brief reflection session with the parent. Clinicians can use active listening techniques to hear how

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the parent found the use of the strategies from the previous session and to work with them to problem-solve challenges. This is an excellent time to recognize parent strengths and efforts, as well as child strengths and successes related to parent efforts. At the end of the check-in period, clinicians and parents can work together to choose the topics and goals for the session. Describe and Discuss the Technique To introduce a new technique, clinicians should briefly describe and discuss the technique in a way that relates it to the parent’s own daily activities and goals for the child. Clinicians should first label and define the technique. They should ensure parents are learning terminology associated with the technique so they understand feedback that is later provided during direct coaching. Clinicians can then provide verbal examples to clarify as needed. It may also be useful to have parents paraphrase the technique to assess comprehension. Parents can also provide examples of application of the technique as another strategy for evaluating comprehension. Providing a rationale for the technique is also important. For example, many NDBI strategies enhance child motivation. A parent who wishes to focus on increasing communication skills may not immediately understand how enhancing child motivation will facilitate progress toward this goal. Providing a rationale will help parents better understand why a technique is being used, in turn increasing their buy-in and follow through with that technique. Clinicians should ask parents questions to ensure they understand the technique and should encourage parents to ask them questions about how the strategy relates to their child. Providing parents with video examples of a technique during this phase may also be useful. Many parent training models use video examples as a standard part of the training package (e.g., Hardan et al., 2015). Relate the Technique to the Child’s Individual Treatment Goals To relate techniques to the child’s goals, the clinician can begin by providing examples, and can also engage the parent in a more active manner by having him or her generate examples of how the treatment technique relates to the child’s goals. This brainstorming provides the parent with multiple examples of the application of a treatment technique, a strategy that is likely to enhance generalization of parent skills (Stokes & Baer, 1977). This can also be a good time to brainstorm what might work well and what might be challenging about using this specific technique with the child at home after the therapist leaves. Demonstrate or Model the Technique During Direct Work With the Child Once the parent has an understanding of the technique and how it relates to the child’s goals, the next step is to briefly demonstrate the technique during direct work with the child. Clinicians may find it useful to narrate for the parent how they are applying the technique and what effect it is having on the child’s behavior in the moment. As parent understanding increases, he or she can be asked to identify the techniques being used with increasing independence. Clinicians should not outshine parents while demonstrating the technique. This can make parents feel disheartened with their own interactions with their child. Although modeling strategies for the parent is important, direct coaching is imperative because it provides parents with an opportunity to practice skills. Therefore, clinicians should not get stuck at the modeling stage and should move to parent practice as soon as possible.

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Have the Parent Practice the Technique With Live Coaching Once the parent understands the strategy, he or she can move on to practicing the techniques with clinician coaching and feedback. Some parents may be hesitant to practice. As such, clinicians may want to develop a routine around how session time is spent. For example, the clinician and parent might spend the first 5 minutes checking in, followed by 10 minutes of new material and demonstration, 20 minutes of parent direct practice and reflection, 10 minutes of review from the week and questions, and 5 minutes assigning next week’s homework in a 50-minute session. Encouraging parents to practice skills with their children during sessions is associated with larger intervention effects than programs without practice, regardless of other program content or delivery approaches (Kaminski, Valle, Filene, & Boyle, 2008). When coaching parents, clinicians can give feedback both as they work with their child and after a technique has been practiced. Clinicians who will regularly conduct parent coaching and training may need to explicitly develop their skills for providing feedback to parents. It can be especially challenging for clinicians to provide feedback in the moment while parents are working with their child, and this skill set may require training, practice, and feedback from other clinicians. When first teaching a parent new skills, clinicians can begin a practice session by telling the parent what the focus will be and then only practice one skill at a time (e.g., “Today while you are practicing, I am primarily going to provide you with feedback on your use of natural reinforcement”). Coaching should focus on that skill. Feedback that is provided while a parent is working needs to be succinct and focused in order to avoid disrupting the flow of the practice (e.g., “Giving him the ball is appropriate use of natural reinforcement,” “He appropriately requested, so go ahead and reinforce”). Additional examples of succinct feedback can be found in Box 4.2. As parents gain skills, it will become feasible to focus on several skills within a practice

Ready, Set, Implement! BOX 4.2: Providing feedback in the moment Feedback that is provided to parents while they are working with their child should be brief, succinct, and specific. The coach can say • You’re doing a good job of imitating your child’s actions. • Your positive affect right now has him really engaged. • Great job maintaining control of the reinforcer until she communicates appropriately for it. • He pointed to the toy! Go ahead and provide him access. • He looks less motivated than a minute ago. What do you think we should do next? • She is really paying attention to the words you are modeling. • He is not attending to you. How can you gain his attention right now? • The way you are looking expectantly makes it so clear that you want him to ask for a turn.

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session (e.g., “Today we are going to focus on setting up clear teaching trials, including using clear prompts, being contingent, and using natural reinforcement”). At times, feedback will need to be more elaborate and may lead to discussion (e.g., if it becomes apparent that the parent does not understand the strategy). In these instances, the practice session may need to pause so the clinician can deliver more detailed feedback, clarify terms, or answer parent questions. It is also useful to provide more detailed feedback following a practice session, which is addressed in more detail in the next section on reflective discussion following practice. During these discussions, clinicians can summarize what the parent did well and what he or she might need to work on. It may also be useful to discuss how a parent’s actions led to a certain child outcome (e.g., “You may have noticed that when you followed his lead he became much more engaged with you”). In contrast, it may also be useful to explore what may have happened if the parent had chosen a different path (e.g., “When you tried to interest him in trains, his motivation seemed to go down. Following his lead to blocks may have resulted in increased engagement”). As mentioned previously, parent practice is critical to learning; thus, it is important not to derail practice sessions by stopping for discussion too often. If this becomes a challenge, clinicians may want to develop a plan to practice for a certain period in which only coaching will be provided but no discussion will occur. The clinician can then take notes to use as discussion points when the practice session is done. Several strategies for providing effective feedback are outlined in the literature (e.g., Brookman-Frazee, 2004; Haine-Schlagel & Martinez, 2014; Ingersoll & Dvortcsak, 2010). These are described in Tables 4.3 and 4.4. Table 4.3 provides examples of different types of feedback (e.g., labeling correct vs. incorrect implementation of the strategy), and Table 4.4 provides information on how to conduct empowerment-focused feedback. Parents are more likely to need a higher level of direct feedback early on in treatment; however, all parents differ in their learning styles, and clinicians should work to assess what type of feedback best suits a parent and his or her skills at a given point in time. For example, some parents may struggle with the multitasking required to receive feedback in the moment, whereas others may benefit from this type of feedback because it is directly tied to their behavior. A parent’s response to corrective feedback should also be considered. Although some parents have no difficulty hearing constructive feedback about how to improve their skills, others may feel defensive, insecure, or self-conscious when such feedback is given. The ratio of positive to constructive comments is important to consider based on individual parent response to feedback. A ratio as high as five positive comments to every one corrective comment may be ideal for enhancing learning (Losada, 1999; Losada & Heaphy, 2004). Clinicians and parent coaches often use at least a ratio of three positives to one corrective comment. Rapport with the parent is also an important consideration because parents may be more comfortable hearing constructive feedback from someone with whom they have a strong alliance. It may be useful to provide more positive feedback early in treatment and choose constructive comments very carefully until a rapport is established that will foster a parent’s comfort level with receiving more constructive feedback. One clear advantage of using empowerment-focused feedback (see Table 4.4) is the increased likelihood of constructive feedback feeling less threatening because the parent is involved in evaluating his or her own performance and discussing both positives and negatives with the therapist.

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Table 4.3. Strategies for providing effective feedback during parent coaching Topic Give behaviorspecific feedback

Definition

Example

Feedback should be specific, related to parent and child behavior in the moment, and clear.

“When you followed Jennifer’s lead from the bubbles to the ball ramp, that was good use of the following the child’s lead technique, and she stayed engaged with you for much longer.” Give focused Focus each session or grouping Current technique: “When you gave feedback of sessions on a single or Charlie his train after he pointed small number of techniques. to it, that was good use of natural Focus feedback primarily on reinforcement.” the current technique. Review of techniques: “When you As parents learn more hold up Charlie’s train, wait for him techniques, review feedback to respond, and then give it to him. on previously learned You are nicely following his lead, techniques; however, make obtaining shared control, setting up a sure to balance this with the teaching trial, and providing natural current technique of focus. reinforcement.” Use positive Provide parents with positive “Nice following the child’s lead from the examples examples about correct use blocks to the markers.” of correct of techniques rather than “Your shared control over the stickers is application of giving corrective feedback. very clear.” techniques. “You are being very immediate in providing reinforcement.” “Nice use of positive affect to enhance engagement.” Use corrective Use of corrective suggestions “Junior seems to have lost interest in the suggestions is also important to ensure game. Rather than continuing to try to when needed. success. Some parents play, let’s see what he does to next.” are more comfortable with “Since Junior just earned access to the feedback than others; you puzzle by communicating, let’s give may need to adjust your him a minute to play with it. While he strategy for giving feedback is playing, it would be a good time for accordingly. you to practice narrating what he is doing to provide language modeling.”

Table 4.4. Types of feedback to use when coaching parents Type of feedback Direct feedback

Indirect suggestions

Empowermentfocused feedback

Definition Suggest something specific, or show the parent what to do.

When to use

Example

Use this in the moment to “Sam just asked for help parents succeed in the ball. If you their interactions. It may give it to him, that be more appropriate will reinforce his for parents who are just communication beginning parent training. behavior.” Indirect suggestions Use this when there is “Sam does not require the time for a parent to seem to be paying parent to make reflect without losing the attention to you right judgements about child’s attention. It may now. Where is his the situation and be more appropriate for attention?” decide on a course parents who are further of action. along in parent training. Feedback is framed Use this when there is time “It looks like Jennifer is in terms of choices for a parent to reflect motivated to turn the parents can make without losing the child’s ball popper on again. about how to apply attention. This can be What communication the intervention adapted based on parent behavior would you strategy in the level of experience. like to prompt her to moment. use?”

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Engage the Parent in a Reflective Discussion of the Interaction To increase parent participation and problem-solving skills, clinicians can ask them how using the strategies during the session worked for them and their child. After each parent practice session, clinicians should allow time for a reflective discussion on these points. They can model reflection by describing what they saw in the interaction and linking the strategies the parent used to child behavior. They should ask the parent to consider what went well and what the challenges were. Together the clinician and parent can brainstorm solutions to the challenges. Ideas for questions that can be asked to promote reflective discussion are outlined in Box 4.3. This reflective discussion helps parents have more successful practice at home and during the next session, as well as understand the techniques more clearly. Encourage Home Practice of Intervention Techniques The last step in each parent coaching session focuses on collaborating with the parent to plan for practicing intervention techniques outside of sessions. This will facilitate parent learning and generalizing of the targeted intervention skill. The clinician can ask the parent to choose a specific day, time, or activity in which they will practice the technique. Again, the clinician and parent can take time in this discussion to troubleshoot anticipated challenges and to come up with some solutions. Between-session activities may also include reading materials for the following weeks or video-recording or tracking child behaviors. To maximize the benefit of home practice, the interventionist should follow up with discussion in the subsequent session to provide further feedback and adjust as needed.

Ready, Set, Implement! BOX 4.3: Promoting reflective discussion with parents Try asking parents these questions to promote reflective discussion after they have practiced working with their child. • What did you think went well? • What challenges did you experience? • Can you think of some examples where your actions enhanced motivation and engagement? • Can you think of some examples of where you struggled to enhance motivation and engagement? • How did you feel while you were working with your child? • How do you think your actions influenced your child’s behavior, performance, or motivation? • How was it to hear my feedback and try to incorporate it in the moment while working with your child? • How do you think it will be to use these skills at home? • Can you provide me with some examples of how or when you might practice these skills at home?

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Case Example: Gabe Gabe is a 3-year-old boy with a diagnosis of ASD. He was diagnosed at the age of 30 months when his speech had not progressed beyond about 20 single words. He showed minimal interest in peers and began lining up objects and engaging in hand flapping. His parents had also started to notice unusual reactions in certain situations, such as crying and covering his ears when his baby sister cried and hiding under the table at a birthday party when everyone started to sing Happy Birthday. Gabe loved cause-and-effect toys such as ball-poppers, musical toys, and car ramps. Although his interest in peers was minimal, he could be readily engaged by adults with gross motor games, such as tickles, chase, and spinning him around. Following his diagnosis, the diagnosing psychologist recommended Applied Behavior Analysis (ABA) therapy. Gabe’s parents understood that ABA therapy was an effective treatment method for children with ASD, but also wanted to learn strategies they could use to support their son, especially because Gabe’s mother was at home with her children full time. They interviewed several ABA treatment agencies and settled on one that would provide regular weekly hours of direct therapy with Gabe, as well as several hours of parent coaching each week. Gabe’s parents met with his treatment providers, and together they developed his treatment plan. The treatment providers discussed their treatment recommendations in detail with the parents and asked for their input about the recommendations being made, as well as their priorities for treatment. Together, they decided on a set of goals to target during parent training sessions. Goals were focused both on skills the parents would target with Gabe, as well as intervention skills the parents would learn. Although Gabe would have a broader range of goals in his overall treatment program, child goals identified by the team for parent education included increasing frequency of single-word requests for objects, increasing attention to people and contingent vocalizations during parent–child play routines, increasing imitation of actions, and increasing hand-holding skills to decrease elopement in public. Parent goals for treatment included learning how to create naturalistic communication opportunities, set up sensory social routines, increase imitation, and implement a behavior plan for teaching hand-holding in public (see Table 4.5). Because Gabe’s parent training plan was designed to target a range of skills in various domains of development, his intervention team then developed a plan for teaching skills to Gabe’s parents sequentially in order to not overwhelm them with too many goals at one time. First, they learned strategies to target verbally requesting objects (e.g., environmental arrangements and shared control), as well as how to use sensory social routines to promote social engagement. Because these strategies focus on teaching parents to embed behavioral teaching trials in natural parent–child interactions, learning them first also laid an important foundation of knowledge about behavioral teaching trials in general. For example, it highlighted the importance of shared control and contingent natural reinforcement. Once these skills were mastered, Gabe’s parents began learning strategies for targeting imitation, such as imitating Gabe to peak his interest and then using balanced turns to cue him to imitate in return and reinforcing him for doing so with ongoing access to preferred materials. While building mastery with these skills, they continued to practice naturalistic

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Table 4.5. Example NBDI parent training plan Child goal

Parent goal or treatment strategy

Example teaching trials

Requesting objects

Environmental arrangements or shared control to target communication trials

Hold up a preferred toy or snack, and wait for Gabe to verbally request it. Place Gabe’s favorite toy on a shelf so he has to initiate communication in order to request it.

Increased attention or vocalizations during parent–child play routines

Sensory-social routines

Pause during a tickle game with hands held up expectantly, and wait for eye contact or vocalization before tickling him again. Pick Gabe up, spin him around, and then pause to wait for eye contact or vocalization before spinning him again.

Imitation of actions

Shared control and balanced turns

First, imitate the child’s actions with plastic animals (e.g., making them walk, climb, jump), then introduce the novel action of making the animal eat. Once the child imitates, return to imitating the child as reinforcement. Imitate the child’s actions with toy cars (e.g., driving) before introducing the novel action of crashing the car. Once the child imitates, return to allowing the child to play as he wishes for reinforcement.

Directive parent coaching feedback example “Gabe seems really motivated to put the balls into the popper again. This would be a great time to hold them up and see if he will verbally request them.” “Holding the balls up and waiting for Gabe to ask would be a nice, clear example of shared control.” “Great job continuing to hold the balls until he asks for them. Good shared control!” “Remember, we don’t want him to gain access to the balls until he asks.”

Empowerment-based coaching feedback example

“Gabe is really engaged with the ball popper! What strategy would you like to use to gain shared control?” “Do you think Gabe looks motivated enough to do some communication trials right now?” “You have great shared control, but he does not seem to be requesting. What do you think we should do next?” “He loves the tickles! Now, pause and “He loves tickles! Can you wait for him to look toward you before think of a way to set up a you tickle him again.” sensory-social routine right “Pausing after spinning him is a nice wait now?” to set up this routine. Now, wait until “Pausing after spinning him he vocalizes before you spin again.” is a nice way to set up this routine. When you pause, do you want to work on attention or vocalizations?” “That’s great imitating Gabe. Now would “Can you think of a novel be a good time to introduce a novel action you’d like to introduce action.” for Gabe to imitate?” “Nice introducing a novel action. Since “You introduced a novel he didn’t imitate you, model it again.” action, but he didn’t imitate you. What ideas do you have for helping him succeed in imitating?”

Increasing hand-holding in public

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Natural reinforcement of hand-holding; visual cues to promote generalization in public

Starting with a controlled setting (e.g., home or clinic), practice handholding by setting a time-based goal, prompting Gabe to walk holding hands, and ending the trial in a location where toys or adult attention are available as natural reinforcement for correct demonstration of target behavior. Increase the time goal over repeated trials. Then, generalize to the community using similar reinforcement strategies.

“You did a nice job making the expectation that he hold hands very clear.” “He let go of your hand, so let’s begin the trial again. He did not earn reinforcement.”

“He needs a clear understanding of the expectation to hold hands. How could you communicate that to him?” “He let go of your hand. What should we do next?”

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communication trials and sensory social routines. As they gained fluency with teaching imitation, they also began to spend a portion of their parent training sessions learning about principles of functional assessment. They then participated in a functional assessment interview to assess elopement in public and began taking A-B-C data during outings (e.g., to the grocery store or park). Once the functions of elopement were clearer, the parents participated in a meeting with the treatment team to develop a behavior intervention plan for elopement. They began by using naturalistic teaching to teach hand-holding in a controlled setting. For instance, they had Gabe hold hands in the house or in the yard for increasing periods of time, reinforcing the skill through access to preferred toys or natural social routines such as tickles and swinging him around. Once Gabe could reliably hold hands in controlled settings, they began generalizing these skills during brief community outings (e.g., to a convenience store to purchase a snack), using visual cues to prime him for behavioral expectations and contingencies that were in place (e.g., first hold hands, then get snack). Parent training strategies used included individual meetings, parent coaching in the home setting, and parent coaching in community settings to assist with generalization. New skills were presented using the strategies outlined in this chapter. For example, when introducing strategies for targeting requesting, social engagement and imitation, clinicians first reviewed the strategies verbally during an individual parent meeting and also provided the parents with reading materials. As clinicians discussed topics, they provided examples in relation to Gabe’s treatment goals. The clinicians then demonstrated the strategies for Gabe’s parents while narrating their teaching trials and discussing which treatment strategies were being used. They then encouraged Gabe’s parents to practice the targeted treatment strategies during direct interactions with Gabe with clinician coaching in the home or clinic setting. Finally, once the parents had mastered skills, they were taken on community outings with clinician support, when appropriate, such as to practice his hand-holding goal.

CONCLUSION This chapter provided an overview of the role and importance of parents and parent training and coaching in NDBI, as well as offering a number of strategies for effective empowerment-focused parent coaching. These strategies are not specific to any one NDBI model and can be applied to any intervention in which parent coaching is a focus. As with child treatment goals, parent goals and coaching methods must be individualized to meet the needs of each family. Taking treatment fidelity data on parent implementation of intervention strategies (Meadan, Ostrosky, Zaghlawan, & Yu, 2009) is also useful. Treatment fidelity data can inform the training and coaching approach and can assist with determining when a parent has received enough parent training or coaching (i.e., met mastery criteria). Strategies for taking treatment fidelity data are discussed in Chapter 16 on quality indicators. The strategies discussed in the present chapter can also be combined with the later chapters that focus on teaching specific skills (e.g., Chapter 11 on communication) when training and coaching a parent on the intervention procedure. Regardless of the NDBI strategies being taught, the empirically supported parent coaching strategies included in this chapter should enhance the effectiveness of a parent training approach to any NDBI model.

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Haine-Schlagel, R., & Bustos, C. (2013). The Parent and Caregiver Active Participation Toolkit (PACT): Therapist training manual. San Diego, CA: San Diego State University. Haine-Schlagel, R., & Martinez, J. I. (2014). Therapist Alliance, Collaboration, and Empowerment Strategies (ACEs) Observational Coding System. San Diego, CA: San Diego State University. Haine-Schlagel, R., Martinez, J. I., Roesch, S. C., Bustos, C. E., & Janicki, C. (2016). Randomized trial of the parent and caregiver active participation toolkit for child mental health treatment. Journal of Clinical Child and Adolescent Psychology, 21, 1–11. Hardan, A. Y., Gengoux, G. W., Berquist, K. L., Libove, R. A., Ardel, C. M., Phillips, J., . . . Minjarez, M. (2015). A randomized controlled trial of pivotal response treatment group for parents of children with autism. Journal of Child Psychology and Psychiatry, 56(8), 884–892. Herschell, A., Calzada, E., Eyberg, S., & McNeil, C. (2002). Parent–child interaction therapy: New directions in research. Cognitive and Behavioral Practice, 9, 9–16. Hodge, N., & Runswick-Cole, K. (2008). Problematising parent–professional partnerships in education. Disability and Society, 23(6), 637–647. Ingersoll, B., & Dvortcsak, A. (2006). Including parent training in the early childhood special education curriculum for children with autism spectrum disorders. Topics in Early Childhood Special Education, 26(3), 179–187. Ingersoll, B., & Dvortcsak, A. (2010). Teaching social communication to children with autism: A manual for parents. New York, NY: Guilford Press. Ingersoll, B., & Wainer, A. (2013). Initial efficacy of Project ImPACT: A parent mediated social communication intervention for young children with ASD. Journal of Autism and Developmental Disorders, 43(12), 2943–2952. Ingersoll, B., Wainer, A. L., Berger, N. I., Pickard, K. E., & Bonter, N. (2016). Comparison of a self-directed and therapist-assisted telehealth parent mediated intervention for children with ASD: A pilot RCT. Journal of Autism and Developmental Disorders, 46(7), 2275–2284. Kaminski, J. W., Valle, L. A., Filene, J. H., & Boyle, C. L. (2008). A meta-analytic review of components associated with parent training program effectiveness. Journal of Abnormal Child Psychology, 36, 567–589. Kasari, C., Gulsrud, A. C., Wong, C., Kwon, S., & Locke, J. (2010). Randomized controlled caregiver mediated joint engagement intervention for toddlers with autism. Journal of Autism and Developmental Disorders, 40(9), 1045–1056. Kasari, C., Lawton, K., Shih, W., Barker, T. V., Landa, R., Lord, C., . . . Senturk, D. (2014). Caregiver-mediated intervention for low-resourced preschoolers with autism: An RCT. Pediatrics, 134(1), e72–e79. Kazdin, A., & Weisz, J. (2003). Evidence-based psychotherapies for children and adolescents. New York, NY: Guilford Press. Koegel, R. L., Bimbela, A., & Schreibman, L. (1996). Collateral effects of parent training on family interactions. Journal of Autism and Developmental Disorders, 26(3), 347–359. Koegel, R. L., & Koegel, L. K. (2006). Pivotal Response Treatments for autism: Communication, social, and academic development. Baltimore, MD: Paul H. Brookes Publishing Co. Koren, P. E., DeChillo, N., & Friesen, B. J. (1992). Measuring empowerment in families whose children have emotional disabilities: A brief questionnaire. Rehabilitation Psychology, 37(4), 305–321. Lloyd, T. J., & Hastings, R. P. (2009). Hope as a psychological resilience factor in mothers and fathers of children with intellectual disabilities. Journal of Intellectual Disability Research, 53(12), 957–968. Losada, M. (1999). The complex dynamics of high performance teams. Mathematical and Computer Modelling, 30(9), 179–192. Losada, M., & Heaphy, E. (2004). The role of positivity and connectivity in the performance of business teams: A nonlinear dynamics model. American Behavioral Scientist, 47(6), 740–765. Lucyshyn, J. M., Dunlap, G., & Albin, R. W. (2002). Families and positive behavior support: Addressing problem behavior in family contexts. Baltimore, MD: Paul H. Brookes Publishing Co. McConachie, H., & Diggle, T. (2006). Parent implemented early intervention for young children with autism spectrum disorder: A systematic review. Journal of Evaluation in Clinical Practice, 13(1), 120–129. McGrath, J. M. (2005). Partnerships with families: A foundation to support them in difficult times. The Journal of Perinatal and Neonatal Nursing, 19(2), 94–96.

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McIntyre, L. L. (2008). Adapting Webster-Stratton’s Incredible Years parent training for children with developmental delay: Findings from a treatment group only study. Journal of Intellectual Disability Research, 52, 1176–1192. Meadan, H., Ostrosky, M. M., Zaghlawan, H. Y., & Yu, S. (2009). Promoting the social and communicative behavior of young children with autism spectrum disorders: A review of parent-implemented intervention studies. Topics in Early Childhood Special Education, 29(2), 90–104. Mesibov, G. B., Shea, V., & Schopler, E. (2005). The TEACCH approach to autism spectrum disorders. New York, NY: Springer. Minjarez, M. B., Mercier, E. M., Williams, S. E., & Hardan, A. Y. (2013). Impact of elicit group therapy on stress and empowerment in parents of children with autism. Journal of Positive Behavior Interventions, 15(2), 71–78. Minjarez, M. B., Williams, S. E., Mercier, E. M., & Hardan, A. Y. (2011). Pivotal response group treatment program for parents of children with autism. Journal of Autism and Developmental Disorders, 41(1), 92–101. Moore, T. R., & Symons, F. J. (2011). Adherence to treatment in a behavioral intervention curriculum for parents of children with autism spectrum disorder. Behavior Modification, 35(6), 570–594. Motzer, S. A., & Hertig, V. (2004). Stress, stress response, and health. Nursing Clinics of North America, 39(1), 1–17. Murray, M. M., Ackerman-Spain, K., Williams, E. U., & Ryley, A T. (2011). Knowledge is power: Empowering the autism community through parent-professional training. School Community Journal, 21(1), 19–36. Murray, M. M., & Curran, E. M. (2008). Learning together with parents of children with disabilities: Bringing parent-professional partnership education to a new level. Teach Education and Special Education, 31(1), 59–63. Murray, M. M., Curran, E., & Zellers, D. (2008). Building parent/professional partnerships: An innovative approach for teacher education. The Teacher Educator, 43(2), 87–108. Murray, M. M., Handyside, L. M., Straka, L. A., & Arton-Titus, T. V. (2013). Parent empowerment: Connecting with preservice special education teachers. School Community Journal, 23(1), 145–168. Nahmias, A. S., & Mandell, D. S. (2014). A meta-analysis comparing parent- and clinicianimplemented early interventions for children with autism spectrum disorders. Paper presented at the International Meeting for Autism Research, Atlanta, GA, May 2014. National Research Council. (2001). Educating children with autism. Washington, DC: National Academy Press. Oono, I. P., Honey, E. J., & McConachie, H. (2013). Parent-mediated early intervention for young children with autism spectrum disorders (ASD). Evidence-Based Child Health: A Cochrane Review Journal, 8, 2380–2479. Patterson, G. (1982). Coercive family process. Eugene, OR: Castilia. Pickard, K. E., Wainer, A. L., Bailey, K. M., & Ingersoll, B. R. (2016). A mixed-method evaluation of the feasibility and acceptability of a telehealth-based parent-mediated intervention for children with autism spectrum disorder. Autism, 20(7), 845–855. Plienis, A. J., Robbins, F. R., & Dunlap, G. (1988). Parent adjustment and family stress as factors in behavioral parent training for young autistic children. Journal of the Multihandicapped Person, 1(1), 31–52. Robbins, F. R., Dunlap, G., & Plienis, A. J. (1991). Family characteristics, family training, and the progress of young children with autism. Journal of Early Intervention, 15(2), 173–184. Rogers, S. J., Estes, A., Lord, C., Vismara, L., Winter, J., Fitzpatrick, A., . . . Dawson, G. (2012). Effects of a brief Early Start Denver model (ESDM)–based parent intervention on toddlers at risk for autism spectrum disorders: A randomized controlled trial. Journal of the American Academy of Child and Adolescent Psychiatry, 51(10), 1052–1065. Rogers, S. J., Vismara, L., Wagner, A. L., McCormick, C., Young, G., & Ozonoff, S. (2014). Autism treatment in the first year of life: A pilot study of infant start, a parent implemented intervention for symptomatic infants. Journal of Autism and Developmental Disorders, 44(12), 2981–2995. Rush, D. D., & Sheldon, M. L. (2011). The early childhood coaching handbook. Baltimore, MD: Paul H. Brookes Publishing Co.

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5 Fostering Inclusion With Peers and in the Community Aubyn C. Stahmer, Connie Wong, Matthew J. Segall, and Jennifer Reinehr

A

ccording to the Centers for Disease Control and Prevention (CDC; 2018), inclusion means “including people with disabilities in everyday activities and encouraging them to have roles similar to their peers that do not have disabilities.” Inclusive education involves adjusting curricula, assessment practices, systems, teaching styles, and the physical environment to allow all individuals to participate equally. The United Nations (n.d.) supports the right of all students, including those with autism spectrum disorder (ASD), to have access to inclusive quality free education in their community with the necessary support to enable them to reach their potential. Effective inclusion involves more than simple integration, which may simply include placing individuals with ASD in situations with individuals who are neurotypical. Communities, schools, and agencies must make changes to enable the individual to participate fully in all activities rather than expecting the person with ASD to conform to the environment (Pellicano, Bölte, & Stahmer, 2018). This chapter discusses the need for inclusion, the evidence base for using inclusive strategies, and how Naturalistic Developmental Behavioral Interventions (NDBI) can successfully support individuals with ASD in inclusive environments.

THE IMPORTANCE OF INCLUSION Both the Individuals with Disabilities Education Improvement Act (IDEA) of 2004 (PL 108-446) and the No Child Left Behind Act (NCLB) of 2001 (PL 107-110) mandated that children with disabilities, including children with ASD, be educated in the least restrictive environment (LRE), which means alongside typically developing peers whenever possible. This ensures that children with special learning needs, including those with individualized education programs (IEPs) and 504 99

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BOX 5.1: What is inclusion? • • • •

Inclusion is not a place. Inclusion is the belief that everyone is a member of the community, regardless of skills, talents, or diagnosis. Inclusion involves more than simple integration. Inclusion involves providing the support needed for everyone to participate fully in the community.

plans, are not isolated. Inclusive practices are increasingly recognized as best practice for children with ASD (DiSalvo & Oswald, 2002). See Box 5.1. This is important because the challenges seen in ASD are primarily related to social interaction and social skills with friends at school and at work. With these policies in place, the number of students with ASD participating in general education has been increasing each year (Leach, 2010). There are, unfortunately, no inclusion mandates for adults with ASD. The Americans with Disabilities Act (ADA) of 1990 (PL 101-336) mandated supports and accommodations for individuals with disabilities from government agencies at work sites and college campuses, which may encourage some inclusion. Most ASD advocacy organizations support the idea of inclusive practices and helping individuals with ASD meet any challenges they face in social situations. For example, the Autistic Self-Advocacy Network (ASAN; n.d.) position statement on inclusion said, “Every person is worthy of inclusion and respect, whatever his or her support needs may be.” The Autism Society of America and Autism Research Foundation both advocate for supported inclusion for the whole life span and link inclusion to improved quality of life (Biggs & Carter, 2016; Hong, BishopFitzpatrick, Smith, Greenberg, & Mailick, 2016).

INCLUSION IN PRACTICE Most research about inclusion comes from studies of preschool and elementary age children, and the most often measured outcomes for children with ASD in inclusive settings are social (Freeman, 2003). Inclusion leads to increases in social engagement and social support, as well as increases in the number of friendships that students with ASD report (Harrower & Dunlap, 2001). Furthermore, involvement in community and leisure activities are positively associated with quality of life because these activities provide opportunities for individuals with ASD to socialize with others and develop friendships (Biggs & Carter, 2016; Chiang & Wineman, 2014). Inclusion can also be beneficial for the typically developing children in a school program. Inclusive early childhood environments encourage positive interactions and learning for all children, including those without disabilities (Hestenes & Carroll, 2000). Typically developing children may learn how to get along with others, improve their social skills, and exhibit fewer disruptive behaviors (Daly, 1991; Strain & Cordisco, 1994). Children in inclusive programs also have higher levels of acceptance of peers with disabilities after participation (Diamond, Hestenes,

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Carpenter, & Innes, 1997). Typically developing toddlers who spend the day in an ASD inclusion program perform well compared to their peers and do not show any increases in stereotyped or aggressive behavior (Stahmer & Carter, 2005). In school classrooms, researchers have found no differences in the amount of instruction time or differences in learning for typically developing students when students with severe disabilities are enrolled in general education classrooms. Also, there may be some academic benefits in math and reading when students are educated with their peers with special needs (see review by Bui, Quirk, Almazon, & Valenti, 2010). Although inclusion provides clear benefits for children with ASD and their typically developing peers, inclusion alone is not enough to increase social integration (Chamberlain, Kasari, & Rotheram-Fuller, 2007). Inclusion is more complex in older grades, probably because games and social interactions become more complex (Rotherham-Fuller, Kasari, Chamberlain, & Locke, 2010). In high school, students in inclusive settings often report feeling lonelier than their peers and say they would like more meaningful relationships (Locke, Ishijima, Kasari, & London, 2010). Children and youth with ASD report lower scores on quality-oflife measures than their peers, especially in areas related to socialization (Ikeda, Hinckson, & Krägeloh, 2014). The reality is that inclusion is more than just being in the same place as other people. Simply placing individuals with ASD in classrooms or workplaces with typically developing peers without systematic supports has limited benefit (Harrower & Dunlap, 2001). That is, students with ASD need help learning to make friends, getting involved in social activities, and succeeding in a busy classroom. As such, evidence-based strategies such as NDBI are key to helping individuals with ASD succeed in inclusive settings. One of the main goals of NDBI is to help families and providers use evidencebased strategies in the natural environment, ensuring that people with ASD can learn to use their skills in new places and over time. See Box 5.2. Of course, one of the most natural environments for everyone, no matter the age or diagnosis, is in the community with peers. This includes attending school and being educated alongside typically developing students. NDBI help students do well in many environments by building social and communication skills across contexts. NDBI work well in inclusive settings at school (e.g., Crosland & Dunlap, 2012; Koegel, MatosFreden, Lang, & Koegel, 2012), for playdates (Koegel, Werner, Vismara, & Koegel, 2005), and at summer camp (Brookman et al., 2003). Many studies used behavioral strategies to help children in inclusive settings (see Harrower & Dunlap, 2001, for a review). The National Standards Project for ASD said evidence-based techniques such as NDBI work well in general education settings (e.g., National Autism Center, 2015). Most data for NDBI are for children younger than age 14, and there have been limited studies with older adolescents and adults (Wong et al., 2015).

BOX 5.2 Because one of the main goals of NDBI is to use evidence-based strategies in the natural environment, these strategies are well-suited for supporting individuals with ASD in inclusive settings.

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USE OF NDBI IN INCLUSIVE SETTINGS A variety of NDBI strategies are used with success in inclusive settings. Some programs, especially in preschool settings, have developed comprehensive programs using NDBI to support students with ASD in settings that include typically developing peers. In addition, multiple focused interventions, such as modeling, peer-mediated interventions, self-management and self-monitoring, and structured playgroups use NDBI strategies to support inclusion in multiple school and community settings for individuals with ASD from childhood through adulthood. This section describes models that incorporate NDBI to successfully include individuals with ASD. Comprehensive Preschool Programs Some preschool programs are specifically designed to serve children with ASD alongside their typically developing peers, and these programs often use NDBI strategies. A review of comprehensive treatment programs for children with ASD looked at four inclusive programs, and all used some type of NDBI strategy. These programs included the Walden School (McGee, Morrier, & Daly, 1999), the Learning Experiences: An Alternative Program for Preschoolers and Parents (LEAP) program (Strain & Bovey, 2011), Project DATA (Developmentally Appropriate Treatment for Autism; Schwartz, Sandall, McBride, & Boulware, 2004), and Alexa’s PLAYC (Playful Learning Academy for Young Children, formerly the Toddler School; Stahmer, Akshoomoff, & Cunningham, 2011; Stahmer & Ingersoll, 2004). Each of these programs reports positive outcomes; only LEAP has comparison data from a randomized trial, whereas the other program results are from quasi-experimental designs. The Walden Early Childhood Program uses incidental teaching (IT) exclusively. Children are in a structured environment for about 20 hours per week, and parents receive education during weekly home visits. The Walden Early Childhood Program has excellent child outcomes in language and social behaviors; in a study by McGee and colleagues (1999), 82% of the 28 children with ASD used spoken words at program exit, and 71% played closer to other children at exit. Project DATA was developed in collaboration with public schools and uses naturalistic behavioral strategies during classroom routines in the context of a qualityof-life curriculum. Children also receive instruction in a smaller group setting and regular home visits, and their families also receive parent education. Outcomes for both toddlers and preschoolers show positive change in social-communication, social skills, and core ASD deficits (Boulware, Schwartz, Sandall, & McBride, 2006; Schwartz, Thomas, McBride, & Sandall, 2013). In a study of 102 toddlers with ASD in Alexa’s PLAYC, 31% functioned in the typically developing range by age 3 (Stahmer et al., 2011). Alexa’s PLAYC serves children for 20 hours per week and uses a combination of NDBI (similar to those described in Project ImPACT in Chapter 2), environmental arrangements, visual supports, and bimonthly home visits that include parent coaching in NDBI. An early study of the program (Stahmer & Ingersoll, 2004) found 80% of toddlers exiting the program at 36 months had improved spoken language skills and decreased severity of ASD behaviors. A majority of children who went to Alexa’s PLAYC enrolled in general education classroom placements by elementary school (Akshoomoff, Stahmer, Corsello, & Mahrer, 2010).

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Programs using the LEAP model also embed evidence-based NDBI strategies (IT) into ongoing classroom activities and use a structured method of peer-mediated instruction in which typically developing classroom peers are a large part of the intervention. In LEAP, peers learn the best ways to interact with their peers with ASD and to encourage ongoing interaction. The program includes parent coaching to address behavior concerns at home and in the community. LEAP has a strong history of research documenting improvements in intellectual development and language (Strain & Hoyson, 2000) as well as for social engagement (Strain, Kohler, & Goldstein, 1996). LEAP is one of the only evidence-based inclusion programs to have large-scale replication. A trial comparing LEAP in 28 classrooms had positive results in comparison to “treatment as usual” preschools programs (Strain & Bovey, 2011). They found that almost 2 years of coaching were needed for classrooms to meet all the steps needed in the LEAP model and that just providing manualized materials without coaching did not produce consistent use of most of the strategies. This is important because the use of the correct strategies was related to all child outcomes. In addition, long-term outcomes of the LEAP model show that children continue to improve their development over time (Strain & Hoyson, 2000). Focused Interventions Across the Life Span Unlike the preschool inclusive programs for young children with ASD, there are no clearly defined, comprehensive treatment models with strong research support for including school-age children, adolescents, or adults with ASD in general education, university, or community settings. The lack of evidence-based inclusive programs for older individuals with ASD can partially be attributed to the fact that educational, job, and community programs often have policies and standards that may not work for a comprehensive treatment model. For example, an educational aide may not be able to assist a student with test-taking in a college course due to concerns about cheating. In addition, inclusive settings for older individuals often consist of typically developing individuals with only one person with ASD. Instead of restructuring an entire program or activity for an individual with ASD, evidence-based focused intervention practices are used to support the individual with ASD without disrupting the program. Focused intervention practices are strategies that address targeted skills or goals and can be used easily in an existing program. A review of the ASD intervention literature identified five NDBI practices that are very useful for inclusive education: comprehensive NDBI (including Pivotal Response Treatment [PRT]), modeling, peer-mediated interventions, self-management and self-monitoring, and structured playgroups or social skills groups (Wong et al., 2015), each of which is briefly explained in the sections that follow. Positive outcomes from these programs include better academic and job performance, independent living skills, social interaction, and emotion management skills. These strategies have been used most often in schools, although there also is growing use in inclusive postsecondary education programs (Hart, Grigal, & Weir, 2010). These programs are typically designed for young adults with intellectual and developmental disabilities (including ASD) and give enrolled students a chance to participate in college course work while also learning social growth, independent living, and vocational skills (Grigal & Hart, 2010; Hart et al., 2010).

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Comprehensive NDBI Some evidence supports the use of comprehensive NDBI in typical settings, activities, and/or routines for older individuals with ASD. Similar to the use of these strategies in special education or individual settings, providers establish the learner’s interest in an activity through arrangement of the setting, activity, or routine; provide support for the learner to use the targeted behavior; expand on the behavior when it occurs; and/or arrange natural consequences for the targeted behavior or skills. Several NDBI strategies have been shown to reduce challenging behaviors, including natural reinforcement, incorporating easier tasks, rewarding attempts, and functional communication training (Machalicek, O’Reilly, Beretvas, Sigafoos, & Lancioni, 2006). Camargo and colleagues (2014) found that IT and peermediated interventions were very successful in inclusive settings. Modeling Modeling, self-modeling, and video modeling are all important strategies that can be used in school, home, and community settings for individuals with ASD. Modeling involves demonstrating a behavior to allow the individual to imitate it, then rewarding the behavior to help him or her learn to use it again later. Young children learn skills such as object play, pointing, and games from observing other children in preschool, on the playground, and in other community settings. Adolescents may learn common expected behaviors to use while watching a movie, attending a sporting event, or chatting with friends at lunch. Adults may learn new job tasks and workplace social norms by watching others. Video modeling of object play has been demonstrated to increase appropriate object play in young children (e.g., D’Ateno, Mangiapanello, & Taylor, 2003; Hine & Wolery, 2006; Nikopoulous & Keenan, 2004). In inclusive school settings, typically developing peers naturally model behaviors that school-age children with ASD can imitate and learn to exhibit in similar situations. In addition to academic tasks, such as explaining thinking and showing work when solving a word problem in Common Core math, peers might model raising a hand and waiting to be called on before shouting out an answer, waiting in line in the school cafeteria, and playing games with rules at recess. In adolescents, the use of static pictures as a self-modeling strategy has also been shown to increase task engagement while reducing the frequency of teacher prompts (Cihak, Wright, & Ayres, 2010). Video modeling strategies can be used to teach many independent daily living skills, such as doing laundry, meal preparation, and self-care. Adolescent students even learned additional daily living skills that were not targeted in the video modeling intervention (Lasater & Brady, 1995). Young adults with ASD have been taught how to purchase items they need (e.g., groceries, clothing) using video modeling strategies (Haring, Kennedy, Adams, & Pitts-Conway, 1987), which can encourage independence in community settings. A related strategy involves presenting scripts to adolescents and then slowly fading them to improve problem identification and seeking help in job settings (Dotto-Fojut, Reeve, Townsend, & Progar, 2011). These strategies can be used with other NDBI strategies, such as direct reinforcement and shared control. Peer-Mediated Interventions In peer-mediated interventions, typically developing peers learn how to interact with and help individuals with ASD learn new behavior, communication skills, and social skills by increasing social opportunities within natural environments. Peers are taught how to engage individuals

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with ASD in social interactions that can be directed by a teacher or initiated by the student with ASD. A review of peer-mediated strategies (Watkins et al., 2015) for individuals with ASD ages 4–21 indicated positive results. In preschool, goals are usually the use of joint play activities. In elementary school, children may learn to initiate games at recess, and in high school, goals may include initiating conversation. Although much of the research evidence for these strategies has focused on younger students, the Circle of Friends intervention is a peer-mediated intervention that was shown to be effective for high school students with ASD (Schlieder, Maldonado, & Baltes, 2014), improving social interaction, empowerment, and sense of well-being. Peer mentoring for college students with ASD may increase academic performance, awareness of social rules, and executive functioning skills (e.g., Taylor, 2005; VanBergeijk, Klin, & Volkmar, 2008). In addition, colleges have started holding special first-year courses for students with ASD that give direct instruction on executive functioning skills, emotion regulation strategies, rules of social interaction, and study skills. Typically developing peers are often an integral part of the success of such courses (Wenzel & Rowley, 2010). Self-Management and Self-Monitoring Self-management is a procedure used to teach individuals to discriminate their own behavior (e.g., appropriate sitting in class) and record the occurrence or absence of that behavior (Koegel, Koegel, & Parks, 1992). It is both a tool to teach new skills and an important skill in itself. Selfmonitoring includes tracking one’s own behavior as part of the self-management process. Self-management and self-monitoring have been used with school-age children, adolescents, and adults to develop appropriate skills that increase their ability to participate in community settings. Children as young as kindergarten age have used self-management to successfully increase on-task performance and reduce disruptive behavior (Koegel, Harrower, & Koegel, 1999). In another example, Newman and colleagues (1995) taught three adolescents with ASD to engage in selfmanagement and provide their own rewards, which improved their transitions to new activities. Likewise, adolescents have learned to improve question asking during social interaction through self-management strategies (Palmen, Didden, & Arts, 2008). Providing adolescent students with the next day’s schedule and activities (e.g., priming) leads to better participation in school tasks (Koegel, Koegel, Frea, & GreenHopkins, 2003). Thoughtful limitation of access to preferred activities has helped adolescents with ASD to increase on-task behaviors and decrease repetitive behaviors associated with intense interests (Sigafoos, Green, Payne, O’Reilly, & Lancioni, 2009). In job settings, self-monitoring strategies have been shown to increase task completion and verbal requests (Ganz & Sigafoos, 2005) in adults with ASD. Structured Playgroups Structured playgroups use small groups to teach social skills. Usually these groups are conducted in a small area with very specific activities and prechosen typically developing peers, as well as clear themes and roles. Although peers are involved, the playgroups are led by an adult who uses prompting and scaffolding to help students learn new skills. In an example of an after-school structured playgroup (Legoff & Sherman, 2006), a school-age child with ASD worked with building blocks to complete a project with two typically developing peers and an adult supervisor. Consistent with NDBI strategies, the adult selected Legos to motivate learning because the child was interested in them. Each group member received a different responsibility (e.g., engineer,

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supplier, builder), and the playgroup emphasized teaching verbal and nonverbal communication, collaborative problem-solving, sharing, and turn-taking, including switching roles during the task. Participating in the group and completing the block project was a natural and direct reinforcer. Children with ASD participating in the structured playgroups showed increased communication and socialization scores as compared to children with ASD who did not participate in the groups (Legoff & Sherman, 2006; Owens, Granader, Humphrey, & Baron-Cohen, 2008).

PRACTICAL SUGGESTIONS FOR INCORPORATING NDBI STRATEGIES INTO COMMUNITY PROGRAMS This section presents key elements of NDBI recommended for community programs. This means not only programs designed to be inclusive but also any community activity in which a person with ASD would like to participate. The goal of inclusion is to help individuals with ASD gain access to the same activities as their peers, so these strategies can be used both in specialized inclusive settings and in usual community programs when a person with ASD wants to attend summer camp, work at the mall, go to a theme park, or join a softball team. Again, this is not an exhaustive list of inclusion strategies, but it specifically recommends NDBI methods that support inclusion. Creating Individualized Treatment Goals Any good treatment program must develop individualized goals. When implementing this NDBI strategy into community programs, the goals should relate to success in the inclusive setting with treatment targets specific to social interaction, adaptive or job skills, and social-communication. Some programs also develop group goals that may include things such as saying positive things to friends, asking for help, and sharing materials, with specific goals and strategies aligned with the individual learner’s needs. Often, inclusive settings require the development of social goals, such as sharing toys in preschool, joining in a soccer game in elementary school, and conversing appropriately with colleagues at lunch in the workplace. In inclusive settings, support staff must be able to determine how much assistance a person with ASD requires and how to reduce the level of support as the individual becomes more independent. Assessments related to social and adaptive skills needed for the environment, such as the Social Skills Improvement System (SSIS; Gresham & Elliott, 2007) or the Adaptive Behavior Assessment System (ABAS; Harrison & Oakland, 2003), may help in generating age-appropriate goals. Conducting a task analysis of skills used in the environment can help generate goals. Observations of interactions between the individual with ASD and peers may also be helpful. Strategies for developing goals are explored further in Chapter 10, but for community programs, those goals may need to focus on skills needed for inclusive settings. Monitoring Treatment Fidelity Monitoring treatment fidelity in inclusive settings can sometimes be challenging, but it is just as important as when working individually. Treatment fidelity indicates the extent to which the intervention was implemented as intended and is

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discussed in greater detail in Chapter 16. Many of the interventions have specific treatment fidelity criteria that can be used to monitor how well teachers, paraprofessionals, job coaches, parents, and other professionals are using NDBI strategies. Even for peer-mediated strategies, treatment fidelity measures can determine whether peers are receiving the supervision, feedback, and rewards needed to help them continue to assist students with ASD successfully. Using treatment fidelity monitoring can ensure the whole team supporting an individual is using strategies well and consistently. For example, paraprofessionals in education settings may have a difficult time understanding the importance of fading prompts and fading their proximity to students in ways that support independence. Treatment fidelity measures can ensure the best service is being delivered throughout the inclusive setting. Arranging the Environment Arranging the environment to encourage the use of appropriate skills in inclusive settings can be very beneficial for individuals with ASD. In classroom settings, this often involves placing desired or needed items out of reach to encourage language or having a peer ask a student to choose a specific crayon color to encourage social-communication. In the workplace, arranging the environment to encourage independence at work or comfort during social interactions during lunch and breaks may be useful. For example, placing checklists and other visual supports within the visual field of an employee with ASD at a checkout register (and other vocational settings) can help him or her use his or her skills more independently. In addition, the thoughtful creation of small groups within large-group learning contexts can reduce social and sensory input while continuing to promote engagement and social interaction. For example, in a high school physical education class that contains a large number of students, students with ASD can be grouped with a smaller group of four to six peers (with appropriate peer training and supervision) who have interest in, and can facilitate, an appropriate reciprocal game of interest to the student with ASD. A designated space in the gymnasium would be ideal for such a small group. On a college campus, peer mentors can position themselves within a campus dining hall so that the student with ASD is encouraged to use appropriate social-communication initiation skills (e.g., “May I join you?”). They can use NDBI strategies during this interaction, such as rewarding appropriate commenting with discussion of preferred topics. Sharing Control Strategies for sharing control are seen most often in preschools but can also be incorporated into activities with older individuals. Sharing control refers to a balanced interaction in which the person with ASD has choices within an interaction and between activities and shares those choices with another person. This strategy is elaborated in detail in Chapter 6. Often, shared control is easier to establish in one-to-one settings; for example, waiting for a child to initiate a teaching activity works better when the adult has control over the toy the child wants. However, children can initiate in group settings as well. This is especially relevant to play and social activities in which initiation is an important way to ensure building friendships and improving general social skills.

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One approach is to design games around a student’s special interest, which ensures the student will be interested in the activity and also allows the student to be a leader in the context of the game. In one study, researchers helped teachers develop a game for a child with a strong interest in state capitals. They drew a map of the United States on the blacktop. The teacher called out a state capital, and students raced to the appropriate state to be safe (Baker, Koegel, & Koegel, 1998). The student with ASD was the expert. Similar games could be developed with other interests. Simple choices in a classroom, such as which color pen to use to write a lesson or which order to complete a worksheet, are also examples of shared control. As individuals with ASD get older, joining clubs or organizations in which others share interests can be helpful. Allowing simple choices of what to have for lunch, where to place their desk in the office, or what role to play in a meeting may also provide a sense of control and comfort in challenging situations. Use of Natural Reinforcement The goals developed for the setting should lead to activities or interactions that the individual with ASD enjoys and that can be linked to natural rewards (i.e., rewards that are available in the environment). For example, playing well with others can lead to longer access to preferred toys and activities. Learning to perform well at a job leads to a paycheck and greater independence. Conversation is an excellent goal that can be rewarded directly across ages. For example, using appropriate conversational skills can be rewarded with talking about a preferred topic (Camargo et al., 2014); likewise, turn taking and waiting provide similar natural rewards, such as getting a turn, positive attention, and sometimes increased access to preferred items or activities. Some data support the idea that delayed contingencies may increase on-task behavior when children are not supervised (Harrower & Dunlap, 2001). However, sometimes these linkages are distant, and providers may need to consider other ways to include direct reinforcement into specific activities and goals, especially when working with children who may need more immediate feedback. In adult social interaction settings for adolescents and adults, the natural reward of building relationships and friendships is paramount. Similar to other group therapy models, it is critical to identify group members (both individuals with ASD as well as typically developing peer models) who can consistently attend and participate within the group, thus creating natural reinforcers of shared enjoyment and experiences. The infusion of cognitive strategies to assist with attending to and storing information about another individual (e.g., name, favorite foods, topics of interest) further helps create natural rewards as future conversations more successfully build on past interactions. Prompting and Prompt Fading Prompting is as an excellent strategy that can also be used in inclusive settings. Often, prompt fading (i.e., reducing prompts to encourage independence) happens naturally because a provider is not always available to prompt. In peer-mediated strategies, peers can provide assistance when needed. In inclusive settings, providers may revert to delivering only verbal prompts, may limit the time between

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prompts for response, or may not use the full range of the prompt hierarchy. Reviewing treatment fidelity can be essential to ensuring appropriate support in all settings as well as ensuring that the individual with ASD has the opportunity to succeed in the inclusive setting. Prompting, modeling, and reinforcement are recommended for older populations to assist with completion of specific skills needed in community settings (Camargo et al., 2014). Prompts can follow the same fading strategies as those described in Chapter 8. They can be provided by a peer, given through visual cues, or integrated into group instructions or activities. Prompts can also be provided using technology, such as a reminder on a phone or a self-management watch. Taking Balanced Turns In inclusive settings, there are increased opportunities for balanced turns with ageappropriate peers as well as with intervention providers or teachers. As such, it is important to encourage individuals with ASD to have back-and-forth exchanges with others. This may be taking turns in a game, passing out materials for a class assignment, or taking turns in a conversation at lunch. In peer-mediated strategies, peers learn to encourage turn taking and help their friends. Modeling Of course, inclusive settings are especially wonderful for having other children and adults model appropriate behavior and interactions as well as complete social, academic, and job-related tasks. Individuals with ASD can learn to observe their peers for clues on how to do things such as play a game, say goodbye before leaving a party, sit quietly in a lecture, or dance at the prom. Broadening Attentional Focus Interventions for social skills should provide opportunities to try new things in many environments and with different people. This allows students to respond to varied cues across people and settings and to learn to respond in socially appropriate ways. For example, it may be appropriate when addressing a peer to say, “Hey, how’s it goin’?” but with a teacher or supervisor, “Hello, how are you today?” may be a more appropriate greeting. Having a chance to try new skills with teachers, coaches, friends, acquaintances, and others in a variety of community settings is one of the benefits of being in inclusive environments. This requires individuals with ASD to attend to multiple aspects of the environment—who they are talking to and where they are, for example—and respond accordingly. Initiating Communication and Interaction One of the challenges individuals with ASD have is initiating communication and interaction, and when they do initiate, it may not be appropriate. Inclusive settings provide many chances for people with ASD to try joining a group, sitting in a movie appropriately, and interacting during meal times, to name a few. Understanding when to initiate is also important. Yelling to a friend across the playground at recess may be acceptable, but yelling across a church during service may not be.

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Table 5.1. Common challenges to inclusion Challenge Inclusion is not just placing an individual in an inclusive environment.

Efficient and accurate data collection during classroom activities is difficult while facilitating learning and managing the behaviors of multiple children. Gaining and maintaining the motivation of typically developing peers to participate in social opportunities with children with ASD is challenging.

Possible solutions Leadership needs to make sure that enough support is in place to help the person with ASD succeed. Teachers, parents, and providers can take data on skills and behaviors to advocate for additional support when needed. Providers in the inclusive setting can learn NDBI strategies and structural supports. Teachers can collect data on one child at a time or use rating sheets they can complete at the end of each activity to gather information on child progress each week.

Teachers can provide rewards or recognition to typically developing peers for their participation. Teachers can use activities that peers and children with ASD both enjoy (even grouping children by interests). Teachers can switch which typically developing children work with the student with ASD throughout the day. Peers (or staff) facilitating interactions do Leadership can train peers and staff in specific not create natural space for interactions methods of prompt fading and waiting for to occur (i.e., doing too much for the initiations. individual with ASD). For example, Leadership can monitor fidelity of the peer takes the student to a break implementation for strategies used by the area when the student is overwhelmed peers and paraprofessionals. rather than prompting the student An experienced provider can provide ongoing to use communication strategies to supervision and assessment to help reduce request a break. prompt dependence. Experienced peers can offer peer mentoring. Providers can provide ongoing monitoring to make sure strategies are appropriate and working. They can adjust strategies as the individual requires more or less support. Teachers place too much emphasis on Program leadership can highlight the importance academic growth in comparison to of social-emotional growth and the links social-emotional and communication between social skills and later success in jobs growth (e.g., we don’t have time to as well as quality of life. work on social skills, we have to work Teachers can prioritize specific time for social on academic standards). skills lessons. Teachers can facilitate using lunch, breaks, and afterschool programs to practice social interaction. Teachers permit students with ASD Teachers can provide a balance between teaching to be alone or sit in silence during social interactions and allowing students with unstructured or free play activities ASD to have time to themselves. at school rather than facilitating peer Teachers can pair students with ASD together so interaction and conversation. they can interact as much or as little as they like for parts of the day. Teachers can use strategies such as shared control and mixing easy and hard tasks to allow students with ASD to have some control over the amount of interaction they have each day.

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Table 5.1. (continued) Challenge

Possible solutions

Teachers use reinforcement and rewards Teachers can set up systems of reward and to only increase academic or behavioral recognition for students with ASD for participating skills; social behaviors and appropriate in social activities and using appropriate social emotional states must also receive behaviors, such as asking for a break. reinforcement. Teachers can keep rewards natural so the individual can use these skills in other settings. Because these social behaviors are hard for individuals with ASD, rewarding them is important. Social learning groups have group Teachers can group students who are similar. members who are drastically dissimilar; If they cannot group students who are similar, thus, goals that are appropriate they can ask students who have mastered the for some group members are skills to be leaders in the group so they can inappropriate for others (e.g., the goal practice new skills and feel proud of the skills is to work on greetings and eye contact, they already have. but some students have mastered this Teachers can break larger groups into small skill). groups to practice similar skills. Teachers do not recognize important Leadership can emphasize the importance of skills for adolescents and adults generalizable skills needed for transitions and (e.g., problem solving, goal setting, adult life. emotion regulation, self-awareness, Learning can happen in many settings, including self-advocacy, self-determination, field trips; these opportunities allow individuals social competency, time management, with ASD to practice skills such as gaining organization, adult independent living access to transportation and using technology skills; Wehmeyer, Palmer, Shogren, for time management and organization. Williams-Diehm, & Soukup, 2010) and Parents can integrate life skills, such as cooking or overemphasize learning activities understanding budgeting, into social activities that have limited generalizability and (e.g., use $20.00 to purchase and cook a dish functionality (e.g., understanding for a potluck). literature themes from world literature).

COMMON CHALLENGES TO INCLUSION Although inclusion is imperative based on current policy and evidence, including individuals with ASD in school and community activities developed primarily for neurotypical populations also presents a variety of challenges. For example, as discussed previously, inclusion involves more than placing an individual with ASD in a general education classroom and hoping he or she will gain access to the curriculum. Research indicates that inclusion is more successful if leadership is supportive, neurotypical peers understand ASD and how to help their peers with ASD, providers and parents have data on the supports needed for effective inclusion, and providers are educated about ASD and inclusive strategies (Pellicano et al., 2018). Educating others in the use of NDBI strategies can support inclusion. NDBI strategies are often seen as making sense to practitioners and are easier to use in inclusive environments than some more structured strategies. They are designed to fit into the community. In addition, NDBI strategies have been successfully taught to children as young as preschool age and can also be motivating to everyone in a classroom or on a team. Therefore, providing training and education on a few of the NDBI strategies discussed here can facilitate inclusion that works for both the learner and the others in the setting. Table 5.1 describes several common challenges to inclusion as well as potential solutions using NDBI strategies.

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Case Example: Preschool Program Alexa’s PLAYC at Rady Children’s Hospital in San Diego is a unique early education program for typically developing children and children with or at risk for an ASD. Alexa’s PLAYC uses NDBI to teach developmentally appropriate communication, cognitive skills, and social skills while fostering independence in young children. Alexa’s PLAYC offers five classrooms for children age 18 months through kindergarten. Classroom educator-to-child ratios range from 1:3 to 1:7, and classroom sizes range from 12 to 20 children. There are no more than four to five children who have ASD in each classroom, and each child attends for a half day to allow access for a greater number of students. Each classroom has an instructional team of early childhood teachers and autism education associates (AEA). Teachers and AEA take on multiple roles within the classroom, such as acting as lead teacher, handling diaper changes/toileting, leading circle time, and developing activities. AEA also collect data and make bimonthly home visits with caregivers. Treatment fidelity checklists are used to monitor implementation of specific tasks and utilization of NDBI strategies by educators and are used at least biannually to identify areas of strength and areas requiring clinical oversight. A multidisciplinary team, including an occupational therapist, speech-language therapist, psychologist, classroom educator, and parents, develops individualized goals for the children with ASD. Goals focus on several developmental domains, such as receptive language, expressive language, pragmatic language, joint attention, object play, social skills, motor skills, functional routines (e.g., potty, greetings, making transitions), and/or behavior reduction. The assessment tool included in the Early Start Denver Model (ESDM) manual (Rogers & Dawson, 2010) is used to assess skills and develop goals. Children’s goals are integrated into weekly, theme-based lesson plans, and the primary focus of each activity is to create opportunities for socialization and communication among the children. Specific tasks are scaffolded to meet the developmental needs of all children. The team measures each child’s progress biweekly via varied data collection methods. The psychologist evaluates goal progress and programming every 5–6 weeks, updates present levels, alters treatment plans, and reviews results with families. During clinical meetings, the full team reviews each child’s goals, assesses specific behavior plans, and explores need modifications to teaching strategies. In order to understand the practical applications of NDBI within a classroom setting, consider Steven, a 2-year-old child at risk for ASD. Steven enrolled in a toddler classroom with a 1:3 educator-to-child ratio, weekly speech and occupational therapy consultation, and bi-monthly home visits with his family and his AEA. At the time of entry into Alexa’s PLAYC at 22 months, Steven’s family expressed concerns with his early language delays and repetitive behaviors. He was not playing appropriately with toys but rather examining parts of objects and playing repetitively with numbers, letters, and shapes. Steven would repeatedly turn on and off the lights and would spill and fill containers. The multidisciplinary team conducted evaluations and observations and developed goals. Steven’s goals focused on following directions involving language and

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gestures, increasing pragmatic language functions, using reciprocal play with adults and peers, increasing complexity of object play, and improving imitation with and without objects. Steven’s initial standardized testing scores fell in the extremely low to below average range. His classroom had a consistent schedule of activities such as circle time, free play, snack time, outside play, and lunch. Steven had some challenges with transitions between activities so the teacher set up visual schedules of the day and specific activities (e.g., hand washing). These strategies were effective for him and aided selfregulation during periods of separation and transition. Teachers implemented NDBI strategies and principles in Steven’s classroom. They arranged the classroom to create opportunities for spontaneous communication, socialization, and play. For example, Steven’s favorite television character figurines were placed on a shelf he could see but that was out of reach to encourage him to use verbal and/or nonverbal communication with adults. Some materials, such as closed playdough containers, toys enclosed in clear bins, and smaller portions of food offered during snack, required initiation with an instructor in order to request help. During these opportunities, Steven was encouraged to appropriately gain the teacher’s attention by calling his or her name or tapping the teacher on the shoulder. At first, he needed hand-over-hand prompting to get attention, but this was quickly faded, and he became independent in his use of gesture to gain attention. Steven had some challenges with attention during circle and free play time, so teachers rearranged the furniture to create defined spaces for playing, to block access to certain areas of the classroom, and to facilitate proximity between children. Steven’s access to numbers and letters was systematically utilized to maintain engagement by controlling access and facilitating reciprocity via balanced turns with his peers. Within each activity, teachers followed Steven’s lead to determine his motivation in that activity, provide a model for play and social-communication (or have a peer provide a model), and create opportunities to prompt more complex skills. During group activities, teachers drew Steven’s attention toward another child’s play to broaden his scope of attention and to encourage imitation of peers. There were many opportunities to support new learning and to provide natural reinforcement. For example, teachers used Steven’s enjoyment of numbers, letters, and shapes to encourage involvement in social games. He passed out letters that corresponded to other students’ names at circle time, handing students the letter, saying their name, and getting another letter as a means of natural reinforcement. During object play, the educator and peers were able to control access to the puzzle pieces to facilitate communication, and they reinforced Steven’s communication attempts by providing him the puzzle piece and giving descriptive verbal praise. The multidisciplinary team specified prompting levels for Steven’s goals and continuously evaluated and communicated them to the teaching staff. For example, during a social game of chase, Steven required an initial verbal and gestural prompt to join a preexisting game. The educator systematically faded these prompts until independence was achieved. Next, the team developed the goal to assess Steven’s request to continue a social routine. Once he was engaged in a game of chase with several peers, an educator joined the activity. Through the educator’s involvement, he

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or she was able to model verbal and nonverbal communication to request the continuance of the routine from peers. Wait time and body proximity were most effective when providing opportunities for Steven to reinitiate the routine. Steven’s developmental levels at 36 months, when he exited the program, fell solidly in the average range based on standardized testing. Although he was initially nonverbal, he was speaking in sentences and used his language for age-appropriate pragmatic functions. His play included simple imaginative play but continued to be repetitive and include intense interest in letters. Steven learned how to join social games involving peers, showing increases in social motivation. At exit, he received a diagnosis of autism spectrum disorder. He was not eligible for public school services, so he enrolled in a private preschool classroom with 20 children and two teachers. This proved challenging for Steven, and his parents asked for reevaluation by the school given his lack of progress in social and play skills. He received placement in an inclusive classroom of 20 children with one special education teacher and one general education teacher. Steven is currently 6 years of age, is enrolled in a general education kindergarten classroom, receives no support services, and is reported to have a “couple of friends” with similar interests.

Case Example: Adult Program The myLIFE program at the Emory Autism Center is a pilot social and life skills program for adults with ASD. Participants in the myLIFE program engage in natural social, leisure, and life skills activities alongside trained same-age typically developing peers. Typical activities in the myLIFE program include exercise and fitness activities, leisure activities (e.g., table tennis, pool, video games), purchasing and eating meals in a group, preparation of meals, home living skills (e.g., cleaning, hosting parties), team-building activities, and using public transportation. In addition, direct instruction of social and independent living skills occurs through invited presentations by community experts. For example, participants have learned about budgeting and money management, resume preparation, social interaction, self-determination, gardening, and other appropriate topics. Participants with ASD in the myLIFE program are grouped according to age (e.g., young adult, 25- to 35-year-olds, age 35 and older) and verbal communication skills (e.g., limited verbal skills, minimal conversation skills, conversational). Activities are differentiated according to the interests and developmental level of group members. Group sizes range from four to eight individuals with ASD, and groups typically meet once per week for a 6-hour schedule of natural routines. The program aims to mimic the pattern of a university schedule; thus, groups meet for two 5-week sessions with a week-long break in between sessions (e.g., fall break; spring break). Most myLIFE program groups have a one-to-one ratio of participants with ASD to volunteers with an Emory Autism Center staff member to facilitate the group. Peers in the program are often volunteers from the Emory University community (e.g., undergraduate students, graduate students, community members). All volunteers are screened via a volunteer application that includes submission of a resume, availability for participation, age-group preferences, professional references, and a criminal background check. Approved interested volunteers participate in a multiday

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training module addressing 1) characteristics of adults with ASD, 2) commonly used strategies, 3) inclusion philosophies and common myLIFE program activities, and 4) safety procedures. myLIFE group programs follow a daily routine. On Thursday morning around 9:30 a.m., the 18- to 24-year-old myLIFE group arrives at the Emory Autism Center. Participants arrive, settle into a multipurpose room, and engage in casual conversation with other adults with ASD and group volunteers as other group members arrive (e.g., arranging the environment, balanced turns, prompting, natural reinforcement). At 10:00 a.m., a member of the community joins the group to teach about home gardening and how to build small wooden planters to grow vegetables (e.g., peppers). The program pairs verbal instruction with visual supports and hands-on learning opportunities (e.g., modeling, imitation), and it strongly emphasizes safety procedures for wood-working (e.g., natural reinforcement). At 11:00 a.m., the group makes the transition out of the center to an Emory University campus shuttle depot. The group then takes the shuttle to a different part of Emory’s campus. During the transition to the shuttle stop, participants engage in conversation, and center staff and volunteers utilize prompting and redirection strategies to promote appropriate conversation and social interaction (e.g., modeling, natural reinforcement). For example, if a participant responds to a comment by changing the topic to a preferred interest, volunteers are trained to interrupt, redirect, and model a more appropriate response that remains on-topic, followed by a natural prompt to encourage the participant to respond appropriately. Though unnatural praise (e.g., “Good job being on topic”) is rarely incorporated into social routines, staff and volunteers often model typical, natural, and age-appropriate social praise comments (e.g., “That’s really interesting”). The group next arrives at the campus recreational center and engages in recreational exercise or fitness routines (e.g., playing basketball, cardio workout). Strong relationships have been built with campus staff, which results in initial opportunities for training on recreational center rules and safety procedures and otherwise limited involvement from staff unless requested (e.g., modeling, natural reinforcement). At 12:30 p.m., the group again makes the transition to lunch at a campus food court. Participants in this group have the ability to independently select and purchase their lunch (e.g., natural reinforcement); other myLIFE groups may require more support, prompting, modeling, and assistance during this activity. The group eats lunch together, practicing a wide array of social interaction skills, including reserving dining space for other group members, engaging in casual conversation, and adhering to age-appropriate dining etiquette (e.g., natural reinforcement, balanced turns, arranging the environment). Staff and volunteers continue to model, redirect, and prompt as needed to facilitate appropriate social interactions and dining behaviors. Following lunch, the group walks to the campus shuttle stop and rides the campus shuttle to an on-campus apartment complex. The Emory Autism Center rents a campus apartment in which to practice home-living and other independent living skills. At the apartment, the group may initially engage in self-directed relaxation (e.g., lounging on a couch, watching television), and after this brief break (e.g., natural reinforcement), the group may participate in a home-living skill such as preparing a

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snack and then cleaning the kitchen. As needed, students learn skills or roles through a combination of verbal instruction and visual supports, and they always review group roles prior to engaging in activities. The day concludes with walking as a group from the apartment back to the Emory Autism Center and continuing to engage in casual conversation prior to participants saying farewell and leaving to go to their homes around 3:30 p.m. Outcomes for the myLIFE program are currently assessed through informal means (e.g., anecdotal observation, self-report). Participants in the myLIFE program demonstrate increases in discrete functional skills, such as creating a planter or cleaning a kitchen sink. Over time, many participants demonstrate increases in social competency skills, such as staying on topic in conversation, though this remains a difficult skill to master for many. Self-report accounts suggest improvements in self-confidence and self-esteem, such as being willing to engage in social chat in vocational settings (e.g., grocery store bagger). Most important, myLIFE participants report increases in social connectedness, and the vast majority of participants enroll in multiple group sessions and look forward to future interaction with their group members. Peer volunteers report increases in awareness of effective strategies in working with adults with ASD as well as increases in attitudes toward individuals with ASD.

CONCLUSION This chapter highlights the importance of including individuals with ASD in the community throughout the life span. This includes access to inclusive school programs, typical community activities (e.g., church, sports leagues, summer camp, museums, movies), meaningful employment, and inclusive housing. Successful inclusive opportunities include support to help the child or adult with ASD actively participate in the activity or event. Inclusion is a right across the life span and has been shown to be effective for skill development, generalization of skills, and improving quality of life. NDBI are particularly well suited for use in inclusive environments due to their emphasis on the natural environment, natural reinforcement, and functional skills.

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III NDBI Strategies

6 Implementing Motivational Strategies Mendy B. Minjarez and Yvonne Bruinsma

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ocial motivation, defined as preference for and attention to social information in the environment because it leads to social reward, is a core area of challenge for individuals with autism spectrum disorder (ASD; Rogers & Dawson, 2010). Children with ASD engage in less attending and responding to others, leading to the hypothesis that these children have a relative lack of sensitivity to social reward. Much has been written and researched in this area. This chapter highlights three slightly different but complementary perspectives on the role of social motivation and the origin of the associated challenges in ASD. First, from a biological perspective, researchers have suggested that the brain of a child with ASD is wired differently from the brain of a typically developing child. This means that children with ASD perceive and process social information differently, which can be observed in the brain activity of a child with ASD (Dawson, Webb, Carver, Panagiotides, & McPartland, 2004). Dawson and colleagues discussed an underlying biological mechanism that shows a “fundamental deficiency in social motivation due to the young child’s relative lack of sensitivity to social reward” (p. 16; Rogers & Dawson, 2010) (Dawson et al., 2002; Dawson et al., 2004; Dawson, Webb, & McPartland, 2005). This difference leads to a decreased preference for and attention to social information (e.g., faces, voices, gestures, speech), which in turn leads to greater impairments in skills (e.g., imitation, sharing emotions, joint attention) over time. In other words, the lack of positive experiences with others may result in withdrawal from others, thus creating a cascading effect of negative experiences that diminish learning over time. A second perspective comes from the developmental literature. Research supports that typical development of social and communication skills occurs in the context of affect-rich social interactions, in which infant attention is directed toward socially rewarding information (Kuhl, Tsao, & Liu, 2003). That is, exposure to language is not enough to promote adequate development; rather, this exposure must occur in a socially rewarding context through affect-laden interactions with 123

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BOX 6.1: Motivation is key! Enhancing social motivation should be a key focus of treatment because it addresses a core deficit in children with ASD!

caregivers (Ingersoll & Dvortcsak, 2010b). Affect-laden interactions are exchanges in which the caregiver is highly responsive to any child behavior while smiling, conveying positive affect, and touching the child. Because children with ASD may not find social interactions reinforcing and pleasurable, they will not necessarily seek them out or sustain them—and may even actively avoid them—thereby compromising their social and language development. Third, from a behavioral perspective, research suggests that children with ASD may experience learned helplessness; that is, they do not perceive a direct relationship between their actions and their environment (Magnuson & Constantino, 2011). In other words, they lack understanding of the contingency relationship between responses and reinforcement (Koegel & Egel, 1979; Koegel, O’Dell, & Dunlap, 1988). This learned helplessness leads to low levels of responses and initiations. As a result, some Naturalistic Developmental Behavioral Interventions (NDBI) focus on eliminating learned helplessness by using motivational strategies that expose the child to the response–reinforcer contingency (Koegel, Openden, Fredeen, & Koegel, 2006). These three perspectives complement each other and lead to the same conclusion: enhancing social motivation should be a key focus of treatment because it addresses a core area of challenge that has cascading negative effects on development over time in children with ASD. Across NDBI, increasing a child’s motivation in interactions is a primary strategy for increasing the child’s ability to gain reward from social context.

NDBI AND MOTIVATION Several of the common elements of NDBI have a positive impact on child motivation. Teaching in the natural environment, including within primary adult–child relationships (e.g., parent–child); using familiar and enjoyable routines; and using preferred activities are key principles of NDBI that have a direct impact on motivation (Hancock & Kaiser, 2012; Ingersoll & Dvortcsak, 2010b; Koegel, Bimbela, & Schreibman, 1996; Rogers & Dawson, 2010). In addition, the NDBI strategies that provide a child with some control over the learning environment (i.e., balanced turns and shared control) also tend to increase motivation. Examples of these types of strategies include choosing motivating and child-preferred activities, sharing control over materials and reinforcement, following the child’s lead, providing choices, and using balanced turns. Finally, NDBI all use natural reinforcement and related motivation-enhancing reinforcement methods (e.g., reinforcing child attempts at target behaviors, responding to communication bids in all forms). The use of strategies such as taking balanced turns and following the child’s lead allows for the use of natural reinforcement as a consequence in naturalistic behavioral teaching trials. Related strategies, such as reinforcing attempts (also known as a

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BOX 6.2: Motivating, establishing, and abolishing operations Motivating operations (MO): An environmental variable that changes the effectiveness of a reinforcer (i.e., it becomes stronger or weaker) and, as a result, the frequency of behavior also changes (i.e., it becomes more or less frequent or intense) Establishing operations (EO): A motivating operation that establishes (increases) the effectiveness of some stimulus, object, or event as a reinforcer Abolishing operation (AO): A motivating operation that decreases the reinforcing effectiveness of a stimulus, object, or event

loose shaping procedure) and the manipulation of access to reinforcers (motivating operations that change the effectiveness of a reinforcer in either direction), are also used to enhance motivation. Box 6.2 provides additional details about how these strategies affect reinforcement, which has a direct effect on motivation. Research also supports that parents demonstrate more positive affect during interventions that use natural reinforcement, compared to parent affect during discrete trial teaching (Schreibman, Kaneko, & Koegel, 1991). Although the various NDBI models focus on the role of motivation when providing opportunities for child-initiated teaching episodes, they have differences in how they conceptualize and target this area. These differences often relate to how much the model emphasizes a specific area, for example, the use of Applied Behavior Analysis (ABA) teaching methods. For instance, the Early Start Denver Model (ESDM) targets motivation using a combination of behavioral strategies drawn from Pivotal Response Treatment (PRT) as well as affect and relationship-based strategies drawn from the original Denver model. Project ImPACT (Improving Parents as Communication Teachers) uses a similar combination of behavioral strategies (e.g., shared control and natural reinforcement) and developmentally based strategies (e.g., imitation of the child, animated affect). In PRT, motivation is considered to be a pivotal area, defined as an area that when targeted results in widespread gains in untargeted areas (Koegel, O’Dell, & Koegel, 1987). To address the area of motivation, PRT focuses on specific behavior analytic strategies, such as the use of natural reinforcement, reinforcing attempts, and interspersal of maintenance (easy) tasks. In addition, research on PRT suggested that the social component in reinforcement delivery plays a key role and that just delivering an object, toy, or activity as a natural reinforcer is not nearly as effective (Vernon et al., 2019; Vernon, Koegel, Dauterman, & Stolen, 2012), which supports other NDBI, such as ESDM, in the idea that teaching in the context of a socially rich interaction facilitates learning.

MEASURING MOTIVATION To address the limited social motivation of a child with ASD, clinicians must first identify and assess one or more measures of the child’s level of social motivation. Motivation is a construct and may seem challenging to measure at first; however, in the behavioral literature, several operational definitions have been proposed and successfully used in research. For example, in the PRT literature (Bruinsma

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& McNerney, 2012), motivation was defined based on 1) the number of child responses to social and environmental stimuli, 2) decreases in response latency, and 3) quality of child affect (engagement, enthusiasm, absence of challenging behaviors) in interactions. It has also been suggested that when child motivation is high, fewer clinician prompts are required, the need for extrinsic reinforcement decreases, interresponse times are low, and response magnitudes are high (Bruinsma & McNerney, 2012; Ward, 2009). ESDM measures social motivation by noting increases in social orienting, joint attention, and imitation skills (Waddington, van der Meer, & Sigafoos, 2016). Although these types of behaviors may not need to be measured in every intervention plan, they can be highly useful when a child is struggling with motivation and treatment strategies are being used in a more targeted way to increase motivation. Constructs that may be useful in measuring variables related to motivation are outlined in Table 6.1. In keeping with behavior analytic principles, it is useful to write down operational definitions when measuring motivation. Operational definitions are clear definitions of behavior that are written to ensure reliability when measuring behavior. Because these variables can be challenging to define, the recommended practice is writing definitions that are specific to the child, including child-specific behaviors that indicate emotional states (e.g., positive affect). Although the measurement strategies discussed in Table 6.1 are somewhat general, they may be useful for capturing these constructs in a clinical setting. Furthermore, clinicians do not necessarily have to measure motivation; rather, they can attend to these variables in a general way when gauging motivation. They may also find it helpful to teach parents to attend to these variables as strategies for reading their children’s cues related to motivation.

STRATEGIES THAT ENHANCE MOTIVATION As discussed in Chapter 1, addressing child motivation in ASD treatment has garnered increased attention since the first studies of behavioral interventions demonstrated efficacy with these children. NDBI are especially well suited to address the lack of social motivation because they tend to include caregivers and other family members in interventions that occur during enjoyable play-based and daily routines. The sections that follow outline a number of NDBI strategies for enhancing motivation. Fostering Engagement, Affect, and Shared Enjoyment NDBI emphasize the importance of positive, warm affect (the extent to which a person conveys positive emotions, such as happiness, joy, interest, and alertness) and shared enjoyment (desire to interact with others just for the sake of connecting) in relationships between the caregiver or therapist and the child during intervention. See Box 6.3 for more ideas about how to convey positive affect. In ESDM, strategies to build relationships with children lay the foundation for social and communication development (Rogers & Dawson, 2010). Rogers and Dawson suggested that “lively, dynamic interactions involving strong positive affect that would lead children to seek out social partners as participants in favorite activities” (2010, p. 15) are advantageous. In other words, ensuring that the child is having fun and experiencing success in a social context are key goals for intervention.

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Table 6.1. How can I tell if a child is motivated? Motivational variable Responsivity

Operational definition

Suggested measurement strategy

How often is the child answering me?

Take a frequency count of social or communication demands placed in 10 minutes, and mark how often the child responded. Calculate a percentage. Reciprocity How often does the child respond Observe a 10-minute adult–child to adult social bids in a interaction. synchronous way? Tally each time the adult makes a social bid toward the child and how often the child responds in a synchronous manner. Calculate a percentage. Synchronous responses must immediately follow and be directly related to adult behavior to be considered synchronous. Synchronous responses can include gestures, affect or facial expressions, eye contact, actions with objects or toys, vocalizations, and other behaviors. Response latency How quickly is the child Measure duration between adult answering me? cue or prompt for communication and the child’s response across 20 prompts or cues. Calculate an average response latency time. Adult prompts or cues do not have to be consecutive. A representative sample is fine. Child affect Affect: How happy is the child? Affect: Develop an operational Do I see smiling, happy facial definition, and code 1-minute expressions, laughing, and high intervals of a 10-minute adult–child energy? interaction as primarily 1) negative Engagement: How engaged is the affect, 2) neutral affect, or (3) child? Do I see that the child is positive affect. interested, even enthusiastic in the Engagement: Develop an operational activity, taking turns, continuing definition, and code 1-minute the activity, and remaining in intervals as primarily 1) total proximity? absence of engagement during the Behavior: How much challenging interval, 2) partially engaged and behavior does the child display? partially not engaged during the Do I see that the child has no interval, or 3) engaged continuously tantrums or other challenging throughout the entire interval. behaviors? If the child has Behavior: Develop operational challenging behaviors, operational definitions of the child’s challenging definitions should be written so behavior, and code 1-minute raters can agree on whether they intervals as 1) presence of occurred or not. challenging behavior during the interval, 2) some challenging behavior and some time free of challenging behavior (even if the child is not engaged), or 3) no challenging behavior observed throughout the entire interval (even if the child is not engaged). If affect, engagement, or behavior is highly variable, coding intervals can be shorter. (continued)

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Table 6.1. (continued) Motivational variable Social orienting

Joint attention

Imitation

Initiation

Operational definition

Suggested measurement strategy

Is the child looking at me? Is his or her body turned toward me?

Take a frequency count of social or communication demands placed in 10 minutes, and mark how often the child showed appropriate body orientation when the demand was placed. Calculate a percentage. Is the child alternating eye gaze to Observe a 10-minute adult–child play share enjoyment? Is he or she interaction. pointing, showing, or giving? Tally how often you observe a joint attention behavior (e.g., showing, giving, alternating eye gaze, pointing, commenting). Is the child imitating actions or Observe a 10-minute adult–child play sounds I am making? interaction. Tally how often the child imitates an adult action, sound, or word. Is the child initiating communication, Observe a 10-minute adult–child play, and interaction with me, play interaction in which preferred or does he or she only respond items are provided to the child when I initiate? and the adult social partner sits and observes the child. If the child approaches the adult, it is okay to respond and redirect the child. Otherwise, do not initiate interactions for 10 minutes. Tally how often the child approaches the adult and initiates interaction. To increase the complexity of the information being gathered, categorize the initiations as 1) to request objects, 2) to request help, 3) to show objects, 4) to seek comfort, or 5) to serve a social purpose (e.g., smiling in the adult’s face).

Many NDBI place a heavy emphasis on sensory social routines at the beginning of treatment. Sensory social routines are joint activity routines in which each partner’s attention is focused on the other person, rather than on objects, and in which mutual pleasure and engagement dominate the play (Rogers & Dawson, 2010). Tickle games, in which the adult pauses and waits for a social response (e.g., eye contact, smile) from the child before proceeding, are an example of a common sensory social routine. Sensory social routines, which are particularly emphasized in ESDM, are described in more detail in Chapter 12. Object play routines are similar to sensory social routines in that they are set up and then repeated. They focus on triadic attention by adding objects, such as a toy, game, or other materials. ESDM refers to these routines as being focused on object-partner-self. Some NDBI, such as Joint Attention, Symbolic Play, Engagement, and Regulation (JASPER), place a heavier emphasis on these object-focused routines, which may lend themselves better to teaching toy play and joint attention (Kasari, Fannin, & Goods, 2012). Like sensory social routines, object play routines focus on making an activity fun and predictable for a child. Then, the adult breaks the routine by pausing or changing the actions to encourage social-communication.

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Ready, Set, Implement! BOX 6.3: Conveying positive affect To convey positive affect, consider the following: • Tone, pitch, and prosody of voice • Word choice in verbal models • Body language and gestures • Body orientation and body proximity to child • Facial expressions • Use of animation (e.g., voice, facial expressions, gestures) • Type of play or activities being modeled • Frequency of positive comments or praise • Matching affect to the child’s current state

Although sensory social routines are mainly focused on toddlers and preschoolers, object play routines can be more easily adapted to a wider age range of children. Any daily living routine or game play can become a routine. Complexity of the routine is determined by the developmental level of the child. For some children, activities have to be simple and routine-based to encourage more exchanges; and more complex activities may only last for a few exchanges. For older and more advanced children, activities can be longer and consist of complex behavior chains and longer interactions. See Table 6.2 for examples across activities Table 6.2. Examples of behaviors that can be repeated and varied during object play routines Activity

Setting up

Memory game Shake the cards in the box while saying, “Shake it up, shake it up,” before opening the box.

Bath time

When going to the bathroom, sing, “Slippery fish going to the bathtub.”

Snack routine

Prepare the snack, get the child seated, and then narrate, “Who is hungry? You are hungry!” to each person who receives a snack.

During

Ending

Model a few standard Measure the stacks of phrases and sounds cards against each during the game, other, and do a victory such as “high five!” dance for a good and “excellent” for a game. match and “oh, man!” or “bummer” for no match. Wash the doll’s hair or Play a tickling game or body before washing hiding game during your child’s hair or body. towel drying. Narrate Narrate, “Wash, wash, body parts while drying wash the hair!” and (e.g., “Dry tummy!” then “Wash, wash, wash “Dry arms!”). the body!” for both the doll and the child. During snack, make a When the child is done game out of pretending eating, make a game to feed each other bites of tickling the tummy or actually feeding each and commenting other bites. Narrate, about it being full. “Yummy, yummy in my tummy!” every few bites.

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and daily routines. Although repetition of actions and phrases can be useful in object play routines, it is also important to ensure they do not promote echolalia or scripted speech and play, which is why communication partners should encourage variation in the reciprocal interaction once the child is engaged. As such, they should develop routines based on individual child needs. ESDM (Rogers & Dawson, 2010), Project ImPACT (Ingersoll & Dvortcsak, 2010b), and other models (e.g., JASPER, Enhanced Milieu Teaching [EMT]) outlined a number of teaching practices related to affect and enhancing relationships that are useful in NDBI, including the following: Effective Use of Affect Therapists and caregivers should use positive affect, defined as an adult display of genuine and natural positive emotions (e.g., happiness, joy, silliness, laughter), which is also matched to child’s state, so they do not overwhelm the child. The use of positive affect should create a positive emotional state in the child and enhance the reward value of social interaction (i.e., motivate the child socially). Some models (e.g., JASPER) place more emphasis on matching the child’s affect and modeling appropriate affect as a way of promoting child regulation (e.g., model regulating affect, as well as use of positive affect, when appropriate). Effective Use of Heightened Animation Using heightened animation is one way to emphasize emotional expressions and affect sharing. Heightened animation can include exaggerated gestures, facial expressions, and vocal quality. It is also important to modulate animation when it may be overwhelming for a child or when a child can benefit from adult modeling of regulation and decreased animation or affect. With this strategy, as well as use of affect, therapists can help the child maintain an appropriate arousal level through the use of adult regulation and matching the child’s emotional state when appropriate. Consistent Response to the Child’s Communication Cues Therapists and caregivers should be responsive to child communication cues, which includes staying attuned to the child’s state, motives, and feelings; reading the child; responding to communicative cues (verbal and nonverbal); and acting contingently in order to reinforce the child’s communicative behaviors. Consistent Response to the Child’s Emotional Cues Therapists and caregivers should demonstrate empathy by mirroring and validating the emotion and demonstrating understanding of it. In this way, the adult can provide acknowledgement of child cues without reinforcing undesirable behaviors. Adult positive affect and creating contexts for shared enjoyment can be used across many contexts and teaching interactions. However, some NDBI models focus more on matching the child’s affect or modeling appropriate affect than solely on the role of positive affect in teaching interactions. For example, both ESDM and JASPER focus on matching the child’s affect as one strategy for promoting self-regulation, but in situations where the child is becoming overexcited or overstimulated, the adult may model calm affect to promote regulation. Furthermore, for some children, high affect may be too overwhelming, and adult matching of the child’s more subdued affect may, in fact, be more motivating. As with all treatment strategies, adult use of affect to promote motivation and engagement should be tailored to the child’s needs.

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Imitating Child Actions Several NDBI incorporate adult imitation of child behaviors, including EMT, Project ImPACT, JASPER, and ESDM. EMT and Project ImPACT suggest that mirroring the child’s actions enhances social motivation because by doing so the adult is automatically following the child’s lead (Hancock & Kaiser, 2006; Ingersoll & Dvortscak, 2010b). Adult imitation of child language, play, or body movements is used as a motivational strategy in NDBI; in fact, it is often used as part of sensory social routines and joint activity routines. Adult imitation deserves additional attention, though, because several lines of research suggested that this alone may account for impressive child improvements. For example, this strategy appears associated with increased attentiveness (Dawson & Adams, 1984), which certainly has a positive impact on motivation and engagement. It is also associated with increased social engagement, imitation skills, appropriate behaviors, and spontaneous language and play (Ingersoll & Dvortscak, 2010b). Imitation strategies should only be used when appropriate behaviors can be imitated. Inappropriate or challenging behaviors should not be imitated. NDBI models use a variety of strategies to promote imitation. These strategies are outlined next and are briefly summarized in Table 6.3.

Table 6.3. Strategies for promoting imitation Type of imitation Imitating actions on objects Mirroring child actions while narrating with language Imitating gestures and body movements

Imitating with novel actions

Imitating vocalizations or verbalizations

Description

Example

Imitate appropriate actions the Bang a drum. child does with objects. Stack blocks. Drive a car. Feed a baby. Extend imitation of actions Make an animal eat while saying, on objects a step further by “Horse is eating!” adding narration. Drive a train while saying, “Train goes fast!” Use this strategy for kids with Use hand movements in songs. minimal object or toy play. Perform fingerplays. Exaggerate subtle gestures to Clap when the child claps. promote child responding. Perform gross motor activities: jumping, spinning, reaching, dancing. Extend imitation of actions on Doll play: Imitate the child 1) patting objects by introducing novel the baby, 2) rocking the baby, and actions. 3) putting the baby to a shoulder. Imitate several child actions; Then, introduce pretending to feed then, introduce a novel the baby. action so the child can Car wash toy: Imitate the child imitate it. 1) driving a car up a ramp, 2) driving This is similar to reciprocal a car down a ramp, and 3) putting imitation training (Ingersoll, a car in an elevator. Then, introduce 2010). pretending to wash the car. Imitate sounds for children Imitate any appropriate sound the who are preverbal. child makes. Imitate words or phrases for Imitate the child saying “bu-bu-bu-bu” children who are verbal. while bubbles are present. Only imitate appropriate If the child says, “car driving,” repeat it. vocalization or verbalization. If the child says, “car driving,” say, Imitate and expand on the “green car driving”. utterance (one-up rule).

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Imitating Actions on Objects The adult can imitate any appropriate action that the child engages in with an object (Kasari et al., 2012; Rogers, Dawson, & Vismara, 2012). For example, when playing with musical instruments, the adult might imitate the child shaking a maraca or banging a drum. Imitating play with toys (Ingersoll & Dvortcsak, 2010b; Kasari, Freeman, & Paparella, 2006) is a similar but more advanced type of action on object imitation. In this strategy, the adult is encouraged to have two sets of each toy available. When the child initiates with a toy, the adult can then follow his or her lead by selecting the same toy and imitating the child’s actions with it. For example, if the child picks up a baby doll and hugs it, the adult can pick up another baby doll and imitate this action. These strategies are also used in reciprocal imitation training (RIT), which is a teaching protocol used to teach imitation that focuses on using adult imitation to motivate the child (Ingersoll, 2010). Components of RIT are used in other NDBI, such as Project ImPACT. Mirroring Child Actions While Narrating With Language This strategy extends the first strategy by adding verbal descriptions of the imitated actions (Hancock & Kaiser, 2006, 2012; Ingersoll, 2010). Narration must be appropriate or slightly more advanced than the child’s developmental level. For example, if the child is driving a train car, the parent could imitate that action and add language by saying, “Drive the train.” Imitating Gestures and Body Movements This strategy may be especially applicable to children with minimal appropriate toy play (Ingersoll & Dvortcsak, 2010b; Rogers et al., 2012). Kasari and colleagues (2006) have also noted that it may be helpful to engage in more relationship-based activities (e.g., sensory social routines) with children who lack toy play, and imitating gestures and body movements is one such strategy. Sometimes children may not engage in many gestures or body movements; instead, they may wander aimlessly or not engage. Ingersol and Dvortcsak (2010b) suggested that it may be useful to imitate and also exaggerate the child’s body movements, even if they are subtle. Rogers, Dawson, and Vismara (2012) described teaching imitation within activities such as fingerplays and songs in which the adult can teach imitation by stopping the song and prompting the imitation before continuing the song. Imitating With Novel Actions Imitating and expanding on actions also involves imitating actions on objects but adds the additional step of introducing novel actions (Ingersoll, 2010; Rogers et al., 2012). When using this strategy, the adult first imitates several child actions and then introduces a novel action so that the child can imitate it. This is the general procedure used in RIT (Ingersoll, 2010). This is also similar to the concept of variation in joint activity routines in ESDM. Imitating Vocalizations or Verbalizations Imitating vocalizations has been associated with increased child vocalizations (Ingersoll & Dvortcsak, 2010b; Kasari et al., 2012; Rogers, 2006a; Rogers et al., 2012). The adult should imitate only appropriate vocalizations and may want to select which vocalizations to imitate based on the child’s language goals or skill level. With children who are not yet

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using verbal communication, imitation of sounds is recommended. In children who are verbal, adults can imitate words, phrases, and sentences as appropriate to developmental level and goals. When imitating vocalizations, the adult may also expand on what the child said in order to provide a model of the next steps in communication development. In ESDM, this is known as the one-up rule, meaning the adult adds one word when imitating the child’s words (Rogers & Dawson, 2010). For example, if the child says “truck,” the adult might imitate and add a word with “truck go!” Using Child-Selected, Highly Preferred Activities All NDBI focus on the use of child-selected, highly preferred activities. Childselected, highly preferred activities are defined as those activities that are chosen by the child at the time of the teaching interaction (i.e., in the moment). Working in the context of such activities has been shown to enhance child motivation and engagement, as well as responsiveness to adults (Kaiser, Yoder, & Keetz, 1992). The use of this strategy is similar across NDBI models. For example, Kasari and colleagues (2012) described that in the JASPER model of teaching joint attention and play skills, intervention is conducted in the context of play activities in which joint attention and other target behaviors can be modeled once a child initiates interest in a preferred toy. Use of this framework requires setting up the environment with developmentally appropriate toys that can facilitate the establishment of play routines. Hancock and Kaiser (2012) emphasized the developmental pragmatic communication approach in EMT, which emphasizes teaching communication and social skills during high-interest activities as one strategy for motivating children to communicate with adults (Rogers, 2006b). Likewise, ESDM, PRT, Project ImPACT, and incidental teaching embrace the use of high-interest, childselected and initiated, motivating activities as the context for learning (Ingersoll & Dvortcsak, 2010b; Koegel & Koegel, 2006; McGee, Morrier, & Daly, 1999; Rogers & Dawson, 2010). Clinicians should remember that motivating activities are defined by the child and may change from moment to moment. For example, the child may be interested in trains for a short period of time and then quickly move on to blocks. In order to continue teaching within the motivating context, the clinician must move with the child, or follow the child’s lead—another motivation-enhancing strategy outlined in this chapter. Child-selected activities may also not always be play based. In fact, for children with ASD, child-selected activities may even be unusual. For example, children may be motivated for academic activities (e.g., letters, numbers, reading, math), topic-based activities (e.g., reading about or watching online videos about preferred topics that are restricted interests), or repetitive behaviors (e.g., lining up objects, access to gross motor activities, such as jumping). Research has demonstrated that repetitive behaviors and restricted interests do not increase or become exacerbated when used as reinforcement in the teaching context (Charlop, Kurtz, & Casey, 1990); therefore, doing so is often encouraged when such activities are a primary source of motivation for a child with ASD. Some children with ASD initially have a limited number of activities or toys they are motivated by, and it can be challenging to identify what motivates them. Box 6.4 contains ideas to identify and expand their interests.

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Ready, Set, Implement! BOX 6.4: Tips for identifying interests The following strategies may be useful for identifying and expanding your child’s interests: • Pay attention to body language regardless of communication skills. Is the child reaching? Turning to or away from the toy or play partner? Initiating? • Let go of the idea that a toy has a purpose or a game has rules. Connect 4 may be a complex game, but filling up the grid with chips and watching them fall out is often highly motivating. No rules necessary! • Rotate toys and activities to prevent boredom and predictability. Keeping toys in bins and rotating the bins every few days to weeks so that only a portion of the toys are available at one time can keep things novel for the child. • Do not forget that restricted interests and repetitive behaviors can be motivating contexts for teaching. • Sometimes it seems that the child is not interested in anything at all. If this appears to be the case, watch what the child does in a free play situation with access to toys and other items or activities. The child will do something, and this something can be used as a reinforcer. Examples include flicking light switches, repetitively tapping on a table, and waving a pencil in front of his or her eyes.

Careful consideration of how the child’s interests can be expanded may also be helpful. For example, if an interest is identified, consider what about the object or activity is motivating. Is it a movement activity? Perhaps similar activities that include movement would also be of interest. Is it a visual activity? Perhaps other visually stimulating activities can be explored. Table 6.4 provides some examples of how to expand interests based on current interests. Following the Child’s Lead All NDBI focus on following the child’s lead in some way. Following the child’s lead is defined in several ways depending on the NDBI model. One form of following the child’s lead relates to observing in the moment what toy, object, or activity the child is interested in and using it as the teaching context. If the child moves on to a new activity, the adult would then follow his or her lead to the next activity of interest or between activities. For example, if the child is playing with cars and decides to move on to coloring, the adult would move to coloring as well and continue to embed teaching strategies in the new activity. With an older child, the adult might follow the child’s lead in conversation by moving with the child from one preferred topic to the next (e.g., talking about the child’s favorite video game and then following his or her lead to the topic of dinosaurs). In this way, the NDBI teaching continues to be embedded in child-chosen activities, even as the child moves from one activity to the next.

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Table 6.4. Expanding your child’s interests Child likes

This may be

Bubbles

Visually interesting

Swinging

Kinesthetic

Pushing buttons on a cause-and-effect toy

Auditory

Exploring clay or putty by pressing and rolling

Sensory

Child may also like Balloons Ball or car ramps Tops or spinners Sensory toys with liquid inside (e.g., glitter wand) Spinning in a chair Tickling games Pulling the child in a blanket Musical instruments Freeze dance Rhyming books Singing songs Pretend sneeze game Dry rice and beans Shaving cream Finger paint Kinetic sand

Following the child’s lead can also occur within an activity. For example, while playing with trains, the child’s attention or interest may shift from building the train track to wanting to drive the trains on the track. Likewise, when engaging in a coloring activity, the child’s focus may shift from drawing a picture to wanting to write letters. This subtler form of following the child’s lead can be a crucial way to maintain motivation within an activity. It has been suggested that the distinction between use of child-preferred activities as the teaching context and following the child’s lead within activities is important because both can be beneficial (Yoder, Kaiser, Alpers, & Fischer, 1993). Some NDBI models also emphasize following the child’s lead when placing demands to practice skills. That is, the adult might wait for the child to initiate a communication behavior (e.g., reaching) and either reinforce it or take the initiation as an opportunity to prompt a more complex communication behavior (e.g., verbal request). These three forms of following the child’s lead (between activities, within activities, and initiation related) are all designed to have a positive impact on motivation because the adult is closely matching the teaching with the child’s focus, interest, and motivation to communicate in the moment. These different forms of following the child’s lead are closely related, and there is a broad consensus about the importance of this strategy (Kern et al., 1998). NDBI vary somewhat as to the degree to which they emphasize each variation. Some models that incorporate the developmental pragmatic communication approach (e.g., EMT, Hancock & Kaiser, 2012; Project ImPACT, Ingersoll & Dvortcsak, 2006, 2010b) place more weight on promoting child initiations by following the child’s communication lead and responding to all communication attempts as if they are purposeful. Incidental teaching also highlights the need to wait for a child’s initiation (McGee et al., 1999). PRT encourages and plans for initiations but does not necessarily wait for a child to initiate and may more actively prompt for learning opportunities.

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Overall, research supports the use of teaching in the context of child-preferred activities and following the child’s lead. For example, using child-preferred activities decreases social avoidance behaviors and increases the length of conversational interactions (Koegel, Dyer, & Bell, 1987). Siller and Sigman (2002) demonstrated that “synchronizing” the adult’s behavior with that of the child (i.e., following the child’s lead and providing little redirection) led to better joint attention and language abilities (Siller & Sigman, 2002). At times, challenges with following the child’s lead may arise. For example, some children wander aimlessly and struggle to engage in activities, whereas others may leave an area or activity as soon as an adult tries to join. It is also inevitable that all children will, at times, select activities that are not available or that the adult does not wish for them to gain access to (e.g., snacks right before dinner). Please see Table 6.5 for tips on dealing with these issues, which are also discussed in more detail in the section on shared control. There are also many strategies in the behavior analytic literature for enhancing motivation and gaining participation in treatment in more systematic ways. Strategies such as preference assessments, visual schedules, first–then programs, and priming can be combined with the strategies outlined in Table 6.5, and such interventions should be tailored to meet individual child needs. Providing Choices Research also supports the notion that providing the child with choices during teaching interactions enhances motivation (e.g., Carter, 2001). A seminal study on incorporating choice found lower levels of challenging behavior and higher levels of appropriate social play and pragmatic skills in the choice condition compared to a nonchoice adult-led condition (Carter, 2001). Even within child-selected activities, children can be provided with choices. Effectively providing choices requires the adult to have shared control over materials (see the section on shared control) so that the child cannot obtain all preferred items in the environment at will. This strategy involves giving the child a clear indication (verbal or nonverbal) that a choice is available either with regard to what he or she is playing with, how it will be played with, or what will happen next. For example, when a child is not actively engaged in selecting an object or activity, he or she can be offered choices of what to play with that are likely to be motivating or preferred. During an activity, the child can also be offered choices about how to play with the toy. This can be done in multiple ways, including 1) choices about what pieces the child wants next (e.g., more trains or tracks), 2) choices about what actions to engage in or how to play with the toy (e.g., make the animals eat or run), and 3) more nuanced or specific choices about how to play with the toy that evoke more complex language and play (e.g., make the animals run slow or fast). When a child ceases to engage in goal-directed play or communication behaviors, he or she can also be given choices about what to do next (e.g., “Do you want more drawing or should we choose a new activity?”). Depending on the context, the activity, and the child’s engagement, some or all of the strategies related to offering choices may be useful for enhancing motivation, thereby maintaining engagement in the learning context. Offering choices provides the child with some control or the suggestion of control, which has a positive impact

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Table 6.5. Addressing challenges with following the child’s lead Challenge Child wanders aimlessly and does not engage.

Possible solutions Offer choices to the child. Play with a toy, or start an activity to entice the child. Offer noncontingent reinforcement (i.e., highly preferred objects or toys, sensory social routines with no demands) to motivate the child to remain in the area. Then, introduce demands or redirect to other activities.

Examples Say, “Do you want to play star stacker or blocks?” Get out a ball ramp, put the balls down, and look enticingly at the child. You can also comment, exclaim, and gesture excitedly. Give the child a highly preferred item. If the child takes it, require him or her to remain in the area to play with it. Try engaging the child in a highly motivating sensory social routine. If he or she engages, begin placing demands and then redirect to other activities.

Child leaves Offer high levels of If the child is trying to build a marble area or activity noncontingent reinforcement, ramp, sit down to join, but do not begin when adult especially if the child cannot taking turns or take control over any of tries to join. independently access the the materials. Rather, allow free access. reinforcement (i.e., try to pair Because the marble track is hard to yourself with noncontingent build, begin helping. Offer the marbles, reinforcement). Slowly begin to and help the child put them in. Cheer introduce demands, beginning with positive affect as they go down the with maintenance tasks, at a ramp. pace the child can tolerate. Use behavioral momentum If you wish, after several repetitions, begin strategies to engage the child balancing turns, and use the adult turns before placing demands. to gain shared control over the marbles and place a maintenance task demand (behavioral momentum strategy). When you join the When joining a child playing babies, bring activity, introduce novel novel items such as a doctor kit or food. noncontingent reinforcement Offer the items noncontingently to that was not previously entice the child to stay and expand play. available. Do not place demands initially. If you eventually place demands, they should be maintenance tasks. Structure tasks, beginning with If you sit down to play blocks and the very short intervals or small child tries to leave the area, stop the amounts of expected behavior, child, and prompt, “First build five so that the child is required to blocks, then all done” or “One more remain with a task for a short minute.” Use physical prompts to gain period before appropriately compliance, if needed. After completion, closing the activity (e.g., prompt the child to clean up before cleaning up or saying “all moving on. When the child arrives at a done” and moving on). Increase new activity, embed a communication expectations for remaining with trial so moving between activities does the activity over time. not serve to avoid demands. Child moves Follow the child from one If the child leaves the blocks area when rapidly among activity to the next, and place you sit down and moves to the art table, activities in an communication demands follow his or her lead and embed a effort to avoid for each one so terminating communication trial to gain access to demands. activities does not result in art materials. If the child moves again, task avoidance. this time to the doll house, follow his or All previous strategies related to her lead and embed a communication when the child tries to leave trial to gain access to the doll house. All the area apply here as well. communication trials are maintenance Consider use of first–then tasks because the child is demonstrating schedules or other behavior low motivation. analytic interventions to decrease avoidance. (continued)

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Table 6.5. (continued) Challenge

Possible solutions

Examples

Child selects In this case, you must set and If the child wishes to paint but the painting activities maintain a limit with the child. supplies are not available, maintain the that are not Regardless of whether the limit (e.g., “Painting is not a choice right available or item or activity is truly not now”) and offer alternatives (e.g., “You not a choice at available (e.g., a snack that has can draw, color, or do stickers instead”). that time. run out) or the adult does not If the child wishes to have a snack before wish to grant access (e.g., a dinner, maintain the limit (e.g., “Dinner snack right before dinner), the is in 5 minutes. We are not having limit must be made clear. The snacks now”) and offer alternatives child can then be redirected (e.g., “You can have a glass of water to select activities that while you are waiting” or “You can help are available. If challenging me finish getting dinner ready!”). behavior occurs, the limit should be maintained, the behavior should be ignored, and available activities can be offered once the child is calm. Setting appropriate limits is part of sharing control with the child.

on motivation. Table 6.6 provides examples of different types of choices and how to use them in teaching interactions. Although providing choices enhances motivation, several common pitfalls must be avoided. First, the adult must consider whether the child has the skills to clearly communicate his or her choice. If the child is unable to reach, point, verbalize, or use another clear strategy to indicate his or her preference, the adult must rely on other cues, which can sometimes be more subtle. Many children who do not yet know how to communicate choices will reach for preferred objects when offered two choices, but some do not understand that the cue of being offered items indicates they should choose. In such cases, adults may have to rely on more subtle cues, such as looking at a preferred object. It may also be useful to offer choices in other ways, such as to leave two or three objects out on a table or in an area while restricting access to others in order to see if a child gravitates toward one. This strategy is similar to following the child’s lead, discussed previously. It may also be useful to explicitly teach children to make choices. Another common pitfall occurs when adults provide choices at times when they cannot follow through. Although this seems like an obvious mistake to avoid, it is a common trap to fall into. When providing choices, adults must ensure that both choices are available. If one choice is not available, then adults must set limits to clearly convey the choice is not an option, and they may need to delay targeting goals in that moment. Adults must also ensure that both choices are available immediately. When setting up an opportunity in which a child must choose, adults should be ready to provide him or her with reinforcement for doing so. If the reinforcement is delayed because the choice is not ready (e.g., the child requests food that the adult has to make), learning may be negatively affected. It is also useful to think about the format for providing choices in light of the child’s skill set. For example, if choices are being provided verbally, does the child have the receptive language to understand? In such cases, visual cues can

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Table 6.6. Types of choices to provide and examples at different developmental levels Type of choice

Younger child examples

What to play Floor activity: “Do you want to play with, do, or talk trains or ball ramp?” about (e.g., in Table activity: “Do you want to do art conversation with or puzzles?” older children) Pretend play: “Do you want babies or animals?” Motor or sensory: “Do you want swing or tickles?” How to play with it or do it • What to play with Trains: “Do you want more tracks or do next within or trains?” an activity Art: “Do you want another marker or stickers?” Dolls: “Do you want bottle or binky?” Sensory: “Swing or stop?” • Choices about actions or how to play

• More complex or nuanced choices about how to play or about the topic

What to do next

Older child examples Activity: “Do you want to build with magnets or blocks?” Conversation: “Do you want to talk about dinosaurs or animals?” Community: “Do you want to get coffee or ice cream?”

Activity: “Should we build a tower or an airplane?” Conversation: “What aspect of dinosaurs do you want to talk about next?” Community: “What kind of ice cream do you want?” Trains: “Should the trains drive or Activity: “Should we build it tall park?” or short?” Art: “Should we color it in or draw Conversation: “Should we talk another one?” about where dinosaurs live Dolls: “Should the baby eat or sleep?” or what they eat?” Sensory: “Should we swing or bounce?” Community: “Do you want your ice cream in a cup or cone?” Trains: “Should the trains drive forward Activity: “Who is going to live or backward?” in this tower?” Art: “Should we put the sticker here or Conversation: “Should we talk here?” about my trip to the dinosaur Dolls: “Does the baby want milk or museum or yours?” juice?” Community: “Where would Sensory: “Do you want to swing slow you like to sit to eat your ice or fast?” cream?” Floor activity: “Are you done with trains Activity: “Are you all done or do you want to keep playing?” building or should we build Table activity: “Should we keep doing more?” coloring or do you want some glue Conversation: “What should we now?” talk about next?” Pretend play: “Do you want to make Community: “Do you want to the dolls eat the food or should we go home or should we go for move on to the farm animals?” a walk first?” Motor or sensory: “Do you want to keep swinging or should we play chase?”

be useful. If a child has been using visual cues to make choices, deciding when to fade them and teach the child to rely on verbal cues can be useful. As discussed previously, management of the environment may also be important when offering choices. For example, removing objects that are not an option and only displaying items that are a choice can be helpful. Sharing Control Shared control is essential to all NDBI models because it is the basis for developing reciprocity and administering contingent reinforcement. NDBI differ across models in their emphasis on various aspects of shared control. Shared control

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increases social motivation by placing emphasis on fostering reciprocity in interactions. Shared control strategies include following the child’s lead; balancing turns with the child; and then using the adult turn to build engagement, model new skills, imitate actions, or embed teaching trials where the materials or activity can be used as reinforcement. Shared control also refers to the balance between following the child’s lead and setting limits as needed because the child cannot always have access to the preferred activity or object. In a more concrete sense, shared control of materials or activities is required in order for the adult to build a back-andforth interaction with the child and to be able to provide contingent reinforcement. Shared control provides the opportunity for the adult to gain control over preferred items or next steps in an activity in order to provide those as natural reinforcement, contingent on correct responses during embedded teaching trials. When applying the behavior analytic antecedent-behavior-consequence (A-B-C) framework to embedded teaching trials, adult control of materials can be thought of as a step that must be completed prior to delivering the antecedent or cue for the teaching trial. Inherent in the definition of shared control is the incorporation of other motivational strategies discussed previously, such as teaching within child-preferred activities, following the child’s lead, or providing choices. These strategies will enable the adult to know which items (e.g., toys, objects, food), activities (e.g., tickles, swinging the child), or possible outcomes (e.g., providing help, picking the child up) are motivating for the child in that teaching moment. Because the shared control also includes balanced turns that result in the adult leading the interaction and having momentary control over reinforcement, it is also considered a motivational strategy. If the adult does not have control over the reinforcement in this context, the child will have uncontrolled noncontingent access, which will make it more difficult for the adult to embed the teaching trial and evoke the desired child response. Retaining too much control over an activity or object by either the adult or the child may decrease the child’s motivation either because the child does not have enough access to the item or he or she has noncontingent access that may not keep him or her socially engaged. Rather, shared control should result in a naturally reciprocal interaction in which the adult and child have balanced turns. For example, when playing with toys with multiple pieces (e.g., puzzles, blocks, art activities), adults can be tempted to embed trials that result in reinforcement one piece at a time; however, doing so may result in too many demands, too little reinforcement, and an imbalanced and unnatural interaction. In order to adjust the pacing of instruction in this way, the adult can consider several strategies, including 1) providing several pieces as reinforcement, rather than one at a time; 2) providing noncontingent reinforcement (“freebies”) between teaching trials; 3) providing noncontingent reinforcement at the beginning of the activity in order to promote engagement and interest and to decrease the avoidance that sometimes occurs when an activity begins with a demand; 4) interspersing other strategies to promote development without explicitly embedding trials, such as verbal narration, imitation of the child’s actions, and modeling of novel play actions; and, of course, 5) taking turns with the child in a fun and engaging way that allows for varying the activity and building social interaction. Shared control can also be defined in a broader sense, meaning that following the child’s lead and providing choices is the focus, but limits must also be set as

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needed. That is, the child may select activities, objects, and so forth, but the adult controls what the choices are at any given time. For example, the child may be motivated by a snack that is all gone, an activity that the parent wishes to limit for other reasons (e.g., repetitive behaviors, screen time, snacks before dinner), activities that are not available (e.g., going to a preferred place, such as a favorite store or park), and objects that are not available (e.g., a toy that was left at school). Parents will often ask during parent training what they should do in these instances because NDBI place so much emphasis on following the child’s lead and teaching within child-preferred activities. Although NDBI certainly focus on maximizing the benefits of teaching in these contexts, there must also be limits when the preferred reinforcement is not available for any reason. In these cases, shared control includes setting limits as needed while providing the child with alternative available choices that are likely to be high interest. When the child’s chosen reinforcer is not available and this type of shared control is being exercised, the child should not be prompted to engage in any target behaviors until a new reinforcer is identified. That is, the child should not be prompted to engage in target behaviors that are related to a reinforcer that is not available. Many shared control strategies are used across NDBI. Table 6.7 lists of many of these, sometimes clustered into categories of related strategies, with definitions and examples of each. Sometimes shared control strategies have to be chosen carefully. For example, as Table 6.7 demonstrates, some strategies lend themselves to teaching certain behaviors better than others (e.g., the assistance strategy is specifically tailored for teaching children to request help). Shared control strategies should also be selected depending on the activity (e.g., breaking it up/inadequate portions for toys with multiple pieces) and the child. Some children may be upset by strategies such as playful interruption or obstruction, interrupting routines, sabotage, or protest techniques, particularly children who are prone to rigid behavior patterns or are very self-directed or agenda-driven. Taking Balanced Turns Balanced turns or turn taking is another motivational strategy used in NDBI. Turn taking is one strategy used in shared control because the adult can gain control over reinforcing materials or activities during his or her turn and then administer these as reinforcement contingent on the child’s next appropriate response. Also, the adult can use his or her turn as an opportunity to model expanded and more complex behaviors. Taking turns during activities automatically gives the child the opportunity to request, imitate, see actions mirrored by the adult, and receive natural reinforcement when it is his or her turn again. By definition, it teaches reciprocity but always within the motivating context of child-selected activities. Across the NDBI models, balanced turns are conceptualized in slightly different ways. For example, in PRT, adults follow the child’s lead, provide choices, and share control in a balanced way, thereby fostering a balance between targeting motivation and embedding behavioral teaching trials (Koegel, Koegel, Bruinsma, Brookman, & Fredeen, 2003; Koegel, Koegel, Harrower, & Carter, 1999; Koegel et al., 1989). In ESDM, turn taking and dyadic engagement are embedded throughout the teaching interaction such that “reciprocity and social engagement permeate

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Table 6.7. Definitions and examples of shared control strategies Shared control strategy

Definition

Example

Environmental arrangements: Organizing the environment to optimize learning Environment: In sight, out of reach

Materials: In sight, out of reach

Storing items where they can be seen but not obtained by the child

Arrange the therapy room so that items are stored up high and/ or in clear bins so the student cannot obtain them without communicating with an adult. Setting up an activity so that Set up clay and supplies (e.g., materials can be seen but rollers, cutters, scissors) on a not obtained by the child table where the adult can reach them but the child cannot without communicating with an adult.

Playful obstruction strategies: Reducing anticipation when the child’s wants or needs may be known; setting up situations in which the child will need to communicate before obtaining what he or she wants or needs Controlled access; shared control

Interrupting routines

Assistance

Inadequate portions; breaking it up

Intentional ignoring

Playful interruption or obstruction

Maintaining control over Hold up a toy or snack, and wait for objects; holding the object the child to communicate. out of reach until the child engages in the target behavior Pausing in the middle of a Stand at the door, ready to go known routine so the child outside, but pause until the child must communicate before communicates. moving on Pause before handing the child his or her toothbrush, and wait for him or her to communicate. Setting up activities or Hand the child an unopened chip situations in which the bag or juice box. child will require adult Wait while the child struggles to assistance; also reducing build a toy to evoke asking for adult anticipation of help. child needs when natural Place snacks or toys in containers opportunities arise in that are hard to open. which the child needs assistance Providing a few pieces or Provide a few goldfish crackers in a parts of a set at a time bowl, and leave the bag in sight. in order to elicit multiple Provide a few stickers during an art communication trials; activity, and let the child know applies best to toys or there are more. snacks with multiple Provide a handful of Legos, and hold pieces or sets of items the rest in the box. Ignoring the child on Turn a toy off, and then turn it purpose, especially away from the child to evoke an when the child needs opportunity for tapping an adult’s help or the adult has shoulder or calling the adult by a preferred object, to name. create opportunities for appropriately gaining attention Playfully interrupting the Pause during a tickle game, and wait child’s play so that the for the child to make a response. child must communicate Pretend that a tree has fallen on the to have the interruption train tracks and must be removed. removed Make a doll fall on the dollhouse stairs so it needs help getting up.

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Table 6.7. (continued) Shared control strategy Protest

Silly situations; playing the naïve adult

Sabotage

Definition

Example

Setting up situations that are known to upset the child in order to provide opportunities to practice appropriate requesting and protesting Setting up situations that are obviously silly or breaking known routines in a silly way

Offer nonpreferred foods or objects. Interrupt rigid routines and repetitive behaviors (e.g., lining up objects).

Turn the power switch to off on a cause-and-effect toy, and laugh or say, “Oh no! What happened?” Put pants on your head, and say, “Is this where they go?” Walk the wrong way at school, and say, “Is this where we go?” Providing parts of an activity Provide cereal without a spoon. while withholding obvious Provide the Wack-a-Mole without the necessary parts hammer. Provide paint without a paint brush.

General shared control strategies Balanced turns or turn taking

Momentum

Positive addition

Taking turns with the child by requiring him or her to relinquish objects for brief turns; in some models, includes modeling novel play actions during the adult turn Creating momentum prior to withholding an object or action by repeating a highly reinforcing action several times in a row before embedding a trial

Adding or enticing the child with a novel object (Note: This strategy is helpful when the adult no longer has control over materials because the child already has all the pieces. It is a good alternative to interrupting or requesting a turn.)

Briefly remove Poppin Pals toy, and hold it up. Briefly remove toy car, driving it once and pausing.

Take turns hammering the workbench really fast back-andforth, and then suddenly pause when you have the hammer. Add several blocks in a row to a tower while making a funny sound, then pause. Push the child several times on the swing, and then hold the child back. When building a tower, add Little People to balance on the top when it is done. Once the train track is built and the train is on it, add people or animals to the train. When playing babies, introduce toy food.

the teaching activity” (Rogers & Dawson, 2010, p. 24). Both verbal and nonverbal turn taking is described as part of the responsive interaction component in EMT (Hancock & Kaiser, 2012). Nonverbal mirroring of appropriate behavior in a turn is expressly encouraged as a way to increase the nonverbal connection between adult and child, much like other models encourage imitation. The Project ImPACT manual (Ingersoll & Dvortcsak, 2010a, 2010b) outline of parent training sessions spends 2 of 24 sessions solely on balanced turn taking and teaches turn taking as an essential strategy that helps create learning opportunities for language and is used to model and expand play.

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As discussed in Table 6.7, turn taking is also often used as a shared control strategy. When using turn taking in a more explicit way (e.g., “my turn”/“your turn”), adults should consider whether this framework is developmentally appropriate for very young children who may not be ready to learn this skill. In such cases, creating reciprocity in a more natural way (i.e., balanced turns through natural alternation of who is in control of materials) may be more appropriate. Integrating Task Variation and the Interspersal of Maintenance Tasks Task variation and interspersal of maintenance (i.e., already mastered or easy) tasks are two related strategies that primarily stem from the behavior analytic literature. Task variation is defined as varying behaviors being targeted in embedded teaching trials, varying the teaching materials, and varying the manner in which they are being used. Research supports that task variation enhances motivation and engagement (Dunlap, 1984). Interspersing maintenance tasks is one type of task variation. It is an antecedent strategy used to enhance motivation. This strategy comes out of the general behavior analytic literature, where interspersing maintenance tasks is used to build behavioral momentum (Belfiore, Lee, Scheeler, & Klein, 2002; Bruinsma & McNerney, 2012; Kennedy, Itkonen, & Lindquist, 1995), thereby enhancing motivation. This strategy is also used to increase general compliance (e.g., Singer, Singer, & Horner, 1987). Interspersing maintenance tasks is most clearly defined in the PRT literature, where this strategy is specifically used to enhance motivation through interspersal of low-effort, high-probability-of-success trials, otherwise defined as tasks the child has already mastered. Studies have shown increased participant response rate and stability and increased observer ratings of child positive affect when maintenance tasks are interspersed (e.g., Dunlap, 1984; Dunlap & Koegel, 1980; Koegel & Koegel, 1986). Maintenance tasks are defined based on individual child goals and progress. Because NDBI all incorporate behavior analytic principles, clearly defined goals with mastery criteria (e.g., 80% correct responding across 3 consecutive days of data collection) should be present. Progress on these goals can then be used to determine when a goal area (i.e., acquisition task) has been met and can be moved into maintenance. At this point, the goal can begin to be interspersed as a maintenance task. This strategy ensures maintenance of skills while also enhancing motivation. Use of this strategy requires clinical judgement in the moment about whether a teaching trial should consist of a maintenance or acquisition task. Adults who work with the child must evaluate the child’s motivation and engagement in the moment and decide whether the teaching trial should be a maintenance task (designed to target motivation) or an acquisition task (designed to target skill acquisition). There is not necessarily a predetermined ratio of maintenance to acquisition tasks; rather, the adult must learn to read the child’s cues about level of motivation and decide on the next steps in the treatment session accordingly. For example, if the adult perceives that the child’s motivation is decreasing, he or she can focus on maintenance tasks to build it back up. In contrast, when a child is highly motivated, the adult can more heavily target acquisition tasks. Sometimes, it helps to think about using a 50/50 ratio of easier and more challenging cues and varying frequency of either based on the child’s motivation and behavior.

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Using Natural Reinforcement Consistent with the behavior analytic focus in NDBI, contingent reinforcement is frequently used to teach skills during behavioral teaching trials that are embedded in natural routines and activities. Contingent reinforcement is defined as reinforcement that is delivered only after the target behavior has occurred. That is, the reinforcement is delivered contingent upon demonstration of the target behavior. Because NDBI are also defined by their naturalistic approach, however, the type of contingent reinforcement typically used is natural. Natural reinforcement is defined as reinforcement that is directly related to the target behavior and embedded within the teaching interaction (e.g., child asks for a block and receives the block as reinforcement, child points to a train car and receives it as reinforcement, child makes eye contact during a tickle routine and is reinforced with tickles). In contrast, unrelated reinforcement bears no relationship to the target behavior or context in which the behavior is being taught (e.g., child labels colors of blocks and receives access to a sensory toy as reinforcement, child points correctly to receptive labels in a picture and receives food treats as reinforcement). Unrelated reinforcement can be effective for teaching skills, but natural reinforcement has the added benefit of enhancing motivation and generalization. Natural reinforcement is characterized in a variety of ways across NDBI models. For example, EMT refers to it as contemporary ABA (Hancock & Kaiser, 2012; Prizant, Wetherby, & Rydell, 2000) and defines it as the use of contingent reinforcement during natural routines to enhance communication skills. Research in the area of PRT has demonstrated that the use of natural reinforcement is more effective for enhancing motivation than unrelated reinforcement (e.g., giving the child the ball when he or she says “ball” is more effective than giving the child an edible reinforcer; Koegel, O’Dell, et al., 1987). Furthermore, studies have shown that use of natural reinforcement leads to more rapid and stable acquisition of target skills compared to unrelated reinforcers (Koegel & Williams, 1980; Williams, Koegel, & Egel, 1981) and also promotes generalization of skills in the natural environment by strengthening naturally occurring direct response–reinforcer relationships (Schreibman, Stahmer, & Suhrheinrich, 2009). In the JASPER model, emphasis is placed on setting up the environment with developmentally appropriate toys that can serve as natural reinforcement for the establishment of play routines (Kasari et al., 2012). Detailed discussion of reinforcement strategies and their clinical application can be found in Chapter 9. Using Reinforcing Attempts or Shaping Procedures Reinforcing attempts or loose shaping procedures are used in many NDBI as a consequence strategy that enhances motivation and learning. Reinforcing attempts is defined as reinforcing any reasonable attempt at the target behavior and then shaping successive approximations of the behavior until the full target behavior is being evoked. For example, for a child who is learning first words, an initial reasonable attempt at saying the word “bubbles” might be “buh.” Once the child has mastered this attempt, the adult can start reinforcing a better approximation, such as “buh-buh,” until finally the child is able to say the word “bubbles.” In strict shaping, once the next approximation is the goal, the previous approximation of the word would no longer be reinforced. This strategy can be frustrating

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for the child, however, so a loose shaping contingency is often used in which more than one approximation of a behavior would be reinforced at a time until the child has clearly mastered the more difficult behavior. For example, for the child who is learning to say “bubbles,” the adult might reinforce both “buh” and “buh-buh” until the more difficult attempt can be consistently evoked. In essence, contingent reinforcement of attempts (or trying) increases the behavior of trying. This, in turn, leads to more trying. In NDBI, reinforcing attempts is used across most models. In EMT, one component of the responsive interaction framework is to contingently reinforce any and all attempts at the target behavior. This strategy is also incorporated into Project ImPACT, especially with regard to language goals. In PRT, reinforcing attempts is a consequence strategy designed to enhance motivation. It is defined as the reinforcement of “reasonable” communication attempts rather than shaping successive motor approximations of speech sounds (Bruinsma & McNerney, 2012). In one study, children in the reinforcing attempts condition, as opposed to motor shaping, demonstrated substantially larger gains, and children were rated as happier and exhibiting more appropriate behaviors (Koegel et al., 1988).

CONCLUSION NDBI utilize a variety of strategies to enhance (social) motivation in individuals with ASD. These strategies are supported by a large body of evidence and provide a clear focus for ASD intervention. Although behavior analytic teaching procedures are useful for targeting specific skills, procedures that enhance motivation play an important role in ASD treatment, particularly because clinicians cannot rely on the same level of social motivation that usually motivates typically developing children to learn. The strategies outlined in this chapter are specifically designed to enhance motivation in treatment and should be considered carefully when developing goals and treatment plans. Subsequent chapters will touch on a number of these strategies in greater detail as they pertain to teaching specific skill sets and reducing behavior challenges.

REFERENCES Belfiore, P. J., Lee, D. L., Scheeler, C., & Klein, D. (2002). Implications of behavioral momentum and academic achievement for students with behavior disorders: Theory, application, and practice. Psychology in the Schools, 39(2), 171–179. Bruinsma, Y., & McNerney, E. K. (2012). Pivotal response treatment. In M. E. Fey & A. G. Kamhi (Series Eds.) & P. A. Prelock & R. J. McCauley (Vol. Eds.), Communication and language intervention series: Treatment of autism spectrum disorders: Evidence-based intervention strategies for communication and social interactions (pp. 281–312). Baltimore, MD: Paul H. Brookes Publishing Co. Carter, C. M. (2001). Using choice with game play to increase language skills and interactive behaviors in children with autism. Journal of Positive Behavior Interventions, 3(3), 131–151. Charlop, M. H., Kurtz, P. F., & Casey, F. G. (1990). Using aberrant behaviors as reinforcers for autistic children. Journal of Applied Behavior Analysis, 23(2), 163–181. Dawson, G., & Adams, A. (1984). Imitation and social responsiveness in autistic children. Journal of Abnormal Child Psychology, 12(2), 209–225. Dawson, G., Webb, S. J., Carver, L., Panagiotides, H., & McPartland, J. (2004). Young children with autism show atypical brain responses to fearful versus neutral facial expressions of emotion. Developmental Science, 7(3), 340–359.

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Dawson, G., Webb, S. J., & McPartland, J. (2005). Understanding the nature of face processing impairment in autism: Insights from behavioral and electrophysiological studies. Developmental Neuropsychology, 27(3), 403–424. Dawson, G., Webb, S., Schellenberg, G. D., Dager, S., Friedman, S., Aylward, E., & Richards, T. (2002). Defining the broader phenotype of autism: Genetic, brain, and behavioral perspectives. Development and Psychopathology, 14(3), 581–611. Dunlap, G. (1984). The influence of task variation and maintenance tasks on the learning and affect of autistic children. Journal of Experimental Child Psychology, 37(1), 41–64. Dunlap, G., & Koegel, R. L. (1980). Motivating autistic children through stimulus variation. Journal of Applied Behavior Analysis, 13(4), 619–627. Hancock, T. B., & Kaiser, A. P. (2006). Enhanced milieu teaching. In R. J. McCauley & M. E. Fey (Eds.), Treatment of language disorders in children (pp. 203–236). Baltimore, MD: Paul H. Brookes Publishing Co. Hancock, T. B., & Kaiser, A. P. (2012). Implementing enhanced milieu teaching with children who have autism spectrum disorders. In P. A. Prelock & R. J. McCauley (Vol. Eds.), Communication and language intervention series: Treatment of autism spectrum disorders: Evidence-based intervention strategies for communication and social interactions (pp. 163–188). Baltimore, MD: Paul H. Brookes Publishing Co. Ingersoll, B. (2010). Brief report: Pilot randomized controlled trial of reciprocal imitation training for teaching elicited and spontaneous imitation to children with autism. Journal of Autism and Developmental Disorders, 40(9), 1154–1160. Ingersoll, B., & Dvortcsak, A. (2006). Including parent training in the early childhood special education curriculum for children with autism spectrum disorders. Journal of Positive Behavior Interventions, 8(2), 79–87. Ingersoll, B., & Dvortcsak, A. (2010a). Teaching social communication to children with autism: A manual for parents. New York, NY: Guilford Press. Ingersoll, B., & Dvortcsak, A. (2010b). Teaching social communication to children with autism: A practitioner’s guide to parent training. New York, NY: Guilford Press. Kaiser, A. P., Yoder, P. J., & Keetz, A. (1992). Evaluation milieu teaching. In S. F. Warren & J. Reichle (Series & Vol. Eds.), Communication and language intervention series: Vol. 1. Causes and effects in communication and language intervention (pp. 9–47). Baltimore, MD: Paul H. Brookes Publishing Co. Kasari, C., Fannin, D. K., & Goods, K. S. (2012). Joint attention intervention for children with autism. In M. E. Fey & A. G. Kamhi (Series Eds.) & P. A. Prelock & R. J. McCauley (Vol. Eds.), Communication and language intervention series: Treatment of autism spectrum disorders: Evidence-based intervention strategies for communication and social interactions (pp. 139–162). Baltimore, MD: Paul H. Brookes Publishing Co. Kasari, C., Freeman, S., & Paparella, T. (2006). Joint attention and symbolic play in young children with autism: A randomized controlled intervention study. Journal of Child Psychology and Psychiatry, 47(6), 611–620. Kennedy, C. H., Itkonen, T., & Lindquist, K. (1995). Comparing interspersed requests and social comments as antecedents for increasing student compliance. Journal of Applied Behavior Analysis, 28(1), 97–98. Kern, L., Vorndran, C. M., Hilt, A., Ringdahl, J. E., Adelman, B. E., & Dunlap, G. (1998). Choice as an intervention to improve behavior: A review of the literature. Journal of Behavioral Education, 8(2), 151–169. Koegel, L. K., & Koegel, R. L. (1986). The effects of interspersed maintenance tasks on academic performance in a severe childhood stroke victim. Journal of Applied Behavior Analysis, 19(4), 425–430. Koegel, L. K., Koegel, R. L., Bruinsma, Y., Brookman, L., & Fredeen, R. (2003). Teaching first words to child with autism and communication delays using pivotal response training: A treatment manual. Santa Barbara: University of California. Koegel, L. K., Koegel, R. L., Harrower, J. K., & Carter, C. M. (1999). Pivotal response intervention I: Overview of approach. Journal of the Association for Persons with Severe Handicaps, 24(3), 174–185. Koegel, R. L., Bimbela, A., & Schreibman, L. (1996). Collateral effects of parent training on family interactions. Journal of Autism and Developmental Disorders, 26, 347–359.

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Koegel, R. L., Dyer, K., & Bell, L. K. (1987). The influence of child-preferred activities on autistic children’s social behavior. Journal of Applied Behavior Analysis, 20(3), 243–252. Koegel, R. L., & Egel, A. L. (1979). Motivating autistic children. Journal of Abnormal Psychology, 88(4), 418–426. Koegel, R. L., & Koegel, L. K. (2006). Pivotal response treatments for autism: Communication, social, and academic development. Baltimore, MD: Paul H. Brookes Publishing Co. Koegel, R. L., O’Dell, M., & Dunlap, G. (1988). Producing speech use in nonverbal autistic children by reinforcing attempts. Journal of Autism and Developmental Disorders, 18(4), 525–538. Koegel, R. L., O’Dell, M. C., & Koegel, L. K. (1987). A natural language teaching paradigm for nonverbal autistic children. Journal of Autism and Developmental Disorders, 17(2), 187–200. Koegel, R. L., Openden, D., Fredeen, R. M., & Koegel, L. K. (2006). The basics of pivotal response treatment. In R. L. Koegel & L. K. Koegel (Eds.), Pivotal Response Treatments for autism: Communication, social, and academic development (pp. 3–30). Baltimore, MD: Paul H. Brookes Publishing Co. Koegel, R. L., Schreibman, L., Good, A., Cerniglia, L., Murphy, C., & Koegel, L. K. (1989). How to teach pivotal behaviors to children with autism: A training manual. Santa Barbara: University of California. Koegel, R. L., & Williams, J. A. (1980). Direct versus indirect response–reinforcer relationships in teaching autistic children. Journal of Abnormal Child Psychology, 8(4), 537–547. Kuhl, P. K., Tsao, F., & Liu, H. (2003). Foreign-language experience in infancy: Effects of short-term exposure and social interaction on phonetic learning. Proceedings of the National Academy of Sciences, 100(15), 9096–9101. Magnuson, K. M., & Constantino, J. N. (2011). Characterization of depression in children with autism spectrum disorders. Journal of Developmental and Behavioral Pediatrics, 32(4), 332–340. McGee, G. G., Morrier, M. J., & Daly, T. (1999). An incidental teaching approach to early intervention for toddlers with autism. Journal of the Association for Persons with Severe Handicaps, 24(3), 133–146. Prizant, B. M., Wetherby, A. M., & Rydell, P. J. (2000). Communication intervention issues for young children with autism spectrum disorders. In S. F. Warren & J. Reichle (Series Eds.) & A. M. Wetherby & B. M. Prizant (Vol. Eds.), Communication and language intervention series: Vol. 9. Autism spectrum disorders: A transactional developmental perspective (pp. 193–224). Baltimore, MD: Paul H. Brookes Publishing Co. Rogers, S. J. (2006a). Studies of imitation in early infancy: Findings and theories. In S. J. Rogers & J. G. Willams (Eds.), Imitation and the social mind: Autism and typical development (pp. 3–26). New York, NY: Guilford Press. Rogers, S. J. (2006b). Evidence-based interventions for language development in young children with autism. In T. Charman & W. Stone (Eds.), Social and communication development in autism spectrum disorders: Early identification, diagnosis, and intervention (pp. 143–179). New York, NY: Guilford Press. Rogers, S. J., & Dawson, G. (2010). Early Start Denver Model for young children with autism: Promoting language, learning, and engagement. New York, NY: Guilford Press. Rogers, S. J., Dawson, G., & Vismara, L. A. (2012). An early start for your child with autism: Using everyday activities to help kids connect, communicate, and learn. New York, NY: Guilford Press. Schreibman, L., Kaneko, W. M., & Koegel, R. L. (1991). Positive affect of parents of autistic children: A comparison across two teaching techniques. Behavior Therapy, 22, 479–490. Schreibman, L., Stahmer, A., & Suhrheinrich, J. (2009). Enhancing generalization of treatment effects via pivotal response training and the individualization of treatment protocols. In C. Whalen (Ed.), Real life, real progress for children with autism spectrum disorders: Strategies for successful generalization to the natural environment (pp. 21–40). Baltimore, MD: Paul H. Brookes Publishing Co. Siller, M., & Sigman, M. (2002). The behaviors of parents of children with autism predict the subsequent development of their children’s communication. Journal of Autism and Developmental Disorders, 32(2), 77–89. Singer, G. H., Singer, J., & Horner, R. H. (1987). Using pretask requests to increase the probability of compliance for students with severe disabilities. Journal of the Association for Persons with Severe Handicaps, 12(4), 287–291.

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7 Applying Antecedent Strategies Jennifer B. Symon, Yvonne Bruinsma, and Erin McNerney

L

earning occurs when an individual interacts with the environment, the environment provides feedback to the individual, and the individual then changes a behavior in response. These feedback loops result in behavior changes or learning based on the individual’s experiences. In general, an antecedent is the environmental or preceding event that sets the occasion for and influences the actions or behaviors that follow. It is the first component in the three-term contingency (A-B-C) in Applied Behavior Analysis (ABA). Antecedents can evoke particular behaviors, allow individuals to discriminate when reinforcement may become available, and change behavior (Cooper, Heron, & Heward, 2007). Behavior in three-term contingency refers to any behavior by the individual, not just challenging behavior. Antecedents immediately precede a behavior and can signal the individual to perform a learned behavior in such a way that the chance of a known consequence is maximized. Examples of antecedents include instructional cues (e.g., “Please brush your teeth”) or contexts that evoke certain behaviors (e.g., being in the kitchen might evoke requesting a snack as that is a place where the request often leads to food; arriving at the dentist office might be followed by challenging behavior to avoid discomfort). Sometimes earlier events can also set the stage for a behavior. These setting events make it more likely that an antecedent will evoke a behavior. For example, not sleeping during the night may increase the likelihood that an antecedent triggers a challenging behavior the next morning because the person is tired. Setting events can also be biological, such as having a headache or menstrual cramps (see Box 7.1). Antecedent-based interventions can optimize the learning environment to enhance the likelihood that successful learning occurs. To enhance the likelihood of learning, a practitioner or parent manipulates elements of the teaching environment, including the physical environment, the materials, the person providing the 151

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BOX 7.1: Setting events Setting events are events (e.g., social, physiological) that increase the likelihood that an antecedent will trigger a behavior.

intervention, and the way in which opportunities are presented. Optimizing the learning environment by altering the first part of the A-B-C sequence is an ongoing process, rather than a one-time effort, because contingencies and environmental variables change during teaching. This chapter provides many examples of these types of planned changes, specifically related to teaching a host of skills across school, home, and community settings. Antecedent-based interventions are useful for reducing challenging and interfering behaviors. Broad empirical support exists for interventions that alter the antecedents in an effort to reduce the likelihood of future challenging behaviors (e.g., Kern & Clemens, 2007; Wong et al., 2014). Research showed that changing antecedents skillfully led to decreases in challenging behaviors and increases in play skills, school readiness, and academics for elementary and middle school students with autism spectrum disorder (ASD); it also showed improvements in core deficits of ASD for individuals from early childhood through adulthood (Wong et al., 2014). When individuals with ASD engage in challenging behaviors as a means of communicating to gain access to preferred activities or to avoid or escape tasks, antecedent-based intervention strategies can reduce the effectiveness of reinforcers that maintain those behaviors by serving to minimize the association between the stimuli and the consequences that follow (Cooper et al., 2007). Reducing setting events that evoke challenging behaviors (e.g., turning down loud music during homework time) can increase the likelihood of learning. As such, a benefit of antecedent-based approaches is the preventative focus; planned environmental design can eliminate interfering behaviors from occurring altogether (Kern & Clemens, 2007). Chapter 13 examines the use of antecedent-based interventions, as well as other kinds of interventions, to reduce challenging behaviors. This chapter examines the influence of antecedents on teaching, including the broader contextual variables and environmental stimuli that set the stage before teaching opportunities are provided. It discusses how to plan for and optimize the teaching environment to support successful learning opportunities. Under the theoretical umbrella of ABA, antecedent-based interventions are employed in Naturalistic Developmental Behavioral Interventions (NDBI) in many ways. Overall, NDBI create an appealing learning environment that is enticing to the learner and sets the stage for high motivation and a desire to socially engage. Indeed, the old saying “an ounce of prevention is worth a pound of cure” holds true when the environment and conditions where learning needs to occur are not just prepared but optimized. The sections that follow provide an overview of NDBI strategies for preparing the environment for successful embedding of learning opportunities (the A in the three-term contingency). This chapter provides specific, practical examples of antecedent strategies used by NDBI.

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PREPARING TO TEACH Learning is mediated by attention, which is affected by how information is presented and received. The same stimuli presented in different ways can have a different impact on the learning outcome. Consider a flock of birds soaring across the sky in the shape of a pyramid. The movement may instantly capture an individual’s attention as the flock transverses directions during flight and forms a line. Yet, the same species and number of birds perched in a row on a street lamp or pecking in a cluster on the ground outside a cafe may go unnoticed or be disregarded. The presentation of the stimuli affects whether the individual attends to it and ultimately if the individual learns from it. In learning situations, antecedent-based interventions are introduced following a similar principle; to create teachable moments, educators optimally construct the environment by presenting materials or stimuli in ways that capture the attention of a particular learner and maximize the likelihood that successful learning will take place. NDBI create teachable moments throughout the individual’s daily life; as such, embedding of learning opportunities is a core feature. Intentionally planning for teaching (i.e., planning antecedent strategies) across typical and novel activities and routines is a well-established and recommended practice in early childhood literature (e.g., Snyder et al., 2015). NDBI adhere to this practice, increasing therapy hours and learning opportunities by integrating them into all daily life activities. Furthermore, use of natural routines for teaching is congruent with NDBI in which parents are highly valued as change agents and interventionists (Dunst, Trivette, & Masiello, 2010). NDBI ultimately focus on increasing the independence of the learner; embedded teaching within routines supports advancement to independence by providing a large variety of teaching opportunities in the most natural context. However, it is essential to organize and prepare the environment to maximize the likelihood that successful teaching can take place. A number of strategies for such organization and preparation are discussed next. Arranging the Environment Before setting up opportunities for social interactions and learning new skills, it is important to first consider the context or environment where learning occurs. When teaching new skills, carefully planning the environment is particularly essential for NDBI, given that intervention typically takes place across natural environments, where there may be less inherent control than in highly structured settings. Purposefully planning the environment to promote learning may include placing furniture strategically in the room; mitigating potential distractions (e.g., noise level, lighting, number of individuals present); and carefully organizing, placing, and managing materials and activities. Planned furniture and student placements have been shown to be successful in classrooms to increase communication between students (Kaiser, Ostrosky, & Alpert, 1993; Odom, McConnell, & Chandler, 1994). As a general example, seating arrangements and location of materials may facilitate or hinder attention toward peers. Environmentally arranging a classroom can include seating a student with ASD next to a classmate with similar interests to promote opportunities for social interaction and enhance motivation to engage. If a student with ASD’s desk is placed within a pod surrounded by classmates, opportunities for observation and

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imitation of correct responses may increase. As an alternative, if all students in a classroom are given their own materials, they may not need to communicate their need for items such as pens, paper, or an eraser. Instead, a teacher might set up the activity to ensure that students need to obtain materials from peers (e.g., one student has access to the construction paper, another one to the scissors, and a third to the colored pencils), which would allow easy opportunities for sharing of materials. It may ultimately lead to increased communication between peers (see also Chapter 12, the section on cooperative arrangements). The environment can also be arranged so that a student must navigate around furniture before getting to the door, increasing the effort needed to elope and thus decreasing likelihood of elopement. In a clinic setting, children may be seated at a small table with highly preferred tabletop activities to focus their attention (Chang, Shire, Shih, Gelfand, & Kasari, 2016). In a community setting, the parent or therapist may purposefully navigate past a colorful water fountain to set the stage for increased communicative opportunities and social initiations, knowing that the child will likely show interest and stop to initiate bids for joint attention. At home, a caregiver may organize toys into clear bins that are in view but out of reach to interest a child with ASD to initiate an interaction to play. All NDBI address environmental arrangements, with minor variations in which types are emphasized. Joint Attention, Symbolic Play, Engagement, and Regulation (JASPER); the Early Start Denver Model (ESDM); and Project ImPACT (Improving Parents as Communication Teachers) explicitly advise initially minimizing distractions during intervention (Chang et al., 2016; Ingersoll & Dvortsak, 2010; Rogers, Dawson, & Vismara, 2012). Minimizing distractions can increase the effectiveness of teaching because the individual can more readily attend to the most salient cue(s), including the communicative partner. As the child’s skills increase, distractions can be reintroduced in order to mirror the environment where the individual will ultimately be practicing the skill and to ensure generalization. Although the previous examples illustrate arranging the broader environment, changes to the presentation of learning materials can also substantially increase the number of learning opportunities. Slight modifications to toy placement during a teaching interaction, for example, may naturally allow for increased engagement and learning opportunities. If a car rolls down a ramp into the child’s lap, there is little need for the child to engage in social-communication, and the child can then continue rolling the car uninterrupted. Simply turning the ramp so that the car rolls just out of reach (or into the adult’s hands) creates an opportunity for the child to request the item or to ask for help. It also allows the adult to become the focus of the interaction rather than the requested objects. Furthermore, if the child really enjoys the ramp and the car that he or she needs is up on a high shelf, an opportunity has been created for the child to initiate a request or ask for help. Likewise, it is helpful to consider the placement of the adult in the interaction. For example, when pushing a child on the swing, parents may position themselves behind the child to push more easily but thus lose an important opportunity for affective sharing and engagement. Reading a book together sometimes prompts the child to sit on a parent’s lap. However, sitting next to or across from each other may provide more opportunities for face-to-face contact and may increase social engagement. Adult placement may be different when the goal of the teaching interaction is peer engagement. In these situations, an adult may consider placing

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him- or herself behind the child with ASD to reduce orienting to the adult and to be able to prompt covertly. Although the organization of the environment is mostly discussed here as a planning tool, ongoing management of toys and materials during teaching is equally important. It is helpful to limit the number of toys or sets of materials out at any one time and to put materials out of sight or have the child pick up as he or she loses interest in items. Routines around starting with new toy materials and cleaning up when done are valuable tools to remain organized and prevent a chaotic teaching environment. Likewise, when taking out toys or materials, it can be helpful to know what part(s) are of the highest interest to the child and remain in control of at least some of them. For example, if the child is naming play actions with three figurines visible in a plastic bag and one of the figurines is of high interest, then taking out the favorite figurine last may ensure the child remains highly motivated. Finally, when using large sets of materials (e.g., a train set with tracks, bridges and trains, an art project with multiple materials), placement of materials is key, and materials can be put away during the activity as they are no longer needed. Selecting Materials NDBI call for carefully preparing materials and selecting toys in a way that promotes specific teaching goals. In JASPER for instance, the adult selects appropriate materials at precisely the child’s developmental play level to target joint attention and active engagement. Selected toys and materials should be exciting and interesting enough to attract the child’s interest, but like other NDBI, JASPER typically recommends limiting the use of toys that do not allow for play expansion because they have just one function, or because they are too self-contained (e.g., a light-up musical toy, a toy with electronic buttons). Often JASPER suggests having two identical sets of toys to ensure the adult can model play behaviors, unless the toy already has multiple pieces (e.g., a shape sorter, a ring stacker, a pig that has coins inserted in it). Toys that target the appropriate play level serve to enhance learning opportunities for coordinated and supported joint attention skills. For example, toys that are too easy or too difficult may cause the child to become too object focused and limit the level of engagement and joint attentions skills exhibited, whereas materials at the correct play level would be more engaging, interesting, and motivating. The child may be more familiar and know what do with the materials, allowing him or her to focus on acquiring new skills. Other models, such as ESDM and Pivotal Response Treatment (PRT), recommend the use of chronologically age-appropriate toys and materials that will likely entice a child to show interest and explore. Age-appropriate toys (as opposed to developmentally appropriate toys) are valued because they are likely to be of high interest to same-age peers, which aligns with the ultimate goal of teaching skills that generalize into social interactions with peers. ESDM also considers toy selection in terms of thematic teaching and selects materials and activities that surround a theme. For instance, a teacher, clinician, or parent can focus teaching skills (e.g., vocabulary and play actions, social conversation) around a theme that may be of interest to the child. For young children, balls can be used to create themes related to bouncing and throwing. As children become more symbolic, blocks, cars, figurines, cones, ramps, and markers can become a racing car theme, whereas

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a house, dolls, beds, blocks, animals, play food items, and markers are well suited for creating teaching opportunities around the theme of playing family. In a classroom, teachers can design lessons and create teaching opportunities around topics or themes of interest to the child, making lesson planning more focused and more likely to capture the child’s attention throughout each lesson. For example, a teacher may decide to use transportation as a thematic unit. In that case, the play centers can include trains, bicycles, cars, buses, trucks, airplanes, and rockets. Spelling words or journal writing assignments can focus on words and topics associated with transportation. Math centers for a young child can include manipulatives such as tires, vehicles, and the number of items that fit into a truck. For older students, calculations of speed and distance related to transportation can be used in a mathematical lesson. Outside of the classroom setting, teachers can create crossword puzzles related to the theme of transportation or social games with peers, such as a transportation obstacle course. The variety of possible interactive play opportunities is limitless when considering grouping toys into a theme whereas a single individual toy or one type of toys may become challenging to expand on by itself. Actively Planning Within Daily Routines and Activities NDBI focus on embedding teaching across daily activities, natural routines, and/or play (Hancock & Kaiser, 2006; Ingersoll & Dvortcsak, 2010; Kasari, Freeman, & Paparella, 2006; Koegel, Koegel, Harrower, & Carter, 1999; McGee, Morrier, & Daly, 1999). Bath time, diaper changing, snack or mealtime, walking to the park, and shopping at the grocery store are all reasonable home and community settings for teaching. Routines at school can also provide students with ASD countless opportunities to frequently practice skills. Across each routine, caregivers, clinicians, and teachers can intentionally plan for learning opportunities. Some questions to consider when planning include the following: What maintenance or mastered goals will be targeted during each activity? Which acquisition or new goals will be included? What materials will need to be created or provided? What instructional cues and prompts will be presented? In what order will goals be presented? For example, a caregiver of a child with ASD might consider several setting events when planning for a trip to the grocery store as an appropriate setting for teaching new skills as well as skill generalization. Some general planning considerations would include going to the store at a time when the store is not very busy and when the caregiver is not rushed. It is also helpful if the child has visited the store several times before and the same routine is more or less followed each time. Furthermore, it would be important to make sure the child is well rested (e.g., not at nap time) and not hungry (e.g., the caregiver could bring some small snacks that can also be used as reinforcers). Before the outing, the caregiver identifies what skills he or she plans to target (e.g., practicing social greetings, counting items, reading food labels, requesting), which targets are maintenance (skills the child already has), and which are acquisition or new skills. The caregiver may also identify items (e.g., favorite snacks and foods) and activities (e.g., pushing the cart, sitting in the cart) that the child enjoys, which can be used as reinforcement and increase participation. It may also be necessary to have a plan for challenging behaviors as well as some general rules dependent on the developmental level (e.g., stay with mommy, use inside voices, you may pick one cereal). See Box 7.2 for more on planning for community outings.

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Ready, Set, Implement! BOX 7.2: Prepare for a community outing Be prepared, and plan for challenges before going out. Keep a small bag or travel box in the car, and fill it with items to keep children busy during unexpected wait times. Remember, these are antecedent strategies, so offer them to the child to prevent challenging behavior rather than after challenging behaviors begin. Below is an example list of items to keep children occupied while waiting at a restaurant. Be creative! • Small puzzles • Rubik’s cube • Deck of cards • Small blocks • Mad Libs or other word games • Dry erase markers and a small white board • Stickers • Beads • Books or magazines • Playdough

Likewise, a teacher at school may plan for teaching particular skills during routines and activities across all academic and co-curricular activities, including recess, and special assemblies. For instance, a preschool teacher can create communication opportunities during circle time for a student with ASD who enjoys numbers. Because circle time includes multiple children, it sets the stage for the teacher to prompt the student to count the number of students present, the number of students wearing long sleeves, or the number of peers signed up to receive hot lunch. An elementary school teacher can alter the environment to create communication opportunities for students to request the type of marker that they want to use before journal writing, to ask for their preferred classroom job (e.g., ask to be the line leader or pencil monitor rather than being assigned a role), or to pick a buddy to go outside with for recess. A high school teacher can also create opportunities for social-communication and active participation as an antecedent strategy by asking each student up front what topic they plan to write about or which classmate they would like to check their work with after their journal assignment is complete. Planning antecedent strategies around naturally occurring opportunities within these routine activities increases both the number and the variety of learning opportunities that can be presented in a day. Table 7.1 provides examples of how to set up goals within activities with planning. The table presents a few examples of social-communication goals, such as making appropriate social comments or sharing toys with a peer that a parent or practitioner might determine appropriate for a child with ASD. Then, for each sample goal in the table, activities are presented as they might be modified or

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Table 7.1. Goals and activities for social communication Goals Expanding one-word to two-word phrases

Blocks

Build a tower Add descriptors to together and the cars going make it crash down the ramp down in varied (colors, speed, ways: by a and size are crane, by a the obvious superhero ones, but flying, after also consider counting, nonsense ones by swinging like a smelly the child and car). allowing his or Use additional her feet to crash objects to block the tower. Prior the cars from to crashing, going down the have the child ramp in order to request with one practice 2-word or two words. phrases like “move it” or “help me.”

Follow Hide a favorite requests with character prepositions behind, under, or on top of the blocks. Make a cage for the character from the blocks.

Imitate pretend play actions

Car ramp

Use the blocks to make a zoo with cages for little plastic animals. Put the animals to bed, take them for a walk, feed them, etc. Some of the blocks can be imaginary animals or figures or objects. Make pretend action with the object and prompt for imitation.

Chalk outside

Playdough

Practice colors and different shapes (draw X or use blue chalk). Animals, letters, and vehicles tend to be most popular items to draw. Use chalk to draw islands in the ocean or lava. Play a game jumping from island to island on one leg or while hopping for safety. Have the child verbalize next steps, for example, “Jump there.” Draw combinations of favorite figurines or objects by using prepositions (e.g., Here is the rocket. Where should I put the superhero?). Have the child lie down and draw the outline of his or her body on the pavement. Next practice drawing favorite objects next to or on top of the outline.

Noun plus verb can be practiced with cutting, rolling, and pushing. Playdough tends to be difficult to get out of containers providing an opportunity to verbally request help. Add additional materials to playdough, such as cotton swabs, glitter, pipe cleaners, or tooth picks to make unusual art.

Use only one car, Display the and hide the car different colors close by. The of playdough child must find and ask the the car following child to find the the directions, playdough that including the is under the preposition prior pillow before to playing with playing with it. the car on the Hide tools under ramp. a bowl while Catch the car as it the child is comes down the watching, and ramp, and make ask the child it fly to a new where it is. location. Ask the child where the car is (e.g., Is it under or on top of the pillow?). Race two cars Draw a pretend Make playdough down the ramp, scene around characters and and pretend the a favorite area provide models slower car is of interest or a of different crying because it favorite book or actions the child lost. Comfort the television show. can imitate. “sad” car with Imitate the the child and actions together. get him a snack to help him feel better.

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Table 7.1. (continued) Goals Use social phrases

Blocks

Car ramp

Chalk outside

Playdough

While the tower is When cars crash Use prompt When the child being built and or get stuck, comments makes a almost toppling, prompt “Oh, no” for drawings, playdough say, “Oh no, oh or “oh, man!” such as “Great figure or art no!” to build Move the ramp job!” or “wow, piece, prompt anticipation close to the awesome!” to say, “Check it of the blocks table edge and Draw targets with out” or “Look” falling. have the car chalk on a fence and have Prompt the child drive off the or wall, and them combine to say, “Boom, table. Prompt hit them with the initiation crash” when the “Oh, oh,” water balloons with showing tower falls. “oopsies,” or or balls. Use behaviors “That’s ok!” social phrases to (holding up the comment on hits item, pointing/ and misses. looking). When the therapist makes a playdough object, prompt, “nice” or “awesome” in response to therapist showing behaviors. Imitates Use blocks Make roads for the Use chalk to Use playdough drawing to make a cars by drawing draw lines and to make circles circles/lines mountain and lines on the road circles and of all sizes, and draw a circle on and circles for make snowmen, circle them paper. The circle parking spots animals, and a on paper with is a landing or the ice cream sun. Add water a preferred pad for pretend store. and a big brush writing utensil helicopters or to “paint” with (e.g., marker, from where the chalk. multicolored superhero takes pen, pencil). off. Prompt child to draw circles for additional landing pads. Utilize and After the block Using multiple After drawing a Make a few balls understand tower crashes, cars for the body of a child and many balls comparatives make two heaps car ramp, ask and body of a of playdough of blocks and which pile has sibling, ask who and prompt the ask which pile the most/least is taller. child to take the is bigger. If amount of cars pile with many the answer is before giving balls. correct the child the child access can build a new to that pile. tower with that pile.

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individualized for the child to promote or create teaching opportunities directed at the goal using antecedent-based instructions. Using Individual Preferences to Select Materials Incorporating the preferences of the individual increases his or her interest in learning, particularly when some of the tasks are difficult. Research shows teaching with high-interest materials substantially increases learning for children with ASD (Dunst, Trivette, & Masiello, 2010, 2011). In addition, children show increased engagement and reduced problem behavior when they actively select their toys, compared to when a teacher selects them (Reinhartsen, Garfinkle, & Wolery, 2002). When children with ASD and language delays are offered choices of materials, they demonstrate improved language and play skills and reductions in disruptive behavior (Carter, 2001). When students with ASD are offered choices between activities, they display fewer problematic behaviors compared to within-activity choices (Rispoli et al., 2013). When a child’s preferences are not clear, clinicians can use tools to identify motivating activities or items. For example, they can complete preference assessments formally or informally through observation and identification of the individual’s interests. There are multiple procedures for conducting systematic preference assessments, such as free operant preference assessments and paired choice preference assessment. These procedures are described in detail in the ABA literature (e.g., Hagopian, Long, & Rush, 2004). Preference is not static; preferences and interests can change even within a session. In addition, PRT and ESDM both support incorporating specific or unusual interests into the interventions in order to capture motivation through these interests, even if they involve activities or materials that are not developmentally typical. Perseverative interests can be used to expand peer play and motivation for social interaction (Baker, 2000; Baker, Koegel, & Koegel, 1998; Koegel et al., 2012; Koegel, Kim, Koegel, & Schwartzman, 2013). Teaching games modified to incorporate restricted interests results in more appropriate social play, maintenance, and generalization of gains. Clubs at school or in afterschool programs can also be designed around a child’s perseverative interest (e.g., Minecraft, trains, dinosaurs, Disney characters). If the interest is very narrow, the club could be built around a broader theme in order to attract a large enough group of children. For instance, children interested in specific scientific topics may enjoy a young inventors club. A child’s interest in numbers or shapes might be incorporated in a cooking club, whereas a child’s interest in a particular cartoon character might be incorporated in a club for movie buffs. Establishing Rapport and Building Relationships In NDBI, the adult and the relationship between adult and child are central to the intervention, and indeed the optimization of that relationship contributes significantly to the child’s success in the learning environment. Because these relationships are established prior to teaching, this is an antecedent-based strategy. NDBI aim to have the child focused on the communicative partner in affectrich reciprocal interactions. Research supports that it is not merely sufficient for adults to deliver reinforcement but that active adult participation in the delivery of

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Ready, Set, Implement! BOX 7.3: It is all about you! Sometimes stuff can get in the way. Remember, toys and objects are vehicles for engagement, and the child’s engagement with other adults or children is key! If motivation decreases (e.g., the child is responding less often, positive affect is decreasing, the child is avoiding interaction by moving away or turning his or her back to the adult), put the stuff to the side, and go back to basic engagement strategies like imitation or sensory social routines. Social motivation is what matters! Once motivation is high again, slowly bring back toys.

reinforcement can increase social engagement and initiations (Koegel, Vernon, & Koegel, 2009; see Box 7.3). When caregivers played with the child and incorporated social reinforcement, such as jumping on a trampoline with the child rather than providing access to jumping alone, the children initiated social bids more often. In addition, the children displayed positive affect toward the caregiver while making requests at substantially higher levels if the adults were engaged in the activities with the child. Establishing a positive therapeutic relationship or rapport between the individual with ASD and the parent or teacher is essential and an important feature of NDBI. Research shows that positive rapport will, in general, result in fewer challenging behaviors than a negative rapport (Koegel, Koegel, & Dunlap, 2006; Magito McLaughlin & Carr, 2005), which can ultimately lead to better rates of responding, more engagement with activities, and improved social outcomes. NDBI practitioners often easily build rapport and positive therapeutic relationships because of the high levels of reinforcement they provide. Not only do they pair themselves with toys, materials, and activities typically highly motivating to the child, but they also provide frequent noncontingent reinforcement (NCR), further strengthening the relationship between the adult and the child. Creating a Schedule Although not specifically part of NDBI, creating a clear schedule across and within routines provides structure and predictability. A clear schedule also serves as a powerful antecedent strategy to reduce challenging behavior and increase independence. Predictability is useful, particularly for individuals with ASD, who experience frustration or anxiety from complex social situations, and for those

BOX 7.4: Noncontingent reinforcement Noncontingent reinforcement is reinforcement that is provided independent of behavior.

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who experience challenges with receptive understanding of a daily sequence of events. Photographic activity schedules increase play behaviors in children with ASD on the playground (Akers, Higbee, Pollard, Pellegrino, & Gerencser, 2016), and visual schedules improve students’ on-task behavior in the classroom (MacDonald, Trembath, Ashburner, Costley, & Keen, 2018). In a classroom, conveying to the students how long they are expected to maintain attention to a nonpreferred academic task can reduce off-task behaviors. Likewise, the schedule can prepare an individual with ASD because the student can clearly see when nonpreferred activities will occur. It can then motivate the student by presenting when preferred activities will be available. Schedules can be individualized to fit the needs, preferences, and abilities of each person. Schedules can be made with objects, photographs, pictures of objects, printed icons, or written words. Assessment of the individual’s skills and context are necessary to determine the most appropriate type of schedule. The individual’s ability to understand that an object, photograph, or icon represents an activity (i.e., iconicity) or whether the individual can read are examples in determining what mode to use on the schedule. In addition, the individual’s ability to understand a long sequence of activities compared to understanding a simple first–then sequence will also affect the schedule’s design. The time associated with each activity may be portrayed on the schedule for those understanding or learning the concept of time. Inclusion of individual preferences (e.g., preferred color, theme, character) and choices (e.g., selection of an outdoor activity at recess) into individual schedules can motivate an individual, thus increasing compliance. For instance, an individual who has a high interest in Star Wars may be motivated by having the characters or related thematic words on his or her schedule. Schedules can also be individualized with the help of technology, especially if the individual is motivated by technology. Auditory reminders or recordings of upcoming activities can take the place of a visual tool. The use of a reminder list or calendar on a tech device may also reduce social stigma and allow the individual to work toward increased independence. Community skills in children with ASD have successfully been taught via a digital self-managed schedule (Cheung, Schulze, Lead, & Rudrud, 2016). Some individuals with ASD experience difficulties when their routine changes, and a schedule that allows for flexibility may be helpful. For example, a situation in which a student receives speech therapy each Wednesday, with the session time rotating so that he or she does not continuously miss the same part of class, can lead to confusion on the part of the student. Therefore, providing a symbol denoting flexibility (e.g., placing a question mark or photograph of the speech therapist shrugging shoulders next to the icon of speech therapy) may offer some predictability for the individual to prepare for the sessions even though the exact time is unknown. In another example, a student may display challenging behavior during physical education (PE) when it is held indoors due to inclement weather conditions. In this case, various icons or photographs may represent options of the PE settings (indoor and outdoor), which can vary on the daily schedule. In a third example, an individual with ASD may not know how to independently engage in an unstructured leisure activity. A schedule may then include options to choose from during these periods (e.g., read a book, use your cell phone, have a snack).

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Priming Similar to the way in which schedules assist in articulating a sequence of upcoming activities and routines, priming is another way to prepare an individual for future events. Priming is a behavioral intervention involving the presentation of upcoming activities in a low-demand context with high levels of reinforcement, prior to when the appropriate behavior is expected to be performed (Gengoux, 2015; Wilde, Koegel, & Koegel, 1992; Zanolli, Daggett, & Adams, 1996). For example, a child with ASD who is isolated during unstructured play on the playground may have a goal to increase social interactions with peers. Using priming as an antecedent strategy, the practitioner or parent could expose the child to several previously learned playground games (e.g., Hide and Seek, Tag) in a more structured one-on-one setting before recess. Likewise, the practitioner or parent could review a variety of social initiations to join play on the playground with the child before the child is in the situation when he or she is expected to initiate. Reminders about how to play the games and learning types of initiations before time on the playground with peers provides reinforcement of expected behaviors before the behaviors need to be displayed. Priming is particularly helpful for individuals with ASD who have challenging behaviors and those who have difficulty with novel situations. It is also a useful tool for increasing skill performance (e.g., a reminder to find a friend to play with at recess). Providing a preview and opportunities to practice difficult social and/or communication skills ahead of time can increase chances of success while reducing the likelihood of challenging behavior. Priming can be accomplished in different ways, including the following: • Verbal explanations and/or reminders (e.g., “Remember to greet your friends when you walk into school today.”) • Visual supports (e.g., pictures or icons showing the appropriate behavioral expectation) • Visual schedule showing an upcoming sequence of events • Actual exposure to and practice of the upcoming event (e.g., visits to meet the dentist, sit in the chair, and see the tools but not actually have any dental work done) The efficacy of priming in preparing individuals for a variety of upcoming events is supported by research, including priming for class assignments (Koegel, Koegel, Frea, & Green-Hopkins, 2003), co-curricular activities, social interactions with peers (Bellini & Peters, 2008; Gengoux, 2015), transitions (Schreibman, Whalen, & Stahmer, 2000), and self-care (Bainbridge & Myles, 1999). Priming can consist of simple verbal cues, photos, or more advanced technology such as video vignettes. Family members, clinicians, and teachers can create videos and present them prior to participation in a potentially challenging situation as a reminder of how to display or maintain appropriate behavior. Before arrival at a new school, the incoming student may view photos or videos of his or her assigned locker, classroom, desk, or teacher. The student may also walk through campus to become familiar with the setting and expectations prior to the first day of classes. Likewise, a teacher could present a short video just prior to

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recess reminding the student how to initiate participation into a playground game and maintain good sportsmanship during the game. At home, just before heading to a birthday party, a parent can show his or her child a brief video of the typical activities, such as handing the gift to the birthday child, participating in games and activities, singing Happy Birthday, and thanking the hosts. Establishing Clear Rules or Expectations Establishing clear rules and setting behavioral expectations is an antecedent-based strategy that increases the likelihood of appropriate behavior and decreases challenging behavior (Kern & Clemens, 2007). Clearly communicating classroom or family rules and expectations and communicating the consequences of a specified behavior (before the behavior occurs) are examples of providing clear behavioral expectations. Generally speaking, rules should be stated clearly and should identify the expected behavior, rather than what the child is expected not to do (e.g., “ask for permission to leave your seat” rather than “don’t get out of your seat”; “walking feet” rather than “no running”). In addition, providers should ensure that any consequences of not following a rule or abiding by an expectation are made clear prior to the individual having an opportunity to not follow directions. For example, in a job setting, an individual could be told, “Employees are required to show up on time each day. If you are more than 5 minutes late, you will receive a written warning after the second time.” This expectation makes it clear that showing up on time is important, and failure to meet the expectation results in a disciplinary action. An added benefit of having clear behavioral expectations is that over time these expectations can become implicit and will not need additional rehearsal; instead, they become just “how we do things.” For example, when a child requests dessert every night and the parent institutes the rule that dessert night is on Wednesday and Saturday only, then the child comes to accept that as a fact of life. In this way, simple overall family rules can help prevent unnecessary challenges.

SETTING UP OPPORTUNITIES IN NDBI The next step after the planning phase, which optimizes the teaching environment and conditions, is optimizing the delivery of teaching opportunities. NDBI incorporate a variety of antecedent strategies, including engaging and enticing, using routines to set up opportunities, getting the child’s attention, using behavioral momentum and varying the task, following the child’s lead, and using shared control to increase the likelihood of success of the intervention. Each of these strategies is briefly reviewed next. Finally, examples that combine antecedent-based components within NDBI are presented at the end of this chapter, and these address specific routines at home (e.g., bath time, dressing and undressing, bedtime, chores) and in the community (e.g., grocery shopping, going for a walk). Chapter 6 (on motivation), Chapter 11 (on communication), and Chapter 12 (on social skills) also provide a wide range of strategies and examples that may be helpful to the reader. Engaging and Enticing As outlined previously, NDBI place high value on social engagement and emphasize the social reciprocity between the individual with ASD and his or her

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communicative partner, whether it be a caregiver, a teacher, or a clinician. Enhanced Milieu Teaching (EMT) and Incidental Teaching include promoting engagement as an important feature of sustaining interaction (see Hancock & Kaiser, 2006; McGee et al., 1999). EMT therapists engage in responsive interaction, which includes behaviors that increase engagement, such as nonverbal mirroring or imitation, following the child’s lead, and pacing the interaction in order to leave space for the child’s initiations. ESDM, Project ImPACT, and JASPER include similar components and specifically include animation by the adult to build interest (Ingersoll & Dvortscak, 2010; Kasari et al., 2006; Rogers & Dawson, 2010). The adult uses his or her voice tone, volume, and affect to interest the child and to get the child excited about materials or an activity (e.g., “Guess what I have?” “Ohhh, look at this cool train!”). Other enticing examples include acting sleepy and whispering when the child is using figures and a house to act out a bedtime routine, acting very excited when pretending to blow out the candles during a birthday party, or acting grumpy when the child wakes up a spider puppet you were using. ESDM and JASPER emphasize the importance of taking into account the child’s preference and temperament; affect and animation can be used to help regulate arousal and attention for the child. For example, when a child becomes too excited, the adult may modulate his or her affect and tone to be lower and slower to help the child calm down. Narration is another way to entice the child into play actions. The adult may narrate his or her actions (e.g., “I am making a snake with my clay”) or the child’s actions (“Your blue car is going fast”). Narrating in this way, including the addition of sound effects or songs, helps to establish and optimize the shared interaction and encourages the child to engage with a partner. Humor can also be helpful when engaging and enticing a child into play. Unexpected actions (e.g., exaggeratedly sneezing a small item off your head) or silly noises (e.g., adding a silly noise when the ball bounces) capture the child’s interest. However, the adult should be careful that this strategy leads to back-andforth interaction and learning opportunities and that the adult is not simply entertaining the child. Using Routines to Set Up Opportunities NDBI aim to establish social routines and create socially interactive teachable moments. ESDM, for example, emphasizes creating routines between an adult and a child as a vehicle for teaching. The adult and child share focus, and once the routine is established, the child anticipates the adult’s actions. ESDM discriminates between dyadic play between child and adult (sensory social routines) and triadic interactions in which the child shares attention toward interesting objects (joint activity routines). As an example of a dyadic routine, a mother might take a blanket and playfully begin the game by covering her face, saying, “Where’s mommy?” then pulling the blanket off her face and tickling the child. The mother may repeat this a few times to engage the child and see if the child will begin showing pleasure and engagement (smiling, looking, reaching, vocalizing) and request repetition of some part of the routine. Then, once the child is smiling, laughing, and/or looking toward the mother, she may use a time delay (pause) before putting the blanket over her head again and provide another opportunity for the child to communicate via eye contact, smiling, pointing gesturing, or vocalizing, thus intentionally creating communicative opportunities. This routine can be further expanded in

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a variety of ways to include placing the blanket over the child’s head or the child placing the blanket over the parent’s head. The key component of such routines is the initial repetition and sameness of it so that the child comes to understand what to expect. Once sameness is created and the child is engaged, the adult can identify what is motivating about the activity and create opportunities for the child to practice new skills (along with easier, already learned skills) within that routine. Getting the Child’s Attention Before providing an instructional cue or prompt, the adult must get the child’s attention. NDBI actively incorporate several strategies to get the child’s attention. Calling the child’s name and acknowledging the communicative partner verbally (e.g., saying “yes” or “what”) or nonverbally (e.g., orienting toward the adult) works with some individuals or in some situations. However, to increase the likelihood of the child responding consistently when his or her name is called, reinforcers can be paired, such as holding up a box of preferred items or pausing in a gesture that often leads to shared enjoyment of an activity. There are other ways to gain attention, such as interrupting the child’s play action, moving into the child’s visual field, lightly touching a child, and using enticing strategies as discussed previously (e.g., animation, narration, imitation, humor). In addition, this strategy can often work best when the environment is arranged in a way that encourages attention, as described previously. When teaching in the context of an engaging activity, the caregiver or therapist may need to occasionally interrupt the action to gain the child’s attention and provide a learning opportunity. When interrupting the child’s actions, the communicative partner must first determine that the child is still interested in an activity and has not yet satiated. The communicative partner can gently or unobtrusively interrupt the child’s action, resulting in the child attending to the partner. For instance, after dinner in the restaurant, a child who is not yet verbal may notice a large gumball machine that sends each giant-size gumball down a swirly ramp. The parent could give the child a coin to put into the machine and immediately gain the child’s attention by slightly blocking his or her access to twist the metal lever. Right when the parent places his or her hand on the lever, the child may make eye contact to begin the communicative interaction. The parent removes the hand and allows the child to twist the lever. Communicative partners may need practice to tell when a child is paying attention because many individuals with ASD prefer not to make eye contact. Often, when the child is oriented or positioned toward the communicative partner, he or she is attending. Other signs that a child is engaged may be reaching or looking in the general vicinity of the play action. Clinicians, teachers, and parents can closely observe the child’s body positioning and facial gaze to know when the child is paying attention to the adult and can learn to deliver cues at the appropriate timing. Using Behavioral Momentum and Varying the Task Research has documented that creating behavioral momentum by presenting simple (maintenance) tasks prior to difficult tasks or learning goals results in increased participation and improved behavior (Belfiore, Lee, Scheeler, & Klein, 2002; Kennedy, Itkonen, & Lindquist, 1995; Kern & Clemens, 2007). Simply said, if a child

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is experiencing success (e.g., when presented with a number of already learned maintenance tasks that are relatively easy), then he or she is more likely to attempt a response to a new or acquisition task. The efficacy of interspersing difficult with already learned tasks is supported by research (e.g., Charlop, Kurtz, & Milstein, 1992; Dunlap, 1984) as a way to increase responding and engagement. The ratio of easy versus novel or difficulty tasks heavily depends on clinical judgement. If a child is highly motivated (for definitions and review of motivation, see Chapter 6), more difficult tasks can be interspersed versus when motivation is low. For example, a parent may plan teaching opportunities for his or her thirdgrade student with ASD to practice on-topic question-asking with peers by inviting a neighbor over for a couple of hours on the weekend. Sustained interaction with a peer may be difficult for this child. To maintain the motivation to engage, the parent can plan for the children to practice question-asking in an activity that is motivating, easy, and low effort for the child (e.g., playing video games). However, before the start of video games, they will make ice cream sundaes together, which is also an easy task and highly preferred but allows for social conversation practice. While making and eating sundaes, the children discuss topics that are high interest (video games) and share components to ice cream sundae making (toppings, ice cream flavors). This interaction includes practice of a variety of maintenance skills, such as asking and answering simple wh- questions. In this case, the only acquisition goal for the child with ASD while making sundaes may be to practice asking on-topic questions five times during the activity. The relatively easy conversational demands in a highly preferred activity, mixed with the more challenging goals of sustained peer interactions and on-topic questions, may likely set this child up for success. Planning and identifying the skills that are mastered as well as those that will be targeted are part of antecedent-based plans when creating teaching opportunities. For a more in-depth discussion on maintenance and acquisition, please refer to Chapter 6, on motivation. Following the Child’s Lead and Using Shared Control All NDBI use the strategies of following the child’s lead and using shared control as ways to enhance child motivation. Chapter 6 discusses the specifics of these strategies in great detail. However, it is important to reiterate the importance of these strategies as a vehicle for antecedent manipulation to maximize learning. Identification of what is motivating for a child and in a balanced way sharing some control over that action or object in order to provide learning opportunities and build interaction is the key. Clearly presented and detailed home and community examples using these NDBI antecedent-based strategies are presented in Table 7.2. Each example presents a common or typical daily routine whereby preparing the environment, preparing the individual, and preparing for teaching opportunities can be embedded through NDBI. This table brings together the antecedent strategies discussed throughout the chapter to show specific examples to engage children with ASD and motivate their interest while targeting core symptoms of ASD. The specific examples offer concrete illustrations of how NDBI are used and may serve as a springboard for creativity across additional routines.

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Table 7.2. Optimizing routines Meal/snack time Get ready Set up for success Wait for an opportunity in which you know your child is hungry (but not so hungry he or she is grumpy!) and you have time to add a few minutes to the mealtime. Make the meal or snack the main feature of your interaction; clear off the table, turn off the television and technology, and take away any loud toys. Provide support such as a high chair or booster seat. Have choices of food or drink available, including some preferred choices. Consider allowing your child to eat and then leave the table, even before the rest of the family is done (although once the child leaves, he or she should be finished eating). Consider a routine around the start and the end of snack and dinner: the child can bring something to the table or take something to the kitchen as a “job.” For older children, have a behavioral expectation about how much the child is expected to eat and a dessert rule.

Focus on your child

Create opportunities

Follow your child’s lead Offer your child choices of foods by holding up two items and letting the child show you what he or she wants (e.g., “Apple or grapes?”). As skills develop, graduate to pointing or verbally indicating choices. Allow your child to choose the placemat, plate, or cup to eat or drink from. If possible, sit face to face with your child while eating so you can respond to his or her subtle signs of communication.

Back-and-forth play Try sharing a snack with your child. Give him or her a bite, then take a bite. Go back and forth until the snack is gone. If your child self-feeds, it helps to have a large item you have control of (e.g., big graham cracker) or to give your child one piece of snack at a time. Ask the child to show or share with Daddy, Teddy Bear, or Brother.

Communication Imitate your child temptations Imitate your child eating Serve small portions of crackers or cereal. favorite foods, and keep Imitate his or her style of the rest in plain sight so eating, noises the child your child can request makes while eating, and more. facial expressions. Fill your child’s cup with a Place food in your mouth at small amount of liquid the same rate as your child. from a larger pitcher. Keep the pitcher on the Model communication table so the child can Describe what your child request more from you. is eating in a repetitive Offer food items your fashion. Say, “BANANA . . . child does not like so Yum yum . . . BANANA . . . he or she can practice Eat the BANANA.” (Point protesting. to the banana each time Be sure to have the Adjust animation you say the word or rub food your child does Take a bite of food your child your tummy when you say like available so your likes, lick your lips, rub your “yum.”) child does not become belly, and say, “Yummy!” Describe what you are doing frustrated. Take a bite of nonpreferred while you eat or while you food or pretend to eat a are setting up the meal. nonpreferred item and Say, “I’m pouring Cheerios. exaggerate saying, “Yucky!” Yum!” Scrunch up your face, and stick Take a bite of apple, lick your out your tongue. lips, rub your belly, and say, “Yummy!” Label various features of the food you give your child, such as the smell, temperature, consistency, or color.

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Table 7.2. (continued) Bath time Get ready Set up for success Have everything ready before your child gets in the tub. This may be a few toys; bubbles; a washcloth for play; and, of course, a towel. Never leave your child alone. Set up a bath time routine so your child knows what to expect. Try to keep the same routine every time. For example, go to the bathroom, turn on the water, help your child take his or her clothes off, turn off the water, put toys in, get in the water, wash body, wash hair, play, then get out. If there are difficult times during the bath time (e.g., hair washing), provide warnings it is coming and, if necessary, priming before bath time. Use a water temperature that is comfortable for your child, and do not fill the tub up all the way. You might want to bring your child water-safe toys. Adjust animation Wash your child, one body part at a time. Make a big gesture to the part you will wash (“I’m gonna wash your . . . TOES!” [big point to the toes]). Pretend to smell each body part and say that it is dirty. Plug your nose, scrunch up your face, and say, “Ooh, stinky!” Wash, and smell it again (“Aaahh, all clean!”).

Focus on your child

Create opportunities

Follow your child’s lead Watch for your child’s special interests. Does your child like pouring, splashing, or dunking things in the water? Imitate and expand these. Offer your child a choice of which body parts you wash first. Make the length of bath time your child’s choice. Stay extra time after washing if your child enjoys playing in the water. End the bath quickly if your child tries to get out.

Back-and-forth play Push a toy under water, and watch it pop back up. Give your child a turn to do the same. Blow bubbles across the top of the water together with a stretch tube or straw. Push bubbles back and forth or take turns putting them on the wall. Bathe a rubber ducky, and encourage your child to help.

Communication Imitate your child temptations Imitate your child’s splashing, Place your child’s favorite looking at items under bath time items in clear water, or watching water plastic containers with run over things. lids. Float the containers If you are imitating splashing, in the bath with the toys show your child big and inside. small splashes to help him Wash one body part at or her learn to splash in a a time, then stop and way that does not make a wait for your child to tell mess. you to continue. Or ask Imitate your child’s play with your child, “Give me the toys, such as water wheels, washcloth,” and wait for cups or other containers, a response. a strainer, toys that float, If your child needs wind-up tub toys, bath assistance undressing crayons, scrubbers, or before bath, only take bubbles. off one item of clothing Imitate your child’s sounds at a time, and wait for and verbalizations while in your child to show you the bath. he or she wants you to do more. Model communication Help your child learn body parts by describing them as you wash. For example, “I’m washing your . . . TOES! (while playfully grabbing toes with washcloth).” “I’m washing your . . . FOOT!” “I’m washing your . . . LEG!” (continued)

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Table 7.2. (continued) Going to the grocery store Get ready Set up for success Try these strategies when you have a lot of time for a trip to the store and not when you are in a hurry. Give your child a snack before going to the store (so your child is not hungry). Bring a jacket for your child in case it is air conditioned in the store. Go to the store during less busy times to keep it from being overwhelming for your child. Have a plan of what you need at the store before you go. If the grocery store is very difficult for your child, practice going to the store when you do not need to purchase anything or can get just one thing and leave. This will help your child build up tolerance for going to the store. Go to the same grocery store each time, establish a routine around the order you gather items, and go to the same checkout line. Prime your child with any limits you need to set during shopping (e.g., the child can pick only one cereal, he or she must stay with mommy). Be aware of your child’s cues in the store. Consider bringing a hat, sunglasses, or earphones to help make the sensory experience better. Adjust animation Use a quiet, calm voice during your trip, possibly whispering to your child. Try putting your child in a cart to create an opportunity to be face to face. If the child wants to walk, consider bending down to the child’s level for communicating important information. Even though you are busy at the store, try to give your child attention when he or she is being good at least once every few minutes.

Focus on your child Follow your child’s lead Hold up two similar items, and allow your child to choose which one you will put in your cart and purchase. Let your child direct you to the next area of the store by pointing. Imitate your child If your child makes sounds or gestures while in the cart, imitate them. If your child is looking at an item you handed him or her, look at a similar item next to the child. Model communication Provide labels for the items you put in your cart. Point to numbers on price signs, and label them individually. Label items you see in the store or point out favorite characters (e.g., “I see a tiger!”). Narrate what is coming up next (e.g., “Now we need to pay at the register!”). Label the sounds and smells that you experience at the store because your child is likely experiencing them too (e.g., “Ooh, that’s cold!” when you open the freezer door, or “Crinkly” when you put a bag of chips in the cart).

Create opportunities Back-and-forth play When picking out produce or something with many pieces, hand each piece to your child and have him or her put it in the bag. Communication temptations If your child likes to ride in the cart, stop pushing, and wait for your child to ask to go again. Ask your child if he or she wants to go “Fast or slow?” and wait for him or her to decide. When you are handing your child multiple pieces of something, pause and wait for him or her to ask for the next one to put in the bag. Play I Spy, and say “I spy apples!” in the produce section. Can you find them?”

Source: Project ImPACT for Toddlers, SoCal Bridge Collaborative, 2020, Unpublished Manual.

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Case Example: Ty Ty is an 11-year-old sixth grader with a diagnosis of ASD. Ty lives with both parents and an older sister and attends the local public school. Ty is at or near grade level academically, with math skills comparable to peers and a reading level at or just below grade level. Ty enjoys pop music and watching movies. With an excellent memory and strong interest in cinema, Ty memorizes entire cast names as well as producers, directors, and release dates. Ty is educated in a general education classroom for the entirety of the school day and receives support from an inclusion specialist, who provides modifications and accommodations. Ty is generally well behaved during class, yet often appears as though not attending. When called on directly, Ty contributes to or participates in class whole-group discussions, and the majority of responses are accurate or relevant. However, Ty needs frequent adult prompting to remain on task. Without verbal or gestural prompts, Ty engages in off-task behaviors, including repetitive finger flicking in front of his eyes and slight body rocking when not engaged in the lesson. These behaviors affect Ty’s grades when he submits incomplete work assignments due to the inability to remain on task and lack of participation in the learning activity. Ty refers to other children as friends; yet, he spends each recess alone eating snacks and roaming around the perimeter of the schoolyard and the track. Sometimes he enters the school building and wanders around the halls. Ty only interacts with peers when prompted and prefers to have conversations with teachers and other adults. Ty’s attempts to initiate conversations include comments about song lyrics and labels or about movie facts such as the date of release or the name of the director, producer, or studio. The other students in the class like music and movies, but they talk about the artists, the actors, or the movie plot and discuss their opinions, likes, and dislikes. Ty contributes rote memory facts to sustain conversations. However, even if other children like the subject matter, they have a hard time feeling engaged and interested in the conversation, and they terminate the interaction quickly. During the previous academic year, at the suggestion of the individualized education program (IEP) team, Ty participated in drama as an elective class for one semester. Without scheduled meeting times, plans for collaboration with the drama instructor, and clear strategies in place, the experience was unsuccessful. Ty does not participate in any extracurricular or afterschool activities. Using antecedent strategies, teachers and therapists can increase Ty’s active participation in class and school activities as well as in social interactions with peers during extracurricular activities. Ensuring Ty is seated in such a way that minimizes distractions is a first step toward increasing his attention to task and participation in class. Taking note of stimuli in the environment that may become distracting (e.g., lighting, noise) and remediating those factors can help him remain engaged with the lesson. Furthermore, seating Ty next to peers who share some interests and incorporating students’ interests (i.e., writing about movies, elements of theatre) along with priming are other antecedent approaches to increase on-task behavior. To prepare Ty for upcoming events, a weekly and/or daily schedule with goals to work toward during each part of the schedule may be beneficial. In addition, priming

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is implemented in a variety of ways. For classroom lessons, the teachers provide Ty with a list of questions in advance that will be asked and provide Ty with options or choices ahead of time of the materials he can select from. With these strategies, Ty should be more likely to attend to the lesson and be prepared for the questions that will be asked. Ty will likely display increased levels of engagement and on-task behavior through the choice of materials offered. During unstructured activities and transitions, an instructional aide may prepare Ty for social initiations by presenting a list of topics that are mutually interesting between peers. This preplanning will likely prompt Ty of the skills needed in unstructured social situations. Then, before dismissal to lunchtime, a teacher or aide may support Ty by creating a visual tool that states clear rules and expectations to help set the stage for appropriate social behavior. Antecedent-based strategies can also be used to increase and improve Ty’s conversational skills. Based on his description, Ty has a number of interests and an excellent memory. Shared control strategies and teaching within natural routines can also be incorporated into an intervention plan. For example, Ty could choose a preferred conversational topic, and after a few exchanges, the peer could select a topic. Ty and the peer could then take turns discussing things they are interested in, with each asking questions of the other or making comments about what they have heard. Ty might need initial prompting to follow this plan, but priming can help increase his success. Furthermore, practicing conversations at home or in other settings with familiar adults can help Ty expand the current repertoire for generalization of the new skills with peers. Selecting appropriate consequences is also a critical part of such an intervention; consequence strategies are discussed in more detail in Chapter 9. Finally, Ty has an interest in drama and theater. To increase success and participation in drama class, a meeting could be scheduled with the drama teacher prior to the start of the school year or semester to discuss the schedule and expectations and to learn about Ty’s preferences and interests. Thus, through active use of a variety of antecedent strategies, Ty can more effectively use the skills he has already mastered and practice new skills as well, all while becoming a more active participant in class, engaging with peers, and enjoying extracurricular activities.

CONCLUSION This chapter described how antecedent-based strategies are used in NDBI, beginning with advanced planning through application to the teaching environment. Antecedent strategies are included in NDBI to maximize motivation to initiate, respond, and sustain social interactions, leading to improved skill acquisition. An early successful learning history can provide a strong foundation for learning in individuals with ASD. When all variables in the teaching environment are optimized for the learner to experience success and to enjoy the interactions, the stage is set for a capable and active lifelong learner who has a positive impact on his or her own education and relationships. After planning and preparing the environmental context to enhance the child’s interest and engagement and reduce interfering behaviors, the next steps in NDBI address how specific instructions are presented and prompts are provided.

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Kern, L., & Clemens, N. H. (2007). Antecedent strategies to promote appropriate classroom behavior. Psychology in the Schools, 44(1), 65–75. Koegel, L. K., Koegel, R. L., & Dunlap, G. (2006). Positive behavioral support: Including people with difficult behavior in the community. Baltimore, MD: Paul H. Brookes Publishing Co. Koegel, L. K., Koegel, R. L., Frea, W., & Green-Hopkins, I. (2003). Priming as a method of coordinating educational services for students with autism. Language, Speech, and Hearing Services in Schools, 34, 228–235 Koegel, L. K., Koegel, R. L., Harrower, J. K., & Carter, C. M. (1999). Pivotal response intervention I: Overview of approach. Journal of the Association for Persons with Severe Handicaps, 24, 174–185. Koegel, R. L., Fredeen, R., Kim, S., Danial, J., Rubenstein, D., & Koegel, L. K. (2012). Using perseverative interests to improve interactions between adolescents with autism and their typical peers in school settings. Journal of Positive Behavior Interventions, 14(3), 133–141. Koegel, R. L., Kim, S., Koegel, L. K., & Schwartzman, B. (2013). Improving socialization for high school students with ASD by using their preferred interests. Journal of Autism and Developmental Disorders, 43(9), 2121–2134. Koegel, R. L., Vernon, T., & Koegel, L. K., (2009). Improving social initiations in young children with autism using reinforcers with embedded social interactions. Journal of Autism and Developmental Disorders, 39, 1240–1251. MacDonald, L., Trembath, D., Ashburner, J., Costley, D., & Keen, D. (2018). The use of visual schedules and work systems to increase the on-task behaviour of students on the autism spectrum in mainstream classrooms. Journal of Research in Special Education Needs, 18, 254–266. Magito McLaughlin, D., & Carr, E. G. (2005). Quality of rapport as a setting event for problem behavior: Assessment and intervention. Journal of Positive Behavior Interventions, 7, 68–91. McGee, G., Morrier, M. J., & Daly, T. (1999). Special section: Interventions for young children with autism. Journal of the Association for Persons with Severe Handicaps, 24, 133–146. Odom, S. L., McConnell, S. R., & Chandler, L. K. (1994). Acceptability and feasibility of classroom-based social interaction interventions for young children with disabilities. Exceptional Children, 60, 226–236. Reinhartsen, D. B., Garfinkle, A. N., & Wolery, M. (2002). Engagement with toys in two-year old children with autism: Teacher selection versus child choice. Research and Practice for Persons with Severe Disabilities, 27(3), 175–187. Rispoli, M., Lang, R., Neely, L., Camargo, S., Hutchins, N., Davenport, K., & Goodwyn, F. (2013). A comparison of within and across activity choice for reducing challenging behavior in children with autism spectrum disorders. Journal of Behavior Education, 22, 66–83. Rogers, S. J., & Dawson, G. (2010). Early Start Denver Model for young children with autism: Promoting language, learning, and engagement. New York, NY: Guilford Press. Rogers, S. J., Dawson, G., & Vismara, L. A. (2012). An early start for your child with autism: Using everyday activities to help kids connect, communicate, and learn. New York, NY: Guilford Press. Schreibman, L., Whalen, C., & Stahmer, A. C. (2000). The use of video priming to reduce disruptive transition behavior in children with autism. Journal of Positive Behavior Interventions, 2, 3–11. Snyder, P. A., Rakap, S., Hemmeter, M. L., McLaughlin, T. W., Sandall, S., & McLean, M. E. (2015). Naturalistic instructional approaches in early learning: A systematic review. Journal of Early Intervention, 37(1), 69–97. Wilde, L. D., Koegel, L. K., & Koegel, R. L. (1992). Increasing success in school through priming: A training manual. Santa Barbara: University of California. Wong, C., Odom, S. L., Hume, K., Cox, A. W., Fettig, A., Kucharczyk, S., & Schultz, T. R. (2014). Evidence-based practices for children, youth, and adults with autism spectrum disorder. Chapel Hill: The University of North Carolina, Frank Porter Graham Child Development Institute, Autism Evidence-Based Practice Review Group. Retrieved from http://autismpdc .fpg.unc.edu/sites/autismpdc.fpg.unc.edu/files/imce/documents/2014-EBP- Report.pdf Zanolli, K., Daggett, J., & Adams, T. (1996). Teaching preschool age autistic children to make spontaneous initiations to peers using priming. Journal of Autism and Developmental Disorders, 26, 407–422.

8 Implementing Instructional Cues and Prompting Strategies Kyle M. Frost, Brooke Ingersoll, Yvonne Bruinsma, and Mendy B. Minjarez

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hildren with autism spectrum disorder (ASD) often require additional assistance when learning new skills. Because Naturalistic Developmental Behavioral Interventions (NDBI) models have their roots in behavioral principles and operant conditioning, they all use instructional cues and prompting strategies to help children acquire new skills outside of their current repertoire. NDBI are also informed by developmental approaches and an understanding of typical development; thus, learning opportunities are embedded in natural interactions and are often more flexible than in more traditional behavioral approaches. The goal of this chapter is to provide an overview of how various NDBI models deliver instructional cues within natural, ongoing interactions and use prompts to support child learning.

DEFINITIONS Although NDBI models focus on embedding teaching opportunities within natural contexts such as daily routines and play, these teaching principles originate from behavioral models and follow principles of operant conditioning. Here, we present an abbreviated review of behavioral terms that are used in this chapter. Learning Opportunities Learning opportunities, also called contingencies or teaching trials, are composed of antecedents, behaviors, and consequences (A-B-C; Cooper, Heron, & Heward, 2007). A learning opportunity encompasses environmental and instructional cues that occur before a behavior, the behavior itself, and the consequences that occur after the behavior, which either increase or decrease the likelihood that the 175

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behavior will follow the antecedent more frequently. The focus of this chapter is on a specific type of antecedent: prompts. Antecedents Antecedent is a broad term for what happens before, and therefore influences or cues, a behavior (Cooper et al., 2007). This may involve a specific instruction, environmental cues, and/or a prompt to support the child’s correct response. Antecedents are discussed in detail in Chapter 7. Instructional Cue An instructional cue or discriminative stimulus (SD) is an antecedent that has been paired with a specific behavior so that, through learning, it becomes more likely to evoke that behavior (Cooper et al., 2007). In practice, the term instructional cue is often used before it consistently evokes the target behavior. In addition, especially early in teaching, prompting (discussed next) may be required to evoke the behavior. For example, a mother says, “Time to put shoes on!” Then, she guides her son to his shoes and helps him put them on. In this case, the mother’s instruction serves as a cue or SD for her son to put his shoes on, although he needs help completing this task (the prompt). However, her goal is to teach him to independently follow the instruction. Prompt A prompt refers to an additional cue that can be delivered with or immediately after the instructional cue (Cooper et al., 2007). The prompt provides the child with an extra cue or support in order to evoke a correct response, for which the child can be reinforced. Prompts vary from highly supportive (e.g., physical guidance, modeling) to less supportive (e.g., subtle gesture, verbal comment), and when used correctly, are adjusted to the child’s current skill level for the target behavior. In addition, prompts can be combined with each other as needed (e.g., providing a verbal choice while pointing to both options). Over time, prompts are gradually reduced or faded in order to support independent correct responses. Stimulus Discrimination and Generalization Discrimination and generalization of stimuli are two inversely related concepts. Stimulus discrimination refers to the extent to which a stimulus evokes a specific response to the exclusion of others (Cooper et al., 2007). An example would be when a child learns to respond to his or her name being called; he or she looks up when the mother calls his or her name but not the sister’s name. Stimulus generalization refers to when related or similar stimuli evoke the same response (Cooper et al., 2007). For example, the child learns to give his or her teacher the ball in response to “Give me the ball,” “Can I have the ball?” and “My turn with the ball.” A balance of discrimination and generalization is important for forming concepts and applying skills flexibly across contexts. These terms are used throughout the chapter to describe how various NDBI models embed learning opportunities within child-directed activities and daily routines and how prompts are used to facilitate child learning.

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LEARNING OPPORTUNITIES ACROSS NDBI MODELS Although learning opportunities across NDBI share the same basic A-B-C contingency structure, they are sometimes more loosely defined and applied than in more structured Applied Behavior Analysis (ABA) interventions. In particular, the distinction between an instructional cue and prompt is often less clear than in more structured ABA interventions, with the teaching procedure as a whole often referred to as prompting or a teaching episode. This is particularly the case when the instructional cue and prompt are delivered simultaneously. Consider the following example: The adult says, “My turn!” while holding out her hand, palm up, close to the child. This includes both a verbal instruction (instructional cue) that is delivered at the same time as a gestural cue (prompt) to help the child respond by handing the adult a toy. Several NDBI also allow the child multiple opportunities to respond to a learning opportunity, with the adult increasing the level of support as needed. For example, a single NDBI learning opportunity may take the following form: the adult asks a question (“What do you want?”), pauses briefly to allow a response, and supports the child with additional prompts until the child successfully completes the target skill (“Blue car or red car?” . . . “Blue car”). This contrasts with more traditional ABA approaches, in which the adult delivers a single cue (alone or in combination with prompts) and provides contingent reinforcement based on the child’s response to that cue. From the vantage point of a traditional ABA approach, this example would be viewed as three teaching trials, with a brief intertrial interval, or pause, between them. In other words, how prompts are used in NDBI and when a trial is considered complete is sometimes defined differently than in more traditional ABA approaches. This reflects the emphasis on naturalistic and developmentally informed teaching that is characteristic of NDBI models. Because learning opportunities are naturally embedded in daily routines and play, the frequency of teaching may also vary across activities and depend on other factors such as child motivation. Embedded Trials Learning opportunities in NDBI models take place within embedded trials. These are teaching episodes that occur within daily routines and play, rather than in a distraction-free therapy setting. Teaching skills within a natural context has several benefits. It facilitates the generalization of skills; not only can learning opportunities occur in multiple contexts, but they also can occur within the child’s natural environment. In addition, this type of embedded learning allows for natural reinforcement, rather than reinforcement that is artificially introduced into the learning environment. For example, when a child asks to go outside to play, the adult can use this natural opportunity to teach the child to zip his or her coat. The child will be naturally reinforced by going outside after zipping his or her coat. See Box 8.1 for more ideas on how to embed learning trials and opportunities. There are different ways to embed learning opportunities that vary in the extent to which they are initiated by the child or adult. Table 8.1 contains examples of varied types of embedded learning opportunities in which a communication response is expected. Learning opportunities are meant to be as natural as possible, although the adult may manipulate aspects of the environment or briefly interrupt the child’s activity in order to set the stage for an embedded teaching trial.

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Ready, Set, Implement! BOX 8.1: Embedding learning opportunities • • • • •

Teach within preferred routines, such as playtime, circle time, and snack. Use naturally occurring opportunities to teach meaningful skills. Wait until you have the child’s attention. Use a clear cue that indicates a need to respond. Use varied cues to promote generalization.

NDBI models describe the importance of taking turns or balanced turns as a natural way to embed learning opportunities that increase joint engagement and evoke communication (e.g., Joint Attention, Symbolic Play, Engagement, and Regulation [JASPER]; Kasari, Gulsrud, Wong, Kwon, & Locke, 2010). Others build in opportunities for sharing positive affect (e.g., Early Start Denver Model [ESDM]; Rogers & Dawson, 2010; Social ABCs; Brian, Smith, Zwaigenbaum, & Bryson, 2017). Another strategy is to wait for the child to initiate prior to cuing the child for a more advanced skill (e.g., Enhanced Milieu Teaching [EMT]; Hemmeter & Kaiser, 1994; Hancock, Ledbetter-Cho, Howell, & Lang, 2016), also known as Incidental Teaching (Hart & Risley, 1975; McGee, Morrier, & Daly, 1999). For example, if the Table 8.1. Examples of different ways to embed learning opportunities Ongoing activity The adult and child are taking turns putting marbles down a marble run.

Examples

The adult pauses, holding his or her marble over the slot, and looks expectantly at the child. The adult playfully blocks the marble as it rolls down and says, “Stop!” The adult closes the jar of marbles tightly and leaves it in sight. The adult collects all the marbles as they reach the bottom of the marble run. When the child reaches for them, the adult asks, “What do you want?” At snack time, the child asks The adult hands the child a bowl of cereal but leaves the milk for a bowl of cereal. on the counter. The adult pours just a few pieces of cereal into the bowl and hands it to the child. The adult holds up two types of cereal and waits for the child to select one. The adult says, “Mmmm, my turn for a bite!” and eats a spoonful of cereal, pausing before returning the spoon to the child. The adult is helping the child The child reaches for the socks. The adult holds up the socks put shoes and socks on and shoes and says, “Want socks or shoes?” before going outside to The adult puts one of the socks on the child, then looks play in the yard. expectantly at the child and waits. The adult pretends to put the child’s shoes on his or her own feet in a silly and exaggerated manner. The adult hands the child a sock (which the child needs assistance to put on).

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child has reached for a cracker, the adult could use this opportunity to teach the child to point or vocalize to request the cracker. The adult may also deliberately create clear opportunities for the child to communicate. This can be accomplished by using environmental arrangement and communicative temptations; for example, the adult may place desired items in sight but of reach, use a clear pause in the activity paired with an expectant look, withhold parts of toys, or playfully block the child’s play (e.g., Project ImPACT [Improving Parents as Communication Teachers]; Ingersoll & Dvortcsak, 2009). In other NDBI models, the presentation of a learning opportunity may be more adultled. For example, in Pivotal Response Treatment (PRT), the adult may present a learning opportunity prior to waiting for the child to initiate (taking out the box of crackers when the child comes into the kitchen, and asking the child if he or she wants one); however, these opportunities are still embedded within an ongoing, motivating activity (Koegel et al., 1989). Pacing of Instruction Knowing when to provide a learning opportunity is as important as knowing how to provide a learning opportunity. Some NDBI models prescribe more frequent learning opportunities compared to others, with some models recommending more than one per minute (e.g., Social ABCs; Brian et al., 2017; ESDM; Rogers & Dawson, 2010 PRT; Koegel et al., 1989), some recommending one every 1–2 minutes (e.g., Project ImPACT; Ingersoll & Dvortcsak, 2009), and other models recommending far fewer to leave space for child initiations and adult modeling (e.g., EMT; Hancock et al., 2016). All NDBI models, however, agree that there should be a period of time in between learning opportunities in which the child is allowed to lead the play activity. In addition, because teaching occurs within ongoing activities, the frequency with which learning opportunities are embedded in NDBI varies according to a number of factors. These include the child’s motivation, the nature of the activity, the difficulty of the task or target behavior, and the value of the reinforcer, as well as individual child characteristics. Across NDBI models, it is considered essential to establish high levels of child engagement prior to providing a learning opportunity. This means that the child should be attentive and interested in the ongoing activity. Learning opportunities can be embedded more frequently during activities in which the child is highly motivated. In these activities, the child is more likely to maintain attention and make continued attempts to respond to instructional cues. In addition, the child is less likely to become frustrated by repeated teaching when he or she is enjoying the activity. Children may be highly motivated during favorite activities or routines or when the activity involves a highly valued reinforcer. NDBI strategies such as following the child’s lead serve to increase child motivation by allowing the child to select a preferred activity. However, teaching can still occur in other less-preferred activities, such as dressing or chores. In this type of activity, increasing the level of reinforcement being provided or using other social engagement strategies can be useful to increase child motivation (e.g., increased animation, singing the clean-up song, tickling in between putting on items of clothing). However, learning opportunities should be delivered less frequently in these nonpreferred activities. In addition, clinicians should consider the difficulty of the target skill relative to the child’s current repertoire of skills. For example, drawing shapes or writing

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letters may be appropriate targets for a child who can hold a pencil using a three-finger grip. However, for a child who holds markers in a fist, this task is much more difficult and is likely to become frustrating with frequent repetitions. Likewise, asking a child to request blocks several times in a Low High Average row may be feasible and appromotivation motivation motivation priate for a child who has phrase Reinforcer value Task difficulty speech but frustrating for a child who is preverbal. To be more speFigure 8.1. Ratio of task difficulty to reinforcer value. cific, the ratio of task difficulty to reinforcer value is key; more frequent teaching can occur when task difficulty is high if reinforcer value is also extremely high. In other words, children are more likely to persevere through a difficult task if they are highly motivated (see Figure 8.1). However, if the task is difficult and the reinforcer value is low, this may not be a productive context in which to embed learning opportunities. The adult should consider these factors when deciding whether to begin a learning opportunity and should initiate learning opportunities at a time and rate that maximize the child’s chance of success. Furthermore, learning opportunities are just one component of NDBI models and are meant to be interspersed with other strategies detailed elsewhere in this book (e.g., strategies that promote social engagement). The long-term goal of intervention is for children to demonstrate skills independently and spontaneously (i.e., without supports or cues from the adult). Therefore, in a situation in which the child demonstrates (or approximates) a skill spontaneously, the adult may choose to reinforce that behavior rather than prompting the child to use a more advanced skill. For example, a parent who has been working on dressing skills may reinforce the child for spontaneously picking up a shirt even if he or she has not put the shirt on independently. This encourages the child to independently perform aspects of dressing, even though he or she may still need support to complete the task fully. Clear Cues Across NDBI, there is consensus that cues provided with the goal of beginning a teaching trial must be clear. A child cannot be expected to engage in a targeted behavior without a clear indication of the expectation. Clear cues should give an obvious indication of the expected behavior, can be verbal or nonverbal, should be appropriate for the child’s skill level, and should be directly related to the context and/or teaching materials. If prompting hierarchies (discussed next) are being used, cues for behaviors should be at the correct level in relation to the child’s performance on the preceding trials. That is, the cue should be matched to the child’s current level of independence. Verbal cues are different from other adult verbal behaviors often used in NDBI to target engagement and enrich the treatment environment (e.g., commenting, modeling, labeling). For example, when modeling language for a child who is minimally verbal, providing a single-word label while gesturing to the toy the child is

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playing with (commenting or narrating) is significantly different from providing a label while holding a toy up and looking expectantly at the child (embedded teaching trial). Likewise, narrating the play of a child who is more verbal (e.g., “Your train is driving so fast!”) is different from playfully interrupting the child and asking a clear question (e.g., “Should the train drive slow or fast?”). Commenting, labeling, and narrating are adult behaviors that are useful for exposing the child to appropriate language models during teaching sessions. When used outside the context of shared control and contingency, these adult behaviors are not part of teaching trials. In this case, adults should differentiate verbal models from cues and prompts through phrasing, gesture, tone, and body language. It is useful to attend to whether adults are asking rhetorical questions during play when they actually mean to narrate because these may be perceived as prompts or cues by the child; lack of child response may give an intermittent message that consistent responding is not required. Adults should also make sure that comments and narration are at the child’s developmental level in order to model appropriate language and not overwhelm the child with verbal input he or she does not understand. Additional details on narration and adult language models are outlined in Chapter 11, on communication. Natural and Varied Instructional Cues Another important shared NDBI guideline for learning opportunities is that instructional cues should be varied, even when working on the same behaviors. This use of varied cues distinguishes NDBI from more structured behavioral approaches, which typically prescribe using systematic cues that remain consistent until the child has mastered a task. Typically developing children respond to a variety of environmental cues or verbal instructions. NDBI models attempt to create a learning environment that includes varied instructional cues, which more closely approximate natural cues in the environment from the beginning. This enhances stimulus generalization in that the child is perhaps more likely to respond to a variety of cues without the need for specific programming. Instructional cues in NDBI may be more or less direct. For example, the cue may include the target word (“blow bubbles”) or explicitly require a behavior (“point to bubbles”), or it may merely hint at or suggest the desired behavior (holding the bubbles and waiting expectantly). A child with limited verbal skills may require a more direct and consistent instruction when first learning new words (e.g., a verbal model), whereas a child who has more skills may be able to respond to indirect cues (e.g., an open-ended question or time delay). Table 8.2 outlines examples of varied instructional cues, some of which are direct and others that are indirect. Task Variation and Maintenance Tasks Some NDBI models intersperse learning opportunities for tasks that are new and for those that have been mastered. This has several functions. First, it promotes maintenance of skills by giving the child opportunities to practice skills that are no longer being directly targeted. Second, this strategy can increase the child’s motivation, as outlined in previous chapters. Third, interspersal can reduce frustration

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Table 8.2. Examples of varied instructional cues Skill Receptive language: Identifying ball

Expressive language: Requesting ball

Play action: Feeding the baby

Varied instructions Direct: Give me the ball. Where is the ball? Point to the ball. Indirect: I see the ball! I wonder where the ball is. Direct: Ball. Ball or car? You want the ball? Indirect: What do you want to play with? What could I give you? What do you need? Holding up the ball and looking expectantly (time delay). Direct: Feed the baby. Give baby some food. Indirect: Baby is hungry! Baby wants her bottle.

by allowing the child to succeed more easily when learning a new challenging skill. Depending on whether a skill is new or has already been mastered, the adult should approach prompting differently.

PROMPTING STRATEGIES When supporting learning in young children, the adult should consider what the child is already capable of versus what he or she may need to learn. For example, a child may need to learn to independently pull up and button his or her pants. At first, the child will likely require assistance, or prompting, in order to complete this multistep task. It is important that the adult teaches the child how to engage in this skill by initially providing the necessary level of support. Prompting must then be decreased over time, eventually providing the opportunity for the child to pull up and button his or her pants independently. Prompts are used to support learning and increase the child’s successful responding during embedded learning opportunities. In general, it is desirable for the child to be successful as frequently as possible and to provide the lowest level of support needed for a child to respond successfully to promote independence over time. At first, however, the child may require substantial support. As the child acquires skills, prompts are quickly reduced or faded, and the skill is generalized to other situations. When the child lapses in performing a mastered skill, the adult may temporarily provide more supportive prompts in order to maintain that skill. Several factors come into play when selecting an appropriate prompt for

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a learning opportunity, including the nature of the target skill, the child’s current skill level, environmental or situational factors, and individual differences in child characteristics. Types of Prompts Prompts can take on several different forms; for example, prompts may be visual (e.g., gestures, modeling, environmental cues), verbal (e.g., open-ended question, verbal modeling), and physical. Physical guidance is generally considered the most highly supportive or intrusive type of prompt (Cooper et al., 2007). However, physical guidance as well as verbal and visual prompts can vary in the extent to which they are supportive. For example, physical prompts range from high support (e.g., hand-over-hand support of a complete task) to low support (e.g., a gentle tap of the elbow to cue a more complex behavior). Likewise, verbal and visual prompts may be highly supportive (e.g., showing the child exactly what to do or say) or less supportive (e.g., subtle or indirect hints such as looking toward the correct item). Tables 8.3 and 8.4 provide examples of several types of prompts that can be used for teaching verbal and nonverbal skills with varying levels of support. The examples are generally organized from most to least level of support; however, the various NDBI models may use these prompts in different orders and may or may not use every type of prompt. NDBI models differ on the extent to which they emphasize or articulate specific types of prompts. The models also differ in the extent to which they adhere to rigid prompting hierarchies versus using prompts that are similar to one another interchangeably to increase stimulus variation. For example, EMT recommends a specific set of prompts for teaching language skills. However, PRT does not outline specific prompts to be used, other than to recognize that prompts vary in supportiveness and should be faded over time. Different types of target skills may lend themselves to different types of prompts. Visual prompts may be particularly useful for children who are learning to imitate gestures, follow directions, use augmentative and alternative communication (AAC), or use a visual schedule. Verbal prompts are particularly useful for teaching verbal skills or providing more subtle prompts for skills that the child has made progress toward learning. In addition, child characteristics may affect the type of prompt the adult chooses. For example, visual prompts may be preferred for children who inappropriately repeat the adult’s speech or are dependent on verbal models to respond to instructions. In contrast, some children may not attend to subtle verbal cues and may require more explicit verbal cues to attract their attention. The final section of this chapter provides examples of different types of prompts that can be used to teach different types of skills. Prompt Hierarchies To help facilitate increased independence over time, NDBI typically include a prompt hierarchy. A prompt hierarchy includes varying levels of prompts meant to be delivered in the order provided. These can be arranged from most-to-least supportive or least-to-most supportive. The adult is meant to move flexibly up and down the prompt hierarchy, increasing support when the child’s response is incorrect or incomplete and decreasing support as the child learns a skill.

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Table 8.3. Examples of different types of prompts for verbal skills, ordered from more supportive to less supportive Prompt Verbal model prompt

Removed model prompt

Partial verbal model Choice prompt

Definition The adult presents the full word or combination of words that the child is expected to repeat verbatim. The adult presents the child with the full word or a combination of words he or she is expected to repeat verbatim but with additional words at the end. The adult models the first speech sound in the target word or phrase. The adult gives the child response options to choose from.

Fill-in-the-blank prompt

The adult pauses before the last word of a phrase, after having used the full phrase during the activity.

Open-ended prompt

The adult asks the child an open-ended question.

Indirect verbal prompt

The adult hints at something without giving an explicit cue.

Time delay

A visual cue is provided but no auditory cue.

Characteristics

Example

Prompt must be faded quickly. It is not a good choice if the child has echolalia. It often is accompanied by questioning intonation. It can be helpful to prevent the child from going on automatic pilot. It helps to prevent or discourage echoing.

“Cookie?” “I want the ball.”

It helps to encourage independent responding. It is useful when kids rely on echoing verbal models. It is useful when kids rely on echoing verbal models (put the child’s preference first). It is more difficult when the objects are not present. It is great for repetitive playful actions (e.g., running, spinning, jumping). Fill-in-the-blanks are naturally part of early word learning for children, so there are many early learning rhymes and songs that can be used. Prompts must be varied. Prompts do not contain the answer. The adult should avoid yes-no questions unless working on teaching yes and no! The adult gives a hint or leading comment. These prompts are less supportive. These prompts are useful when trying to entice a child’s interest. The cue is an expectant look or clear pause. This is an important step toward independence. The child must retrieve word(s) independently.

“Buh. . . .”

“Cookie? What do you want?”

“Play ball or play cars?” “Juice or water?” “Ready, set, go! Ready, set, go! Ready, set, . . . .” “The doors on the bus go . . . .” “The itsy, bitsy spider went up the water . . . .” “What do you want?” “Which one?” “What should I do?” “There are cookies on the top shelf.” “I have a toy in this box!” The adult holds up the bubbles and pretends to almost blow but does not.

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Table 8.4. Examples of different types of prompts for verbal and nonverbal skills, ordered from more supportive to less supportive Prompt

Definition

Characteristics

Example

The adult uses hand-over-hand assistance. Prompts are highly supportive. Prompts should not be forceful or forcing. The adult uses his or her finger tips. The adult helps the child start the behavior or complete the behavior but not both. The adult helps the child learn through imitation.

The adult places his or her hand over the child’s hand to guide the child to pick up the marker and then to guide the child’s hand with the marker to the table.

Full physical prompt

The adult physically guides the child in completing the target behavior.

Light or partial physical prompt

The adult uses physical guidance to support some independent response by the child.

Action model prompt

The adult demonstrates an action, play act, or gesture to show the child what to do. The adult provides The adult provides a picture, icon, or a nonverbal cue printed text to help to provide extra the child emit the support for the correct response. child.

Visual prompt

The adult lightly touches the child’s arm to pick up the marker or gently guides the child to the table.

The adult points to the plastic container, which has snacks in it. When teaching yes-no, provide a child who always responds in an echoic manner (“Do you want the cookie? Yes!”) with a visual cue immediately following the question “Do you want the cookie?” to ensure the child cannot echo the question and the answer. The adult extends a hand while saying, “Give it to me.”

Gesture prompt The adult provides The adult provides a gesture that a cue of what is indicates the correct expected. answer or supports comprehension. Positional The adult moves the The adult provides A blue car and a red car are prompt correct item closer extra support to on the table. The adult to the child. increase the chance moves the blue car closer the child will select to the child and says, the correct item. “Please give me the blue one.” Direct verbal The adult gives a Important step “Give the baby a drink.” prompt direct instruction to towards “Point to the ball.” perform an action, independence. “Put your shoes on.” gesture, or play act. The child must perform skill on his or her own. Open-ended The adult asks a Prompts must be “What should baby do prompt question to cue a varied. now?” behavior. Prompts do not “What do we need before contain the answer. we go outside?” Indirect verbal The adult gives a The adult gives a “Show me where that goes.” prompt verbal cue but does hint or leading “Go ahead.” not explicitly ask a comment. “Baby looks so thirsty!” question or give an These prompts are instruction. less supportive.

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As mentioned previously, NDBI models differ in the extent to which they adhere to prompting hierarchies, with some models using clearly defined hierarchies (e.g., incidental teaching, EMT, JASPER; Hancock & Kaiser, 2012; Kasari, Fannin, & Goods, 2012; McGee et al., 1999) and others using hierarchies more flexibly (e.g., PRT). Using Most-to-Least Supportive Prompting Prompts can be delivered via most-to-least supportive prompting—the most intrusive, or most helpful prompts, are provided initially and then are gradually reduced in subsequent learning opportunities (Cooper et al., 2007). A most-to-least approach can be used in order to provide errorless learning, in which the child’s successful responding is maximized when learning new skills. Errorless learning allows for the child to be successful during all early learning opportunities, which allows for frequent reinforcement. This approach is often used to teach new skills to reduce frustration during the learning process. Using Least-to-Most Supportive Prompting Prompts can also be delivered via least-to-most supportive prompting—the least supportive prompts are provided initially, often first providing an opportunity for the child to engage in the response independently (Cooper et al., 2007). If the child does not respond correctly at first (within a few seconds of the instructional cue), the adult provides increasingly supportive prompts in subsequent learning opportunities until the child responds successfully. In order to prevent prompt dependence, the adult provides a higher level of support on the following learning opportunity, then quickly fades it. This approach is often used to increase the child’s independence in performing a skill he or she has accomplished with support. Choosing a Prompt Hierarchy The supportiveness of the prompt is meant to match the child’s skill level, with the goal of providing the child enough support to respond correctly while providing the opportunity for the child to respond as independently as possible. Some NDBI models outline a specific prompt hierarchy to follow for teaching new skills. For example, Project ImPACT and incidental teaching recommend a least-to-most prompt hierarchy, along with specific types of prompts. However, other NDBI models do not articulate a hierarchy as clearly, other than recommending that prompts are faded as quickly as possible. There is limited research to guide the selection of a prompt hierarchy for NDBI. Research on prompt hierarchies in discrete trial training has had variable results. One study suggested that most-to-least prompting resulted in more efficient learning among preschoolers with ASD who were learning one-step directions (Cengher et al., 2016). Another study that examined individuals’ ability to learn to build structures with blocks found that a least-to-most prompting procedure was more efficient because it allowed for individuals to skip steps in the prompting hierarchy, which was not true in the most-to-least condition (Seaver & Bourret, 2014). However, in both studies, there were individual differences among the children in terms of how quickly they attained independent responding using different prompt hierarchies. In addition, it is not clear whether these results would generalize to prompting that occurs within naturalistic teaching.

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Ready, Set, Implement! BOX 8.2: Prompt fading • • • • •

Prompts should match the child’s skill level; a brand-new skill may require highly supportive prompts. Provide just enough support for the child to respond and no more. As the child learns a skill, quickly reduce the supportiveness of prompts. If needed, provide increasingly supportive prompts until the child is successful. Use prompts that fit the situation and child characteristics; be creative!

PROMPT FADING The goal of NDBI and other teaching models is for the child to initiate spontaneously and independently, without the need for prompting or other supports, such as an expectant pause from the adult. Therefore, the adult must reduce the supportiveness of prompts over time. This means that the adult must provide prompting only to the extent that it is necessary. Providing supportive prompts consistently over time may lead to a pattern in which the child does not engage in the behavior without prompts or assistance; this is sometimes referred to as prompt dependency. In other words, the child may become reliant on prompts to complete a skill, rather than gaining the ability to perform the skill independently. As an alternative, adults may overprompt by quickly providing prompts that are overly supportive, without giving the child ample time to practice skills independently. Fading to the use of very subtle prompts, as well as using time delays to allow the child time to respond independently, supports the child’s independent use of skills. Many NDBI models also incorporate strategies such as environmental arrangements to promote child spontaneous initiation behaviors as a final step in fading adult support (see Chapter 7 for more information). Prompts can be faded, or gradually decreased, by moving up and down the prompt hierarchy as needed (see Box 8.2). In addition, the type of prompt may be adjusted over time (e.g., from verbal to visual, from physical to verbal) as the child progresses. Progress is not necessarily linear, and it may take several attempts before a prompt is successfully faded.

EXAMPLES OF PROMPTS FOR SPECIFIC SKILLS Some examples of different types of prompts for specific skills are listed next to illustrate how adults might support the child in learning new skills in a variety of domains. Different NDBI models focus on more specific teaching targets (e.g., joint attention skills in JASPER, expressive language in EMT), whereas other models are broader in scope (e.g., ESDM and Project ImPACT). However, across NDBI, it is considered important to individualize teaching targets as well as prompts based

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on the child’s skills and level of need. When delivering prompts, the adult should be flexible, creative, and responsive to the child’s needs. Expressive Communication Expressive communication is a broad term describing communication that is produced by an individual for a variety of purposes, including showing interest, connecting with other people, and obtaining wants and needs. Expressive communication includes spoken language, as well as gesture, AAC, and other nonverbal behaviors. Verbal Various types of prompts can be used to teach verbal expressive communication. Verbal prompts are useful for modeling verbal skills and for providing natural conversational cues to which the child can respond. However, some children become reliant on mimicking verbal prompts or rarely initiate without a verbal cue from the adult. For these children, visual and gestural prompts can support them in responding more independently. In addition, the adult can strategically use verbal prompts that the child should not repeat (e.g., fill-in-the-blank, a choice prompt in which the desired item is stated first). More advanced verbal skills, such as asking questions or using pronouns, can be targeted by creating fun situations for the child to use that skill (e.g., hiding toys so the child can ask, “Where is it?”; playing I Spy to work on using pronouns). • The adult and child are giving the baby doll a bath. After taking the baby doll out of the tub, the adult, towel in hand, says, “Baby is cold!” (indirect verbal prompt). After a pause, he or she says, “What should we do?” (open-ended prompt). When the child still does not respond, the adult says, “‘Dry the baby?’” (direct verbal prompt). • After the child asks for a snack, the adult asks, “Do you want chocolate ice cream or vanilla ice cream?” (knowing the child wants chocolate) (choice prompt). After scooping the requested ice cream flavor, the adult hands the child the bowl without a spoon and waits (time delay prompt). Gestures Physical prompting, as well as modeling the desired behavior, are particularly useful ways to support the child in learning to gesture, sign, or use joint attention skills such as showing. • The child finishes a drawing and wants to start another one. The adult takes the child’s hand to hold up the picture (full physical prompt) while modeling “Look, Mommy!” (verbal model prompt) to show the picture to the parent. • The adult sings “Wheels on the Bus” with the child, pausing at each verse to gesture along with the song. When the child does not gesture spontaneously, the adult playfully touches the child’s hands to prompt him or her to continue the gestures (partial physical prompt). Augmentative and Alternative Communication Learning opportunities can be embedded as usual for children who use AAC, with the AAC device or Picture Exchange Communication System (PECS) book within reach of the adult and child. In addition to providing verbal prompts, the adult can gesture toward, touch, or model communicating with the AAC. If needed, the adult can also shape

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the child’s hand into a point to use a touchscreen or guide the child’s hand toward the AAC. • The adult hands the child a bin he or she cannot open. When the child looks up, the adult pushes the AAC device toward the child (positional prompt). When the child does not use it, the adult points (gesture prompt) to the icon that says “open” and says the word “open” (verbal model prompt). • When giving the child a snack, the adult places three chips in the bowl and holds on to the bag. When the child reaches toward the bag of chips, the adult shapes the child’s hand into a point (partial physical prompt) and helps him or her press “more snack” (full physical prompt). • The adult gives a choice, “Train, or tracks?” while pointing to each piece on the child’s PECS book (choice prompt). • The adult helps the child select the correct icon using hand-over-hand physical prompting (full physical prompt). Receptive Language Receptive language focuses on the understanding or comprehension of language. Receptive language targets can be embedded in the natural environment in a number of ways and can be targeted using a range of prompts. Receptive labeling can be taught with a combination of verbal and gesture prompts and may sometimes incorporate positional prompts (e.g., placing the correct object closer to the child). Following directions can be targeted with simple actions (e.g., give me, get the, put in, give to) and supported by action modeling or gestural or physical prompts. A combination of verbal and nonverbal prompts is commonly used when first being taught, and nonverbal prompts are then typically faded as the child gains skills. • When coloring with the child, the adult says, “Use the red pen” (direct verbal prompt) and points to the red pen (gesture prompt). • When shopping with the child, the adult says, “Put the cereal in” (direct verbal prompt) and models putting the cereal in the cart (action model prompt). The adult puts the cereal back on the shelf and waits for the child to put the cereal in the cart (time delay). Play Skills Depending on the child’s current play skills as well as receptive language skills, prompts used in play can be verbal or nonverbal. For children with limited receptive language skills, modeling play actions as well as physical prompts will help them perform new play skills. For children with more language skills, the adult can suggest or hint at new play actions to perform. • In the presence of toy food, the adult picks up the hot dog, pretends to eat it, and then hands it to the child (action model prompt). • When the child is pushing a car, the adult hands him or her a toy person and says, “The boy wants a ride” to help the child put toys together (indirect verbal prompt). • When the child is playing with playdough, the adult models rolling the playdough into a snake to show the child how to make something new with the playdough (action model prompt).

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Social Skills Much like skills in play, use of social skills can be supported using verbal or nonverbal prompts. This decision is largely dependent on the child’s receptive language skills. • When the child enters the classroom, the adult models saying “hi” to the classmate closest to the child (verbal model prompt) and then looks expectantly at the child (time delay prompt). • When the child has finished drawing a picture, the adult says, “Show your sister” (direct verbal prompt) and models holding the picture up for the sister to see (action model prompt). • At an art activity, the adult hands the child a marker and says, “Give your friend the pen” (direct verbal prompt) and points to the child next to him or her (gesture prompt). The adult then physically guides the child to give his or her peer the pen by lightly moving the child’s elbow toward the friend (partial physical prompt). Daily Living Skills Daily living skills can be supported using verbal or nonverbal prompts depending on the child’s receptive language skills and required level of support. A child who can complete a task independently but needs reminding may benefit from verbal prompts or visual cues to help him or her initiate. For children who need support performing a new action, the adult can perform the skill as a model or physically guide the child in completing the action. • When getting ready to go outside to play, the adult puts a jacket in front of the child and waits (positional prompt). • The adult places a picture schedule of washing hands next to the sink (visual prompt). As he or she helps the child wash his or her hands, the adult points to each step.

Case Example: Leah Leah is a 5-year-old girl with limited verbal skills. Her father, who has been trained in NDBI strategies, is playing with her. They enter the playroom, where her father has placed some of her favorite toys on the shelf. He sees her look up at the barn, and he points at the barn and waits. She reaches toward the barn, so her father shapes her hand into a point and says, “Get the barn!” before getting the barn off the shelf. After playing for a few minutes, putting animals in and out, Leah’s father pauses, holding the cow next to the barn, and says, “The cow goes in the . . . .” Leah does not respond. After confirming he still has her attention, he says, “The cow goes in the . . . buh,” and Leah replies, “Barn.” Her father playfully exaggerates the cow walking into the barn, and says, “Yay! In the barn!” before continuing to play. A few minutes later, Leah walks over to the door and looks out the window. She wants to play outside. Her father decides to use this opportunity to help Leah learn to put her socks and shoes on more independently. He says, “Get your shoes,”

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and guides Leah toward her socks and shoes. He places her socks closer to her so that she reaches for them first and narrates the process as she gets ready to go outside. When she is ready to close the straps on her shoes, he says, “Close,” and points to the straps. He provides hand-over-hand support to help her close her shoes tightly. He follows her outside to the next activity.

CONCLUSION All NDBI use prompts and prompt fading, and most use prompting hierarchies, although some are more structured and explicit than others. Awareness of the type of prompt is critical in high-quality teaching, particularly because prompt fading often requires systematic steps be taken that may require advanced planning. Although not all NDBI have clear systems for doing so, systematically tracking the prompt level promotes both consistent teaching procedures and appropriate prompt-fading procedures that are based on analysis of performance at each prompt level. Although NDBI often fade prompts in a looser fashion than traditional ABA models do, reliance on the systematic prompt-fading procedures outlined in the ABA literature may be useful in certain instances. This chapter provided an overview of how these procedures are applied in NDBI and how they can be implemented in the natural environment.

REFERENCES Brian, J. A., Smith, I. M., Zwaigenbaum, L., & Bryson, S. E. (2017). Cross-site randomized control trial of the Social ABCs caregiver-mediated intervention for toddlers with autism spectrum disorder. Autism Research, 10(10), 1700–1711. Cengher, M., Shamoun, K., Moss, P., Roll, D., Feliciano, G., & Fienup, D. M. (2016). A comparison of the effects of two prompt-fading strategies on skill acquisition in children with autism spectrum disorders. Behavior Analysis in Practice, 9(2), 115–125. Cooper, J. O., Heron, T. E., & Heward, W. L. (2007). Applied behavior analysis (2nd ed.). Upper Saddle River, NJ: Pearson. Hancock, T. B., & Kaiser, A. P. (2012). Implementing enhanced milieu teaching with children who have autism spectrum disorders. In M. E. Fey & A. G. Kamhi (Series Eds.) & P. A. Prelock & R. J. McCauley (Vol. Eds.), Communication and language intervention series: Treatment of autism spectrum disorders: Evidence-based intervention strategies for communication and social interaction (pp. 163–187). Baltimore, MD: Paul H. Brookes Publishing Co. Hancock, T. B., Ledbetter-Cho, K., Howell, A., & Lang, R. (2016). Enhanced milieu teaching. In Early intervention for young children with autism spectrum disorder (pp. 177–218). New York, NY: Springer International. Hart, B., & Risley, T. R. (1975). Incidental teaching of language in the preschool. Journal of Applied Behavior Analysis, 8, 411–420. Hemmeter, M. L., & Kaiser, A. P. (1994). Enhanced milieu teaching: Effects of parentimplemented language intervention. Journal of Early Intervention, 18(3), 269–289. Ingersoll, B. R., & Dvortcsak, A. (2009). Teaching social communication to children with autism: A practitioner’s guide to parent training and a manual for parents. New York, NY: Guilford Press. Koegel, R. L., Schreibman, L., Good, A., Cerniglia, L., Murphy, C., & Koegel, L. K. (1989). How to teach pivotal behaviors to children with autism: A training manual. Santa Barbara: University of California. Kasari, C., Fannin, D. K., & Goode, K. (2012). Joint attention intervention for children with autism. In P. A. Prelock & R. J. McCauley (Eds.), Treatment of autism spectrum disorders (pp. 139–161). Baltimore, MD: Paul H. Brookes Publishing Co. Kasari, C., Gulsrud, A. C., Wong, C., Kwon, S., & Locke, J. (2010). Randomized controlled caregiver mediated joint engagement intervention for toddlers with autism. Journal of Autism and Developmental Disorders, 40(9), 1045–1056.

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McGee, G. G., Morrier, M. J., & Daly, T. (1999). An incidental teaching approach to early intervention for toddlers with autism. Journal of The Association for Persons with Severe Handicaps, 24(3), 133–146. Rogers, S. J., & Dawson, G. (2010). Early Start Denver Model for young children with autism: Promoting language, learning, and engagement. New York, NY: Guilford Press. Seaver, J. L., & Bourret, J. C. (2014). An evaluation of response prompts for teaching behavior chains. Journal of Applied Behavior Analysis, 47(4), 777–792.

9 Using Consequence Strategies Allison B. Jobin and Laura Schreibman

A

s discussed in Chapters 7 and 8, understanding how antecedent events (both setting up the environment and instructional cues) can affect behavior is a very important part of designing and implementing effective and efficient strategies for teaching. Certainly as important in implementing Naturalistic Developmental Behavioral Interventions (NDBI) strategies is the appropriate use of consequences, which is the third component in the antecedent-behaviorconsequence (A-B-C) sequence of learning. Most people likely are more familiar with strategically using behavioral consequences than they are with using antecedents. Consequence terms such as positive reinforcement and punishment are familiar words in the popular vernacular, and most educators have used the terms and the strategies on many occasions. However, implementing consequences correctly requires very specific definitions and procedures that are far more precise than the colloquial use of these terms. This chapter focuses on the implementation, nature, and effects of consequence events in NDBI teaching strategies. Although most of these strategies are also used in the broader field of Applied Behavior Analysis (ABA) interventions, this chapter discusses their specific application in NDBI. An antecedent stimulus gains control over a behavior only to the extent that it promises or predicts a certain consequence (Cooper, Heron, & Heward, 2007). For example, a special education teacher might notice that one boy in a class with autism spectrum disorder (ASD) is highly motivated by greetings from adults. When he says, “Good morning” to his teacher, Ms. Carolyn, she always responds with a very nice smile and cheery response such as, “Good morning to you, too!” On the other hand, when he greets Mr. Richard in the same way, Mr. Richard does not usually return the greeting. Before long, the student greets Ms. Carolyn every morning but does not greet Mr. Richard. Ms. Carolyn is an antecedent stimulus that promises a positive social consequence for his greeting, whereas Mr. Richard is an antecedent stimulus promising no return greeting. This student’s greeting behavior to these antecedents was controlled by their consequences. 193

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Another all-too-familiar example is how children learn which parent to ask for something. If mom usually says “no” to a cookie before dinner and dad usually gives in to the request, the child will learn which parent is the antecedent promising a positive outcome for that cookie request! When altering or teaching a behavior, the focus is on changing the strength of the behavior. Strength of a behavior is measured in terms of its frequency (how often it occurs, e.g., how many tantrums in a day), latency (how soon after the antecedent does the behavior occur, e.g., how quickly does the child say “Daddy” when her father appears), and magnitude (with how much force the behavior occurs, e.g., decibel level of screaming) (Cooper et al., 2007). There are two basic directions to changing behavior: increasing it or decreasing it. The section that follows examines how the use of consequences contributes to such changes.

INCREASING THE STRENGTH OF A BEHAVIOR As exemplified in Table 9.1, there are two main ways of increasing a behavior. The first is to follow a behavior with a positive stimulus (i.e., object or event). A positive stimulus is anything the individual likes or enjoys. Presenting a positive stimulus is called positive reinforcement, and it is a commonly used procedure. Thus, a child is presented with a stuffed cat and says “cat.” The correct response is followed by a positive stimulus such as, “Yes! That’s right!” and access to the toy cat. This sequence of events serves to increase the strength of the correct response. Sometimes using positive reinforcement is called rewarding the behavior; this term might be more familiar. Any behavior followed by a positive stimulus will increase in strength over time. The second means of increasing the strength of a behavior is to follow a behavior by the removal or successful escape or avoidance of an aversive or unpleasant stimulus. Many drivers remember to buckle the seatbelts in the car because buckling the belt stops the annoying buzz emitted by the car. Likewise, a child might Table 9.1. Types of consequences Behavior more likely to occur in the future

Behavior less likely to occur in the future

Addition of stimulus

Positive reinforcement

Positive punishment

Removal of stimulus

Negative reinforcement

Negative punishment

Extinction

Refraining from providing reinforcement after a behavior that has previously been followed by reinforcement

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come home from school and immediately start his or her homework to avoid his or her mother’s nagging. This way to increase the strength of a behavior is called negative reinforcement. The aversive stimulus avoided is the negative reinforcer. A behavior followed by negative reinforcement will increase in strength over time.

DECREASING THE STRENGTH OF A BEHAVIOR There are three ways to decrease the strength of a response. One way is to follow the occurrence of a response with an aversive stimulus. An aversive stimulus (punisher) is anything the person does not like. This procedure is called punishment by application or sometimes positive punishment and is another commonly used strategy. People encounter punishing events all the time. If Susan reaches to touch a hot stove and burns her finger in doing so, she is less likely to touch the stove again. This behavior was punished by the unpleasantness of pain. Another behavior-reducing strategy is to follow a response by removing or avoiding a positive stimulus. If a child bites his or her sister, the parents remove the child from the room and place him or her in time-out, where he or she has no access to favorite toys or television. Because the child has lost positive things after biting his or her sister, the child is less likely to bite her in the future. This type of strategy, wherein the person loses something positive, is referred to as punishment by withdrawal, or negative punishment. A third strategy for reducing the strength of a behavior is to no longer provide reinforcement after a behavior that has previously been followed by reinforcement. This strategy is referred to as extinction and is sometimes described as planned ignoring. To use a common situation, consider a mother whose child has learned that he or she can get mom’s attention whenever he or she has a tantrum. Tantrums have been positively reinforced in the past with mother’s attention (most likely inadvertently). Mom can use extinction by not providing attention when the child has a tantrum. If mom can consistently ignore the tantrums, the child learns that this behavior no longer leads to attention, and the behavior will decrease. When extinction is initially implemented, there is typically a temporary increase in the strength of the behavior (called an extinction burst) before the behavior decreases. It is crucial that an individual using extinction expects this so that he or she does not decide the strategy is not working and prematurely abandon it. For example, when the child is used to a tantrum resulting in reinforcement, he or she may think trying harder (e.g., crying louder, throwing objects) will work when a parent first begins ignoring this behavior. If the parent responds, the child learns that crying harder, louder, and so forth works. The parent must understand this predictable phenomenon and continue to ignore the behavior during this temporary burst. Another important nuance to extinction is that the person or environment must be able to tolerate this temporary increase in the behavior. This strategy would be contraindicated for severe behaviors such as self-injury or aggression to others. Such considerations are important in the selection of the most effective and appropriate consequences for behavior change. Parents, teachers, and other caregivers should carefully consider whether extinction-based interventions are appropriate for a specific behavior or setting. Behaviors that are hard to ignore because of the setting (e.g., tantrums that occur in public) may also not be appropriate to target with extinction. In these cases, antecedent interventions may be more appropriate, which are discussed in detail in Chapter 13 on addressing challenging behaviors.

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Play on tablet after school.

Do your homework.

Help set the table.

Eat dinner.

After implementing the Premack Principle

Do your homework.

Help set the table.

Eat dinner.

Play on tablet.

Figure 9.1. Before and after implementing the Premack Principle.

APPLYING THE PREMACK PRINCIPLE A strategy often used by professionals and caregivers alike is the Premack Principle. This approach involves positioning a higher probability behavior after (or contingent on) the occurrence of a lower probability behavior in order to increase the likelihood of the lower probability behavior’s occurrence (Cooper et al., 2007). For example, a parent might say to his or her child, “First, I need you to do your homework, and then you can play on your iPad,” (see Figure 9.1) or, “If you read a chapter in your book, then you can go play on your scooter.” By altering the order of activities the child may already be doing so that the more preferred activities follow the less preferred ones, the child is more likely to be successful in all of them! The Premack Principle is sometimes referred to as the first, then; if, then; or high probability, low probability technique. It has been more fondly referred to as Grandma’s Rule, based on the history of innumerable grandmothers enticing their loved ones to eat their broccoli before they can have delicious cookies. The Premack Principle can make a big impact on positive behavior change by structuring the sequence of expectations and emphasizing what preferred activities a child can earn for demonstrating a newer, less preferred skill.

PROMOTING CONSEQUENCE EFFECTIVENESS A contingent consequence is one that occurs because the specified behavior has been emitted (Cooper et al., 2007). To increase the frequency of a child saying “thank you,” the adult would apply the positive consequence only when that verbal response occurred and not when other verbal responses or no response occurred.

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The consequence must be applied immediately after the behavior or as closely as possible. This is because the consequence that follows right after the behavior is emitted has the most effect on behavior. For example, a child is having a tantrum in the backyard. The mother wants to provide a negative consequence to the tantrum, but by the time she gets outside, the child has quieted down and is playing nicely with a toy car. If the mother then takes the child into the house for a time-out, she will essentially be punishing the nice toy play. This is because the behavior most closely preceding the time-out was toy play. The general rule is that the more quickly after a response the consequence is presented, the more potent the effect it will have. To a great extent, the number of times a consequence follows a behavior will affect the consequence strength. Thus, a response followed many times with the consequence will be stronger than one followed only a few times. The more times the child’s “thank you” is followed by a positive reinforcer, the more frequently the child will say “thank you” in the future. The magnitude of the consequence may also determine its effect. A large bite of a candy bar might have more effect than a small bite. Clinicians and parents can also use motivating operations (MOs) to strengthen or weaken the effect of a consequence, as discussed in Chapter 6. An establishing operation, or an EO, is an environmental event that increases the value of a stimulus due to deprivation, in this case a consequence (Cooper et al., 2007). To increase the reinforcing value of a particular toy, the toy should only be available when the desired behavior occurs. Likewise, the value of a readily available toy might be less than a special toy available only in certain instances. Indeed, an abolishing operation (AO) is the reduction in value of a reinforcer due to satiation. In another example, a hungry child will likely find food a powerful reinforcer, whereas a child who has just eaten a meal will likely find food a less powerful reinforcer. Individual differences always play a role in the effectiveness of any consequence. Indeed, people always have to be flexible and not tied to a specific consequence. The value of a certain consequence is even likely to vary depending on the day for the same child. Preference assessments, following the child’s lead, and related strategies can be helpful in determining whether consequences will be reinforcing (see Chapter 7 on antecedent strategies for additional information). See Box 9.1 for a summary of factors that affect consequence effectiveness and Table 9.2 for an example of how these factors should be taken into consideration in practice. ABA is a science and a technology. As such, it uses a very specific vocabulary to describe itself. This has led to some terms that have rather unpleasant and negative colloquial connotations. Punishment, negative reinforcement, extincBOX 9.1: Factors affecting consequence effectiveness • • • • •

Contingency (immediately and depending on the behavior) Number of consequences (following the target behavior) Magnitude (amount or strength of the consequence) Motivating operations (establishing operations and abolishing operations) Individual differences (value will vary depending on for whom and when)

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Table 9.2. Considerations in applying consequences Questions to ask

Response

Example: Leah is learning to brush her teeth to earn pouring out the water at the end. Is the reinforcer immediate and dependent on the child’s response?

Yes! Leah earns pouring out the water immediately after she completes the other steps of brushing her teeth. Her father holds the cup so she only gets to pour water once she is done.

Are the frequency Yes! Leah just started brushing her teeth by herself. She gets and magnitude of to pour the water out every time she demonstrates the skill. reinforcement appropriate? Is the reinforcer actually motivating for the child?

Yes! She really enjoys watching the water go down the drain. Her father changes the cup every couple of days and tries to have two choices on the counter. Her parents have been limiting water play to brushing teeth because she used to play with pouring cups all the time during free time.

Is the reinforcer directly related to the child’s behavior?

Yes! Pouring out the water from a cup follows naturally from brushing one’s teeth. First, Leah brushes her teeth. Then, she drinks some water and spits it out. The last step is pouring out the water, which Leah loves to do! Leah is more likely to keep brushing her teeth because the last step is enjoyable and has promoted learning the steps of teeth brushing.

tion, and control are just some of these terms. However, when used in the context of behavior analytic intervention strategies, these terms denote very specific procedures. Furthermore, these terms refer to the effect the procedure has on a behavior. This means determining the nature of a consequence by its function, that is, what it does to the behavior. Thus, a positive reinforcer is a consequence stimulus that, when presented after a behavior, has the function of increasing the behavior it follows. In fact, this is the only way to define a positive reinforcer. For example, Ben, a student with ASD, frequently greets his teacher, Ms. Maxwell. Ms. Maxwell decides to reinforce the greetings by giving Ben a hug each time he greets her. Although Ms. Maxwell assumes the greetings will increase, she is surprised when the greetings decrease. By definition, the hugs were not a positive reinforcer but a punisher—the greeting behavior decreased when the hugs followed the greeting. It is possible, and alas not unlikely, that Ben did not enjoy the hugs because such expressions are aversive to some children with ASD. Now consider Margie, who is acting out in class by jumping out of her chair and grabbing other students’ papers. Her teacher decides to punish her by verbally reprimanding her by saying things such as, “Margie, get back in your chair right now! I have told you to keep your hands to yourself!” He expected Margie to improve her behavior but found that Margie became more disruptive. The verbal reprimands acted as positive reinforcers—when presented after the disruptive behavior, the behavior increased. Mr. Washington assumed the reprimands were aversive because for most individuals they would be. However, Margie is a child for whom any attention, even negative, serves as a positive stimulus. As highlighted in these examples, educators, clinicians, parents, and practitioners must keep in mind that they will not always be able to determine a priori the function a stimulus will have and can only identify it by the effect it has on behavior. At times, a stimulus selected to serve as a reinforcer may not actually function

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as such in a given situation. This should serve as a cue to the therapist or teacher to try something new to increase the skill being targeted. It is important to be flexible in approaching teaching methods and students and clients! Another point is that the way behavior analysts and interventionists use the term punishment does not necessarily denote pain. More often pain is not involved in punishment at all. One very common punisher is saying “no” to a child. A therapist’s frown, a mom’s icy stare, and a father’s hands on hips are all punishers if they serve to decrease behaviors. A punisher is any stimulus that, when presented following a behavior, functions to reduce that behavior. As with the child who stopped greeting his teacher when hugs were offered, an assumed positive stimulus may actually serve as a punisher. This is the same for time-out. Indeed, many children engage in disruptive behaviors to avoid a task they do not like. Imagine an adolescent, Gabriel, who looks down and walks away each time his father tells him to put his dishes in the sink. Each time, he is told to go to his room (i.e., time-out). This behavior is actually strengthened or reinforced because it leads to avoidance of the task he was seeking to avoid from the start. At other times and for other children, time-out might be a very effective strategy. When deciding on punishment or extinction as a means to decrease behavior, clinicians should be familiar with the different features and effects of the two strategies (Cooper et al., 2007). The main difference is that punishment (when used correctly) leads to a rapid decrease in the behavior and is not associated with an initial temporary increase. Extinction, as noted previously, typically begins with a temporary increase in behavior followed by a more gradual reduction in strength. Extinction also has the advantage of not involving the presentation of an aversive stimulus. These considerations are essential in determining which type of consequence to provide for a certain situation. Another point to consider is that punishment has additional limitations. Punishment teaches a child what not to do but not necessarily what to do. Therefore, punishment is not a standalone procedure because it should be accompanied with teaching another response. For example, an educator says “no” to Francie when she wiggles her hands in front of her eyes (the “no” serves as a punisher because she stops the finger wiggling), but Francie needs something else to do with her hands. Thus, the educator might reward Francie with verbal praise for using her fingers to do a puzzle or clap her hands to music. Finally, using only punishment procedures to reduce a challenging behavior can lead to poor generalization, as behavior change only occurs when the punisher is present. Generally, NDBI favor the use of antecedent and reward strategies and limit the use of punishers.

USING CONSEQUENCES TO MAINTAIN BEHAVIOR CHANGE When implementing NDBI, the goal is to have the effects persist. In fact, if achieved behavior change is not maintained, then little has been accomplished. Different schedules of reinforcement are utilized to accomplish this maintenance and to provide a teaching environment more like the natural environment. This means that adults provide consequences in different patterns that are designed to make behavior change more durable (Cooper et al., 2007). Because the real world seldom provides consequences after every response, teachers do not provide consequences after every response.

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Table 9.3. Schedules of reinforcement Schedule Continuous Variable ratio Fixed ratio Variable interval Fixed interval

Description Reinforcement after every occurrence of behavior Reinforcement after a variable number of occurrences of behavior (around an average number) Reinforcement after a fixed number of occurrences of behavior Reinforcement after a variable amount of time (around an average amount of time) Reinforcement after a fixed amount of time

When first teaching a new behavior, reinforcing every occurrence of the behavior typically is best because this makes the connection between response and consequence the clearest. This is called a continuous reinforcer schedule (CRF or CRS) and is also referred to as an acquisition schedule because it is used during the acquisition phase of teaching. Once the individual learns the behavior, gradually reduce the amount and frequency of reinforcers to more closely mimic the real world. Also, behaviors on a CRF schedule are highly susceptible to extinction (which, alas, does happen in the real world all the time). Therefore, it is common practice to gradually move from a CRF to a maintenance schedule, which is one implemented to make behavior more durable and resistant to extinction. The main types of maintenance schedules, which are summarized in Table 9.3, include ratio schedules and interval schedules. In ratio schedules of reinforcement, every response is not followed by a reinforcer, but rather reinforcement delivery is determined by the number of responses that have occurred since the last reinforcement for the target behavior. In a fixed ratio (FR) schedule of reinforcement, the number of responses required for the reinforcer is consistent. For example, the child receives 5 minutes of video game time for the completion of every 15 math questions. In a variable ratio (VR) schedule of reinforcement, the number of responses varies between reinforcements. Of course, the best example of a variable ratio schedule is gambling. The number of times a person has to activate a Las Vegas slot machine to win varies. Gambling behaviors are strong, and individuals who program the machines are truly experts in building rapid and durable behaviors in people! Ratio schedules can be used to build very high rates and durable levels of responding. (However, clinicians must be careful not to make the ratio too high or extinction might occur.) In interval schedules of reinforcement, the reinforcer is delivered after a specified amount of time. The reinforcer is not delivered for free, though. Rather, it is available after the first response occurs after the interval has passed. For a fixed interval (FI) schedule of reinforcement, this time interval is consistent. Thus, a child receives 5 minutes of video game time after working on math for 15 minutes. It does not matter how many math problems are completed but rather how much time the child has spent appropriately working. A variable interval (VI) schedule of reinforcement is one in which the reinforcer is available after a specified time interval but the intervals vary. The child may earn the 5 minutes of video game time but after differing amounts of time working on math. He or she gets the video game time after only 5 minutes on one interval but after 20 minutes on the next interval, and so forth. Interval schedules typically are associated with moderate but stable levels of responding.

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SHAPING AND CHAINING Sometimes a therapist wishes to strengthen a behavior that does not occur. In these situations, he or she needs to build up to it. The two main methods of achieving this are shaping and chaining (Cooper et al., 2007). Shaping occurs when the therapist provides consequences to responses that gradually lead to the final response. The therapist does this by reinforcing successive approximations to the target response. To illustrate, a therapist wants to teach a child to say “dog” when presented with a toy dog. At first, the child is unable to say the word, so the therapist presents the dog, and as soon as the child vocalizes, the therapist provides the reinforcer (“Good talking!” and a toy dog). When the child consistently vocalizes when presented with the dog, the therapist now waits with the reinforcer until the vocalization approximates a /d/ sound. Because other sounds are not reinforced, they will extinguish. When the child consistently makes a /d/ sound when presented with the dog, the therapist waits until his or her vocalizations sound like “da” or “du” before praise. The therapist continues reinforcing successive approximations of the word “dog” until the child consistently responds to the toy with “dog.” In shaping, strict definitions are used for which responses will be reinforced (i.e., the next version of the target behavior) and which will be put on extinction (i.e., the previous version of the target behavior). Many NDBI use a looser shaping contingency, such as reinforcing attempts in Pivotal Response Treatment (PRT; Koegel, Schreibman, Good, Cerniglia, Murphy, & Koegel, 1989), in which successive approximations are reinforced and reinforcement of previous approximations is slowly faded as the child gains skills, or responding to all communicative bids in Project ImPACT (Improving Parents as Communication Teachers; Ingersoll & Dvortcsak, 2009) to increase initiation and build toward specific words and gestures. Chaining is another method of building up to a more complex target behavior. Rather than waiting for the individual to make the next advancement in behavior (as in shaping), in chaining the instructor determines the steps of advancement. Chaining involves breaking a behavior into component steps and teaching the steps individually in sequence so that when these steps are performed in sequence the target behavior is achieved. Self-help skills are frequently taught in this manner. In teaching a child to pull up his or her pants, the instructor might start with having the child stand with his or her feet in the leg holes of the pants. When the instructor says, “Pants up,” the child might be prompted to lean over and touch the pants. The instructor reinforces this response. When the child consistently touches his or her pants when told “pants up,” the instruction would progress to the next step in the chain. This involves the child grabbing the waistband of the pants, perhaps with a prompt at first. Once this step is mastered, the child is required to raise the pants to his or her knees before reinforcement is delivered. Once this is mastered, the child is required to pull the pants all the way up to his or her waist. This is an example of forward chaining, where the instruction begins at the beginning of the complete response. Most responses can be taught using backward chaining, where the chained steps are taught from the end step to the beginning. For the pants example, the instructor would begin with having the pants pulled up and start by reinforcing touching the waistband. The next step in the chain would be starting with the pants pulled up to within a few inches of the waist, and the child would have to pull the pants all the way up. The next step might be starting with the pants at the knees, and the child would pull them all the way up, and so forth.

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Thus far, this chapter has discussed the foundational components that underlie consequence strategies in NDBI and, in fact, all behaviorally based interventions. However, there are unique ways that consequence strategies are applied in NDBI. The following section reviews the applications of consequence strategies specific to NDBI and highlights some ways NDBI may be different from other commonly used behavioral intervention strategies.

USING NATURAL CONSEQUENCES NDBI use natural, rather than unrelated, reinforcement to follow target behaviors (e.g., Ingersoll & Schreibman, 2006; Koegel, Camarata, Koegel, Ben-Tall, & Smith, 1998). Natural reinforcement is contingently providing an item, activity, or response that is directly related to the child’s behavior. It often mimics the natural consequence that might occur if the child were to demonstrate the target skill in the natural, realworld environment. In some cases, natural consequences are straightforward to set up. For a child just learning to use words, a mother using NDBI would reinforce her daughter’s vocalization of “buh” to earn her blowing bubbles. A young boy learning to expand his language to full sentences would receive reinforcement with stopping a nonpreferred task—such as completing homework—by saying, “I need a break.” Use of natural reinforcement can be more complex, as well. Imagine that a teacher is teaching 7-year-old Mateo to ask another child to play with him. The teacher tells Mateo to pick between two preferred games, Connect Four and Uno, and to ask another child to play with him. When Mateo asks his peer, “Do you want to play Uno with me?” Mateo and his friend get to play the game. In this example, saying “Do you want to play Uno with me?” is directly reinforced by getting to play the game. Natural consequences are sometimes referred to as direct reinforcers because there is a direct relationship between the child’s response and the reinforcer he or she receives contingent on that response. For example, Solomon is learning to imitate actions. He loves playing with instruments by banging them on the ground and on tables. The therapist prompts him to imitate clapping the cymbals together and then gives Solomon free access to the cymbals. He then chooses to bang them on the table in front of him, which serves as reinforcement for imitating the therapist’s action. In another example, imitation of a symbolic play act with a preferred toy would be reinforced by the child’s continued access to the preferred toy and freedom to play as the child wishes (generally paired with social attention). This relationship between the response and the reinforcer promotes maintenance and generalization of learned skills (Schreibman & Koegel, 2005). For example, when Mateo learned to invite his peer to play using NDBI, his behavior was reinforced by getting to play a game. When Mateo uses this skill during a playdate at his house or at the park, he is likely to be reinforced in a similar way—at least some of the time. When the other children respond to him by playing the game he suggests, he receives reinforcement for this behavior in the real world, thereby maintaining the skill over time and across environments. This is in contrast to more traditional behavioral strategies that might involve the child completing a task to receive a reward unrelated to the specific behavior being taught. For instance, a child learned to say, “Will you play with me?” in order to earn a token on a token chart or a high-five from the teacher for practicing the appropriate social phrase

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at the table during a lesson. The token is not related to saying “Will you play with me?” whereas getting to play is directly related to asking the question. It is optimal when the natural reinforcer matches and is specific to the language or behavior that was demonstrated. For instance, if a child says, “Ball, please,” it is best to give him or her a ball. However, if he or she were to say, “Roll the ball,” the therapist should roll the ball to the child rather than just hand it to him or her. Social praise also has an important role in consequence strategies. In NDBI, tangible natural reinforcement should be paired with social praise (e.g., “You did it!”). When possible and developmentally appropriate, specific social praise is recommended (e.g., “Great! You asked me an on-topic question!”) to better link the feedback to the target behavior. Sometimes, the natural consequence is socially based. For instance, Sylvia is learning to broaden her conversational segues with peers. When she uses an appropriate segue—or one that she has not readily used before—the therapist might smile at her and respond with an interesting tidbit. Children differ in the degree to which social praise or social consequences are of interest to them. Regardless of whether these types of consequences have current value, they should be paired with more tangible rewards. This not only helps the child to associate social praise with positive, preferred consequences—which should in turn increase the value of social praise—but it also increases the value of the therapist as the number one reinforcer! Indirect or unrelated reinforcers also serve an important function in behavioral intervention and may, at times, be the most appropriate consequence (LohrmannO’Rourke & Browder, 1998). Indirect or unrelated reinforcement involves providing a contingent item, activity, or response that is desirable to the individual child but not related to the child’s behavior. There are certain goals that are not necessarily amenable to natural reinforcement. Some skills, such as toilet training or refraining from repetitively tapping the desk with a pencil, do not seem to have a related motivating component. Consider if there is a natural consequence that could be motivating to the child. Or, is there a natural consequence that encourages other people to keep doing that behavior? If a natural reinforcer does not seem to exist, an indirect reinforcer may be integrated. A child could earn something highly preferred after using the potty or earn a check on his or her self-management chart for keeping hands folded in his or her lap during a math lesson. Because NDBI focus on the use of natural reinforcement, clinicians should think creatively when struggling to identify this type of consequence. For example, if a child needs to write a nonfiction report for school, choosing a preferred topic (e.g., dinosaurs) and then being reinforced with an object related to that topic (e.g., a dinosaur toy, sticker, television show) is still more natural than reinforcing the child with candy. Likewise, practicing math with Legos instead of counting bears might be naturally reinforcing for a child who likes Legos and could then add them to a Lego tower after completing each math problem. One last point to emphasize: When antecedent and consequence strategies common to NDBI are used together, it is often easier to identify an effective reinforcer all together. To illustrate, the antecedent strategy of using highly motivating materials to teach a child to imitate a pretend play sequence (e.g., a monkey climbing a vine, jumping into the tree, and picking a banana on a jungle play structure) could be followed by free play with the monkey and the jungle for a few moments—serving as positive reinforcement of the imitation sequence.

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Of course, if an arbitrary or preselected set of pretend play materials were chosen by a therapist to teach imitation, free access to the materials afterward would not serve as reinforcement. This is one reason why incorporating preferred materials, when possible, can have a big impact on treatment effectiveness. Likewise, when setting up a teaching opportunity for behavioral flexibility, a therapist might take out the child’s favorite Legos. After he or she practices being flexible by building the therapist’s idea of a castle, the therapist then follows the child’s idea to build a ship like the Titanic. Although antecedent and consequence strategies from NDBI are discussed in separate chapters, it is important to remember how they truly work in tandem. Figure 9.2 includes several examples across

Communication

• Getting a break for saying “break” or handing a break card • Giving the student a toy from the shelf after he or she points to it • Making a silly face after the child makes eye contact with the therapist • Giving the child the food he or she chooses after offering a choice of crackers or goldfish • Going to play outside after the child follows the instruction, “Put on your shoes and jacket” • Turning the page in a favorite book after the child points and comments on what he or she sees

Play

• Flapping the board game cards up and down after taking a turn with the game • Pouring all the Lego pieces into another container (dumping things out is the student’s favorite sensory activity) after building a pretend castle • Sharing a preferred play idea for the pirate ship after following the therapist’s idea first • Earning a chance to play freely with cars (e.g., lining them up, parking the cars) after pretending to fill up the gas tank and go through the carwash

Social interaction

• Getting a turn talking about a favorite topic, volcanoes, after asking a question about a less preferred topic • Getting to pick the game after inviting a peer to play together • Continuing a song with gestures with the teacher after filling in the blank on the lyrics during the pause • Adding more favorite character figurines to the play activity after responding to a peer requesting a turn • Getting to play alone after playing near peers for 5 minutes

Daily living skills

• Letting the child flush the toilet after going potty by him- or herself • Getting to pick out a favorite shirt after the young child puts on pants by him- or herself • Listening to a silly bathtime song after going to bathtime the first time asked • Letting the child who loves to take a bath get in the tub after getting his or her bath towel first

Figure 9.2. Examples of natural reinforcers.

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different types of activities, routines, and skills to demonstrate natural reinforcement possibilities in action.

REINFORCING ATTEMPTS A procedure related to natural reinforcement is the use of loose reinforcement contingencies, also referred to as loose shaping or reinforcing attempts (Koegel, O’Dell, & Dunlap, 1988). This component involves providing reinforcement not only for the requested behavior (e.g., for the child to clean up all the toys on the floor) but also for a goal-directed attempt in the right direction (e.g., the child cleaning up the blocks and cars but not the train set). The goal of this strategy is to keep the child’s motivation high and to reinforce trying, or initiating, while teaching novel behaviors. There is some variation across NDBI approaches in terms of how closely the child’s performance matches the target in order to receive the reinforcer. Also, the range of responses that might be reinforced will gradually shift as behaviors develop to closer and closer approximations of the final target. For example, Monica is learning to say “go outside” to request to play in her backyard. At first, her father might provide reinforcement for “go,” “outside,” and “go ouh.” Once she starts doing these more consistently, he may only reinforce initiations that are two syllables. The range of responses may eventually become slimmer until Monica is ready for an even more complex initiation. It may feel difficult to reinforce an attempt when the child can (and has) done better before. However, it is important to remember that reinforcing attempts follows “good trying” with positive outcomes. This, in turn, reinforces trying or initiating, which leads to more trying and more initiating—which is essential to building new skills!

MODELING AND EXPANDING ON CHILD’S RESPONSE Modeling and expanding on the child’s response includes an adult demonstration of appropriate behaviors during interactions (e.g., Ingersoll, Lewis, & Kroman, 2007; Ingersoll & Schreibman, 2006). For example, the therapist might provide a compliment about what the child is building (e.g., “Vincent, I love that tall tower!”) or narrate what he or she is doing (e.g., “I am building a pool with a diving board.”) Expanding on the child’s response, also referred to as recasting, involves adding on to what the child said or did, often along with providing reinforcement. For instance, Joanna is giving her daughter, Molly, a bath. Molly bounces the rubber ducks up and down in the water, making a splash. Joanna exclaims, “Duckies! Splash, splash!” while taking a rubber duck and bouncing it in the water. Modeling and expanding on the child’s response should follow the child’s focus of interest and often demonstrates a target skill of interest. As has been previously highlighted, NDBI optimally involve the use of multiple components together during learning opportunities. In regard to modeling and expanding, these strategies can actually be utilized as both antecedent strategies (i.e., before the child’s response) and consequence strategies (i.e., in response to the child demonstrating a target skill). These strategies are discussed in the context of consequence approaches within NDBI. Their use as antecedent strategies is discussed further in Chapter 7.

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Modeling is used to teach target skills from many domains, including language, imitation, social, play, cognitive skills, motor skills, and even some selfcare skills. The rationale for modeling and expanding on the child’s response is that it provides additional opportunities for the child to hear or observe appropriate and more complex responses. In NDBI, children often practice the modeled response immediately after or at another time. In some NDBI approaches, modeling is used as a specific prompt strategy such that the child is expected to imitate the modeled action or language. In these situations, the model may serve as both a consequence to an earlier response and an antecedent setting the stage for the next teaching moment. In other NDBI approaches, modeling provides an opportunity for the child to learn from observation, but the child is not expected to demonstrate the skill (although the child often does!). The modeled behavior is carefully chosen with developmental considerations in mind, such as modeling behaviors slightly more advanced than the child’s current developmental abilities.

IMITATING THE CHILD’S RESPONSE One additional technique common to many NDBI is the practice of imitating the child’s response. This is often referred to as contingent imitation, mirroring, or reciprocal imitation. This strategy is used to increase the child’s responsivity and attention to adults, to increase the child’s future imitation of adult-modeled behaviors, and to promote continuation of the interaction. As an example, a grandmother and granddaughter are playing on the grass at the park. They have a playset of picnic materials. The granddaughter claps two cups together, and her grandma follows suit. Soon, the two are swaying back and forth, clapping the cups together. As the granddaughter puts the cups down, the grandmother picks one up and takes a big pretend sip of water. The granddaughter then takes the other cup and puts it to her lips, as well. Imitating the child’s response is another strategy that sometimes feels unnatural to use at first, especially if the child is using unusual behaviors or sounds. However, for many children, imitating their sounds and actions can truly increase their engagement and help them to share their activity. This opens up the door for other learning opportunities during that episode of engagement. Research indicates that both children with ASD and typically developing children respond with increased attentiveness to the adult partner when being systematically imitated (Dawson & Adams, 1984; Dawson & Galpert, 1990). NDBI vary in the degree to which imitating the child is a central feature of the intervention, and none recommend imitating inappropriate or dangerous behavior. See Table 9.4 for an example of how consequence strategies, including imitating and modeling, can be effectively implemented.

TROUBLESHOOTING NDBI CONSEQUENCE STRATEGIES Although the NDBI strategies are likely to be effective much of the time, there may be roadblocks along the way. This section provides strategies to troubleshoot difficulties and avoid some of the most common pitfalls. Overall, the soundest advice regarding implementation of NDBI is to learn and understand the foundational principles. With a firm grasp on these, practitioners can step back, evaluate each

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Table 9.4. NDBI-specific considerations in applying consequences Questions to ask

Response

Example: Katie is learning to take turns with another child, Jackson, while playing with trains. After she takes a turn with the train tracks, she gets another train added to the track. Jackson gets more figurines added to the play scene for taking turns and responding to turns. Is the reinforcer actually motivating for the children?

Yes! Katie loves vehicles, including trains. Because Jackson does not like trains very much, the therapist considers his favorite activities, playing with figurines. The therapist incorporates trains, train tracks, and figurines into the play materials. Jackson earns figurines for demonstrating turn taking, and Katie is reinforced with trains. Is the reinforcer directly Yes! The children are learning to take turns during play. When related to the child’s Katie asks for a turn with the train, she gets a train. (Sometimes behavior? the therapist has to help Jackson give the train to her.) When Jackson responds to the turn request, Katie is prompted to give Jackson one of the figurines. Are attempts reinforced? Yes! Jackson and Katie receive reinforcement not only for taking turns independently but also for when they need prompting. Katie earns her reinforcer even if she gives Jackson a train when he says, “My turn with the little boy (figurine).” Is there modeling and Yes! Katie usually says, “My tuh,” when asking for a turn with the expanding on the train. Her therapist then says, “My turn, please.” Sometimes she child’s response? asks for a turn by pointing to her preferred toy. Her therapist then expands on this response by overlaying “My turn!” while Jackson gives her the toy. Is there imitation of the Yes! The therapist imitates the target responses of requesting and child’s response? responding to turns. The therapist also imitates the play she observes from Katie and Jackson, such as connecting the train tracks, having the figurines talk to each other, and including unique actions such as when Katie makes the trains fly in the air.

obstacle, and adapt their approach more effectively while maintaining the integrity of the models. • “It isn’t working.” When it seems that an intervention is just not working, there are a few questions to consider. First, “What is the goal of the interaction?” Although this seems like a silly question at first glance, NDBI look and feel like play or natural day-to-day interactions by design. Sometimes this can lead to lack of clarity about the learning opportunities. It is essential that a clear goal is set when implementing NDBI. For example, the goal may be building conversation skills on topics chosen by another person, playing cooperatively on the same theme, or protesting appropriately. This question may help add that missing structure needed to set the child up for success. The second most important question is “What is the reinforcer?” If the answer is not clear, consider restructuring the opportunity to include a clear and motivating reinforcer. Individuals are much more likely to learn something new when it is followed by a desired outcome. Along these lines, remember the foundational tenets surrounding effective use of consequences. Potential reinforcers must be provided immediately after the target response (or as soon as possible) and contingently. If it seems the reinforcers are not working, consider whether the reinforcement is being provided on the right reinforcement

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schedule (Is it consistent enough?) and at the right potency. Is the reward worth the work? Is it restricted to teaching opportunities, or does the child get to play with it in and outside of treatment sessions? • “My child is not motivated for anything!” Another common snag in implementing NDBI is that reinforcement does not work. This statement in and of itself is a misnomer. By definition, a reinforcer is a consequence that increases the future likelihood of the behavior it follows. So, if the consequence does not change the behavior it follows over time, it was not actually a reinforcer. This is not an uncommon problem because motivation can change at the drop of a hat. Moreover, many children with ASD are motivated by less traditional items and activities. There are a variety of ways to address this potential setback in implementation of NDBI. The first step is to evaluate the use of reinforcement. Perhaps the iPad is a highly desirable item for a young girl. However, the young girl can play on the iPad any time she wants—regardless of whether she has demonstrated a new skill. Or, perhaps there is a gap of time between when the girl earns the iPad and when she can use it because it has to be charged first. Or, maybe the child gets brief iPad breaks after practicing conversations about her favorite game, Minecraft, but the game she wants to play takes more than a couple of minutes, thereby making the reinforcer frustrating. The most dependable strategy for identifying effective consequences for increasing positive behaviors is to conduct a reinforcer assessment. This might include simply observing the child in a free operant situation, in which he or she is given free access to the materials in front of him or her. The observation should clarify what the child would do if given free reign of the environment. This free operant observation is a great approach to take before using NDBI of any kind. It is important to be flexible when looking for reinforcers because the child’s reinforcer might not be a predicted one. If the child in the free play situation just sits on the floor and spins the wheels of the car, it may be tempting to think that he or she is not interested in anything in the environment, but actually the reinforcer is spinning. Because there are many behaviors relating to spinning (and many toys that spin), it may be effective to incorporate spinning in the response and the consequence. The child could be prompted to say “spin” and then be allowed to spin an object he or she likes to spin. Spinning is not necessarily a behavior that clinicians want to encourage in children with ASD because it is often an inappropriate stereotypic behavior. However, if this is the only behavior that clinicians can use, they will use it. By switching to an appropriate spinning toy as the child progresses, the reinforcement will move away from spinning to incorporate a wider range of reinforcing consequences. In addition to informally observing the child to identify reinforcers, there are also more structured and formalized reinforcement assessment procedures that are commonly used in the broader ABA field, as well as tools that are available for purchase or for free online (see Kang, O’Reilly, Lancioni, & Falcomata, 2013, for review).

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• “My child demonstrated the target skill, but other children are not responding, so he or she is not reinforced!” Sometimes, the way to reinforcement is through the social behavior of another child. Setting up opportunities to practice social-communication, social interaction, or play skills with peers is often ideal to promote generalization and to use the most natural consequences possible. Yet, difficulties can arise when relying on peers. For example, Jackson is learning how to ask for a turn. The toy he asked for is something he truly wants (so it reinforces “asking for a turn” behavior). His peer, Mitchell, however, does not give him the toy when Jackson asks for it. One possibility is that Mitchell did not know Jackson was asking for the toy because Jackson forgot to say his name and they were on a busy playground. In this case, the teacher might tell Jackson that Mitchell did not hear him and prompt him to try again while saying his name. Here, the teacher is highlighting the natural consequence and then teaching him something new. Another possibility is that Jackson provided an excellent turn request, but Mitchell did not want to give up the toy. In this situation, the teacher might either prompt Jackson to wait and ask again later or consider the motivation for Mitchell. When incorporating the use of peers into NDBI implementation, all participants—peer models included—must have appropriate motivation or reinforcement to demonstrate target skills. In this example, perhaps the teacher reinforces children who respond positively to turn requests by offering them a different toy or by reminding them to ask for their turn back in just a few minutes. • “I don’t want to bribe my child.” Sometimes people see reinforcement as a form of bribery and are uncomfortable using it. However, a bribe is usually something a person uses to get someone to do something wrong. NDBI instead provide reinforcement for positive behaviors that adults wish to encourage. Furthermore, a bribe is typically presented before the behavior, whereas a reinforcer is presented after the behavior. For instance, giving a child a piece of candy to go hit another child would be a bribe. Giving the same child a piece of candy for not hitting a child would be a reinforcer. Even more, adults may at times feel they are forfeiting the authority of their word if they incorporate rewards for an expectation. In actuality, they are strengthening the power of their word by associating it with preferred items. Also, in everyday life, rewards are truly natural and universal for positive behaviors. Reinforcement is a common part of daily life for children and adults alike, not only in circumstances that could be considered a bribe. When adults get a paycheck for doing their job, they certainly do not consider it a bribe! • “I don’t know how to use NDBI to teach more advanced skills.” As discussed previously in this chapter, use of NDBI is more straightforward with early learning skills that have clear direct reinforcers and target skills. For instance, when teaching a child his or her first words to request or protest, educators should select words around the child’s primary interests and gripes. The reinforcement would be receiving those preferred items (or stopping those

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nonpreferred activities). On the other hand, implementation of NDBI with older children and higher level skills can be daunting. It is more difficult to identify the natural consequence of an abstract social skill, such as responding to nonverbal social cues, or a more complex social interaction, such as reciprocal conversation at lunchtime. To use NDBI to teach these more advanced skills, consider the incentive for why other individuals engage in the target skill, and explore the natural consequence that would follow—at least some of the time. The finesse is setting up the opportunity to allow for that direct reinforcement to occur. For example, Michael is an 8-year-old who enjoys having conversations with others—as long as he gets to talk about his favorite topics: dinosaurs and earthquakes. One of his goals is to expand conversations to less preferred topics, especially those another peer has chosen. Right now, he changes the topic to his favorites or just does not respond if another person starts a conversation on another topic. To utilize NDBI consequence strategies, his therapist tells him that he can take turns choosing the topic of conversation. Once he makes three or four exchanges on a topic chosen by his peer, he can then segue into his preferred topic of conversation (i.e., the direct reinforcer). The therapist remembers to reinforce attempts by moving on to the other topic of conversation, sometimes after just one exchange on a neutral or nonpreferred topic and other times after he has made at least three exchanges.

CONCLUSION Application of these consequence strategies is critical to the effective implementation of NDBI. Consequence strategies are founded in traditional ABA approaches but also have unique adaptations in NDBI. These strategies are likely to not only support the teaching of new skills but also maintain previous learning. Consequence strategies have their greatest impact when effectively incorporated with others that have been reviewed in prior chapters. As a reminder, all NDBI learning opportunities occur within the context of the three-term contingency, or the A-B-C sequence of learning. Thus, when setting out to use NDBI, first consider the antecedent strategies to set the stage for learning and to create effective teaching opportunities. Also identify the child behaviors to reinforce and the behaviors to not reinforce. Finally, as discussed in this chapter, decide how to respond to the child to promote long-lasting learning. Even though NDBI often look and feel like play and natural, real-life interactions, informed observers will find multiple iterations of the A-B-C sequence. Now that you are familiar with the core antecedent and consequence strategies central to NDBI, the following chapters explore teaching specific new skills.

REFERENCES Cooper, J. O., Heron, T. E., & Heward, W. L. (2007). Applied behavior analysis (2nd ed.). Upper Saddle River, NJ: Pearson. Dawson, G., & Adams, A. (1984). Imitation and social responsiveness in autistic children. Journal of Abnormal Child Psychology, 12, 209–225. Dawson, G., & Galpert, L. (1990). Mothers’ use of imitative play for facilitating social responsiveness and toy play in young autistic children. Development and Psychopathology, 2, 151–162.

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Ingersoll, B. R., & Dvortcsak, A. (2009). Teaching social communication to children with autism: A practitioner’s guide to parent training and a manual for parents. New York, NY: Guilford Press. Ingersoll, B., Lewis, E., & Korman, E. (2007). Teaching the imitation and spontaneous use of descriptive gestures in young children with autism using a naturaistic behavioral intervention. Journal of Autism and Developmental Disorders, 37, 1146–1456. Ingersoll, B., & Schreibman, L. (2006). Teaching reciprocal imitation skills to young children with autism using a naturalistic behavioral approach: Effects on language, pretend play, and joint attention. Journal of Autism and Developmental Disorders, 36, 487–505. Kang, S., O’Reilly, M. F., Lancioni, G., Falcomata, T. S., Sigafoos, J., & Xu, Z. (2013). Comparison of the predictive validity and consistency among preference assessment procedures: A review of the literature. Research in Developmental Disabilities, 34, 1125–1133. Koegel, R. L., Camarata, S., Koegel, L. K., Ben-Tall, A., & Smith, A. E. (1998). Increasing speech intelligibility in children with autism. Journal of Autism and Developmental Disorders, 28, 241–251. Koegel, R. L., O’Dell, M., & Dunlap, G. (1988). Producing speech use in nonverbal autistic children by reinforcing attempts. Journal of Autism and Developmental Disorders, 18, 525–538. Koegel, R. L., Schreibman, L., Good, A., Cerniglia, L., Murphy, C., & Koegel, L. K. (1989). How to teach pivotal behaviors to children with autism: A training manual. Santa Barbara: University of California. Lohrmann-O’Rourke, S., & Browder, D. (1998). Empirically based methods to assess the preferences of individuals with severe disabilities. American Journal on Mental Retardation, 103, 146–161. Schreibman, L., & Koegel, R. L. (2005). Training for parents of children with autism: Pivotal responses, generalization, and individualization of interventions. In E. D. Hibbs & P. S. Jensen (Eds.), Psychosocial treatments for child and adolescent disorders: Empirically based strategies for clinical practice (pp. 605–631). Washington, DC: American Psychological Association.

10 Guiding Meaningful Goal Development Grace W. Gengoux, Erin E. Soares, and Yvonne Bruinsma

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he previous chapters highlighted that the Naturalistic Developmental Behavioral Interventions (NDBI) approach focuses on the selection of meaningful goals. Many of the previous chapters emphasize how to select functional goals in specific skill domains such as communication, social skills, adaptive behavior, and academics and how to teach these skills in developmental sequence using NDBI strategies. This chapter extends these discussions to provide practical guidance on how clearly operationalizing goals can make tracking progress and mastery easy, as well as how NDBI providers select and prioritize meaningful objectives across developmental domains. Parents and providers may find it difficult to write goals that adequately capture the meaningful changes that they want to promote in a child or adolescent’s development. In fact, one of the major challenges in NDBI goal development is that the most important goals can be difficult to measure. For instance, when the true goal is improving social reciprocity, that objective may seem difficult to break down into achievable subcomponents (e.g., imitating an action) that can be practiced in treatment sessions and daily activities. NDBI approaches are unified in emphasizing the importance of selecting meaningful, measurable, and attainable goals for individuals with autism spectrum disorder (ASD). They highlight creating and teaching goals that follow a developmental sequence and advance a child’s capacity for independence. The constructivistic approach inherent in NDBI means that goals should be taught in settings that naturally capture children’s attention, engage them to connect their new skills to previously mastered skills, and systematically increase the level of difficulty of targeted skills. Writing goals that are just one step beyond a child’s current knowledge helps to promote success, as well as generalization of targeted skills. In addition, it is suggested that goals include the full range of developmental domains (cognition, social, communication, daily living skills, motor, and play) and integrate knowledge across domains. This approach increases the generalizability of learned skills; when 213

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skills are taught in a discrete or isolated manner, children struggle to absorb them and practice them in alternative settings. Instead, the NDBI approach suggests using varied materials and people to teach skills to children within their daily interactions and routines to provide a solid foundation for effective and efficient learning. Theories of child development suggest that skills develop in a certain order; thus, it makes sense to follow this order when teaching. In fact, one important contribution of the developmental theory underlying NDBI approaches is the emphasis on ensuring that therapy goals are just above a child’s current skill level and, as such, fit within the developmental skill sequence. Selecting skills in a predetermined rigid order from a curriculum may be convenient but may also result in low skill maintenance. In addition, an uninformed goal-selection process may produce goals the child has already mastered or those that are too advanced. Furthermore, a child should learn to use a skill under different conditions with many communicative partners (generalization), and the skill should have enough depth and fluency to be truly useful to the child. The important constructs of developmental sequence and generalization are at the heart of the NDBI approach to goal selection and are central in the discussion throughout this chapter.

FORMULATING GOALS When developing NDBI goals, providers must create target skills and write goals that are not only functional, developmentally appropriate, and individualized to each child but are also relevant to the child’s culture and valued by the family. Before discussing these issues in detail, this section provides practical guidance on writing and working toward measurable objectives across the different developmental domains. NDBI goals should be written with an instructional program outlining exactly how they will be practiced to ensure that all providers are teaching the skills in a coordinated manner. The Project DATA (Developmentally Appropriate Treatment for Autism) model, for instance, recommends writing instructional programs that clearly delineate the target skill, the steps of that skill, examples of how to teach the skill, mastery criterion (how to know that the skill has been effectively learned), and ways in which both generalization and maintenance will be promoted. As advocated by various NDBI, well-written goals across domains share many characteristics. Goals should be specific, be measurable, have mastery criteria, and be written based on the typical sequence of development. Target skills and goals should also be relevant to the child’s culture and important to the child’s family. When family members consider the goal to be meaningful, they are more likely to present naturalistic opportunities for the child to practice and maintain the skills, which subsequently facilitates generalization. Measurable Goals All NDBI are congruent in their emphasis on goals that are measurable. Measurable goals need a clear statement of whichever behavior is expected. This should be written with adequate descriptive information, and the behavior should be observable and specific. If the overarching goal is to foster and practice joint attention, observable behaviors might be pointing at something, gazing in the same direction as a peer, or orienting one’s head to an object or item that another person has identified. These goals are measured by observation so that an adult could determine the

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success of a child with this goal by reading the objectives and observing his or her play. The following example is a goal written in NDBI format: “Amad will visually follow when a peer points to an object at a distance, look at the object, and then make eye contact with the peer. He will demonstrate the behavior at least two times across three consecutive play sessions, with at least three different peers.” Goals should also list the antecedent to the target behavior. This helps to provide context for the skill as well as to outline a goal that has a clear identifier to maintain consistency across teachings. For example, if a child has a goal of using the toilet independently, an antecedent could be the identification of the need to use the toilet. Or, if a child’s targeted skill is to say a reciprocal “hi” when seeing or meeting a new person, the other person saying “hi” would act as the antecedent. For instance, in the example with Amad, the addition of the following specification would make the antecedent for the goal more clear: “In response to a peer saying, ‘Hey, look at that!’ while standing no more than 5 feet away from Amad and pointing to an object across the room (antecedent), Amad will visually follow when a peer points to an object at a distance, look at the object, and then make eye contact with the peer. He will demonstrate the behavior at least two times across three consecutive play sessions, with at least three different peers.” Mastery Criteria As evidenced in the previous example, reasonable and measurable mastery criteria are also crucial to include when writing goals consistent with the NDBI approach. Mastery criteria specifically define how providers can judge if the child learned a specific behavior, as well as the child’s level of mastery with the target behavior. Including mastery criteria ensures that teaching is focused and retains clarity. Without clear mastery criteria, providers would have difficulty determining when a child has successfully learned a skill and thus when to proceed to more advanced skills. Mastery criteria also help determine how quickly a child might learn skills by providing time-limited goals within the child’s developmental and individual abilities. In the previous example, evaluators would consider that Amad has mastered the specific joint attention task after completing the behavior two times within three consecutive sessions, with three different peers. It is important to note that special care should be taken when mastery criteria utilize percentages (e.g., Amad will look at the object 75% of the time). Percentages can be poor characterizations of success; can be very hard to measure, as in the previous goal example; and can be meaningless with few trials. In addition, percentages can be especially unhelpful in writing goals that target behaviors that are spontaneous or independent of a peer or teacher because providers would have difficulty defining the opportunity. Maintenance and Generalization NDBI goals specify the criteria for maintenance and generalization of each targeted behavior. Focusing on maintenance ensures that skills are maintained over time and thus saved in a child’s tool box of skills for regular and repeated use. For generalization, skills must also be performed successfully across various naturalistic settings and with various people. When target behaviors are used in novel situations or with novel people, this is usually an indication that a skill has been

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generalized. Goals should be written with specifications about the settings, materials, and individuals with whom the skills should be demonstrated. Criteria can also be included about how long the skill should be maintained. After sufficient practice, a learned skill should be robust enough to be demonstrated consistently across all relevant contexts. Table 10.1 includes several examples of measurable goals for a 3-year-old child with ASD. Sample objectives are provided across several important domains, including joint attention, imitation, play, and self-care. Each objective clearly specifies the relevant setting or antecedent, as well as mastery and generalization criteria. Objectives are then broken down into five or six steps to illustrate how a provider may sequentially teach components of the objective to a child. The objectives are written clearly and concisely and are formatted to include the setting, the specific behavior of focus, an antecedent if applicable, and the mastery and generalization criteria. Parent Training Goals Parent training goals can be identified based on assessment of parent skills at the start of treatment and also based on discussion of parent priorities for their own learning. Just like goals for child skill acquisition, parent training goals should be meaningful, individualized, and clearly operationalized. Many NDBI programs have criteria for treatment fidelity. These can be applied to assessment of therapist treatment fidelity but also assessment of parent treatment fidelity. However, parent training goals can also span a wide range of additional skills, depending on the parent’s learning priorities. Parent training goals fall into several categories. As described previously, these goals may relate to parent acquisition of specific skills. A parent may decide that he or she wants to learn to implement a particular NDBI approach with treatment fidelity. For instance, the Pivotal Response Treatment (PRT), JASPER (Joint Attention, Symbolic Play, Engagement, and Regulation), and Project ImPACT (Improving Parents as Communication Teachers) programs often include parent training as a core part of intervention and systematically teach parents to implement the same procedures therapists are using. A parent might also select a specific treatment strategy to learn and practice (e.g., natural reinforcement, reinforcing attempts). Another approach to goal development would involve selecting a specific child skill and then teaching a parent how to use NDBI techniques to target that skill. For instance, a parent might decide that he or she wants to learn how to incorporate NDBI strategies for facilitating peer play or into homework sessions. Goals may also relate to style of interaction. For instance, in Early Start Denver Model (ESDM) treatment, the emphasis is on teaching parents to use a responsive interaction style that complements the therapy delivered by ESDM providers. Parent goals might also be for frequency of practice. A provider might recommend 30 minutes of practice per day, and the parent goal could be to consistently achieve this objective. Another option would be to set a goal for incorporating practice into a particular daily routine. In this case, a parent might have the goal to prompt for at least five communication behaviors and three play skills during each bathtime. Regardless of the exact focus, clear parent training goals that are mutual priorities can form the basis for collaborative and productive treatment progress. Box 10.1 provides a simple way to organize one’s thoughts while writing a goal.

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Table 10.1. Examples of measurable goals that specify the antecedent, as well as mastery and generalization criteria Joint attention objective

Step 1 (baseline) Step 2 Step 3 Step 4

Step 5

When engaged in toy play within a routine (setting), child will spontaneously share a smile with a nearby adult (3–6 feet away) by clearly shifting gaze from object to adult eyes and back to object, while smiling, to share pleasure (behavior), three or more times in 10 minutes of social play on 3 different days of treatment (mastery criterion) with mother and therapist across three different object activities (generalization). Child shares a smile with eye contact for 2–3 seconds with partner during coordinated play. Child shares a smile with nearby adult during object activity by shifting gaze partially (either from object to adult or from adult to object). Child shares a smile with nearby adult during object activity by shifting gaze from object to adult and back at least one time in 10 minutes of play. Child shares a smile with nearby adult during object activity by shifting gaze from object to adult and back at least three times in 10 minutes of play on a single day with mother or therapist during one or more object activities. Child shares smiles with nearby adult (3–6 feet away) during object activity by shifting gaze from object to adult and back three or more times in 10 minutes of play on 3 different days with mother and therapist across three different activities.

Imitation objective When songs are sung during intervention sessions (setting) and the adult models a novel motion (antecedent), the child will independently imitate by copying the same motion (or approximation) within 5 seconds of the first model (behavior) across five or more different actions and three or more songs during three consecutive intervention sessions (mastery criterion) with mother or therapist in home and in clinic (generalization). Step 1 (baseline) Child independently imitates three familiar motions within 5 seconds of the first model. Step 2 Child independently imitates 10 different familiar motions across five songs within 5 seconds of the first model without adult prompting. Step 3 Child independently imitates one novel motion within 5 seconds of the first or second model. Step 4 Child independently imitates three novel motions across two songs within 5 seconds of the first model. Step 5 Child independently imitates five novel motions across three songs during one intervention session with mother or therapist at home or in clinic. Step 6 Child independently imitates five novel motions across three songs during three consecutive intervention sessions with mother or therapist in home and in clinic. Play objective

Step 1 (baseline) Step 2 Step 3

During independent play time (designated time during clinic sessions or outside of intervention sessions when adults are otherwise occupied; setting), child independently gets materials for either an open-ended or closed-ended activity, brings to table or other play space, completes play task, and puts away (behavior) at least two times in a single day for a duration of at least 15 minutes for three consecutive sessions (mastery criterion) with three different activities at home and in clinic (generalization). Child can occupy self appropriately with trains for up to 10 minutes with occasional adult guidance. When prompted verbally to get play materials, child retrieves items, takes to play space, and plays independently for at least 10 minutes; child may need assistance (modeling and repeated gestural prompts) to clean up. Child independently gets play materials, brings to play space, and completes task of at least 10-minute duration; child may need verbal prompting to clean up. (continued)

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Table 10.1. (continued) Step 4 Step 5

Self-care objective

Step 1 (baseline) Step 2 Step 3 Step 4 Step 5

Child plays independently by getting materials, bringing to play space, completing play task, and putting away at least one time for a duration of at least 10 minutes. Child plays independently by getting materials, bringing to play space, completing play task, and putting away at least two times in 1 day for a duration of 15 minutes for three consecutive sessions with three different activities at home and at clinic. During morning or evening self-care routine in bathroom (setting) when adult instructs child to brush teeth (antecedent), child independently brushes toothbrush over teeth (upper and lower teeth, front and back; behavior) two times per day for 3 consecutive days (mastery criterion) with both mother and grandmother at home and at grandmother’s house (generalization). Baseline: Child puts toothbrush in mouth independently. Child brushes toothbrush over back teeth (upper and lower) with gestural prompt. Child brushes toothbrush over front teeth (upper and lower) with gestural prompt. Child brushes toothbrush over all teeth one time per day for 2 days independently. Child independently brushes toothbrush over all teeth two times per day for 3 days with mother and grandmother at home and at grandmother’s house.

ASSESSMENT Before developing goals for an individual child, providers must conduct careful assessment to establish an understanding of the child’s baseline level of ability in each area of interest. Practice parameters for assessment of children with ASD emphasize that information about cognitive development, adaptive skills, communication abilities, and family context are critical for inclusion in any comprehensive assessment (Volkmar et al., 2014). Assessment can be formal and include standardized tests but should also include observation in the natural environment and parent and caregiver input. Assessment looks different for every child, based on many factors, including age, developmental level, and abilities. NDBI approaches commonly

Ready, Set, Implement! BOX 10.1: Identify a goal Think of a new behavior you want to teach, and write it down in the center of a piece of paper. Make sure you provide enough observable details that it will be clear to any observer whether the behavior occurred. Next, at the top of your page, add information about the context in which the behavior is supposed to occur and any cue or prompt that should happen first. At the bottom of the page, write down how many times the behavior should be observed to be considered mastered and across which generalization contexts. You should now have a clear written goal including antecedent, behavior, mastery, and generalization criteria.

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utilize a combination of standardized assessments, curriculum checklists, and behavioral observation to develop goals for children with ASD. Each method offers a distinct type of information relevant to goal selection. Standardized Assessments Standardized assessments have been developed to be delivered in a consistent manner across children. When administered by trained providers, the results of these assessments should be directly comparable and should therefore be easily interpreted across settings by practitioners trained in the assessment. Some standardized assessments involve direct interaction with a trained evaluator, and other assessments involve parent or caregiver responses to a standard set of questions. Norms available for many standardized assessments also provide helpful benchmarks for comparing a child’s current performance level with that of typically developing peers in the same age range. Norm-referenced standardized tests are commonly used to measure child developmental level. These include tests such as the Mullen Scales of Early Learning (MSEL; Mullen, 1995), Bayley Scales of Infant and Toddler Development (BSID; Bayley, 2006), Differential Ability Scales (DAS; Elliott, 2007), and Wechsler Preschool and Primary Scale of Intelligence (WPPSI; Wechsler, 2012). Intelligence tests (e.g., Wechsler Intelligence Scale for Children [WISC; Wechsler et al., 2003], Stanford Binet Intelligence Scales [SBIS; Roid, 2012], Kaufman Assessment Battery for Children [KABC; Kaufman & Kaufman, 2004], Woodcock-Johnson Tests of Cognitive Abilities [Schrank, Mather, & McGrew, 2014]) can provide similar information about broad aspects of cognitive functioning and relative strengths and weaknesses in aspects of learning and information processing for school-age children and teens. There are also a wide range of standardized language and communication tests (e.g., Preschool Language Scale, 5th Edition [PLS-5; Zimmerman, Steiner, & Pond, 2011], Communication and Symbolic Behavior Scales [CSBS; Wetherby & Prizant, 2003]) often used with children with ASD. Standardized, norm-referenced tests provide the most global-level information about a child’s developmental level. They do not identify specific target behaviors to be addressed in intervention but rather broad areas of functioning in which the child may be performing below the expected level. Because of their broad focus, these measures are typically administered at infrequent intervals, as they are not very sensitive to change. A child’s progress is likely to be observable by behavior observation or a skills checklist long before it would be detectable on a developmental or intelligence test. However, for NDBI implementation, knowing a child’s developmental level or cognitive profile can be invaluable for helping the provider design developmentally appropriate goals. For instance, a low score on the Visual Reception subscale of the MSEL or on the Cognitive subscale of the BSID at the start of treatment could indicate that the child has limited understanding of visual symbols. For this child, it may be appropriate to prioritize goals involving play with toys and real objects rather than pictures and books. In contrast, another child might show relative strengths on the DAS Nonverbal Reasoning Ability or WISC Visual Spatial scale, which could indicate that inclusion of visual supports in the initial treatment goals would help the child progress more quickly. As another example, if a child who is nonverbal shows relative strengths in Receptive Language abilities on the MSEL or BSID,

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this information could guide providers to use activities such as following verbal instructions (i.e., receptive language skills) as a maintenance task while teaching more difficult expressive communication behaviors. Thus, knowing about broad areas of strength and weakness can help providers determine an appropriately individualized developmental sequence for teaching. A number of parent/caregiver report measures have also been standardized and allow for comparison of a child’s reported skills to a large normative sample. For instance, measures of adaptive behavior (Vineland Adaptive Behavior Scales [Sparrow, Cicchetti, & Saulnier, 2016]; Adaptive Behavior Assessment System [Harrison & Oakland, 2003]), communication (MacArthur-Bates Communicative Development Inventories [Fenson, Marchman, Thal, Dale, Reznick, & Bates, 2007]; Communication and Symbolic Behavior Scales Developmental Profile Infant Toddler Checklist [Prizant & Wetherby, 2002]), and social skills (Social Responsiveness Scale [Constantino & Gruber, 2012], Social Skills Improvement System [Gresham & Eliott, 2008]) are commonly used in assessment of children with ASD. Although not developed specifically for the purpose of identifying treatment goals, information from these types of assessments is also highly relevant to goal selection. Some items on these measures are specific enough that they can be considered possible treatment targets (e.g., naming common objects, greeting familiar people, washing own face). Other items suggest broader areas of deficit where a series of sequential goals might be developed (e.g., reading at the second-grade level, imitating play acts, taking care of a cut or scrape). Because these measures are typically completed by parents, they often give important insight into a child’s typical performance in the natural environment, which is a critical consideration in planning treatment priorities. For instance, if a child performed well on a standardized test of expressive language but the parent report indicates that adaptive communication skills in natural contexts are still significantly impaired, then additional treatment of communication skills would be needed, in spite of strong tested language ability. Curriculum Checklists Skill checklists are another useful method for identification of potential treatment goals in NDBI. These tools often list skills both by domain and in developmental sequence, making them easy to use for identifying next steps for a child’s treatment. These tools typically are designed with the treatment modality in mind and already have embedded assumptions about which types of skills will be important to target (e.g., high density of social-communication skills with emphasis on behaviors such as joint attention and imitation). There are many available checklists, both those developed specific to an individual NDBI approach and those developed for more general use in Applied Behavior Analysis (ABA) programming. Recommended methods of administration vary across tools but often include parent report of skills as well as observation of the child. As an example, ESDM typically uses play-based methods for in vivo assessment of a child’s skills across a range of developmental areas and complements the clinician observation with parent report of a child’s typical performance at home, particularly for skills that are difficult to observe in a clinic setting. Using a curriculum checklist, interventionists conduct one or more play sessions to observe various types of play (parent–child play, solo child play, assessor-directed play) and may interview family members to collect a full picture of the child’s typical performance

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across key developmental milestones (Rogers & Dawson, 2010). Once complete, this information forms an assessment profile organized by developmental domains (e.g., expressive and receptive language, social skills, motor skills). The profile can yield information about skills that are firmly established and always performed, as well as skills that are partially established and demonstrated intermittently. Upon completion of the initial assessment, the child’s team and parents can collaborate to form a plan of objectives to be taught to the child in naturalistic, play-based teaching sessions. For instance, two to three goals per developmental domain may be identified as priorities for a 12-week intervention period (Rogers & Dawson, 2010). Checklists are also used by several other NDBI approaches for identification of key target behaviors for treatment (structured play assessment used in JASPER and social-communication skills checklist used in Project ImPACT). Though these tools are most relevant to young children and are not yet widely disseminated or standardized, they have the advantage of being highly specific to NDBI treatment. See the following case example for samples of clearly operationalized and developmentally based learning objectives.

Case Example: José José is a 22-month-old boy recently diagnosed with ASD. He has limited verbal abilities, lacks eye contact, and engages with toys by lining them up and then moving along to another activity. Table 10.2 includes examples of goals, by developmental domain, that might be created for José. Table 10.2. José’s goals by developmental domain Receptive communication Expressive communication

Joint attention

Social engagement

Peer interaction Fine motor skills

Gross motor skills

José will follow four out of five one-step directions (e.g., “sit down”) in a 50-minute therapy session for three consecutive sessions with at least two different adults. While playing an activity with a parent, José will request that the activity continue by naming the game or saying “play again” during four out of five opportunities for three consecutive sessions with at least two different activities. José will follow the gaze of someone pointing at a novel object at a distance during four of five opportunities across 3 consecutive days with at least three different types of items (e.g., an item of food, a toy, a person). During a social routine with a parent, José will remain engaged as evidenced by appropriate eye gaze, facial expression, gesture, body orientation, or vocal communication for a period of at least 45 seconds during four out of five opportunities over three consecutive sessions with mother and father. José will ask a friend to share a snack with him by saying “more snack” during four out of five opportunities over three consecutive sessions with at least three different peers. José will open a container independently on four out of five opportunities across 3 consecutive days with at least three different types of containers (including containers with screw-on lids) at home and in clinic. During song routines when an adult models a gross motor action, José will spontaneously (within 3 seconds) imitate at least four actions in three different songs across three consecutive sessions with his mother and therapist at home and in clinic.

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Other types of curricular assessments can be helpful for identification of specific treatment goals, even if they do not include norms to allow comparison with typically developing children. These are tools that measure discrete behaviors that can be directly targeted as treatment goals, in contrast to the developmental tests discussed previously that evaluate global areas of functioning. For instance, tools such as the Assessment of Basic Language and Learning Skills (ABLLS; Partington, 2010) and Verbal Behavior Milestones Assessment and Placement Program (VBMAPP; Sundberg, 2014) may be useful for NDBI providers because they have been developed specifically for use in identifying ABA treatment goals. By comparing a child’s performance across one of these comprehensive assessments, providers can identify areas of particular deficit to prioritize. In contrast, if an important development area has already been identified (e.g., joint attention), tools such as the Early Social Communication Scales (ESCS; Mundy, Hogan, & Doelring, 1996) can be used to obtain detailed information about performance on discrete aspects of this skills (e.g., initiation of joint attention vs. response to joint attention). These measures are useful because the results directly identify behaviors that can be taught in treatment sessions. An even wider range of checklists has been developed for ABA treatment and for early childhood education generally, and many of these tools will also be useful to NDBI providers. For instance, the published skills checklist from Project DATA (Schwartz, Ashmun, McBride, Scott, & Sandall, 2017) is highly compatible with the NDBI approach and can be used for identifying behavioral teaching targets for preschool-age children with ASD. NDBI programs, particularly those embedded in or formatted like preschools, also often take advantage of published goaldevelopment materials designed for use in early childhood education settings (e.g., Carolina Curriculum for Preschoolers with Special Needs [Johnson-Martin, Attermeier, & Hacker, 2004]; Assessment Evaluation and Programming System for Infants and Children [AEPS®; Bricker, 2002]). This can be especially helpful when providers seek to align treatment goals with standards being applied to typically developing children in the same age range (e.g., for group instruction of children with varying abilities), or when the overall goal is to prepare the child with ASD to function as independently as possible in an inclusive preschool setting. In the same spirit, curricular materials from the classroom of a school-age child with ASD can be used to form the basis for selection of treatment targets relevant to that child’s classroom participation. Behavioral Observation Children with ASD often present with an uneven profile of skills, or with so-called splinter skills. As a result, merely using a curriculum based on general chronological age, or on overall developmental age for that matter, may be insufficient. It may be more helpful to carefully observe the child in each skill domain and determine which skills the child can perform independently; which skills the child needs support with but can do partially; and which skills the child is absolutely not able to do at all, even with help. Observation also often provides valuable data regarding skill performance. Sometimes a child has acquired a skill but is not reliably or independently using the skill. Such challenges with skill performance can occur for a number of reasons, including poor skill fluency, challenges with generalization, or environmental

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Table 10.3. Examples of external variables that may impact skills performance Variable that affects skill performance Caregiver or teacher

Siblings or peers

Environmental factors

Limiting variables

Enhancing variables

Adult overprompts and does not allow the child to answer. Teacher does not have a clear prompt. A sibling or peer with challenging behaviors may prevent the child with ASD from exhibiting appropriate sharing behavior. Toys are freely accessible without the need for the child to request. A single copy of each toy limits the possibility of play imitation.

Teacher is priming the student. Caregiver arranges the environment to optimize the chance the student will engage in the target behavior. A sibling or peer can persevere in prompting greeting behavior while the child is distracted. Toys are organized out of reach to promote requesting. Duplicate items are available to promote imitation.

barriers. In this case, observations may reveal mediating variables enhancing or limiting a child’s skill performance, such as parent or caregiver skill level, sibling or peer help or interference, or environmental factors influencing performance. Knowledge of these variables may result in goals that are more specific and individualized, while also taking into account mediators of the child’s behaviors. For example, if there is an environmental issue that makes performance of a skill difficult, barriers can be removed or caregivers can be taught alternate behaviors. When teaching handwashing, ensuring the child can push the soap dispenser is an easy fix, as is making sure that the child can reach the faucet handle or that there is a towel available. A more difficult barrier to address can be a caregiver insistent on motoring the child through handwashing sequences to ensure cleanliness. Table 10.3 includes additional examples of external variables that may affect a child’s skill performance. Several NDBI programs have developed specific protocols for observational assessment that rely on either live observation or review of video-recorded interactions or transcripts to obtain detailed behavioral data used to assess baseline functioning and track treatment progress. For instance, enhanced milieu teaching (EMT) emphasizes the importance of careful assessment of language levels and analyzes language samples from play and routine interactions between the child and the parent or interventionist (Hancock & Kaiser, 2002). Language samples are subsequently examined to determine the length of the child’s utterances (mean length of utterance), the total number of words, the number of different words, the number of utterances with a certain length, and the number of spontaneous and prompted target words. EMT also uses SALT, or the Systematic Analysis of Language Transcripts (Miller & Chapman, 1985), after transcription to generate detailed analyses. Observation can also provide valuable information about strategies parents are already using to enhance a child’s development and provide insight into which parent training goals may be most important to target in initial sessions. Some NDBI programs include assessment of parent skills as part of the treatment planning process. This can be implemented via informal observation and discussion. Other times, assessment focuses on measuring parent treatment fidelity of the specific treatment strategies. For example, parent training in PRT and ESDM routinely involves observational assessment of parent implementation of the targeted motivational strategies. This information can then be used to plan subsequent parent

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training sessions to teach specific intervention strategies that were not observed in the assessment. In a case where a parent is already using clear prompts and contingent reinforcement to teach new skills, the parent training feedback may focus primarily on incorporating the child’s interests and interspersing maintenance tasks or utilizing those prompting and reinforcement skills in the context of affect-laden interactions. In contrast, if a parent is observed at baseline to ask frequent questions without contingent reinforcement, a provider may focus first on establishing a shared understanding of the benefits of natural reinforcement and coaching the parent in strategies for establishing shared control of items of interest during play. Regardless of whether standardized assessments, checklists, behavioral observation, or (ideally) a combination of methods is being used, clinical judgment is critical when selecting and prioritizing goals. The following section outlines family and cultural factors, as well as child-related developmental considerations, which can help providers effectively use assessment results in selecting goals that will be the most meaningful for children and their families.

CONSIDERATIONS FOR GOAL SELECTION If a child’s skills are significantly delayed across multiple areas of development, one of the most difficult decisions for a parent or provider to make is which goals to prioritize. Even the most intensive programs often need to trim down the number of goals to ensure that each objective receives sufficient practice to improve. Parents who work with their children during daily routines will also find that the days pass quickly. Without a clear plan for which goals to practice each day, progress on important goals can be slow. Yet, selection can seem overwhelming when there are many possible skills to target. Thus, having clear priorities helps everyone on the treatment team work toward the same objective and provide the most effective treatment. Cultural Considerations One critical aspect of meaningful goal selection includes considering family values and culture, as well as ecological goodness of fit (i.e., the extent to which the selected goals are relevant in the child’s natural environment and consistent with the family’s daily routines). There is a large body of literature highlighting the importance of family-centered practices (Sukkar, Dunst, & Kirby, 2016) and the importance of involving parents as stakeholders and equal and essential partners in the intervention (Keilty, 2010). The process of incorporating a family’s culture and values into treatment plans starts during assessment. If providers are using standardized assessments to establish baseline abilities, it can be especially important to actively seek out parent input to determine how representative the child’s performance on standardized tests is of actual skill performance in natural environments. Even if a skill appears mastered during testing, it could be a critical goal to incorporate if the child does not regularly perform that skill at home or in important community settings. For instance, a child may show the ability to respond to his or her name or follow a simple instruction during testing; however, if those behaviors are not typically performed at home, they should likely be incorporated into the treatment plan. Parents and other caregivers should be asked to contribute their opinions and wishes early in the process of treatment planning. If a parent feels that a particular

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goal is important to the family, it should be strongly considered for the initial treatment plan. For example, in some families it might be important that the child learn to properly greet family members, take off shoes before entering the house, or eat with utensils. In other contexts, demonstration of solitary play skills, academic abilities, and independent toileting might be more important to family members. This consideration is particularly important when establishing goals for parent training. Parents must be involved in decision making about which skills they will learn. Although further research is needed into how ASD treatment should be modified to benefit ethnically and culturally diverse families, cultural beliefs clearly affect how important specific goals (e.g., compliance, initiations, reduction of self-stimulatory behavior) are for family members. In fact, many evidence-based treatment programs may differentially incorporate values from the dominant European-American culture, such as the importance of individualism, competition, speed, and explicit communication, and may require modifications for appropriate use with diverse families (McDermott, 2001). The more carefully family values are incorporated at the start of treatment, the bigger long-term positive impact that treatment is likely to have on the family because parents are more likely to practice goals that they view as a priority. Importance of Caregiver Buy-In Often parents and caregivers have clear preferences regarding important skills to target, and providers should take careful account of these. For instance, some families consider self-help goals to be top priorities because of the immediate impact they have on reducing parental stress and improving family quality of life. Other families prioritize safety skills, reductions of specific challenging behaviors, or value-specific communication objectives, such as saying “mama” or “papa.” If a parent feels strongly about a goal that providers consider to be well beyond a child’s current level of ability, providers can collaborate with parents to select interim goals that move the child toward the long-term objective. For instance, parents often wish their children would answer questions about things that happened during the day at school. For a child who does not yet know how to answer any open-ended questions, a provider could encourage focusing first on the descriptive language necessary for answering questions about immediate events while they are occurring. A child who is already able to answer questions about current events could work on answering questions about past events that are known to the parents (which allows parents to prompt correct responses if needed—something they cannot do if they do not know what happened at school). The fact that family members value a particular goal is an important reason to make it a priority because doing so will establish the family as active stakeholders and increase buy-in. When developing a short list of top goals, providers should make a habit of asking parents for their input early in the process so that any strong preferences can be built directly into the treatment plan. It is particularly important to have parent buy-in related to the parents’ own learning objectives; therefore, parents should be intimately involved in selecting goals for parent training as well. Providers should work collaboratively with parents to develop parent training goals that are aligned with skills that the parents have shown strong interest in learning. Such parent training goals will not only assist

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Ready, Set, Implement! BOX 10.2: Consider family values and preferences To explore goodness of fit for a new goal, you will want to consider family values, cultural practices, and daily routines. Make a list of at least three specific questions you could ask family members in order to determine whether a proposed goal is likely to be a good fit for the family. Here are some examples: 1. Does this goal match with your top priorities? 2. Will changing this behavior make a meaningful difference in your life? 3. Will you have a lot of opportunities to practice this goal? 4. Is this goal relevant and important for your family’s daily life? 5. Does this goal align with your family’s values? 6. Does this goal help you get to your long-term objectives for your child and family? parents in being able to support and teach their child but also show respect for their values and parenting priorities. Box 10.2 summarizes goodness of fit for goal development and provides some sample questions to investigate stakeholder buy-in. Selecting Functional Skills The term functional refers to the importance of ensuring that anything taught is relevant to the student’s life and can be used right away. Chapter 3 reviews the importance of selecting functional skills in NDBI; this section offers a practical application for goal selection. One way to determine whether a skill is functional is to assess whether it will make a substantial difference in the person’s life. Will the new skill be valuable to the individual (i.e., improve quality of life or provide the individual with more independence)? For example, if a child is struggling to learn how to speak, the provider may want to teach words that will help him or her to be more independent. Teaching to say or sign “thank you” is less relevant at that stage and less functional when compared to teaching requests for actual items. The case examples that follow highlight these important considerations.

Case Example: Jenna Jenna is a 2-year-old girl with ASD who is not yet verbal and engages in high levels of challenging behaviors. She enjoys bubbles and playing tickle games with her parents. Her current goal is to learn functional words: When Jenna wants an item or activity, she will independently use 10 words to request items or actions within a 10-minute sample with at least three communicative partners and across at least two settings. Is this goal functional? Maybe; Jenna’s provider should choose words for items or actions that Jenna loves and encounters regularly; some of those key words include bubbles, tickle, and cracker. Because Jenna exhibits challenging behaviors, it

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may also be important to pick words that can serve the same function of the problem behavior (e.g., teaching “no” for escape or “mama” for attention). Will these skills have a meaningful effect? Yes; learning first words will make a big difference for Jenna’s independence. It can be tempting to pick first words that are important to adults (e.g., hi, thank you) or that apply to lots of activities (e.g., more, go), but children with ASD often learn best when requesting things they really want and when the natural consequence for each new word is different (as it would be for tickle, cracker, and bubbles). In addition, Jenna’s provider should avoid teaching one word that can be used for everything but rather should teach the labels for actual items, actions, or activities.

Case Example: Kaleb Kaleb is a 10-year-old boy diagnosed with ASD. He enjoys playing board games. He is currently working on cognitive and academic skills. Kaleb’s therapist has decided to target the skill of reading: When asked about a book he read that day, Kaleb will independently answer three content questions about the reading, accross at least three reading assignments. Is this goal functional? Likely; for reading skills to be functional, Kaleb must understand what he is reading (e.g., reading comprehension). To begin, Kaleb could read about topics that interest him in environments that are motivating (e.g., reading instructions to operate a toy or game that he is interested in playing). Another idea is to try writing a message about how the child can find a hidden preferred item. When information that is useful or interesting to the child is embedded into text, reading comprehension will be naturally reinforced. Will teaching reading skills have a meaningful effect? Yes; reading is a critical learning skill for children at this age. If it is within his cognitive capacity, improving Kaleb’s reading skills as well as his motivation to read (by practicing his skills in motivating and reinforcing contexts) will enable him to find greater academic success.

Case Example: Ashir Ashir is a 13-year-old boy diagnosed with ASD. He has conversation-level language skills, enjoys playing video games, and largely struggles with social skills, particularly at school. His current goal is to improve his personal boundaries: Ashir will demonstrate appropriate social boundaries with peers at recess, defined as remaining at least 2 feet away unless whispering, for at least 80% of 10-minute samples (scored in 1-minute intervals) on three consecutive occasions with at least three different peers. Is this goal functional? Yes; this goal is functional, especially if skills are practiced in the context where problems are occurring (e.g., school recess) and across interactive partners. Will improving his personal boundaries have a meaningful effect? Yes; especially for teens, knowing how close to stand and when touching is appropriate is critical for social success. Some teens may be motivated by positive peer response; others may need additional natural reinforcement for practicing this skill.

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DEVELOPMENTAL CONSIDERATIONS As noted previously, students learn skills best when they are presented and taught in a predictable developmental sequence so that targeted skills are incrementally above the child’s current abilities and the selection of subsequent skills follows a clear trajectory from the current level of functioning toward more advanced age-appropriate skills. When considering developmental principles in writing goals, providers should focus on core deficits in various developmental domains, teach the next skill in the developmental sequence for that domain, consider the cascading effect while teaching skills and writing goals, focus on the depth of the skills taught, and ensure that goals are age appropriate. Each of these issues is outlined in detail next. When setting goals, providers should take current developmental level into account and then set the child up for success by programming just slightly above the current level without setting the goals too high. This approach is related to Vygotsky’s theory that children learn best the skills that are within a “zone of proximal development” (Rutland & Campbell, 1996). This zone includes skills that the child can do with guidance but not yet independently or spontaneously. When programming in this way, therapists focus on the skill in the child’s zone of proximal development, practice the skill with modeling and guidance, and then gradually move on to more advanced skills one step at a time upon mastery of previous skills. For example, if a child can already combine words into short phrases, the next developmentally appropriate goal within this domain could be to model, prompt for, and practice expanded utterances. In addition, if a child was able to understand, process, and complete one-step instructions, interventionists could work on modeling and prompting for two-step instructions. Once two-step instructions are mastered, they could move on to novel combinations of instructions, three-step instructions, and so forth. This progression of goals follows a clear, linear developmental trajectory and focuses on teaching the next skill that is just one small step above the child’s current ability level. Key Challenges Theories of ASD can provide some guidance about the most important skills to target. For instance, a number of specific social skills have been identified as critical targets for early intervention, including joint attention, initiations, imitation, and play skills (Kasari, Freeman, & Paparella, 2006), because these skills form a foundation for understanding other individuals and participating in social activities with others (Baron-Cohen, Lombardo, & Tager-Flusberg, 2013; Roeyers, Van Oost, & Bothuyne, 1998). Based on this rationale, some NDBIs target specific core deficits thought to be responsible for broad aspects of autism-specific impairment. For instance, the JASPER program deliberately prioritizes joint attention and symbolic play due to theoretical rationale that these skills are critical for enhancing engagement and remediation of the core symptoms of ASD (Kasari, Gulsrud, Wong, Kwon, & Locke, 2010; Kasari, Paparella, Freeman, & Jahromi, 2008). Other approaches have prioritized imitation skills, given the critical role that imitation plays in learning from others, taking turns, and sustaining both verbal and nonverbal engagement (Ingersoll & Schreibman, 2006; Schreibman et al., 2015). In contrast to behavioral imitation training focused on copying of discrete and often

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nonfunctional behaviors, the NDBI reciprocal imitation training approach teaches imitation as a means of enhancing social engagement and capacity for naturalistic learning (Ingersoll, 2010; Landa, Holman, O’Neill, & Stuart, 2011). A similar rationale underlies the concept of targeting pivotal areas, which is central to the PRT approach. Research on PRT has aimed to identify pivotal areas, which, when targeted, produce widespread effects across broad areas of development. For instance, the PRT approach places priority on incorporating a child’s interests, including easy tasks, and reinforcing attempts because when treatment is provided in this way it enhances the child’s overall motivation for social-communication, leading to reductions in learned helplessness and generalized improvements in symptoms of ASD (Koegel & Koegel, 2006). Likewise, providers may prioritize teaching of initiations, response to multiple cues, or selfmanagement because these skills have also been shown to result in widespread improvements in untargeted areas. The case examples that follow examine goal setting through a developmental perspective.

Case Example: Alex Alex is a 2-year-old boy diagnosed with ASD. He is not yet verbal, prefers solitary play, and displays flat affect. His current goal is to increase his joint attention initiations: During play with a peer or adult, when Alex sees something interesting he will initiate joint attention at least five times in a 15-minute activity, independently across two settings and with both a peer and an adult in two consecutive probes. Joint attention initiations are defined as looking, giving, or pointing accompanied by alternating eye contact, for the purpose of sharing enjoyment or attentional focus. Probes must include an example of each type of initiation to consider the goal fully mastered. Is this goal a good fit for Alex from a developmental perspective? Probably; within the range of joint attention behaviors (e.g., looking, giving, pointing), eye gaze alternation to share enjoyment or attentional focus would be the earliest skill to teach Alex. Joint attention begins to develop around the first birthday and is a precursor to and prerequisite for learning how to talk. Will increasing his joint attention have a meaningful effect? Yes; joint attention is likely to increase positive affect for Alex and his parents, as well as communication skills, by means of improving triadic attention. Additionally, joint attention skills are a foundation for later learning from peers and in the classroom.

Case Example: Cole Cole is a 3-year-old with ASD. He currently communicates by using about 20 single words and enjoys cause-and-effect toys. He has high levels of stereotypy and typically screams when near peers. One of his current treatment goals is sharing toys with peers: During structured play at school, Cole will independently hand a toy to a peer upon request four out of five times in a 30-minute probe across two consecutive sessions and with two different peers. Is this goal a good fit for Cole from a developmental perspective? Maybe not; parallel play remains the preferred type of play with objects until around age 2. Sharing with peers begins between age 2 and 3 but remains difficult for many

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typically developing 3-year-olds, especially with highly preferred toys. Increasing proximity with peers and parallel play may be foundational skills for this skill set, followed by making simple requests from peers and responding to peer initiations. Will teaching sharing skills have a meaningful effect? Yes; tolerance of peer proximity and ultimately sharing will provide opportunities for inclusion and peer modeling.

Case Example: Josephine Josephine is a 10-year-old with ASD who speaks in full sentences and enjoys game play. She is often inflexible and perseverative in topic selection. One of her current treatment goals is reciprocal commenting in play and conversation (nonobject or action-related comments): Josephine will independently comment on an action by her peer during game play at least three times in a 15-minute sample across two consecutive sessions with at least three different peers. Is this goal a good fit for Josephine from a developmental perspective? Maybe; most 10-year-olds engage in complex and sustained play with others, but most 10-year-olds do not sit around and chat. Conversations still center around activities, games, and rule-governed social play. Will increasing her reciprocal commenting skills have a meaningful effect? Yes, because reciprocal commenting will be reinforcing to a communication partner and allow for practice with flexibility and topic expansion during conversations.

Case Example: Marco Marco is a 15-year-old with ASD who is nonverbal and uses the Picture Exchange Communication System (PECS) Phase 4 for requesting. He has limited play skills and limited peer interaction. One of his current goals is increasing greetings and good-byes: Marco will independly gesture hello and goodbye (e.g., waving) to at least three different peers at the beginning and end of music club at school across two consecutive sessions. Is this goal a good fit for Marco from a developmental perspective? Yes; this is an early-emerging component of social interaction that is simple and highly ritualized. Will increasing his greetings have a meaningful effect? Yes, because greetings are likely reinforcing to a communication partner.

Cascading Effects Developmental cascades can be defined as “the cumulative consequences for development of the many interactions and transactions occurring in developing systems that result in spreading effects across levels, among domains at the same level, and across different systems or generations” (Masten & Chicchetti, 2010, p. 491). Models of developmental cascades suggest that certain skills may be foundational for the development of other important skills and that not acquiring these foundational skills can result in so-called negative cascading effects. As an example, responding to joint attention bids is a skill often considered to be a critical foundation for subsequent learning. That is, once a child learns to consistently respond when his

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or her attention is directed to another object, he or she will more easily follow other instructions and have the opportunity to learn about many new materials. Another example is the pivotal area of initiations (Koegel, Koegel, Harrower, & Carter, 1999). When children learn to initiate by asking questions (e.g., “What’s that?”), this opens up opportunities for learning new vocabulary. If a skill is expected to provide such a foundation for the development of other meaningful skills, it makes sense to make this an early target in treatment. It is important for clinicians to have an understanding of how skills layer one on top of the other, so prerequisite or foundational skills are not overlooked and treatment goals are not set for skills that the child lacks readiness for. Other goals, when accomplished, may increase access to valuable learning environments. For instance, once basic reading ability is established, the child can take advantage of a whole new array of learning environments not previously accessible to him or her. When parents and providers are selecting goals, skills expected to have significant cascading effects are excellent priorities, whether because of their foundational nature or because of the access to subsequent learning that they facilitate. Depth of Skills Another important developmental consideration is the depth of skills being taught and practiced. Depth means making sure that a variety of related skills are also learned and that the child can perform the new skill flexibly and in a variety of ways. Although skills should be taught in a particular developmental sequence, they should also increase in depth to eventually provide a strong skill base for the child. For example, a pretend play goal may include a variety of actions to ensure enough depth: feeding the baby, giving the baby a drink, putting the baby in bed, changing the baby’s clothes, burping the baby, and singing to the baby. This variation in play behaviors ensures that children can use the skills they have in a flexible way, without too much reliance on specific contextual cues or models. It is also important to consider fluency of these skills to ensure performance deficits do not emerge due to lack of fluency. Age Appropriateness of Goals A final consideration for goal selection pertains to the need to contemplate whether selected goals fit with the chronological age of the individual with ASD, as opposed to the developmental age of the person. This is especially relevant for adolescents and adults with ASD with limited verbal skills and/or intellectual disability because they may developmentally function at a much younger level compared to their chronological age. Selecting goals that are closer to age may provide additional independence as well as increased access to age-appropriate materials, activities, and resources.

CONCLUSION Inherent in the NDBI approach is the assumption that not all potential goals are equal. There are some skills that are clearly more important to teach and should be a focus of any treatment program for a child with ASD. Although it may be easier to target goals that are simple to define, measure, and practice repeatedly, the most important objective is actually to select goals that will produce meaningful changes in

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child and family functioning. This chapter tackled the challenge of selecting meaningful goals, acknowledging that the core ASD deficit of social reciprocity is difficult to measure but critical to address for real progress to occur. It acknowledges how overwhelming it can be to select among hundreds or thousands of potential goals and provide guidance to parents and providers in prioritizing. To guide the provider, this chapter recommended specific goal areas that should be included in any program for a child with ASD. It also discussed the theoretical rationale for prioritizing pivotal skills, such as joint attention and initiations, and the importance of considering family values and designing goals in a way that they can be embedded into daily routines. Finally, it outlined the importance of selecting goals that are both functional for the child and developmentally appropriate and defining them in a way that is measurable and relevant across environments. Chapter 11 discusses NDBI strategies for targeting communication skills, followed by social skills in Chapter 12 and adaptive skills in Chapter 13. Enhancing functional communication, social interaction, and adaptive skills is critical for enhancing independence and self-determination for many individuals with ASD. By incorporating the strategies for goal selection discussed in this chapter, parents and providers can design focused treatment programs for communication and other skill areas that will facilitate meaningful progress.

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IV Applications of NDBI Strategies

11 Targeting Communication Skills Mendy B. Minjarez, Rachel K. Earl, Yvonne Bruinsma, and Amy L. Donaldson

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ommunication is a fundamental component of early development and is widely acknowledged as an area of need in autism spectrum disorder (ASD). ASD is characterized in part by deficits in social-communication, which includes both verbal and nonverbal communication (American Psychiatric Association, 2013). This chapter begins with an overview of communication development and communication challenges often observed in children with ASD. It then moves to examination of Naturalistic Developmental Behavioral Interventions (NDBI) strategies used to target communication goals and finally provides a discussion of the application of NDBI strategies to specific target behaviors across developmental levels.

COMMUNICATION PROFILE OF CHILDREN WITH ASD Communication challenges are often the first concerns to be identified in the development of a child with ASD. Most, but not all, children with ASD exhibit a delay in production of first words (Tager-Flusberg, Paul, & Lord, 2005), although a smaller proportion (25%–30%) experience a loss or regression in acquired language skills in the second year of life (Goin-Kochel, Esler, Kanne, & Hus, 2014; Lord, Shulman, & DiLavore, 2004; Werner & Dawson, 2005). When parents were asked retrospectively about their child’s early development, communication deficits were reported to be present as early as 12 months of age (Mitchell et al., 2006; Osterling & Dawson, 1994). Prospective studies of infants with an older sibling with ASD, and thus at an elevated risk for developing ASD themselves, have identified communication impairments within the first year of life and delays in the onset of babbling and consonant acquisition by 6 months of age (Iverson & Wozniak, 2007; Paul, Campbell, Gilbert, & Tsiouri, 2013). Infants who go on to be diagnosed with ASD also show delays in nonverbal communication, such as imitation, joint attention, and gesture use, within their first year of life (Ozonoff et al., 2010; Zwaigenbaum et al., 2005). These early impairments 237

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in nonverbal communication correlate with spoken language, cognitive, and motor skills early in a child’s development (Iverson & Wozniak, 2007; Luyster, Kadlec, Carter, & Tager-Flusberg, 2008; Thurm, Lord, Lee, & Newschaffer, 2007). Spoken language acquisition within the first years of life, along with cognitive abilities, have been linked to overall outcome of individuals with ASD across the life span, highlighting the importance of early intervention that targets communication (Billstedt, Carina Gillberg, & Gillberg, 2007; Howlin, Goode, Hutton, & Rutter, 2004; Venter, Lord, & Schopler, 1992). Although communication deficits are considered universal within ASD, the type and severity of challenge is highly variable (Kjelgaard & Tager-Flusberg, 2001; Tager-Flusberg et al., 2005). Some children with ASD demonstrate vocabulary, semantic, and grammatical skills congruent with typical development, and they struggle instead with the social-communication, such as breadth and depth of communicative intent (Prizant & Wetherby, 1987); coordination of nonverbal and verbal communication (Stone, Ousley, Yoder, Hogan, & Hepburn, 1997); social and communicative reciprocity; reading social and contextual cues; and adjusting communication use to context (Tager-Flusberg & Joseph, 2003; Tager-Flusberg et al., 2005). On the other hand, a significant number of children with ASD demonstrate severe language deficits or complex communication profiles in which the child does not develop spoken language (Kjellman, Hedvall, Fernell, Gillberg, & Norrelgen, 2012; Tager-Flusberg et al., 2005). This variable presentation of communication difficulties underscores the importance of dynamic, personalized treatment objectives and interventions for children with ASD and their families.

COMMUNICATION DEVELOPMENT IN TYPICALLY DEVELOPING CHILDREN In order to understand early differences in the communication skill development of children with ASD and to develop appropriate treatment targets to support skills acquisition, clinicians need to understand how communication develops typically (Tager-Flusberg et al., 2005). Although some variations exist in the rate at which typically developing children gain communication skills, a common developmental trajectory has been well established (e.g., Bates, 1976; Brown, 1973; Owens, 2015; Tager-Flusberg et al., 2005). Communication is typically categorized in three areas: use, content, and form. In the first category, use (defined as pragmatics or the rules for communicating through language), children learn to communicate through nonverbal means, which develop into coordination of nonverbal and verbal communication. Within the first months of life, a typically developing infant begins to recognize his or her mother’s voice and to synchronize eye gaze and facial expressions with his or her caregiver. Throughout the first year of life, an infant will develop a variety of communicative behaviors that serve the purposes of requesting, indicating preferences, and directing attention. What begins as simple gestures, such as reaching and pushing away, evolves into more complex gestures, such as pointing to request and giving an object to request assistance, by the end of a typically developing child’s first year of life. As early as 7 months of age, young children will use eye gaze (initiating joint attention) to direct another’s attention to an object or event of interest. They will coordinate with vocalization and gesture between 9 and 13 months of age; these behaviors differ from requests because their intent is to

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draw and share attention to an object or event of interest for the purpose of showing, giving, commenting, or requesting information but not to gain access (Crais, Douglas, & Campbell, 2004). By 12–18 months of age, a child will often coordinate such gestures with vocalizations, eye contact, and/or verbalizations. At preschool and school age, children continue to expand their use of communicative intent, as well as their use of social-communication within discourse, social interaction, development of relationships, and conflict negotiation. By preschool, the following social competencies should be demonstrated with peers: describing play to peers, clarifying peers’ comments, expanding on peers’ comments, responding to initiations, asking peers questions, maintaining conversation topics, giving information to peers, asking for help from peers, initiating conversations, and giving peers compliments (Brown & Conroy, 2001). Once they reach school age, children increase the sophistication of their social-communication skills, using discourse to gain access to sustain cooperative group participation, resolve conflicts, persuade others, participate effectively with others, gain access to social activities, offer contradicting opinions, and develop rich relationships (Brinton & Fujiki, 2005). With regard to the second category, content (which includes semantics or the meaning of words [vocabulary]), typically developing infants between 6 and 12 months of age begin intentional vocalizations, or babbling, while also making rapid receptive communication gains, including the understanding of infant social games and words that correspond with a particular action. First words typically emerge between 10 to 16 months of age, beginning with familiar objects and individuals and appearance or disappearance and recurrence (“more,” “all gone,” “hi”; Chapman, 2000). As children develop, their vocabulary progresses from primarily agents, actions, and modifying words to include prefixes and suffixes, root words, figurative language, and understandings of word relationships by later school-age years. Related to the third category, form (which includes phonology [rules about speech sounds], morphology [small units of meaning within words], and syntax [word order]), this vocabulary expansion typically progresses to combining two words together between 18 and 30 months of age. Children typically start combining words after their single-word vocabularies reach a certain level (50–200 words; Bates, Dale, & Thal, 1995). The typical profile and progression of syntactic and morphological development can be described using Brown’s Stages of Language Development (Brown, 1973). Following acquisition of two-word combinations, children increase their sentence complexity from approximately 24 to 30 months using prepositions (in, on), plurals, and -ing verbs. From 30 to 36 months, children start using three-word utterances with irregular past tense and possessives, and then by 42 months, they combine nearly four-word sentences with use of past tense, three-person verbs, and articles (a, the). Finally, by 5 years of age, children typically speak in complex, 4+ word utterances with use of contractions (e.g., “Kitty’s eating”; “He’s little”) and irregular forms. Paramount to early communication, particularly in the area of use, is development of different types of communicative intent or the functions of communication (Bruner, 1981). Individuals use communication for multiple reasons or functions— to gain access to something, to negotiate, to compliment someone, to share attention, to request information, and so forth. These have also been referred to as speech acts (Dore, 1975). Three early emerging communicative functions or intents fundamental to early development include 1) behavior regulation—behaviors that

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Table 11.1. Intent or functions of communication What is the child telling you? Function

Definition

Example

Behavior regulation Behaviors that regulate the behavior Requests for objects, actions, or of another person assistance; protests Social interaction Behaviors that draw and/or maintain Gaining attention, social games attention to oneself (e.g., Peekaboo), and greetings Joint attention Behaviors that draw another person’s Showing, commenting, and attention to an object or event of requesting information interest Sources: Bruner (1981); Crais, Douglas, & Campbell (2004).

regulate the behavior of another person; 2) social interaction—behaviors that draw and/or maintain attention to oneself; and, 3) joint attention—behaviors that draw another person’s attention to an object or event of interest (see Table 11.1 for further discussion of each). Successful interventions targeting communication development in children with ASD are careful to align treatment targets with typical communication milestones and the typical progression of language acquisition (Schreibman et al., 2015; Tager-Flusberg et al., 2009). Attention to these emerging communicative intents is often the starting place for NDBI, especially those interventions that focus more on communication targets, such as Pivotal Response Treatment (PRT) and incidental teaching.

USE OF NDBI FOR TARGETING COMMUNICATION As early as the 1960s, Applied Behavior Analysis (ABA) was used as a means to improve communication skills in young children with ASD (Lovaas, Berberich, Perloff, & Schaeffer, 1966; Risley & Wolf, 1967). Lovaas and colleagues (1966) found that use of reward contingencies was successful in teaching increasingly accurate imitation of spoken language to two nonverbal children with symptoms of ASD. As the field has recognized the importance of contextualized, naturalistic social interaction in social-communication and language development, particularly related to intentionality and reciprocity, and as early intervention objectives have shifted to a greater emphasis on generalization of skills outside of the treatment setting, ABA has evolved from exclusive discrete trial training (DTT) to behavioral interventions implemented in naturalistic settings with developmentally informed learning targets (NDBI; Schreibman et al., 2015). Since the late 1990s, the evidence to support the use of NDBI for targeting early communication skills for individuals with ASD and a range of baseline cognitive, communicative, and behavioral abilities has grown substantially. In accordance with a developmental perspective, NDBI integrate goals for language acquisition within a social context and in alignment with a child’s other treatment targets. Numerous studies have shown that ABA principles in a naturalistic setting promote significant communication gains in children with ASD (Koegel, O’Dell, & Dunlap, 1988; Rogers et al., 2006; Rogers & Vismara, 2008). For instance, in 2010, Dawson and colleagues conducted a randomized control led trial (RCT) of the Early Start Denver Model (ESDM) for 48 toddlers with ASD between the ages of 18

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and 30 months of age. Toddlers who were randomly assigned to the ESDM intervention showed significant improvements in receptive and expressive language and an overall reduction in ASD symptoms over 2 years compared to toddlers receiving treatment as usual from community providers. Mohammadzaheri, Koegel, Rezaee, and Rafiee (2014) conducted an RCT comparing PRT to a more traditional ABA approach for children ages 6–11 years of age and found that children receiving PRT showed significant increases in length of spoken utterances and social-communication skills. In 2013, Ingersoll and Wainer showed significant gains in frequency of spontaneous language for children 3–6 years of age whose parents received training in Project ImPACT (Improving Parents as Communication Teachers). An RCT of the Joint Attention, Symbolic Play, Engagement, and Regulation (JASPER) intervention conducted with children 3–5 years of age who were minimally verbal found that, when compared to a matched group receiving traditional ABA-based services, children enrolled in JASPER showed increased gesture use, including use of coordinated gaze, points, gives, and shows to request (Goods, Ishijima, Chang, & Kasari, 2013). These and other NDBI programs, all of which have robust evidence to support their efficacy in improving communication skills in children with ASD, target shared domains of communication and use similar strategies for teaching communication skills, reviewed in detail next. Specific NDBI Strategies for Targeting Communication Goals Although NDBI may vary in the extent to which they prioritize certain communication goals and may emphasize certain strategies more than others, they all target communication skills in some way. The following sections provide a more detailed overview of strategies most commonly used in NDBI to target the developmental domain of communication, including how to embed basic communication trials, specific strategies (e.g., use of narration, recasting, and imitation), and strategies to target motivation (e.g., shared control strategies). Embedding Communication Learning Trials When targeting nonverbal and verbal communication skills, most NDBI focus on strategies for embedding opportunities for communication during naturally occurring adult–child interactions. Such opportunities incorporate principles of ABA in that they typically rely on the three-term contingency or the antecedent-behavior-consequence (A-B-C) framework for setting up learning trials. They incorporate developmental principles by being embedded during child-selected or preferred activities and natural routines, by employing natural consequences whenever possible, and by focusing on target behaviors that are functional and developmentally appropriate. When adults (e.g., parents, clinicians) become aware of how to set up communication trials in the natural environment, they realize that there are hundreds of opportunities per day to practice various forms of communication. Communication trials can be embedded in multiple ways but will always rely on following the child’s interest and building interaction by sharing control and then continuing by following and leading in a reciprocal manner. In addition, adults should have the child’s attention prior to beginning a trial, should embed the trial in a motivating activity, and should have momentary control over some aspect of that activity (another aspect of shared control) in order to give access to reinforcement following the communication behavior. Once the child’s interest is understood and attention and brief control of

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materials are obtained, the trial should begin with an antecedent (A), which is a verbal or nonverbal indication that the child needs to communicate. Once the child makes a response (B), the adult must make an assessment of the correctness or appropriateness of that response and provide contingent reinforcement or error correction (C). It is important to set up naturalistic opportunities in the environment that will serve as the antecedent (e.g., a desired toy on high shelf, a missing puzzle piece, a snack enclosed in an inaccessible jar) in order to encourage initiation of communication bids to environmental stimuli rather than primarily responses to adult communication bids. These types of environmental arrangements are explicitly emphasized in several NDBI, such as incidental teaching (IT). This type of teaching trial can be applied to many nonverbal and verbal communication goals across settings, activities, and routines. Word use can be evoked through a time delay (waiting for the child to come up with the word spontaneously), a carrier phrase (e.g., “ready, set . . .”), or a situational cue (holding up an item and waiting for the child to label it with a word) (see also Chapter 8, on cues and prompting). When the child uses the correct word or a reasonable attempt, the adult then reinforces the response with praise and access to or continuation of a desired activity. When the child does not respond correctly, NDBI encourage an errorless instructional format in which the adult prompts the correct response, thereby giving the child the opportunity to be successful. With verbal children, this prompt might consist of a verbal model. With nonverbal individuals, a physical prompt might be provided to ensure success, for example, if the child is working on goals such as pointing, use an augmentative and alternative communication (AAC) device or Picture Exchange Communication System (PECS). The same format can be applied to other nonverbal communication behaviors, such as gestures, eye contact, and joint attention. Narrating and Modeling Most NDBI models encourage adults to model words in the context of the child’s interests and within daily routines (Hancock & Kaiser, 2002; Ingersoll & Wainer, 2013; Rogers & Dawson, 2010). Research shows that consistent exposure to developmentally appropriate language models is associated with enhanced language skills in typically developing children (Hart & Risley, 1995), as well as children with developmental delays. For example, when changing a diaper, a parent may label each action and object: “up” to lift the child onto the changing table, “tickle” when tickling the child’s tummy, “wipe” when wiping, followed by “all clean.” Repetition within daily routines ensures the child hears the words many times, even when the parent is not sure the child understands or is paying attention. Most NDBI suggest using simple words or very short phrases when narrating and expanding as the child’s language develops, although some models have more emphasis on narration (JASPER) compared to others (PRT). However, even when using short phrases, use of grammatically correct language is recommended to promote language development (use “eat the cookie” instead of “eat cookie”) (Sandbank & Yoder, 2016; Venker et al., 2015). Over time, vocabulary and increased verbal complexity can be introduced through play narration and through teaching trials embedded in a child’s daily routines. For example, narration while playing with trains can increase from single-word labels (e.g., “train,” “Go!”) to phrases (e.g., “Go train!”) and sentence speech (e.g., “The train is going fast!”). Ingersoll and Wainer (2013) encouraged adults to avoid questions when narrating during this first words stage and to use

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comments instead to promote language acquisition. For example, instead of asking a child at play, “What’s that?” or “What are you doing?”, an adult could comment on what the child is playing with (e.g., “red car,” “big ball”). This format also avoids confusion for the child, as questions imply that a response is required, whereas comments do not. Narration of play by adults is beneficial not only for children’s acquisition of expressive language skills but also their acquisition of receptive language. For children who do not acquire spoken language skills, such exposure is still instrumental in development of language skills for communication via AAC methods. Recasting and Using the One-Up Rule When using embedded communication trials, additional modeling strategies can be added following a trial to enhance learning over time. Recasting is defined as repeating the word the child attempted but correcting the production and/or elaborating on it. For example, if the child says “buh-buh” for bubbles, the adult might say, “Bubbles!” while blowing bubbles for the child. If the child says, “Red go car,” the adult might say, “Red car go.” Recasting can also include expansions of the child’s language to model language that is slightly above the child’s language level. Rogers and Dawson (2010) suggested the one-up rule, in which adults speak to children in phrases or sentences that contain the same number of words the child’s spontaneous sentences contain plus one additional word. For example, if the child says “block,” the parent models “green block.” At first, the additional word can be added in the recast, providing models before requiring the additional word: Adult: “Block?” Child: “Block.” Adult: “Green block!” (while giving the green block to the child) This way, learning is scaffolded to ensure that the child is exposed to increasingly longer phrases or grammatical structures without being required to use them. The child eventually can be required to use the longer phrases to obtain a desired item or continue a preferred activity (McGee, Morrier, & Daly, 1999). Again, the adult should use grammatically correct sentences when employing this technique. Implementing Shared Control Strategies Because setting up opportunities for communication relies on both the child’s motivation to participate and the use of natural reinforcement in most NDBI, shared control must be a part of implementing any learning trials. The adult follows the child’s interest and then can take a turn in order to gain control over an object or outcome that can be used as contingent reinforcement. Shared control occurs when the adult balances following the child’s lead with turn taking (balanced turns). Direct and natural reinforcement can then be facilitated when the adult creates or capitalizes on situations in which he or she has control over an object or outcome (e.g., getting help, getting picked up) that a child wants or finds rewarding. That is, the adult’s turns are used as opportunities to embed teaching trials because the object or activity can then be used as natural reinforcement. In addition to following the child’s lead, the adult may also share control by modeling new actions or activities, taking turns where teaching trials are not embedded and noncontingent reinforcement is given, imitating the child, and setting limits as needed. For example, if the child is interested

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in or motivated by something he or she cannot have access to, the adult may offer choices that are currently available. There are many shared control strategies outlined across NDBI, including Project ImPACT, PRT, ESDM, and IT. Together, these strategies can result in a wide variety of types of trials embedded in a wide variety of activities and routines. Shared control strategies, their definitions, and examples are outlined in Table 11.2. Although these strategies are focused on the portion of the interaction in which the adult has control over the materials in order to evoke a communication behavior, the full shared control of an interaction includes the reciprocity and balanced turns that occur between the adult and child. Shared control strategies are discussed in Chapter 6 as well. Using Motivational Strategies The many motivational strategies used in NDBI are often incorporated when targeting communication goals with children with ASD. These are discussed briefly here in terms of teaching communication because they are elaborated in more detail in Chapter 6, on motivational strategies. Noncontingent Reinforcement Noncontingent reinforcement (i.e., giving the child access to reinforcement without placing demands) can be used in two primary ways to build motivation when targeting communication skills. It should not be used when an instruction or cue has already been provided. If no instruction has been delivered, noncontingent reinforcement can be provided to enhance motivation. The first way noncontingent reinforcement is often used is when the child is given access to a small amount of reinforcement as a way of enticing or trying to gain the child’s interest in an activity. For example, the adult might tickle the child briefly or swing the child around and then pause for communication or give a few pieces of a toy to get the child started before having the child request more pieces. Several additional examples can be found in Box 11.1. In these examples, the child is initially given noncontingent access to a part of the toy or activity. As this strategy often piques motivation, the next steps are then held back in order to set up a communication trial and then provide contingent reinforcement. The second way noncontingent reinforcement is used is to create behavioral momentum when targeting communication. This procedure entails giving the child the requested action or item while modeling the target word or behavior, preferably in rapid succession, prior to stopping and prompting for the response. After multiple models and multiple doses of reinforcement, the child is more likely to respond to the cue or prompt independently. Reinforcing Attempts or Shaping Reinforcing attempts or shaping is often used to target communication goals. As discussed in Chapter 6 (on motivation) and Chapter 9 (on reinforcement), this process entails providing reinforcement in response to a good attempt for the child’s communication level, even if it was not entirely accurate, in order to build motivation, increase success, and encourage future attempts. If a child is using single words, the focus is likely to be on word attempts, for example, a child who says “ca-cuh” for “cracker” or “nana” for “banana.” If the child is using multiword phrases, the focus may be on reinforcing phrases even if articulation is lower quality than it is with single words. Good attempts at phrase and sentence speech may also be longer or more complex utterances that contain grammatical errors. Research shows that when attempts at communication are reinforced,

Table 11.2. Shared control strategies for targeting communication goals Shared control strategy

Definition

Nonverbal example

Early language example

Later language example

Environmental arrangement—Arranging the environment to foster communication Environment: In Storing items where they can sight, out of be seen but not obtained reach (e.g., storing preferred toys up high or in clear bins that cannot be opened without help) Activity: In Setting up an activity so that sight, out of materials can be seen but reach not accessed (e.g., setting up art supplies on the table but out of the child’s reach)

Store snacks on a high shelf. Provide them to the child contingent on pointing to request.

Store the phone or tablet on the counter. Provide access contingent on a single-word request (e.g., “phone”).

Store the remote control on the mantle. Provide access contingent on using a phrase to request (e.g., “Please turn on Daniel Tiger”).

Place crayons out of reach on the table while coloring. Exchange a Picture Exchange Communication System (PECS) card to request a crayon.

Place tools out of reach while playing with playdough. Require a single-word request (e.g., “roller”) to receive a new tool.

Place stickers out of reach during art. Require a phrase (e.g., “three green stickers”) to request stickers.

Reducing adult anticipation of child wants or needs—Wait for the child to communicate before providing what he or she wants

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Control access or shared control

Following a child’s interests After a child begins playing with and taking turns; embedding a ring stacker, place another learning opportunities ring on. Then, hold up a new that lead to natural, direct ring and wait. Provide the toy reinforcement when the child exchanges a PECS card.

Hold up a piece that goes with the puzzle the child is doing. Provide the piece when the child labels it (e.g., “cow”). Then, take a turn after the child places his or her piece in the puzzle.

Interrupting routines

Pausing in the middle of a known routine so the child must communicate before moving on

Pause with the child’s shoe in hand Pause with the child still buckled and foot in the air. Put the shoe into the car seat at the park. on when the child says “shoe.” Unbuckle when the child says, “Let’s go do the swings.”

Stand at the door, ready to go outside. Open the door when the child uses the “outside” button on his or her augmentative and alternative communication (AAC) device.

When engaging in reciprocal play with a child using a barnyard and animals, model a new activity by driving a tractor. Then, offer two sets (e.g., tractors and horses) for the child to choose from. Provide a set when the child uses a phrase to request (e.g., “Let’s play tractors”).

(continued)

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Table 11.2. (continued) Shared control strategy

Definition

Nonverbal example

Early language example

Later language example

Reducing adult anticipation of child wants or needs—Wait for the child to communicate before providing what he or she wants Assistance

Setting up activities or situations in which the child will require adult assistance; reducing adult anticipation of child needs when natural opportunities arise in which the child needs assistance Inadequate Providing a few pieces or portions/ parts of a set at a time in breaking it up order to generate multiple communication trials (applies best to toys or snacks with multiple pieces or sets of items) Intentional Ignoring the child on purpose, ignoring especially when the child needs help or the adult has a preferred object, to create opportunities for appropriately gaining attention

Hand the child an unopened chip Place the child’s snack in screw-top bag. Open it when the child containers. Wait until the child hands it back for help. says “help” before opening it.

Provide a few goldfish crackers in a bowl. Provide more when the child reaches for the bag on the table.

Turn away from the child when his or her cup is empty. Turn back to accept the empty cup for help when the child appropriately taps your shoulder.

Provide the child with Mr. Potato Head, but keep the pieces. Provide each piece as the child labels it (e.g., “nose,” “eyes”).

Open a marble ramp toy. Provide a few pieces, and wait while the child struggles to build it. Provide help when the child says, “Let’s build the ramp.”

Provide the child with several magnetic tiles while keeping the rest. Provide more pieces as the child says what he or she is going to build next (e.g., “I am going to build the roof now”). Turn away while holding the Turn away while holding the needed puzzle piece. Turn back to paintbrush for the paints the provide the piece when the child child already has. Turn back, says “mom.” when the child calls your name.

Other shared control strategies Playful Playfully interrupting the interruption child’s play so that he or she or obstruction must communicate to have the interruption removed

Pause during a tickle game. Continue when the child makes eye contact and/or vocalization.

Make a toy tree fall on the tracks to block the train. Move it after the child fills in the adult phrase “ready-set” with “go.”

Sabotage

Providing parts of an activity while withholding obvious necessary parts

Provide cereal without a spoon. Give the spoon when the child points to it.

Provide tracks without any trains. Give the trains when the child says “train.”

Protest

Setting up situations that are known to upset the child in order to provide opportunities to practice appropriate requesting and protesting Setting up situations that are obviously silly (e.g., putting pants on head) or breaking known routines in a silly way (e.g., going the wrong way when walking into school)

Offer a nonpreferred food. Remove it when the child appropriately pushes it away.

Stop the balls part way down the ball track. Let them go when the child says “move.”

Silly situations/ playing the naïve adult

247

Turn the power switch to off on a Give Daddy a child’s fork at dinner cause-and-effect toy and laugh and say “Here’s your fork, or say, “Oh no!” Turn it back on Daddy” in an exaggerated tone. when the child taps it. Give the fork to the child when he or she says, “Mine!”

Place a hand over the carwash entrance on a toy garage. Move it after the child uses a phrase to state what is next (e.g., “It’s time to wash the car”). Provide the pieces to the game but not the board. Give the board when the child says, “We need the board to play the game.” Go out of turn during a board game. Give access to the spinner when the child appropriately says, “It’s not your turn.” Pretend to put pants on your head during the dressing routine, and act silly. Help put pants on correctly when the child says, “Pants go on legs!”

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Ready, Set, Implement! BOX 11.1: Noncontingent reinforcement Try these uses of noncontingent reinforcement to enhance a child’s interest when starting a new activity! • Give a few blocks, train tracks, Magna-Tiles, and so forth to get the child started with building, but keep the rest in the box. • Give the child one marker to begin coloring, but maintain control over the rest. • Help the child spread the glue on his or her paper, but keep the glitter on your side of the table. • Give the child a small amount of snack (e.g., crackers), and keep the bag on the table out of reach. • Throw the ball to the child, and when he or she throws it back, pause. • After setting up the marble ramp, put the marbles in, but remove them from the bottom before the child can do so.

motivation remains strong and the attempts improve over time. It can be helpful to use recasting when reinforcing attempts. That is, while reinforcing the child’s approximation of the target behavior, model the full correct target behavior. Task Variation, Varied Turns, and Interspersal of Maintenance and Acquisition Tasks Task variation strategies are also often used when targeting communication goals. These strategies are elaborated in Chapter 6, on motivation. Task variation is simply making sure that demands are varied so as not to induce boredom. Interspersal of maintenance and acquisition tasks is defined as switching between easy (maintenance) and hard (acquisition) tasks as a way of maintaining motivation. Maintenance tasks are motivating and can enhance behavioral momentum because the child experiences success and reinforcement easily. Acquisition tasks ensure that the child is practicing new skills. Because all types and levels of communication are useful, no matter what a person’s language level may be, interspersal is also important for maintaining a range of language skills while also moving goals forward. Imitating the Child Imitating the child’s actions, sounds, or expressions is another widely used strategy for introducing and evoking verbal and nonverbal communication. For children who are nonverbal and not yet imitating speech sounds, imitation of actions on objects and song routines are helpful tools to introducing this skill (see also Chapter 6, on motivation, and Box 11.2). Sensory social routines, described in more depth in Chapter 12, on social skills, are especially useful for promoting imitation. Adults can imitate their child’s actions, termed nonverbal mirroring in Enhanced Milieu Teaching (EMT), then introduce a new element and wait to see if the child imitates the new action (Kaiser & Delaney, 1998; Kaiser & Trent, 2007). The use of contingencies, access to the reinforcing object or interaction following the completion of these desired actions, are often built in to imitation teaching and can also be applied to teaching verbal skills.

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Ready, Set, Implement! BOX 11.2: Imitate the child Try the following types of imitation when engaging the child to teach socialcommunication skills: • Imitation of motor actions • Imitation of sounds and words • Imitation of facial expressions • Imitation of gestures • Imitation of actions on objects • Imitation of actions within song routines

TEACHING COMMUNICATION ACROSS DEVELOPMENTAL LEVELS USING NDBI STRATEGIES The NDBI strategies outlined in this chapter can be used to teach at all developmental levels. The following section discusses the application of these strategies across multiple developmental levels and target behaviors. Intent and Preverbal Communication The first time a parent hears a word from his or her child is never the first time the child actually communicates. Before that first word, the child has communicated with the parent for months—requesting, sharing, and drawing attention to him- or herself in complex nonverbal or prelinguistic ways. The earliest forms of communication begin with the reciprocal back-and-forth nonverbal interactions as well as vocalizations and other social and communicative interactions between parent and baby throughout the first year of life. These seemingly simple, yet actually complex turn-taking sequences set the stage for the emergence of increasingly longer and more varied exchanges. Eye contact, shared enjoyment, joint attention, and gestures (discussed later) are all forms of preverbal communication that occur early in development. These early forms of communication create essential pathways to verbal communication and cannot be overlooked when teaching first words to children with ASD. Children with ASD who are preverbal may or may not engage in these skills, and building these skills up is the starting point for any child who is not yet using verbal speech. Selecting Preverbal Communication Targets and Strategies for Intervention As indicated previously, given the foundational nature of intentionality in communication, intervention for any child typically focuses on these functions as a starting point. Communicative intent is expressed in many ways—through eye contact, gestures, vocalization, and verbalization. Behaviors that regulate others are typically the first to develop; these include requests for objects, actions, or assistance and protests. Social interaction behaviors include gaining attention, social games (e.g., Peekaboo), and greetings. Finally, joint attention behaviors include showing, commenting, and requesting information (Bruner, 1981; Crais et al., 2004).

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Although many children with ASD demonstrate behaviors that regulate others, such as requesting actions and objects, some may not (Wetherby & Prutting, 1984). Because these behaviors are often the first demonstrated by young children and can be paired with tangible reinforcers, such as food and highly preferred objects, they are readily taught. Children can learn such behaviors progressively in a naturally occurring developmental sequence—first using eye contact to request objects and actions, then reaching to request, followed by pointing, and progressing to vocalization and verbalization (Crais et al., 2004). Sophistication in the behaviors can be added through combinations of behaviors, such as reach plus eye contact, or point plus vocalization plus eye contact. For example, if a child demonstrates interest in a toy or activity, such as bubbles, the adult might blow the bubbles. For children encountering an activity or toy for the first time, a useful guideline may be to engage the child in three opportunities to experience the activity or toy so he or she may understand and fully appreciate it. As such, the adult might blow the bubbles three times in an unhurried manner, assuming the child is engaged and appears to enjoy the bubbles. After the third time, the adult could pause and wait for the child expectantly, holding the bubbles in the child’s sightline. If the child looks at the adult and/or reaches for the bubbles (depending on the expected developmental level of the request), the adult should immediately reinforce the request, for example, by saying, “Bubbles! You want bubbles” and blowing again. Development of behavior regulation intentionality is a significant step in development of more sophisticated intentional communicative acts, such a joint attention. Behavior regulation requires a child to focus his or her attention on an object and communicate the intent to a partner about that object. Ingersoll and Dvortcsak (2006) emphasized that parents use the previously mentioned strategies in Project ImPACT, along with highly animated interactions to increase communication engagement opportunities, such as exaggerated body movements and facial expressions. ESDM recommends that parents and teachers intentionally position themselves in front of children to assist with eye contact (Rogers & Dawson, 2010) for both behavior regulation and social purposes. ESDM and PRT both recommend teaching children to use eye contact to request; one way to do this is to wait for eye contact prior to granting access to a desired item (Koegel, Koegel, & Brookman, 2003; Rogers & Dawson, 2010). For example, an adult can hold up a bottle or desired snack and wait for the child to look at him or her before giving the item to the child. ESDM also introduces nonverbal communication as “talking bodies” and suggests that parents wait for a cue from the child rather than anticipating the child’s needs by automatically meeting them. Environmental arrangements and a large variety of communication temptation strategies are essential tools in this phase to create learning opportunities throughout daily routines and play (see Chapter 12, on social skills interventions, for a detailed discussion, including discussion of sensory social routines). Social interaction requires the child to focus his or her attention on the communication partner—another key developmental step in intentionality. Thus, it is not surprising that children with ASD may rely on development of both behavior regulation and social interaction skills to demonstrate joint attention behaviors. When teaching social interaction skills, adults might use a similar progression as behavior regulation skills. That is, if teaching a child to initiate and/or maintain interaction during a social game, the child might first use eye contact, then a

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facial expression (e.g., smile), then a reach or gesture, then a vocalization, then a verbalization. For example, the adult might initiate a Peekaboo game with a scarf by first placing it over the adult’s head and saying, “Where’s X?”, then slowly pulling it off. This might be repeated two more times, assuming the child is engaged and interested in the game. On the third trial, the adult pauses with the scarf still on his or her head expectantly, giving the child an opportunity to initiate a gesture (pulling off the scarf) or a vocalization or verbalization (“Where’s X?”). If the child does so, the adult and child continue taking turns with high affect. If the child does not produce a communication bid, the adult slowly pulls off the scarf with a big smile. If the child still appears interested in the social game, on the next trial the adults might try placing the scarf loosely on the child’s head for variation. Finally, joint attention is of particular interest with regard to children with ASD. It develops near the end of the first year of life for typically developing children. Sometimes joint attention is called triadic attention because attention is literally shifted between the communication partner and a third object—hence the importance of the foundation skills of focusing communicative intent related to an object (behavior regulation) and focusing communicative intent on a person (social interaction). Most developmental researchers think this is a necessary step in order for the child to begin to understand that a word references a specific object or action. Indeed, the strong predictive relationships between early joint attention behaviors and later expressive and receptive language appear to support that notion (Morales et al., 2000; Mundy & Gomes, 1998). Joint attention is key to socialcommunication and interaction. Many of the early interactions have high affective value and appear highly reinforcing for both child and adult, further establishing strong social bonds and reciprocity. Children with ASD often lack both early joint attention behaviors and the high affective state that typically developing children demonstrate. There are two aspects to joint attention: initiating joint attention and responding to joint attention. Initiating joint attention is when a child directs another person’s attention to something of interest (e.g., the child says to a peer, “Look! An airplane” while pointing in the sky). Responding to joint attention is when a child reacts to another person’s initiation of joint attention (e.g., while sitting in a classroom, the teacher looks out the window, and the child looks out as well). Children should be initiating and responding to joint attention by 12 months of age; the complexity and subtlety of the communication bids increases with age. Although children with ASD demonstrate use of behavior regulation communicative intents and/or are often responsive to teaching of such behaviors, joint attention behaviors can be challenging for children with ASD and may need to be explicitly taught, which is why they are emphasized in many NDBI treatment models (e.g., JASPER, ESDM). Please see Table 11.3 for additional examples of different types of joint attention behaviors. Teaching joint attention is separated across initiation and response. As to be expected, teaching initiation can be challenging. Adults must set up opportunities for the child to express interest in an object or event and capitalize on the child’s motivation to share such interest. This means following the child’s gaze or point and commenting on it. Adults must demonstrate to the child that they are interested in what the child is looking at, observing, interested in, and engaged in. By creating natural opportunities such as these, adults encourage the child to share

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Table 11.3. Joint attention behaviors Behavior

When does it develop?

Example

Eye gaze alternation

6–12 months

Pointing Giving Showing

9–12 months 9–11 months 9–14 months

Looking from airplane in the sky to communicative partner Pointing at a trash truck driving by Sharing food with family members Holding up a toy of interest and looking at an adult until he or she reacts

Initiating joint attention

Responding to joint attention Following a point

6–9 months

Following an eye gaze

9–12 months

Looking at the truck as the parent points to it Shifting eye gaze to what the parent is looking at

Source: Bruinsma, Koegel, & Koegel (2004).

interesting stimuli in the environment and activities. Adults can also create more contrived situations with specific cuing hierarchies for the child to point to, show, and tell about objects and activities until more spontaneous productions occur. For example, adults can encourage the child to point out particular objects of interest or specific categories of objects (e.g., animals, cars) when reading books. As the child is learning to point to things to draw attention, adults can support the child by giving him or her a target that is pre-positioned into the book or physical environment to support the child in this task. Small, round, removable stickers (often found in office supply stores) can be helpful in creating visual cues and decreasing reliance on adult prompts when working in this way. With regard to responding to joint attention bids, progression in both linguistic and contextual cues is required—that is, when drawing a child’s attention to an object or event of interest, adults should start with high affect and a clear linguistic and visual cue (e.g., “Look, X” with point and head turn). In addition, they should make sure that the object they will be looking at holds high reinforcement value! The child needs to receive reinforcement for looking if adults hope to encourage the child to repeat the behavior. Adults should slowly reduce the saliency of the cuing and the magnitude of the reinforcer as the child becomes responsive to joint attention bids across communication partners. JASPER emphasizes joint attention behaviors and constantly models a variety of examples while also promoting an affectively rich interaction with some labeling. In addition, some research in PRT has shown that eye gaze alternation to share enjoyment (a social purpose) increases during child–parent interactions as a collateral effect of PRT (Bruinsma, 2004). This suggests the focus of PRT strategies to enhance the child’s success in the interaction may support the development of early forms of joint attention behaviors and may in fact help to explain why children learn to use verbal communication in PRT programs. Selection of highly preferred materials, especially those that are related or part of a child’s perseverative interest, may be especially important. Vismara and Lyons (2007) showed that incorporating these interests into interactions may increase a child’s joint attention behaviors, making the case for a careful selection of materials for teaching interactions.

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Augmentative and Alternative Communication for Individuals Who Are Nonverbal Some individuals with ASD will benefit from AAC systems that support communication across multiple modalities. AAC can take many forms (or a combination of forms), including use of sign language, low-technology picture symbol systems, such as PECS (Frost & Bondy, 2002), or high-technology speech-generating devices, such as applications on iPads or devices developed specifically for the purpose of generating speech (e.g., Dynavox). The main goal of any communication system is always to encourage the individual to communicate his or her message, regardless of the modality. For example, a child might be using a speech-generating device for communication, but adults should never ignore the child’s request using a pointing gesture (just as they would never ignore the same gesture from a child who is verbal). Research supports that children with ASD demonstrate effective communication across multiple modalities (Mirenda, 2003). In addition, use of some types of AAC may provide support as children acquire verbal language; for example, PECS has been found to be an effective bridge to verbal communication for some children with ASD (Carr & Felce, 2007; Ganz & Simpson, 2004). Although parents and clinicians sometimes worry that the use of AAC will hinder the development of verbal language, research does not support this concern. Thus, it is essential to support the child’s acquisition of communicative intentionality regardless of modality in order to pave the way to successful communication. Progress monitoring, defined as careful data collection regarding the child’s progress in intervention, is key to determining if providers should seek alternative communication methods for a child. For example, within ESDM, if a child is not making sufficient verbal language progress (acquisition of 5–10 spoken words) within 3 months of intensive intervention focusing on verbal language, the team begins to support the child’s acquisition of communicative intent via alternative methods while continuing to support acquisition of verbal language. If the child demonstrates strong motor imitation skills, use of sign language is introduced as an alternative communication method to possibly bridge verbal language acquisition. Should the child demonstrate motor imitation challenges, PECS can be introduced (Dawson et al., 2010). Frost and Bondy (2002) indicated there are no prerequisite skills required to introduce PECS, although clinicians should be mindful as the child progresses through the phases because skills such as matching pictures to objects in the environment may facilitate successful use of PECS as the complexity increases. When using PECS, careful adherence to the manual is recommended for effective acquisition of communicative intent. If verbal language does not develop as the child progresses through these low-tech methods (or others), the child should receive consultation from a speech-language pathologist (SLP) who specializes in AAC to determine the next steps in determining the AAC device and programming to fit the child and family’s needs. Indeed, consultation with an AAC team, including an SLP and occupational therapist skilled in serving children with complex communication needs, should be pursued prior to implementation of any long-term AAC protocol. Strategies for Teaching Augmentative and Alternative Communication Goals Teaching children to use AAC via NDBI strategies is very similar to teaching any early communication skill. When teaching PECS, NDBI clinicians should follow the

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PECS protocol (Frost & Bondy, 2002) because it outlines very clear steps for teaching PECS as well as ABA-based strategies for doing so. In order to ensure access to communication across contexts, the child’s communication book should include PECS icons for all possible communication contexts, objects, and events of interest that may be encountered throughout the day. One area of frequent communication breakdown is when a child wishes to use his or her communication book to comment on or request a particular object or event and the PECS icon is not present in the book or the child does not have access to the book at that time, which severely limits the child’s communication opportunities. Continual updating of the book reinforces communication, maintains child motivation, and promotes reciprocal social interaction. It may be useful to consider that a verbal child has their words with them at all times, as should a child using AAC! The use of other communication devices can be taught in the same way. These devices are often introduced and initially taught during speech and language services or NDBI therapy sessions. As such, treatment should be closely coordinated with an SLP with specific AAC expertise when necessary. Again, the same strategies for teaching early communication skills can be applied to teaching device use. Very quickly after introduction of the device, communication partners across contexts should be trained in use of the device in order to maximize opportunities for use across communication contexts and to ensure access to communication for the child. Again, it is important that the device be available at all times because this is the child’s means of communication. Adults would not limit a child’s verbal language opportunities to specific times of day or physical environments; children who use AAC devices (both low and high tech) require the same universal access. A PECS system or device is only useful to the child if it is available or feasible to use in the natural environment! When teaching AAC, adults should remember to continue recasting, narrating, and modeling language. Indeed, adults and peers should be taught and encouraged in use of the AAC device themselves during interactions with the child with ASD; this is called aided language modeling (Drager et al., 2006). When children are nonverbal, their lack of verbal responsiveness sometimes conditions adults to become less verbal during adult–child interactions. However, continuing to expose these children to a language-rich environment, through both verbal and AAC modeling, remains critical to their development; adults must scaffold their receptive and expressive development in this way. First Words As indicated previously, initial treatment goals are often focused on intentionality. As the child’s expression of intentionality progresses developmentally (e.g., eye contact, gesture, vocalization, verbalization), the focus can begin to shift to assisting the child in shaping his or her vocalizations closer to accurate productions. Production of first words may occur concurrently with other behaviors to demonstrate intentionality. An example would be the child who first looks at the caregiver to indicate wanting to be picked up, then starts to raise his or her hands to request, then vocalizes, then combines the approximation for “up” with raised arms. Once a contingent vocalization is consistent, then the parent or teacher can begin to introduce new word approximations. Vocalizations and

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verbalizations can be encouraged by the use of imitative songs, narration and word modeling during play, recasting, and contingent social games in sensory social routines (see also Chapter 12, on social skills). Early vocalizations can form the foundations of first words for preferred objects and can encourage contingent word use as a means to request (e.g., “bu” for “ball”). However, adults should be cautious in early stages of communicative intent about requiring a vocalization or verbalization (approximation) for every opportunity; they should remember to intersperse acquisition and maintenance. As children are first acquiring early communication skills, development can fluctuate, and a child’s motivation can be diminished if he or she is constantly pushed to maximize his or her performance. Interspersing reinforcement of nonverbal communication behaviors (e.g., gestures, eye contact) can be useful for ensuring motivation remains adequate. Selecting First Word Targets Selecting first word targets carefully is important to ensure many opportunities for success (Koegel, 2000). Parents, therapists, and teachers often teach nouns first when building vocabulary, with an initial focus on words used to request, because children with ASD learn best when highly motivated, and their motivation is often highest when requesting preferred objects. However, teaching action words is also key. Children need a way to describe what they want to do and the way they participate in their daily lives. The ability to prompt for the word many times throughout the day is essential, as is the need to select words based on the child’s preferences. Developmental literature shows certain sounds develop earlier and will most likely be easier for the child to produce (e.g., “buh,” “mah”). Because all children are different—and children with ASD can have unusual and complex patterns of speech development—it can be useful to consult with the child’s SLP when selecting first word targets. Some first word targets may be challenging for a variety of reasons, as described in Table 11.4. In this table, examples of first words or word categories are listed, along with a description of why they are or are not good first word targets. In many cases, verbs and words like “more” may be good first word targets but some may have some pitfalls (e.g., prone to overgeneralization). These pros and cons are also briefly discussed in the table. Strategies for Teaching First Words First words are typically taught using some of the shared control strategies outlined previously to target verbal requesting and vocalizing or verbalizing during sensory social routines. These strategies all incorporate child-preferred objects or activities, shared control, and natural reinforcement to motivate children to verbally communicate. Strategies that lend themselves particularly well to teaching first words include sensory social routines, environmental arrangements (in sight, out of reach), playful interruption or obstruction, controlling access, and inadequate portions or breaking it up. Table 11.5 outlines a range of ideas for materials that can be used at this stage and some advantages and disadvantages of each for teaching first words. For example, some toys lend themselves better to multiple trials than others, are ideal for taking turns, or facilitate shared control more naturally than others.

256 Table 11.4. Tips for selecting first word targets Example first words Carrier phrases: Ready, set, go; one, two, three Labels for preferred actions: Up, push, hop, pop More

Yes

Good first word target

These are usually helpful for first Child must understand to fill in, rather words because they create inherent than repeat. momentum and can easily be associated with fun actions. Many children with autism spectrum Be sure the child understands verbs. disorder (ASD) love physical stimulation, Some children do better starting out and these are usually top picks. with nouns. This usually is not a good first word Once a child has 25–50 labels, this can target, although it is frequently taught be an easy word to add as long as early as a sign. the child continues to use specific labels. This usually is not a good first word This word can be added into the target. child’s repertoire later and may need to be specifically taught.

No, all done, or They can be good first word targets other words that because protest emerges with indicate an activity communicative intent. ending or stopping Animal sounds: Moo, meow, ruff-ruff

Child-specific considerations

They can be useful as a replacement behavior if the child engages in problem behaviors.

Possible challenges Child can become prompt dependent and have difficulty moving on to acquiring more words. Be careful to ensure that the action is specific and clear. You may wish to avoid consonant blends as first word targets. This word is easily overgeneralized. The child may use “more” for everything he or she wants. Remember that you want to teach object–label correspondence at this stage of development. This word is easily overgeneralized, as described previously. It can also be conceptually challenging or some children to learn. These words are often hard to teach because they may be needed when the child is frustrated. Specific teaching strategies may be required, which will be more successful once a child can easily say other words. These may not be as functional or universal as teaching animal names.

These can be good first word targets. They These are often a fun way to label often appear early in development for animals, but they are not reinforcing typically developing kids. to all kids. They should only be taught to children who are reinforced by play or activities that relate to animals. Labels for preferred These are helpful for most kids. Once you It can be useful to choose labels for For children who are struggling to learn words, items, such as pick a few labels, try to ensure that there items that are both highly preferred it may be challenging to choose a word that bottle, block, chooare many opportunities throughout the and include sounds you have heard they can practice often enough. choo, and baby day for requesting the item. the child say. Academic objectives: These can be good first word targets These are only good first word targets They are often loved by parents and can be Colors, numbers, because they are clear labels, like any if they are motivating for the child. highly preferred, but they are not always shapes other noun. functional. Try to incorporate them once the child has 50 or more consistent functional words or only rely on them for children who are difficult to motivate with other objects.

Table 11.5. Material selection for teaching first words Type of material

Examples and suggestions

Advantages

Disadvantages

Simple toys that consist of one piece, often with buttons to manipulate

Pretend telephone Pretend car keys Steering wheel iPads Poppin’ Pals Leapster Toy instruments (e.g., piano)

Simple cause-andeffect toys with multiple pieces

Ball ramps Car ramps Marble ramps Ball popper Connect Four Cookie Monster that eats cookies Toy piggy bank with giant coins Toy gumball machine with balls Puppets with mouths you can stick your hand into to manipulate as if they are talking Colorful big monsters, animals, or dinosaurs

They are often highly motivating and interesting to manipulate, especially for younger children or those who are less verbal. Try to have two of the same object so that you can imitate what the child is doing in order to promote interaction and communication. It is easy to follow the child’s lead in interactions because the toys are simple. These are coveted toys that lend themselves to both action words (in, on, or go) and nouns (cookie, chip, or ball). They can be good for breaking it up. You can elaborate on the play and communication.

If you only have one of these toys, it can be difficult to foster reciprocity and balanced turns, which can result in one type of opportunity to gain initial access, unless you incorporate turn taking. Kids can get overly focused on the electronic nature of these toys, which can interfere with interaction and reciprocity. Because the actions on these toys are repetitive and the vocabulary can be limited, be sure to mix it up with your words and play acts. For example, add other targets, such as receptive skills, following directions, sharing, or turn taking.

Puppets can be involved as an addition to many activities and can bring humor to play. Routines that involve sound effects (e.g., pretend sneezing) are particularly effective. Children also often find it funny when puppets eat or spit out toy food. They allow for modeling and creation of imaginative play schemas. It is great for teaching actions such as roll, push, and cut. There can be many items and colors associated with the activity for the child to request.

Some children find puppets scary, at least initially. For first word learners, make sure the verbal targets are clear (e.g., have the child label the food the puppet will eat).

Puppets

Playdough

Sets with a clear action (e.g., figurine with hair that grows, contraption that produces spaghetti) Playdough tools (e.g., roller, pizza cutter, plastic scissors) Different colors of playdough

Playdough can quickly turn into a solitary activity, so balanced turns and shared control are important. Some children try to eat it. Some adults object to the mess. Try containing the activity by presenting it on a plastic tray!

(continued) 257

258 Table 11.5. (continued) Type of material

Examples and suggestions

Advantages

Disadvantages Be sure to use balanced turns. It is tempting to have the child communicate for each puzzle piece, but this may be frustrating and does not create a natural interaction. Intersperse having the child communicate to receive a piece with giving noncontingent access and commenting or initiating joint attention and shared affect with regard to his or her pieces. Because the vocabulary can get repetitive, it may be helpful to intersperse different tasks (e.g., receptive targets) into the activity. Bigger books or books with added features such as sound or pop-ups can increase opportunities for reciprocity, shared enjoyment, and balanced turns. A useful strategy for embedding trials is to have the child label something on the page and then turn the page as reinforcement. Avoid taking too many of the turns yourself and asking lots of questions to keep the interaction reciprocal. At first, try to use the game for its motivating and engaging materials. The object is not necessarily for someone to win but to have fun with the materials as a toy. This is why games for older kids will sometimes still work. If Connect Four is about putting chips in and seeing them fall out, then you do not need to understand the objective of the game. Be sure not to get stuck on trying to play the game by the rules if this is not developmentally appropriate or motivating for the child.

Puzzles

Sound puzzles Wooden inset puzzles Shape sorters

Puzzles can provide a range of vocabulary if the pieces are different objects (e.g., animals, vehicles). Sounds are often highly motivating. Varied sounds can provide a range of opportunities. It is easy to incorporate actions with puzzle pieces if the pieces contain animals, vehicles, and so forth. They provide lots of opportunities for different communicative functions, such as requests for information (“Where’s the missing puzzle piece?”) and commenting.

Books

Touch and feel books Sound books Pop-up books Simple storybooks

Books offer many opportunities for labels, actions, and joint attention. They can be highly preferred, and it is easy to incorporate the child’s favorites. There are good opportunities for varied vocabulary once the pictures have some complexity to them. Be sure to follow the child’s gaze and label what the child is looking at—this promotes initiating joint attention.

Preschool games that have a simple (often electronic) action (Note: These do not have to be played according to the rules. Many children just find the materials to be fun and motivating.)

Gone Fishin’ (or any fishing game) Elefun (elephant that catches butterflies) Lucky Ducks (pond with ducks) Balloon Lagoon Penguin Race Game (penguins that climb and slide down a track)

Simple actions (“swim” and “on”) and nouns (“duck” and “net”) are easy to label. Communication trials are easily embedded if you retain control over some of the pieces and use breaking it up (e.g., the fish, ducks, butterflies, penguins). There are lots of opportunities for reciprocity, joint attention, and shared enjoyment (e.g., watching the elephant spray the butterflies in Elefun).

Music or musical instruments

Blocks or building toys

Pretend play toys

Balloons

259

Small harp Drum Small guitar or ukulele Xylophone Maracas Tambourine Triangle Kids’ songs Freeze dance Big blocks Lego or Duplo blocks Wooden building sets Lincoln Logs Magna-Tiles

Doctor kit Babies with bottles, binkies, or blankets Dolls and dollhouse Barn with animals Pretend food and dishes Plastic dinosaurs Balloon pump Rocket balloons Different color balloons

If you have multiple instruments, you can easily target requesting and turn taking. These lend themselves nicely to interspersing imitation trials as well. Freeze dance is easy to request for first word learners. It is fun, too! Kids’ songs are easily found on many web sites, such as YouTube. Many kids love the versions of pop songs that are adapted for kids (e.g., Kidz Bop). Multiple pieces are good for breaking it up. Have the child request a few pieces at a time. First word learners often like to knock down towers. The bigger the better! This is also a fun opportunity for joint attention and shared enjoyment! Building (e.g., building a house, barn, or castle) lends itself easily to play expansion (adding other play items). Multiple pieces are good for breaking it up. Have the child request one or a few pieces at a time. You can incorporate these items with other play sets, such as puppets, and building toys.

Musical instruments can be difficult for shared control but great for turn taking, imitation, and small-group music-making activities. Try having duplicates of instruments so the adult can imitate the child’s actions to encourage engagement and reciprocity.

Small Legos can be a choking hazard. Sometimes the actual building of structures is too difficult, and reinforcement is too delayed for first words learners. Be aware of this pitfall, and provide assistance with the building to enhance motivation.

Although thematic play with these items is usually above the developmental level of first word learners, these items might provide opportunities to model simple functional play acts (e.g., feed baby). Due to lack of play skills, these items are not motivating for all first word learners. They lend themselves nicely to routines that can Balloons can be a choking hazard. A child repeat (e.g., blowing up balloons and letting them should not be allowed to blow up a balloon go). Model the routine, then pause and have because it can pop, which may force the child request (verbally or nonverbally), as in particles into the child’s mouth and possibly sensory-social routines. down his or her airway. You can create many routines (e.g., balloon soccer, in Some children are afraid of balloons, which the adult picks up the child so he or she can especially if the game is to blow them up kick it). and then let them fly around the room. When you rub balloons, they become static and stick; this can be funny. Balloons create fun opportunities for balanced turns, reciprocity, shared enjoyment, and joint attention. (continued)

260 Table 11.5. (continued) Type of material Water play

Bubbles

Train sets and other vehicles

Examples and suggestions

Advantages

Water balloons Many of these activities can have multiple pieces that Hose and buckets are easy to have shared control with and work well Small watering can for verbal requesting. You can practice turn taking, Bath toys too! Water sensory bin with cups, Water play can be combined with many other water wheel, and other activities (e.g., make plastic animals or dolls swim). items for scooping and Water balloons are amazing, and filling them is an pouring—fun to include activity on its own. Throw water balloons at targets soap bubbles drawn with chalk. Dumping and splashing water is a popular early play activity. During cooler days, make a water sensory bin with a plastic tub or container and some scooping and dumping toys. The bathtub or the sink can also be great places to play with water. Hand blown with many Easy activity that can be used for prompting a variety different shapes, tools, and of words such as “blow,” “pop,” and “dip.” so forth Bubbles create good opportunities for joint attention Bubble machines and shared enjoyment. Train sets with many pieces Trash trucks that can really dump Dump trucks Small vehicles (e.g., Matchbox) Car ramps Toy garage (some have an elevator) and cars Bridges and especially tunnels that make sound

Multiple pieces are good for breaking it up. Have the child request a few pieces at a time. The child can practice varied vocabulary because there are many pieces and different actions and locations are possible. Adult imitation of the child’s actions is easy because multiple pieces are typically available. Embedded trials are easy with these types of activities (e.g., add a figurine on the track for playful interruption, dump over and over for momentum, and set up for initiations when important pieces are missing).

Disadvantages Never leave a child alone with water. Water can become repetitive and perseverative for some children. In this case, you might have to limit access. For children who become rigid about wanting access to water play, it is best not to allow play in the sink because this may make other routines (e.g., hand washing and brushing teeth) more difficult. Instead, use a water sensory bin.

They can become boring quickly for some children. They can become perseverative for some children, in which case you may have to limit access. It can be difficult when you only have one vehicle. Be sure to determine why this type of play is most interesting and reinforcing for the child. For example, does the child like driving the train? Seeing the train emerge from the tunnel? Listening to the sound of the train going through the tunnel?

Arts and crafts

These activities lend themselves well to multiple strategies for embedding trials because there are many pieces for the child to request. Try using a variety of fun craft supplies, such as colorful pom-poms for gluing; cotton balls for making puffy clouds; Popsicle sticks for coloring or gluing things to; pipe cleaners for easier beading; beading with uncooked pasta; glitter or large sequins for gluing; cut or torn tissue paper, old magazines, or colored paper for collaging; and vegetables (e.g., potatoes and carrots cut in shapes) for stamping. Sensory activities Shaving cream They provide many opportunities for embedded Fake snow trials, where the child has to request items. Sensory bins (e.g., dry Activities such as parachute and swinging lend beans, rice, kinetic sand) themselves nicely to sensory-social routines. with accessories (e.g., cups They are often highly reinforcing. for scooping, small toys You can incorporate a range of items (e.g., paint for burying) brushes to make patterns in shaving cream; small Finger painting toys in sensory bins, such as sea creatures in Parachute kinetic sand). Blanket for swinging, pulling There are lots of opportunities for shared enjoyment, the child across the floor, balanced turns, and reciprocity. or hiding under Cooking activities Cookie decorating Take shared control over ingredients and utensils (e.g., Ice cream sundaes measuring cups), and prompt single word requests. Ants on a log (nut butter on Balance turns with who gets to add ingredients. celery with raisins) Practice following simple verbal instructions (e.g., Smiley face sandwiches, “put in”). pancakes, and so forth These are especially great activities for older children Jell-o still working on first words. Playing with random Rope or string These activities are completely dependent on objects Cups the creativity of the adult but are often highly Lids motivating for the child. Sticks Plastic storage containers Tubes 261

Coloring Pasting Stamps Stickers Collaging Painting Beading

Some first word learners do not have an interest in these types of activities yet; however, most children can do all these activities at their own level. Some adults do not like the mess. Try doing these activities on plastic trays, and limit how many supplies you allow the child to obtain at once. This is another way of applying shared control. They can be messy. Some of these activities can also be done on plastic trays (e.g., shaving cream) or in bins (e.g., sensory bins). Some children can perseverate on these activities, so you may have to limit access. Be sure you know which sensory activities are motivating for a child and which may be aversive. These activities need to be tailored carefully to the child’s preferences. They may not be appropriate for young children or children with severe impairments, but activities can often be adapted. As long as you can have multiple pieces, steps, or repetitive actions, these activities work well. It can be challenging to come up with more than a few different types of opportunities to communicate.

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The most common prompting strategies for teaching first words are time delay and model prompt. Prompting strategies are outlined in detail in Chapter 8. Depending on the child, one prompting strategy may come before the other. For example, if a child has quickly learned several object labels, a time delay can be used almost from the beginning, with a model prompt as backup if the child does not respond. Within the context of play interactions and joint activities, commenting on objects or events and pausing provides the child with a verbal model and then allows him or her to engage. This is often effective, not only for engagement and social interaction, but also for assisting the child in verbal production and/ or initiation of a new, related interaction behavior. Particularly for children with limited vocabularies, this provides opportunities to increase exposure to words within context. This can then be faded to time delay once the child has gained some vocabulary knowledge. Carrier phrases may also be useful at this stage as a strategy for prompting the child to fill in the missing word (e.g., adult says, “ready, set” and child responds with “go”). Even in the first words stage, many NDBI place an emphasis on ensuring that opportunities for initiations are created. Use of sensory social routines, in which the adult repeats a motivating action (e.g., tickles) several times and then pauses so that the child can indicate a desire to continue, can be very helpful at this stage of development, especially because these routines tend to be motivating for children at the first words developmental level. Environmental arrangements, in which objects are out of reach or in closed containers, are also helpful for promoting initiations at this stage. Reducing adult anticipation of the child’s needs and waiting for the child to initiate is another useful strategy. For example, the adult might wait expectantly for the child to say “shoe” before helping put shoes on. Controlling access or shared control with a time delay cue may also be helpful for teaching verbal initiation behaviors. Building behavioral momentum by providing noncontingent reinforcement is also especially effective at this stage. This entails giving the child the requested action or item while labeling the target word without prompting the child to say it. When this is done in rapid succession prior to prompting for the word, the child may be more likely to respond. Please see Table 11.6 for additional examples. Phrase Speech The transition from single words to word combinations is a slow, deliberate process that cannot be rushed. Expecting a child to speak in short phrases too quickly can result in decreased motivation, echoic responding (the child simply repeats what the parent said), prompt dependency, and thus a lack of initiations. As such, if a Table 11.6. Noncontingent reinforcement Target word Ball Chip Go

Action with target word Rapidly tickle the child with a ball.

Description of momentum

Each time you tickle the child, say “ball.” After two to four times, hold back the ball and model, “Ball?” Fill up the Connect Four Each time the chip goes into the game frame, say game with chips. “chip.” After a few times, hold up the chip and ask, “Chip?” Pick up the child, and swing Each time the child is swung, say “go.” After two to him or her once around. four swings, pick up the child, wait, and ask, “Go?”

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child is taught to use phrase speech before he or she is developmentally ready to do so, the language will be rote and will not be meaningful to the child; it is analogous to how young children first learning the alphabet think of the letters LMNOP as one unit until they learn that each letter is distinct and separate. Once a child has obtained a range of single words (at least 50) and can use them spontaneously, independently, and functionally, an adult’s efforts can shift to continuing to expand the child’s vocabulary and targeting length of utterances. It is important to make sure the child is using a variety of words consistently (nouns, verbs), functionally, and spontaneously before moving on to word combinations or phrases. Many clinicians use about 50–80 single words as a benchmark before moving on to focusing on phrase speech; in typical language development, children start to combine words together when their vocabularies reach 40 to 200 words (Bates et al., 1995). It is also important to continue to intersperse teaching trials for single words to ensure that vocabulary is expanded and motivation remains high. Interspersing teaching trials for words the child already knows (maintenance tasks) is important for enhancing motivation at this stage. It can be helpful to make lists of these new words and possible two-word combinations for each highly preferred activity so that the same combinations across and within activities are targeted. Please see Table 11.7 for an overview of considerations on when to begin interspersing word combinations. Although this table does list criteria, acquisition of the listed skills is not necessarily a requirement prior to targeting phrase speech. Rather, the information provided may be useful to consider when evaluating the child’s progress and skill level with single words and can be used to guide how and when to move into phrase speech. Selecting Phrase Speech Targets Selecting phrase speech targets carefully is important to maintain child motivation as a new, more challenging skill is introduced. Phrase targets that can be easily practiced in the natural environment are a good place to start in order to ensure many opportunities for success. The ability to prompt for the phrase many times throughout the day is essential, as is the need to select phrases based on the child’s preferences. Some common patterns exist with regard to how children develop production of short phrases. Table 11.8 indicates common patterns as children begin putting two words together (Bowen, 1998; Brown, 1973). In addition to the combinations of words listed previously, between 27 and 30 months of age children typically demonstrate use of present progressive (-ing), in, on, and plural (-s). Strategies for Teaching Phrase Speech Phrase speech is taught using the same embedded teaching trials that were used to target single words. At first, frequent models (i.e., model prompts) will be required to prompt the child to expand beyond single-word responses. For example, if the child responds with “car” when the parent holds up the car, the parent might have to model the phrase “red car” to prompt the child for the phrase. The parent should not deliver the reinforcement until the child has used the phrase. To practice a newly taught phrase, the adult can wait expectantly (i.e., time delay) for the child to elaborate on his or her initial communication before reinforcing the child’s request. When modeling, the adult should teach a variety of two-word combinations and vary those phrases within and across activities from the beginning. This will help prevent prompt dependency, rote phrase learning, and overgeneralization. For example, some children will learn a phrase within a specific activity and will not vary their phrases when prompted

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Table 11.7. Ready, set . . . phrases! Criteria Are the single words spontaneous and independent?

Examples

Saying the word with object not present: • Asking for “bubbles” while bubbles are not in sight • Saying “juice” while standing in front of the refrigerator Saying the word without prompting: • Using the correct word to request an object when the object is offered • Commenting or labeling by using the correct word when not requesting the objects Using multiple words in the same situation: • Asking for “open” while bringing the bubble container to the parent • Then, saying “bubbles” to the parent when all the bubbles have popped Are the single Are the words directed to the communicative partner and related to words something in the environment (e.g., an object the child is requesting or functional? commenting on)? If the words can be identified as delayed echolalia or scripting, they should be correctly used in context, be directed at the communicative partner, and directly related to something in the environment, as above. A portion (half or more) of the words should be clearly spontaneous and not stereotyped. Are the words Using the word across activities: generalized? • “Bubbles” when playing bubbles outside and to refer to bubbles in the bathtub • “Open” to open a door, a snack bag, and multiple types of containers Using the word with different communicative partners: • With therapist • With mom • With dad • With sibling • With peers Are the words Using a variety of words within an activity demonstrates that the words are varied within spontaneous, independent, functional, and generalized. For example: an activity? • “Blow,” “blowing,” “more,” or “go” during bubbles • “Big” or “little” when playing with blocks of different sizes • “Fast” or “slow” when driving cars or trains • Labeling the pictures (e.g., vehicles, animals) rather than saying “puzzle” for each puzzle piece • “Up” or “down” when engaged in the sensory-social routine of being picked up or spun around Do the words Saying the word to obtain access as well as to comment: serve • Saying “open” while the parent holds the container up multiple • Saying “open” to comment when the child successfully opens the container functions? independently Saying the word to request as well as to draw attention to an action or object: • Saying “bubbles” to request more bubbles • Saying “bubbles!” to the parent in response to bubbles being blown Can the words By adding grammatical markings: be simply • “Bubble” to “bubbles” expanded? • “Pop” to “popping” By adding a simple second word to make a phrase: • “Open bubbles” • “Big bubbles” • “Blow bubbles” Are there any Although useful to learn in the long run, be careful when adding words that words to can be overgeneralized at first because these may hinder development of avoid? phrase speech: • “Want” • “More” • “Go”

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Table 11.8. Common patterns of two-word utterances Pattern

Example

Meaning

Reference operations Nomination Recurrence Negation—denial Negation—rejection Negation—nonexistence

That boy More cookie No hit No water Cat go

That is a boy. There is more cookie. I did not hit. I don’t want water. The cat has gone.

Mommy kiss Push choo-choo Daddy car In home Sissy swing Mommy cookie Milk cold This bug

Mommy is kissing. Pushing the train. Daddy (drives) the car. I am at home. My sister is on the swing. Mommy’s cookie. The milk is cold. THIS bug (not THAT bug).

Semantic relations Action + agent Action + object Agent + object Action + locative Entity + locative Possessor + possession (object) Entity + attribute Demonstrative + entity

(e.g., the child only uses “water on” when playing with water balloons but will not request “fill it up,” “water,” or “balloon”). Others will learn to use a phrase within one context but will not use the phrase in the next (e.g., the child will use “open the door” to leave the house but not to open the door on the toy car garage). Modeling, recasts, and use of the one-up rule (discussed previously) can be helpful ways to introduce new phrases or word combinations into an activity, familiarizing the child with the new phrase without placing demands to say it just yet. Please see Table 11.9 for the four steps for introducing a variety of phrases into an activity. This example might be applicable to a child who is building single-word vocabulary or just expanding beyond single words; however, the same sequence can be used to target a range of communication skills. As demonstrated in the example, the adult should occasionally repeat the phrase that the child independently chose because he or she is teaching that all of these phrases are acceptable within this activity. The adult should also remember to vary the productions to avoid fostering stereotyped speech by associating specific phrases with certain activities. By alternating the productions, the adult shows the child that all of the phrases are acceptable. Questions Throughout communicative development, asking questions for social and needsbased purposes is an important skill. Likewise, responding to questions is key to developing social reciprocity. The following section addresses strategies for selecting targets in this skill area, as well as strategies for teaching question asking and answering. Selecting Targets Early in development, requests for information, a joint attention behavior, might be expressed by a point and a shrug or a point and a vocalization with a rising intonation (i.e., a “proto-request for information”; Crais et al., 2004). For example, a toddler might hear an airplane, look out a window, point, and look back at his or her caregiver with a quizzical expression, to which the caregiver responds,

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Table 11.9. Using modeling to introduce new phrases Mastered skill (maintenance task): “Push me” Goals (acquisition tasks): “Go faster” and “Let’s swing” Teaching step

Antecedent

Behavior

Consequence

Step 1: Introduce Therapist says, “What Child says, “Push me!” Therapist swings the child. trial should I do?” while He or she models the new holding the child phrase, “Go faster!” still in the swing. Therapist repeats this process several times. Step 2: Introduce Therapist says, “What Child says, “Push me!” Therapist continues to the new phrase should I do?” while withhold swinging from (acquisition) holding the child the child. still in the swing. He or she prompts again (see next trial). Therapist models Child says, “Faster” Therapist swings the child. the new phrase, or reasonable He or she recasts, “Go “Go faster?” while approximation. faster!” holding the child Therapist repeats several still in the swing. times. Step 3: Practice Therapist asks, “What Child says, “Go Therapist swings the child. the new phrase should I do?” while faster!” He or she repeats, “Go until mastery holding the child faster!” still in the swing. Therapist continues to repeat. Step 4: Vary Therapist asks, “What Child says, “Go Therapist swings the child. phrases should I do?” while faster!” He or she repeats, “Go within tasks holding the child faster!” by adding still in the swing. additional Therapist holds Child says, “Go Therapist swings the child. phrases the swing while faster!” He or she models with waiting. the new phrase, “Let’s swing!” Therapist holds Child says, “Go Therapist continues to the swing while faster!” withhold swinging from waiting. the child. He or she prompts again (see next trial). Therapist models the Child says, “Swing” Therapist swings the child. new phrase, “Let’s or reasonable He or she could swing!” while approximation. use differential holding the child reinforcement of the still in the swing. new word by swinging the child even higher. Therapist recasts, “Let’s swing!” He or she repeats the phrase several times. Therapist asks, “What Child says, “Let’s Therapist swings the child. should I do?” while swing!” He or she could holding the child use differential still in the swing. reinforcement again. Therapist repeats, “Let’s swing!”

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“It’s an airplane.” Encouragement of such requests for information is key throughout communicative development, and adults should not wait until the child has reached a certain level of language development to encourage such behaviors. Indeed, consistent with most language input, research indicates that children understand questions prior to expressing them; as such, asking children questions and modeling answers from an early age is fundamental to language development. Requesting information supports a child’s understanding that other people have information that they can obtain. The child also learns that he or she has information to share with others (Donaldson & Olswang, 2007). With regard to the linguistic form of common types of requests for information (e.g., wh-questions), questions with clear, concrete answers that provide information (e.g., “What’s that?” “Where is it?”) often emerge before questions with more abstract answers (e.g., “Why?”). Children typically first understand and produce questions in the following sequence: what; yes/no; where; who; when; and why, how, which, and, whose (Bloom, Merkin, & Wootten, 1982). However, research indicates that this order may be influenced by frequency of use of these words and frequency of exposure (Rowland, Pine, Lieven, & Theakston, 2003). Strategies for Teaching Question-Asking and Responding Prior to targeting production of questions, adults should target responding to questions. Doing so will ensure that children understand question forms and will support later production of questions—the developmental sequence is the same for both comprehension and expression, as indicated previously. When targeting responding to questions, adults should embed opportunities within highly preferred activities and natural contexts whenever possible. For example, within a preferred music activity, the adult might bring out two instruments and ask, “Who gets the tambourine, and who gets the cymbal?” After the child makes a selection, the question can be reinforced, “Who chose the tambourine? You did!” Book activities can provide additional opportunities for targeting responding to and understanding requests for information, particularly as children are learning to distinguish between question types. For example, pictures in books that depict characters doing actions allow children to respond to specific questions (e.g., a picture showing a boy sitting and eating ice cream and a girl sitting and petting a cat allows for responses to who, what, and which questions). As the child demonstrates increased responses to comprehension of questions based on his or her responses, the child may start to spontaneously produce questions as well. With regard to targeting production of questions, Koegel and colleagues (2014) supported use of child-preferred objects and NDBI motivational strategies to teach this skill. It can take some creativity on the part of adults to set up situations where questions can be prompted and then naturally reinforced. When first teaching questions, it can be helpful to have two adults, one to prompt the child from behind (prompter) and one to reinforce the child’s question by providing the answer and access to natural reinforcement (communicative partner). If only one adult is used, the child can become confused by the prompt because a model prompt (e.g., “What’s that?”) can be perceived as the adult asking the child the question, rather than modeling it. It can also be helpful to brainstorm how to set up situations in which the targeted question can be asked within preferred activities. Making a list of preferred activities, which questions to target, and how they will be targeted can be a useful exercise. Table 11.10 provides several examples for several types of questions commonly targeted in intervention for children with ASD.

Table 11.10. Ideas for teaching question-asking Question What’s that?

What?

Where?

268

General teaching strategy Start by teaching the child to ask, “What’s that?” in relation to items that are hidden in a bag or box. Once the child understands the cues to ask the question, generalize to items the child actually does not know the name of.

Example 1 Place several preferred toys in a bag. Shake the bag expectantly while looking at the child. Have the back-up prompter model the prompt, “What’s that?” while pointing to the bag. Reinforce the child with an item from the bag when he or she asks, “What’s that?” Provide the answer to the question when handing the item to the child.

Example 2

Gather random items that the child does not know the name of. Introduce them into play with other preferred items. Ask novel questions, such as “Do you know what this is?” or “Hmmm. This is a new toy. Do you know the name of it?” Reinforce the child with the item when he or she asks, “What’s that?” and provide the answer to the question. It may be helpful to demonstrate novel, exciting actions with these items because they may not be familiar to the child. After you have targeted labeling, move Use pop-up books with clear pop-up actions to Play a guessing game with random objects on to other types of “what” forms, prompt for a variety of “what” questions. in which each person pretends to perform such as “What is X doing?”, then “What Make the popping action several times, and a common action with the wrong object (function)?” (e.g., What do I wear on my engage the child in the action. (e.g., pretend to brush teeth with the feet?) then “What if X?” Model the phrase “What is the bunny doing? He dishwashing brush; brush hair with a fork). is hiding.” Model and then prompt “What is X doing?” If the child is indicating interest, prompt to ask It is helpful to have at least three players in the question “What can you ask me?” (or use a the game or a back-up prompter. back-up prompter). Reinforce with the pop-up action. Start by teaching the child to ask, “Where Gain shared control over a preferred item in play, Hide several pieces to a toy prior to starting is it?” or “Where is the ___?” in relation and hide it in the immediate vicinity. an activity in locations that are nearby but to items that are hidden in readily Look inquisitively at the child, shrug shoulders, and not within arm’s reach. available locations (e.g., under your leg, hold hands out as if to say, “Where did it go?” Ask novel questions or make statements, inside your hand). Another way to provide a clear cue is to have such as “I have more trains, but they are Once the child understands the cues to ask a single item in a container that the child can hiding!” or “If you want more trains, we the question, generalize to items that are see. Then remove it, hide it, and show the need to find them!” hidden further away (e.g., in a cabinet). empty container to the child while looking Reinforce the child with the item when he Make a game of it! inquisitively. or she asks, “Where are the trains?” and provide the answer to the question.

269 Hide and Seek can also be a fun way to teach this skill. Have a preferred adult hide and another adult to whom the child can direct the question (e.g., “Where is mommy?”). Who?

Start by teaching the child to ask, “Who is it?” or “Who has it?” in relation to preferred materials. Then, generalize to other naturally occurring situations (e.g., “Who is coming?” “Who is it?” in relation to someone the child does not know).

When?

Start by teaching the child to ask “When?” or “When can I have it?” in relation to preferred materials. Then, generalize to other naturally occurring situations (e.g., “When can I have my snack?”).

Have the back-up prompter model, “Where is it?” or “Where is the ___?” Reinforce the child with the item when he or she asks the question. Provide the answer to the question when handing the item to the child (e.g., “It’s under my leg!”). Using two to three people, make a game of passing objects among the adults so that the child does not know who has them. Cue the child with comments such as, “Someone has the toy!” or “I wonder who has the toy!” Have a back-up prompter prompt the child to ask an adult, “Who is it?” or “Who has it?” When the child asks, the person who has the toy can respond with “I have it!” and provide the toy as reinforcement. Set up play with several preferred items or an item with multiple pieces. Gain shared control over the pieces, and cue the child with comments such as, “You can have these soon!” or “I’ll be done with these in a few minutes.” Have the back-up prompter prompt the child to ask, “When?” Respond with an appropriate answer (e.g., “Right now!”), and provide the item to the child as reinforcement. When first teaching this skill, always reinforce the child immediately. Once the child can ask “when” more independently, you can start delaying reinforcement (e.g., by saying “in 1 minute”) because this is an appropriate outcome of this question. Some children may need to formally be taught how to wait before introducing this step.

Make a game of it! Use exaggerated speech when giving the answers and make it silly! For example, “The trains are in the closet! How did they get there? Silly!”

Generalize the skill to other situations, such as the following: • If someone comes to the door, prompt the child to say, “Who is it?” before opening the door. • When plans are made for someone to come over, make comments, such as, “Someone is coming over later!” to prompt the child to ask, “Who?” Generalize the skill to other situations by delaying access to preferred items throughout the day on purpose and prompting the child to ask “when”. For example, if the child wants a snack but will be told to wait, prompt him or her to ask, “When can I have it?” and either reinforce immediately with “Right now!” (if just learning) or shortly thereafter, for example, “In 1 minute” (if working on expanding time frame).

(continued)

Table 11.10. (continued) Question Why?

How?

270

General teaching strategy Start by teaching “because”: “We eat because we feel X.” Have the child fill in the blank. Do several of these examples. After the child has the idea, switch the examples to question form, “Why do we eat? Because we are hungry.” Use only concrete examples that the child may have experienced very recently until the concept is very clear. Then, move to more abstract examples, again starting with “because” and shifting to question form (e.g., “We sit by friends at lunch because X”). Start by teaching the child to ask “how” in relation to preferred toys or materials. Set up situations where the child may not know how to do something and can ask more concrete “how” questions, such as “How do we do it?” or “How does it work?” “How” questions may need to be taught after the more concrete “what,” “where,” and “who” questions are mastered. These questions require greater receptive language and cognitive ability to learn.

Example 1

Example 2

Use fill in the blank to prompt “because” in a Identify a highly motivating game such as tickling game: “I tickle you because I love you.” water balloons. Progressively leave off more words until the child Model “why” questions and “because” reliably says “because.” answers: “Why did the balloon pop? Introduce the question “Why do I tickle you?” Because you threw it!” “Because I love you!” Reinforce with silly tickle Hold the next water balloon contingent on games. the child answering the question, and then prompt to ask you (“What can you ask me?”) Reinforce with new water balloons.

When using a toy that the child may need help with (e.g., Lego building, snap circuits), get out the toy, and cue the child with comments such as “Hmmm, this looks tricky. I wonder how we do it.” Have the back-up prompter model varied questions, such as “How do we build it?” or “How does it work?”

When doing a project with the child (e.g., craft kits, cooking) that has a clear outcome, begin the project, and cue the child with comments such as, “We are going to bake cookies. Do you know how to do it?” or “We are going to make paper snowflakes. What should we do?” Have the back-up prompter model varied questions, such as “How do we make them?” or “How do you do it?”

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Stockall and Dennis (2014) found that the use of visuals within a PRT framework helped to teach basic “what” and “where” questions. Visual cues can be especially helpful when a backup prompter is not available or as a strategy for fading the backup prompter. For example, when teaching “What’s that?” after the adult cues the child by presenting the bag of toys, a visual cue can be used to prompt “What’s that?” Likewise, when teaching “where” questions, the adult can present the toy in a container, then remove it, as discussed previously, and present a visual cue to prompt the child to ask, “Where is it?” Visual cues can then be faded using prompt fading strategies. Furthermore, Donaldson and Olswang (2007) found that simply providing opportunities to engage in highly preferred activities with typically developing peers increased the likelihood of using requests for information (questions) by young children with ASD. As such, targeting this social-communication skill within naturally occurring social interactions with high likelihood of engagement, perhaps with siblings or neighborhood peers, may be warranted to increase generalization. Reciprocal Conversation As indicated previously, reciprocal interaction starts well before a child becomes “conversational” (whether via verbal language or use of an AAC device). A child’s social and communicative reciprocity is developed through the initiation and responsivity of his or her early communicative intents with caregivers and early communication partners. It is essential that parents, teachers, and communication partners focus on early communicative reciprocity through interactions that are responsive and engaged, whether the child is communicating via gestures, vocalizations (vocal play), verbalizations, or language use. Conversational reciprocity is built on this early interaction and turn taking. For example, when the child initiates a social game such as Peekaboo with a blanket, the caregiver responds by lifting up the blanket. When the child responds by placing the blanket back on her head, the caregiver elaborates on the game by saying, “Where’s Sophia?” The child starts giggling and waits for the adult to pull off the blanket. The adult slowly starts to pull off the blanket, elongating the phrase, “Peeeeee-kaaaaa.” The adult waits. The child giggles. The child pulls off the blanket and approximates “booo.” The adult elaborates on the game, putting the blanket on his or her own head. The game continues with gestures, facial expression, affect, vocalizations, and approximations. It is a complex engagement that lays the foundation for later conversational reciprocity. Although all NDBI include instruction in the foundational components of language, fewer detail instruction of more advanced language use, such as backand-forth conversation. Strategies for teaching reciprocal conversation within an NDBI framework have been most studied in the context of PRT (Boettcher, 2004; Koegel et al., 2014; Stockall & Dennis, 2014). Stockall and Dennis (2014) showed that visual cues can be an effective tool for targeting conversation, particularly when using items that are a topic of interest and motivation for the child. The use of self-management motivational strategies has been found to be effective in teaching early conversation skills to children with ASD with more developed language (Boettcher, 2004). Skills such as responding to conversational bids with comments or questions, remaining on topic, and sustaining responding for several

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conversational exchanges or for a specified period of time have been effectively taught using self-management, in which the child monitors these skills during conversation and self-evaluates afterward whether reinforcement was earned. In self-management, the parent or teacher teaches the child to discern whether he or she has engaged in the targeted behavior (e.g., remaining on topic) and then teaches the child to self-monitor responses on an ongoing basis in order to earn reinforcement. The use of a behavior recording chart, which allows the child to earn points for on-topic and sustained conversation toward a desired reward, is an effective tool for teaching self-monitoring conversation practice, as well as teaching the child to reinforce his or her own behavior over time. Chapter 13 presents elaboration on teaching self-management skills. Another method that may support conversational reciprocity for some children is video modeling (VM), which has been shown effective for targeting socialcommunication skills (Ferraioli & Harris, 2011; Schreiber, 2011; Wang, Chui, & Parrila, 2011). Within VM, the child watches a video of a peer and/or adult demonstrating a discrete skill or target behavior and then practices the skill, often with facilitation from an adult within the context of a motivating activity. This method can be effective in supporting social interaction and relationship building between children with ASD and peers or siblings. As children gain skills or when it is feasible to prompt the target skills, children can sometimes star in their own modeling videos. It is important, however, to ensure that correct production of the skill can be evoked so incorrect responding is not modeled. Peer mediation has also been found effective in supporting the socialcommunication skills and reciprocity of children with ASD (National Autism Center, 2015). Peer or sibling mediation involves the direct teaching of peers or siblings to increase their initiations and responsiveness to the child with ASD in order to facilitate communicative success. Peers have been successfully taught to initiate interactions; maintain interactions; and promote a variety of play, motor, and communicative interactions with children with ASD (Zhang & Wheeler, 2011). Within peer mediation, Pierce and Schreibman (1995, 1997) taught strategies based on PRT, such as gaining attention, elaborating and extending communication, narrating play, and offering choices. The overall emphasis was to increase the child with ASD’s social and communication skills by motivating him or her to socially engage. Adults can teach peers and siblings to change their own social and communicative behaviors to enhance their social interactions with children with ASD, resulting in increased social opportunities and authentic relationship development (Donaldson, Nolfo, & Montejano, 2018).

CONCLUSION There are many communication skills to target when working with individuals with ASD. This chapter focused on expressive communication; teaching receptive communication requires developing a separate set of goals. We hope the strategies elaborated here will provide clinicians with examples and ideas for how to target communication goals, but this information is not a substitute for solid clinical assessment based on clinician expertise and the use of appropriate assessment and monitoring tools, including standardized assessments, checklists, and data collection over time.

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12 Improving Social Skills and Play Yvonne Bruinsma and Grace W. Gengoux

D

evelopment of meaningful social skills for children with autism spectrum disorder (ASD) is important for optimizing outcomes and quality of life (Bellini & Peters, 2008). Although deficits in social reciprocity are a defining feature of the condition and can be restricting and challenging to treat, there is robust evidence that these necessary skills can be improved with intervention (e.g., Rogers, 2000). Naturalistic Developmental Behavioral Intervention (NDBI) strategies can be utilized in teaching beginning, intermediate, and advanced social skills; however, as discussed throughout this chapter, it is not enough simply to be able to perform specific social skills. True social competence and meaningful social relationship development involves much more than the discrete behaviors (e.g., saying “hi,” taking turns, sharing toys). High-quality social skills intervention must foster reciprocity and affective sharing and enhance social motivation to allow social interaction to become truly enjoyable. Generalization of skills, individual interests and motivators, complex combinations of social behaviors adapted flexibly across providers, caregivers, and settings, and natural reinforcement of social interactions are ultimately important components to think about when designing a social program. The final goal, after all, is to help individuals with ASD build capacity for a lifetime of meaningful relationships with others in a way that is enjoyable to them. This chapter begins with a focus on foundational social skills, such as social initiations and imitation. Then, the development of play skills is briefly reviewed. Because children interact and learn through play, tips and ideas for utilizing and teaching play activities across developmental levels are provided. Social, play, and communication skills develop concurrently, and advancement in one domain is often necessary for another skill to improve. As a result, the reader is sometimes referred to the chapters on communication skills (Chapter 11), inclusion (Chapter 5), or motivational strategies (Chapter 6). Finally, this chapter provides practical strategies and tips to organize and structure interactions between peers. 277

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This chapter focuses on treatment strategies that can be delivered in the natural environment and with typically developing peers. It does not include a review of the many existing evidence-based social skills treatment models designed to be implemented with groups of children with ASD outside the context of the child’s daily routines. Although social groups can be effective, they fall outside the scope of NDBI. Excellent reviews of the current evidence for social skills group treatment can be found elsewhere (Gates, Kang, & Lerner, 2017; Williams White, Keonig, & Scahill, 2007).

SOCIAL INITIATIONS Social initiations include both the ability to initiate interaction and the desire to do so for a social purpose: to comment, to call attention to oneself, to show, and to share an experience. Social initiations are one of the most important priorities when addressing the development of social skills in ASD because they serve as building blocks for social interaction. The specific behaviors used to initiate a specific social interaction depend on the child’s developmental level, the communicative partner, and the context. For example, an early social initiation in a child who is prelinguistic may simply be looking up to the communicative partner to share enjoyment while being pushed on the swing. During that early preverbal phase of development, typically developing children engage in many nonverbal social initiations, including giving objects, alternating eye gaze, sharing enjoyment and affect, showing objects and actions, and pointing (please refer to Chapter 11 for a more in-depth discussion of joint attention initiations). Once the child becomes verbal, social initiations expand to include requesting information, usually beginning with “What’s that?” questions and then increasingly more complex wh- and other questions or comments about interesting things in the environment. As the child’s verbal and social skills develop, initiation behaviors become increasingly more complex and context specific. For example, initiating access to a group of kids playing a ball game during recess will likely be different from initiating a game of catch during a one-on-one playdate. Even more complex behaviors may include asking someone for a ride or asking someone to the school dance. Social initiations allow children to join others in play and social interactions and sustain those interactions across a variety of environments and help to build key skills and relationships. In addition, and perhaps even more important, social initiations allow the child the opportunity to begin interactions with others and create his or her own learning opportunities and relationships. The ability to engage in social initiations appears to be associated with long-term positive outcomes for children with ASD (Koegel, Koegel, Shoshan, & McNerney, 1999) and predict future social competence with peers (Meek, Robinson, & Jahromi, 2012). Less frequent initiations have also been associated with lower levels of social engagement with peers (Sigman & Ruskin, 1999). Research suggests that social initiations generally, and joint attention behaviors specifically, do not naturally emerge from intensive, highly structured, Applied Behavior Analysis (ABA)-based intervention focused on prompting and reinforcing skills and may therefore need to be explicitly taught (Jones, Carr, & Feeley, 2006; Kasari, Freeman, & Paparella, 2006; Martins & Harris, 2006; Whalen & Schreibman, 2003). In addition, even when taught, these skills are especially difficult to generalize and maintain across environments, although generalization may be more

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common when joint attention skills are taught during play interactions by natural caregivers and providers such as educators, coaches, parents, and peers (White et al., 2011). Evidence exists that natural caregivers and providers can learn to implement strategies that enhance engagement with strong treatment fidelity, and that this produces meaningful and substantial change in child outcome variables (Gulsrud, Hellemann, Shire, & Kasari, 2016; Harrop, Gulsrud, Shih, Hovsepyan, & Kasari, 2017; Kasari, Gulsrud, Wong, Kwon, & Locke, 2010). The naturalistic interactions of NDBI make them especially effective for teaching social initiations. Four strategies especially stand out for teaching social initiations: sensory social routines, object play routines, environmental arrangements, and time delay strategies. Sensory Social Routines Sensory social routines consist of back-and-forth ritualized social exchanges between the adult and child that are highly reinforcing for both (Rogers & Dawson, 2010). Beginning in infancy, caregivers sing silly baby songs in high-pitched voices while babies babble back at exactly the right time and even in the right cadence when the parent pauses (Longhi & Karmiloff-Smith, 2004). Many nursery rhymes across cultures allow for repetitive interactions and entice both caregiver and child to be silly, use imitative gestures, and have fun. Emotional attunement (Rogers, Dawson, & Vismara, 2012) and dyadic synchrony (Harrist & Waugh, 2002) are key to a successful sensory social routine. In addition, affective sharing, which is often reduced in children with ASD (Kasari, Sigman, Mundy, & Yirmiya, 1990), is an important part of sensory social routines. Harrist and Waugh (2002) described three components to a successful synchronous interaction. First, there must be a shared focus of attention in which caregiver and child both visually follow each other. Then, during this period of extended engagement, caregiver and child coordinate their interactions in time. This is mostly driven by the caregiver and refers to a matching of the caregiver to the child’s activity level in body movements, orientation, vocal rhythm, vocal pitch, and sounds. This coordination can include imitation and expanding the child’s utterances or actions. The last component of the synchronous interaction is the addition of contingency, which simply means that actions by the caregiver will likely lead to actions by the child, which then leads back to actions by the caregiver and so on (Harrist & Waugh, 2002). Successful sensory social routines have a strong affective component: The play partner is smiling, modulates his or her energy to be slightly higher than the child, uses large exaggerated gestures and facial expressions, uses movement, sings, and closely watches the child to maximize engagement and initiations. An example of using a sensory social routine to encourage social initiation in a child with ASD might appear as follows: For a child who likes the “Itsy Bitsy Spider” song, the parent may start singing while pretending to be a tiny spider crawling up the child’s arm. The child and parent take several turns and establish a period of prolonged engagement until a pace has developed within the routine with reciprocal affective sharing in which child and parent both smile, alternate eye gaze, and alternatively approach and retreat. The parent may then pause to wait for the child to make eye contact or show an excited facial expression (the social initiation) before continuing the song. In this way, the parent provides a behavioral contingency with natural reinforcement for appropriate eye contact/expression,

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which may enhance the child’s motivation to look at the adult’s face and share positive affect as the interaction continues. This type of behavioral contingency (in which the parent does not respond until the child shows the target behavior) in the context of an affectively charged interaction can be a powerful way of enhancing social-communication above and beyond the natural interaction contingencies described by Harrist and Waugh (2002). During these prolonged interactions, the parent will closely watch the child to see if the child remains motivated and engaged. When the child’s affective sharing behaviors reduce (less frequent looking, smiling, reaching, vocalizing), the parent may end the activity, or as an alternative, the parent may try to expand the routine, introducing novelty, such as a new song or a novel gesture added to the routine. Sometimes the child may become too excited, as evidenced by high-energy behaviors that do not match the activity or the caregiver (screaming, high-pitch noises). Rather than vary the task, the caregiver can model calm affect, shift the routine to a calming theme, or slowly end the activity and help the child reregulate. Table 12.1 contains tips for generating ideas to establish a shared focus of attention and coordinated synchronous periods of engagement. With a little bit of practice, sensory social routines can be implemented with relative ease and can provide an important sense of connection between adult and child. Although the routines described so far do not use objects, object play can easily be interspersed into sensory social routines, making them into what are typically referred to as object play routines. Object Play Routines Object play routines are like sensory social routines with the addition of a toy or an object (Rogers & Dawson, 2010). Like sensory social routines, these routines are typically repetitive in nature—the adult and child repeat some sequence of events with slight variations. Object play routines go beyond simple turn-taking activities because while an object is introduced in the interaction, the adult remains the essential ingredient. The importance of the role of the adult was further confirmed in a study by Koegel, Vernon, and Koegel (2009), suggesting that social engagement and initiations were higher when the adult participated in the delivery of reinforcers (e.g., the adult jumped on the trampoline with the child) rather than simply delivered the reinforcer (e.g., the adult provided access to the trampoline to allow the child to jump). Data suggested that in the condition where the adult actively participated in reinforcement, the child exhibited increased social engagement and initiations, which this study defined as affect and eye contact directed to the adult, physical orientation toward the adult, and more positive affect in general (see also Vernon et al., 2019). One example of a routine with objects is building a tower with blocks together. Most children will find building high towers and the subsequent crashing highly reinforcing. Building and crashing are repetitive actions that can easily be expanded over time. For example, sound effects can be added to blocks crashing; anticipation of block placement and the subsequent potential for crashing can be exaggerated with excited and suspenseful facial expressions and careful placement of additional blocks; and overstated gestures can enhance affective sharing and increase the salience of the cues. In many object play routines, adding novelty is an important strategy that helps to expand the routines, can promote affective sharing through novelty and surprise, and can serve to increase initiations. Introducing novelty to

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Table 12.1. Tips to create a shared focus of attention for coordinated joint engagement Sensory social routine component Facial expressions

Tips

Exaggerate: Overdo facial expressions and gestures. Take big breaths, widen eyes, raise eyebrows, and amplify a silly “mad” face. Smile and laugh while making eye contact. Silly faces: Exaggerate unexpected and funny expressions with props (glasses, wigs, and fake mustaches). Imitation Copy a movement the child is already making, but exaggerate it. Copy and enlarge sounds (slurping, sneezing, coughing). Imitation can be subtle: copy the way the child is sitting or standing. Gestures Use popular gestures: • “Where is it?” (hand in the air halfway up with palms up) • “I don’t know” (shrug shoulders) • “Oh, no!” (widen eyes, hand clasped on mouth) • “Surprise!” (widen eyes, raise hands up) • “Hooray” (raise hands up in the air) • “I’m disappointed” (slump shoulders, look down) • “Shhh” (finger on mouth, eyes squinting) • “No-no” (wag index finger) Sing popular songs (see examples on YouTube): “Itsy Bitsy Spider,” “Slippery Fish,” “Wheels on the Bus,” “Speckled Frogs,” “If You’re Happy and You Know it,” “Hokey-Pokey,” “I’m a Little Tea Pot,” “Twinkle Twinkle Little Star,” or “Pat-a-cake.” Physical action Pretend to be a spider coming to tickle. Play a chasing game (“I’m going to get you!”). Bounce on pillows or exercise balls. Spin in office chairs. Pull the child on a blanket or in a box. Sway in hammocks. Swing and toss the child into blankets or pillows. Sing nursery rhymes: “This Little Piggy”; “Row, Row, Row Your Boat”; “Five Monkeys Jumping on the Bed”; or “Motorboat, Motorboat.” Using your voice Singing: Traditional songs can be adapted to be silly. Any routine can also be a repetitive song or rhyme. Sound effects: Pretend cough or sneeze. Pretend to eat something and not like it (“Eew, yak!” This is also fun with puppets). Talk really low or high. Make animal sounds. Make loud snoring when pretending to sleep. Make raspberry noises. Use dramatic play voices: • Troll: “Who’s that tromping over my bridge?” • Evil queen: “Would you like to eat my poison apple?” • Olaf: “I like warm hugs.” Pretend to have a really high or really low voice. Energy Use slightly higher energy. Use slightly lower energy. Keep watching: The child’s energy may change during an activity. Modulate right around the child’s level, and be sure to be calmer when the child is becoming too excited to help regulate Interrupting routines: Make a regular activity into a routine by adding repetitive phrasing and gestures (e.g., as you are walking up the stairs say, “We go UP, we go UP, we go UP” while tickling the child on UP. Then, pause right before the next UP. Surprises: Draw an elephant on a thumb. Play Peekaboo with a tickling hand under the table. Hide behind the door, and peek out suddenly. Using daily routines Play Peekaboo during dressing or folding laundry. Play Head Shoulders Knees and Toes during bath time or dressing. Use sound effects during mealtime (“Ahhh!” after sipping a drink, “Yumm!” after a bite of food).

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building a tower might include adding new building materials, such as different kinds of blocks or little figurines to balance on the blocks. The block tower can be knocked down by a ball, a car, a little battery-powered train, or a monster puppet eating the bottom block. Tickling could be added after the blocks crash. Another strategy for promoting initiations during object play, which is outlined in the Project ImPACT (Improving Parents as Communication Teachers) approach, is called The Wrong Way. In this strategy, the adult performs a routine or action in an incorrect or silly way with lots of animation to entice the child to tell the parent it is not right. Examples of this could be to wear something obviously backward, provide a fork with a bowl of soup instead of a spoon, or attempt to put toothpaste on the hairbrush instead of the toothbrush. Table 12.2 provides additional examples of object play routines. Environmental Arrangements Incidental Teaching (IT; McGee, Morrier, & Daly, 1999) places a substantial emphasis on the importance of all initiations. In this NDBI, the adult waits to provide any instructional cues or prompts until the child has made an initiation toward the object or activity. IT organizes the environment to increase the likelihood of initiations by placing toys in sight but out of reach, or in reach but in containers that the child cannot open. Frequent rotation of toy sets and regular sensory preference assessments (Mason, McGee, Farmer-Dougan, & Risley, 1989) ensure highly desired toys are available for each child. Environmental barriers to access, such as a gate dividing up sections of a classroom, may also provide opportunities for initiations while separate but overlapping zones in a classroom may function as visual cues to prompt teachers and students to initiate activities and optimize engagement. Enhanced Milieu Teaching (EMT; Hancock & Kaiser, 2006) also places high value on initiations, especially verbal social initiations, and assesses for the number Table 12.2. Examples of object play routines Toy Shaving cream

Balloons

Water balloons

Spinning tops and Bey Blades

Ideas for adult actions Squeeze out a little at a time. Push the shaving cream inside a latex glove. Add food coloring to the shaving cream. When the child is in the tub or a little wading pool, smear shaving cream on arms or legs for sensory effect. Blow up the balloon, and let it fly away. Inhale a little bit of the helium of a balloon, and use that funny voice to speak. Draw a face on the balloon, and make it talk. Rub the balloon to increase static electricity, and attach it to the child’s hair. Lift the child up to push the balloon with his or her head or swing the child with his or her legs to kick the balloon. Attaching the balloon to the faucet, opening the faucet, and uncoupling and tying the balloon typically all need adult support. Draw targets with chalk on the sidewalk or a fence. Exaggerate the anticipatory reaction of getting hit by a water balloon. Even simple tops usually need adult spinning to get them started. Bey Blades have launchers that are difficult to operate. While tops or Bey Blades are spinning, provide barriers with your foot and exaggerate both the anticipation of contact and the reaction when it does touch.

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of initiations at the beginning of intervention. If initiations are low, EMT recommends greatly reducing or removing all prompting and using a combination of environmental arrangements with responsive interaction (verbal and nonverbal turn taking, adult imitating the child, and following the child’s lead) until initiations increase. Project ImPACT utilizes communication temptations specifically to increase initiations (Ingersoll & Dvortcsak, 2010). For example, providing inadequate portions refers to the strategy of giving the child a little bit of something (e.g., a food) that is highly reinforcing. The adult then stays close to the child and waits to see if the child will indicate a desire for more of the item. Time Delay Strategies Time delays are a valuable tool to promote initiations, and all NDBI use time delays to design opportunities for social initiations. The simplest way to think about time delays is to think about designing opportunities for a child to respond to environmental cues alone and refrain from providing other types of prompts. Often this involves first establishing a routine in which the child learns to respond to verbal prompts and then removing the verbal prompt and pausing for the child to fill in the learned response out of habit. IT uses this in its prompting hierarchy very specifically when teaching adults to “wait, ask, say, do” (McGee, Morrier, & Daly, 1999). For example, during a music activity, the caregiver and child may be taking turns with a drum, but the child has begun to look over at the maracas, which are in a closed transparent container. The caregiver may acknowledge the child’s interest in the maracas but wait to provide any type of prompt to see what the child will do. If the child continues to look at the maracas and maybe try to open the container but does not provide any request (verbal or gestural), the caregiver may then ask, “What do you need?” If the child continues to try to open the box, the caregiver may ask, “Open?” If the child still does not respond, then the caregiver may physically guide the child to give the container to the adult to ask for help. The Early Start Denver Model (ESDM; Rogers & Dawson, 2010) notes the importance of carefully selecting the toy for the interaction and recommends using those toys that require adult cooperation to create the desired effect. This will ensure the adult is an active participant and part of the natural reinforcer, and it also provides the adult with built-in shared control. Time delay can then be used during these familiar routines to allow the child to practice verbal initiation. For example, bubbles are often reinforcing for children and usually require an adult to open the bubble jar, take out the wand, blow the bubbles, and dip back into the jar. If the routine has been established and the child is in the habit of verbally requesting bubbles, the time delay can be inserted just before the child would request more bubbles. As the child is excitedly popping the bubbles, the adult will stop blowing and wait for the child to return. A time delay prompt would then be provided, where the adult may hold up the wand or exaggerate sucking in air to begin blowing but stop right before blowing while looking at the child expectantly. Once the child reliably responds to theses cues to request bubbles to be blown, the adult may then fade the time delay prompt and close the bubble jar and place it nearby. When all the bubbles are popped, the child is likely to return to the adult to find the adult smiling and oriented to the child but not getting ready to blow more bubbles. Thus, the child’s behavior will become increasingly more independent of the adult.

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IMITATION SKILLS In typical development, imitation skills appear early in the first year of life (Meltzoff & Moore, 2000) and expand quickly in those first 2 years to include vocal imitation (sounds and words), object imitation, and gesture imitation (Masur & Rodemaker, 1999). Imitation is thought to be a foundational skill with a cascading effect to other areas, meaning imitation skills may enhance or limit the acquisition of a number of other (social and communication) skills, including intentional communication (Sandbank et al., 2017), expressive language (Charman et al., 2003; Stone, Ousley, & Littleford, 1997; Stone & Yoder, 2001; Toth, Munson, Meltzoff, & Dawson, 2006), play (Stone et al., 1997), and potentially joint attention (Carpenter, Pennington, & Rogers, 2002). Imitation skills, in particular motor imitation, together with joint attention and social approach behaviors also appear to help predict treatment outcomes (as measured by IQ score and adaptive behaviors) in early intervention programs (Sallows & Graupner, 2005; Smith, Klorman, & Mruzek, 2015). For children with ASD, the skill of imitating others tends to be delayed or limited, but the ability to notice that others are imitating them appears relatively intact (Berger & Ingersoll, 2013, 2015; Contaldo, Colombi, Narzisi, & Muratori, 2016). Evidence suggests that when adults, especially mothers, imitate the child with ASD (copy movement, repeat verbal utterances, copy facial expressions), the number of social gazes, joint attention behaviors, play skills, and proximity (child tends to move closer to the person imitating them) increase substantially (Dawson & Adams, 1984; Dawson & Galpert, 1990; Ezell et al., 2012; Field et al., 2013; Ishizuka & Yamamoto, 2016; Slaughter & Ong, 2014). These findings provide support for use of adult imitation of the child in NDBI as a strategy to promote social engagement. Strategies for Teaching Imitation NDBI use a number of strategies to teach imitation, including reciprocal imitation training (RIT), turn taking, modeling, and prompting. Reciprocal Imitation Training RIT is a naturalistic intervention that focuses first on teaching object imitation, then expansion of play skills, and finally gesture imitation skills. RIT has several studies showing its effectiveness in increasing object and gesture imitation skills and expanding play skills (Ingersoll & Lalonde, 2010; Ingersoll, Lewis, & Kroman, 2007; Ingersoll & Schreibman, 2006). Some of these studies indicate collateral effects in language, pretend play, and joint attention (Ingersoll & Lalonde, 2010; Ingersoll & Schreibman, 2006). RIT has been successfully implemented by siblings (Walton & Ingersoll, 2012) and by parents (Ingersoll & Gergans, 2007) and can be successfully taught via an innovative self-directed distance learning format (Wainer, Pickard, & Ingersoll, 2017; Wainer & Ingersoll, 2013, 2015). RIT was designed to be implemented with children but has shown some promising efficacy with adolescents with ASD and significant intellectual disability (Ingersoll, Berger, Carlsen, & Hamlin, 2017; Ingersoll, Walton, Carlsen, & Hamlin, 2013). A brief overview of RIT is provided here, but the manual is an excellent resource with helpful details for parents and clinicians wishing to use RIT (see Box 12.1).

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BOX 12.1: Reciprocal imitation training Reciprocal imitation training (RIT) is described in a detailed parent manual by Dr. Brooke Ingersoll. This resource is available online at https://ieccwa.org /uploads/IECC2014/HANDOUTS/KEY_2720064/RITManual.pdf

For object imitation, RIT recommends using two of the same set of toys of interest to allow both the adult and the child to have access to the same toy without requiring turn taking. The manual provides some pointers about where the parent should position him- or herself in relation to the child and what types of toys work well. Before teaching in RIT begins, the adult starts by imitating the child’s play actions, gestures, body movements, and vocalizations or sounds while narrating and describing actions the adult observes. Once a back and forth is established like in a social game, every 1–2 minutes the parent provides a model of an action with an object and waits up to three times for 10 seconds each to see if the child will copy the action. If the child does not copy, the parent provides a verbal prompt: “You do it.” If the child still does not respond, the parent uses partial or full physical prompts to help the child imitate the action. Once the child imitates the action, the parent praises the child and allows him or her to play with the toy for 1–2 minutes while the parent returns to imitating the child until the next teaching trial. Expanding the child’s play skills and teaching gesture imitation follow the same pattern. A final section in the manual provides ideas about how to intersperse imitation teaching trials throughout daily routines. Turn Taking, Modeling, and Prompting ESDM refers to RIT as part of how it teaches imitation (Rogers & Dawson, 2010), and its manual shows considerable consensus with RIT on how to teach imitation skills. However, as a more comprehensive program, ESDM provides imitation teaching trials throughout its full curriculum (e.g., within sensory social routines, in joint activity routines) and often uses turn taking with one toy to set up a teaching trial. ESDM breaks object imitation down into increasingly complex levels from one step imitation to imitation with “a series of counterconventional acts” (Rogers & Dawson, 2010, p. 140) such as using a plate for a hat and cardboard boxes for shoes. ESDM also prompts for oral-facial imitation (within games that involve identification of body parts or by exaggerating facial expressions such as exaggerating puffing of cheeks for blowing a balloon up) and gesture imitation. EMT uses a combination of turn-taking strategies, modeling, and prompting to teach imitation on objects, called nonverbal mirroring. The adult begins by imitating all actions by the child. He or she then introduces a new action and waits to see if the child imitates the new action (Kaiser & Trent, 2007). Strategies for Vocal Imitation ESDM addresses teaching vocal imitation as an important precursor to expressive communication skills, especially for those children who do not produce many noises and sounds on their own yet. Teaching vocal imitation is mentioned separately here because it is slightly more intricate. Vocal imitation teaching trials involve modeling,

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prompting, and immediate reinforcement for correct responses and attempts, just like motor, gesture, or oral-facial imitation. Both Pivotal Response Treatment (PRT) and ESDM suggest carefully observing the sounds that the child is making, even if these are unintentional sounds as part of a stereotypic behavior or a play routine. This ensures that targets for vocal imitation are selected to incorporate the sounds the child already makes (Koegel, Sze, Mossman, Koegel, & Brookman-Frazee, 2006; Rogers & Dawson, 2010). Rogers and Dawson (2010) noted that children who tend to be relatively quiet in general may be more likely to emit sounds when engaged in a high-energy exciting routine that is predictable in nature. Once the child vocalizes, the adult imitates the sound immediately and reinforces the child with a high-value natural reinforcer (e.g., more intense tickles). Of course, the adult would not reinforce any sound associated with challenging behaviors (e.g., crying, shrieking, or whining sounds). ESDM emphasizes the importance of building up the use of the sound by tempting the child to engage in “vocal rounds” (Rogers & Dawson, 2010, p. 144), in which the adult and the child engage in back-and-forth imitation of each other with the same sound. Once a sound is identified and the child is regularly initiating the sound, the adult can assign meaning to it and incorporate it into a joint activity or sensory social routine. For example, if the child makes a humming sound (i.e., “mmmm”), the parent may use a cow puppet to tickle the child and model “mmmooo.” In addition, the adult can pair the sound with an object by providing the child access to the action or toy as soon as the child is making the targeted sound, even if the sound is initially unintentional. Once the child reliably imitates the target sound, the adult can expand the repertoire by differentially reinforcing other sounds and combinations of vowels and consonants in the same way as described previously.

PLAY Children with ASD often have difficulty integrating social dimensions into their developing object play (Wolfberg & Schuler, 2006), and they tend to engage in less frequent functional and symbolic play overall (Rogers, 2005). These characteristics are symptomatic of broader social and cognitive impairments of ASD, such as problems with reciprocity, flexibility, and symbol use. However, limited play skills also place children with ASD at a developmental disadvantage because play provides a context for a diverse set of naturally occurring learning opportunities (Jung & Sainato, 2013) that are often social in nature. These factors make play a critical target for intervention (National Research Council, 2001). Play Development In infancy, play begins as an exploration of objects as the child engages in touching, smelling, banging, and mouthing. Play also includes affective social exchanges between parent and child (Rogers, 2005), often in the form of reciprocal social games and sensory social routines such as Peekaboo and tickle games, as described previously. Children typically begin to demonstrate functional play with objects and then add symbolic elements to their play later in the second year of life (Wong & Kasari, 2012). During the preschool years, play becomes increasingly more socially complex as pretend play schemes are expanded into imaginary and sociodramatic play. See Table 12.3 for a condensed time line of play development. Although it is

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Table 12.3. Play development in typically developing children and approximate age of emergence Type of play and approximate age of emergence Exploratory or sensory motor play (3–6 months) Presymbolic play I or combinatorial play (8–12 months) Presymbolic play II (13–17 months) Functional play (18–24 months) Animated play (18–24 months) Autosymbolic play (17–24 months) Symbolic play Level 1 (19–22 months)

Symbolic play Level 2 (after 24 months)

Constructive play (after 24 months) Symbolic play Level 3 (after 30 months) Symbolic play Level 4 (after 36 months) Game play (after 36 months) Symbolic play Level 5 (36–42 months)

Examples Banging a block, pushing a block off the table, mouthing, smelling or visually examining an object Child combines actions on a toy (e.g., banging, throwing, turning). Child dumps objects from containers. Child puts objects into toys that belong (e.g., figurine in car). Child uses objects how they were intended (e.g., builds tower with blocks, rolls playdough). Child combines toys consistently for short one-step actions (put the baby in the bed). Child extends functional play actions by adding sounds and making them “live” (e.g., baby doll talks, airplane crashes with crash sounds). Pretend actions are directed at self (e.g., pretending to fall asleep). Play actions are still short, and objects are used in predictable ways. Child pretends to do imitative activities familiar to others (e.g., cooking, reading, cleaning, shaving). Play includes short, isolated schema combinations (child combines two actions or toys in pretend, e.g., rocking the doll and putting it to bed; pouring from a pitcher into a cup). Child performs pretend actions on more than one object or person (e.g., feeds self, doll, mother, and/or another child). Expansions of imitative play from Level 1 with more details: Pretend cooking now includes putting a lid on the pan, putting the pan in the oven, and collecting items associated with cooking or eating such as dishes, pans, silverware, glasses, and a highchair. Child may reverse roles: “I play you, and you play me.” Child makes something novel from pieces (e.g., building a palace from blocks or sand). Pretend play routines begin to include personal experiences that make an impression (e.g., going to the doctor, having a birthday). Child talks to and with inanimate objects. Compensatory play: Child reenacts experienced events as in Level 3 but may modify the ending. Play sequences are longer and develop during play. Child will play simple games with some rules, although he or she does not like losing and views rules as flexible. Child uses representation regularly (e.g., a stick is a snake or a hairbrush). Imaginative play includes “set ups” that incorporate blocks, sand, pillows, or other constructive materials. Fences, houses, and parking garages are popular to organize objects and favorite items. Child uses multiple reversible roles (e.g., child is the manicurist, hair dresser, and cashier, but the parent is always the customer). Child uses a doll or puppet as a participant in play. (continued)

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Table 12.3. (continued) Type of play and approximate age of emergence Symbolic play Level 6 (42–60 months)

Symbolic play Level 7 (after 60 months) Game play with rules (after 60 months)

Examples Child elaborates play sequences through planning and building of scenes and may hypothesize different outcomes. Child uses dolls and puppets as play agents, and each can have multiple roles. Child has expanded play into imaginative integrated sequences with many steps and multiple participants. Child may have several storylines going at one time. Child collaborates with others in play. Child can play complex games with multiple rules. Child accepts rules and limits. Child can independently make up games with rules.

Sources: Belsky & Most (1981); Casby (2003); Westby (2000).

easy to forget about the importance of play in adolescence and adulthood, shared recreational leisure and athletic activities (e.g., hobbies, organized sports) remain critical opportunities for socialization and connection with others throughout the life span. Play development in both typically developing children and children with ASD is not necessarily linear or straightforward. Although Table 12.3 shows types of play as distinct categories, these do not necessarily emerge one at a time, and multiple types of play are often observed simultaneously, especially as children gain increasing skills. The table is provided to give the reader a broad overview of types of play and should be used flexibly as a resource when thinking about what play skills to teach. Research shows it is important to select play goals that match a child’s developmental level, rather than age, and to select goals at or just above the child’s current play level (Lifter, Ellis, Cannon, & Anderson, 2005; Lifter, Sulzer-Azaroff, Anderson, & Cowdery, 1993). Furthermore, because plays skills build on each other developmentally, it is important to not jump ahead too rapidly but to allow for substantial expansion within each phase. Teaching Play in NDBI Because appropriate social play depends on the context, it is not effectively taught as a discrete set of skills. Instead, teaching needs to involve meaningful and enjoyable engagement with materials, which is often best accomplished in natural social settings (Liber, Frea, & Symon, 2008; Strain & Schwartz, 2001). In fact, acquisition of play skills is complex and circular: Children need to have play skills in order to participate in social interactions with peers, but they also need exposure to social opportunities in order to learn to play appropriately (Jordan, 2003). Research suggests that play skills can be taught (though quality may be different; Thorp, Stahmer, & Schreibman, 1995) and that improvements in play may also lead to better social interaction, better language skills, and decreased self-stimulatory behavior (Baker, 2000; Stahmer, 1995; Thorp et al., 1995). Teaching children with ASD to engage in thematic play also allows for interactive play with peers (Rogers, 2005), and

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play is generally considered a critical context for friendship development in childhood (Jordan, 2003). Research has suggested that symbolic play skills can be taught using a variety of behavioral approaches and prompting methods (Stahmer, Ingersoll, & Carter, 2003). However, rather than relying primarily on adult prompts and praise to teach play skills (as in Colozzi, Ward, & Crotty, 2008), naturalistic techniques have had success promoting spontaneous play by incorporating the child’s interests and arranging environments to be conducive to play (Kohler, Anthony, Steighner, & Hoyson, 2001). Kasari and colleagues (2006) conducted a randomized controlled trial using naturalistic strategies combining behavioral and developmental methods; they found that children who were taught functional and symbolic play behaviors showed more diverse types of symbolic play and higher play levels during interaction with their mothers than children in the joint attention or control conditions. Several other studies have suggested that NDBI strategies (following the child’s lead, using a least-to-most intrusive prompt hierarchy, and providing natural reinforcement) are effective at enhancing play skills. Still, it appears necessary to directly teach symbolic play behaviors because many children with ASD do not spontaneously start using these important skills without targeted intervention (Lifter et al., 2005; Wong, 2013, Wong & Kasari, 2012). Several studies examined the effectiveness of PRT for expanding play skills. In addition to improvement in language and joint attention, collateral changes in toy play were reported (Pierce & Schreibman, 1995, 1997b). Results also indicated increases in symbolic play (Stahmer, 1995) and sociodramatic play (Thorp et al., 1995) as well as play complexity and social interactions. Lydon, Healy, and Leader (2011) compared PRT with video modeling and showed improvement and better generalization in the PRT condition. ESDM has developed a detailed curriculum that breaks down play skills into progressive developmental steps (Rogers & Dawson, 2010) up to and including construction and representational or symbolic play. This helpful list of increasingly more complex tasks provides an excellent overview of the development of play. The Joint Attention, Symbolic Play, Engagement, and Regulation (JASPER) model uses play with objects as the main conduit for intervention and emphasizes that it is important that play is varied within a play level prior to moving on to a more difficult play level. Box 12.2 provides some practical tips for play with toddlers. Symbolic Play Symbolic play is play where the child uses actions or objects to represent other actions or objects. It begins to develop around the middle of the second year of life and tends to progress from pretend actions by the child, to imaginary objects, and then simple one-step actions with functional objects (feeding the doll with a spoon). Imitation plays a central role because imitative pretend play actions and dress up begin to take center stage (e.g., wearing Mommy’s shoes, copying the way Daddy talks on the phone by clenching the pretend phone between the ear and the shoulder while walking). Over several years, symbolic play then continues to expand across a large variety of themes, from simple one-step sequences to multistep, multiple-role schemas with other children. This type of play closely mirrors language development in both typically developing children and children with ASD or other disabilities (Kasari, Paparella,

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Ready, Set, Implement! BOX 12.2: Tips for toddler play • •

• •

•

• • • •

Engage and entice the child first: Follow the child’s lead by imitating his or her play actions and providing noncontingent reinforcement. Use general household items that are readily available, such as food cans for stacking, plastic food containers for hiding items, and spoons and metal pans or bowls for drumming. Avoid electronic toys with buttons and sounds. They tend to be a distraction from the social aspects of play. Think about the toy prior to presenting it to the child: What could be fun about this object? The sound of the blocks falling? The view of the parachute figurine falling down from the landing? The feeling of the playdough being squished? When presenting the toy and the action, watch the child closely to see if he or she is engaged and enticed to play. Follow the child’s lead to maximize engagement. Oftentimes your affect while presenting the new action and toy makes a big difference: Be enthusiastic and excited! Have backups available if the child is not interested. Having several toys available and a plan for each can keep motivation and interest high. Consider having multiples of the same toy for easy modeling of actions. Use daily routines to intersperse modeling of simple play actions or silly play. For example, an adult wearing a diaper as a hat is funny and engaging to most children.

Freeman, & Jahromi, 2008; Thiemann-Bourque, Brady, & Fleming, 2012; Toth et al., 2006). Symbolic play tends to be especially difficult for children with ASD, likely because it requires many social skills to execute (Jarrold, Boucher, & Smith, 1996) and because symbolic understanding is delayed or impaired. Furthermore, as play sequences get longer and more complex, children with ASD may have difficulty planning these longer sequences and managing the different roles. Adults should ensure that symbolic play in this phase is varied and flexible. Thus, the play partner must model flexible and varied actions, scripts, and schemes in play and should avoid repeating the same actions over and over. It is also important to provide varied play materials to encourage flexible play. NDBI are especially well suited for teaching this type of play because of the emphasis on embedding teaching in natural routines and using varied teaching examples, but it is up to the play partner to model variety. Motivation for symbolic play can often be enhanced easily with the use of sound effects, funny voices, unexpected actions, silly faces, and creative use of many different play materials. A play partner’s energy, humor, ingenuity, and resourcefulness can make NDBI feel almost irresistible to the child. See Box 12.3 for more tips on teaching symbolic play.

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Ready, Set, Implement! BOX 12.3: Tips for teaching symbolic play •

•

•

•

• •

•

•

•

A favorite play routine for pretend actions is to pretend to go to sleep and snore loudly. Be sure to act very surprised when the child wakes you up with a pretend alarm clock or rooster call. Taking turns in this activity is an easy way to build engagement. Model functional play actions that the child can recognize from his or her own daily routines, such as actions in bathing (wash Superman in the bath with the washcloth), bedtime (put the elephant in bed), shopping (“pay” for a special treat with pretend money), or cooking (stir the pot with big wooden spoon to make soup, then feed a figurine). The easiest mistake to make in this phase is too much too fast. Remember to build a lot of variety and spontaneity in the child’s repertoire of play actions before moving on to more complex play. Some children with ASD do not see the fun in dress-up activities, but dress up can be minimal with a silly hat, a pair of plastic glasses, or a power shield made from cardboard box. The important thing is to have fun with the dress-up activity. Make sure to include maintenance tasks so that not all of the play actions are novel and difficult for the child. If the child always wants to play the same sequences or with the same materials, try providing a first, then approach. That is, reinforce varied and spontaneous play or responding to another person’s topic of play with access to the child’s preferred play materials or sequence. Accepting others’ ideas in play is hard for many young children but tends to be especially hard for children with ASD. Make sure that the child has a large repertoire of possible play actions and sequences to pick from before targeting flexibility. Choices can be among sets of symbolic play toys (e.g., doctor set and puppet, pretend utensils and dolls, figurines with cars and a toy garage). Then, within the choices provided, follow the child’s lead to see what is of interest. Remember not to start prompting immediately. Build engagement, find the motivator, and then intersperse a novel action or sequence. Narrating appropriate play actions can provide important feedback and build vocabulary, as long as the child is attending to most of the narration and the adult is not just background noise. Be sure to match the child’s language level.

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Game Play Between ages 3 and 4, typically developing children begin to engage in a variety of board games. Some early games lend themselves more to teaching compared to others. Games that have an exciting action associated with a turn or games in which the child is anticipating a surprising or exciting ending tend to be more motivating. For example, in the Doggy Doo game, the object is to make the dog poop. In Pie Face, the object is to avoid getting hit in the face with whipped cream. In Pop the Pig, the pig is fed until it burps, and in Pretty Pretty Princess, the players collect jewelry along the way. Sometimes games can be adapted to be more exciting or incorporate a child’s restricted interest. Memory can be more motivating if it contains pictures of the child’s favorite toys, objects, or characters, and perhaps special prizes can be earned for matches. Candy Land, a short board game where game pieces are moved on the game board, can be much more fun if small candies are earned along the way. A child whose perseverative interest is maps may like Candy Land if it is presented as a way to explore the map. A child who likes car brands may be enticed to play Don’t Break the Ice if car logos are attached to the ice cubes and tapped by the hammer. See Box 12.4 for more strategies to make game play successful. Game play also includes a variety of social games. Social games are not that different from sensory social routines, except they become increasingly more complex and more rule governed. Social games are helpful because their rules are easily changed to accommodate children with ASD who may be struggling with a certain component of a game, and they incorporate many of the reinforcing features of sensory social games. Table 12.4 shows examples of favorite social games and how they can be varied and adjusted.

Ready, Set, Implement! BOX 12.4: Game play tips for board games • •

•

Initially make games super short; end the game when the child is still very motivated to play! Prompt a variety of tasks (not just asking for a turn). Commenting on the other person’s turn, giving items, and responding to the play partner should also be prompted throughout the activity and can be good ways to introduce task variation and interspersal of maintenance tasks with turn-taking goals. In addition, if the game requires dice or other items to be handed back and forth between players, prompt a variety of requests for dice: “Give me the dice,” “Can I have the dice?” and “Dice please” are all good options and can be alternated. Variety builds the child’s repertoire and prevents inflexible language and play behaviors. If multiple children are playing the game, be sure to prompt and praise all participants, not just the child with ASD (see also the section on cooperative arrangements and successful playdates).

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Table 12.4. Tips for social games Game: What Time Is It, Mr. Fox? Description In this game, Mr. Fox (the adult) stands a short distance from the child, turned away so that he or she cannot see the child. The child calls to Mr. Fox and asks, “What time is it, Mr. Fox?” The adult states it is 3 o’clock, and this allows the child to take three steps toward Mr. Fox. This process is repeated until either the child touches Mr. Fox and wins the game or Mr. Fox answers, “It’s lunch time!” and chases the child to pretend to eat him or her. Tips This game initially needs a prompter to help the child understand the game, and the ability to count up to five is helpful. Mr. Fox should initially be played by the adult. Add painters, tape to the floor to mark where the child is supposed to step. The reinforcer is usually the sudden chase at the end. Game: Hide and Seek Description The adult counts to a predetermined number while the child hides. The adult searches for the child until he or she is found. In some versions, both run back to “home,” and whoever gets there first wins. Tips When priming for the game, set clear up-front limits about where the child is allowed to hide (e.g., only hide in the living room, stay in the garden) to prevent not knowing where the child is. In open spaces, it can be helpful to draw the boundary with chalk or ensure there is a physical barrier for safety. If multiple children participate, have children search in pairs with one child asking, “Am I getting warmer or colder?” and the other child answering “warmer.” Priming can include reminders about what to do when finding the individual who was hiding (e.g., “You can say, ‘I found you’ or ‘There you are!’”). If the child appears underwhelmed by finding the hiding individual, it may not be sufficiently reinforcing. This can be addressed by adding a chase at the end back to the base, or the hidden child can be primed to jump out and give high-fives or other actions the child may find exciting. Game: Red Light, Green Light Description One person calls “red light . . . green light” while the other person moves toward the caller on “green light” and stops on “red light.” Sometimes the person calling red light, green light is turned away from the individuals moving. In this version, the winner is the person who reaches the caller first. Tips Place snack items or another desired activity at the end so children will be motivated to reach the caller. In summer, have children carry small buckets of water or water balloons while moving toward the person calling red light, green light. When the caller calls an agreed on “magic” word (e.g., “rainbow light”), the children are allowed to run toward the caller to attempt to throw the water or water balloons at the caller. Game: Freeze Dance Description While the music plays, all participants dance. When the music stops, everyone freezes in place. If you are still moving when the music stops, you are out. Tips Prompt children to ask a question or make a comment to a peer before they can be unfrozen. This is a great family game to involve younger siblings and other family members. (continued)

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Table 12.4. (continued) Game: Duck, Duck, Goose (requires three or more participants) Description Everyone but the counter sits in a circle. The counter walks behind the children in the circle while lightly tapping each person saying “duck” or “goose.” When the word “goose” is used, the person tapped with goose must jump up and attempt to tag the counter before he or she completes the circle and sits down in that person’s spot in the circle. Tips Partner children who are “it” to give them an opportunity to discuss and decide when to say “duck” and when to say “goose.” Change it up with favorite phrases: “duck” becomes “pepperoni pizza,” and “goose” becomes “breadsticks.”

Useful NDBI Strategies for Teaching Play All NDBI value the importance of play and its role in development, and many general NDBI strategies can be used to teach play. These include a variety of prompting strategies, turn taking and balanced turns, child choice and shared control, and balancing new or acquisition tasks with maintenance or already learned tasks. Prompting Strategies When teaching functional play acts (e.g., using the hammer to beat down a peg, hitting a drum, rolling a car), the adult should begin by providing some choices of preferred toys. Once the child selects a toy or indicates an interest by reaching or approaching it, wait and see if spontaneous functional play occurs (e.g., the child begins to roll the car). If the child initiates an appropriate action, the adult immediately imitates the action and describes the action with praise (e.g., “Drive the car; great job!”). If the child continues to explore the toy but does not use it functionally, the adult can provide a model in his or her turn with the car and prompt for imitation by handing the car back to the child saying, “You do it.” If the child does not imitate the action, a most-to-least prompting hierarchy is used to help the child complete the action. Momentum is another antecedent strategy that sets the stage for an upcoming play act and helps to entice the child into a play action. For example, when modeling rolling a car down a ramp, the play partner may roll the car in place to “rev it up” with sound effects and excited facial expressions before actually rolling the car down the ramp. This may create anticipation and excitement and make it more likely that the child will engage with the adult and the toy and imitate the action. Modeling and nonverbal prompting can be used to teach simple or advanced play skills, such as symbolic substitution in play, or the ability to pretend something is different from what it actually is, using ambiguous objects. Ambiguous objects are similar in shape or color compared to the actual object but not distinctive on their own. Rogers and colleagues (2012) used the example of a Popsicle stick to represent a spoon. Then, during an established joint activity routine (feeding the baby with a spoon), a variation is presented that models a mastered play action (feeding with the spoon) with the actual item and then immediately following the same action with the new ambiguous item (feeding with the Popsicle stick). The child is prompted to imitate both actions, and if two sets are available, parent and child may alternate using the actual item (spoon) and the ambiguous item (Popsicle stick).

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Games tend to provide excellent opportunities to prompt more advanced communication skills such as commenting. The inherent structure of the game already provides visual and gestural cues (e.g., dice or a hammer that is passed over) to take a turn, allowing for natural prompt fading quickly. Pairing comments with common gestures used to congratulate or commend others on their turn (e.g., high-fives, fist bumps) can be helpful in prompting procedures because the verbal prompt can be faded more easily to a time delay or gestural prompt. Given that game play consists of a series of repetitive actions, it is important to make sure interactions remain varied because children with ASD tend to remember patterns. For example, when playing the matching game Memory, a play partner could model a variety of responses when turning two nonmatching cards, rather than saying “no match” in the same tone each time. Fading prompts quickly is essential when teaching game play to ensure the game is not rote. When playing games with multiple partners, the prompter should consider carefully where to prompt from. For example, if the child is playing with a peer, the prompter may want to be behind the child rather than as a third partner at the table. This prevents the peer from referencing the adult rather than the child with ASD and prevents the child with ASD from referencing the adult rather than the peer. In addition, it is much easier to fade out—the ultimate goal for any prompter. Priming can also be used to teach the rules of social games in advance and has been shown to enhance peer social interactions (Gengoux, 2015). Priming can also be used to clarify behavioral expectations (e.g., “Keep your hands to yourself, and wait your turn”) and prepare for winning or losing the game (e.g., “Remember, it is about having a great time with your friends, not winning or losing”). Turn Taking and Balanced Turns Turn taking supports back-and-forth interactions (Harrist & Waugh, 2002) and may enhance requesting, commenting, and toy play skills (Rieth et al., 2014) during any stage of play development. When children are learning functional and symbolic play, having two sets of the same toys can allow the play partner to model the desired play actions. On the other hand, it is also sometimes helpful to have only version of the toy (e.g., one ball for the ball ramp) to play with. This naturally provides opportunity for turn taking. The adult can also add novel components to his or her turn—a sound effect, an element of speed, or an unexpected change that mixes up the interactions and increases the likelihood of high interest in continuing the activity. This strategy is often called addition and can be used to make the play partner’s turn more reinforcing. Turn taking can also be helpful when the child is engaging in repetitive play patterns. Using a child’s strong interest in repeating the same action over and over may function as a way to motivate the child to practice novel but related skills. For example, the adult can copy the child’s behavior, then model slight variations on the repetitive action and encourage the child to try imitating the variation before returning to playing the way he or she usually does. The adult thus establishes a turn-taking routine, taking advantage of his or her turn to model a creative or silly use of the same materials, thereby encouraging the child to expand his or her play routine. Turn taking is a natural part of most game play and includes watching the play partner, waiting for a turn, commenting, requesting, and affective sharing. At first, the goal may be to take the turn when the opportunity is presented,

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but ultimately affective sharing regarding the play partner’s turn is at least as important because it increases the likelihood that the child is a preferred play partner. Sometimes it can be easier to teach the finesse of turn taking in advanced social games rather than board games because these provide less structure and fewer rules. When beginning to practice this new skill, limit prompting of turn taking in the third person (avoid overusing “It’s Miss Mia’s turn”). Instead, prompt the child to say “my turn” to request his or her turn and “your turn” when giving a turn to the partner. The adult should not provide a teaching trial every time a turn is taken, and some turns should just be that—a turn in a play exchange. Turn taking in games can be prompted in diverse ways because play partners should not consistently require the child to ask for a turn or announce a turn (“Whose turn is it?” “My turn” or “Your turn”). Rather turn taking should naturally flow within the activity in the same way it would in a joint activity routine. If a play partner needs to constantly prompt the child to take a turn or give a turn, the adult may consider tweaking the game or going back to social games to ensure that the child is picking up on the nonverbal cues of turn taking and is interested in the game. Child Choice and Shared Control Strategies It can be challenging to establish shared control of materials in a way that keeps the play fun. For instance, if a child is interested in dumping balls out of a bucket (an interest common in young children), simple blocking is not necessarily recommended because many young children reject this type of incursion into their play. A more helpful strategy may be to arrange the environment in such a way that adult help is required to play with items. For example, the bucket is accessible, but the balls are in a box that cannot be opened alone (using transparent plastic boxes with snap-on lids is helpful). Although adult play partners may be tempted to simply open the box, waiting for a behavior that indicates a desire to access the balls provides a natural communication temptation. Addition is another shared control strategy that tends to be successful; for example, while the child is playing with a bucket and balls, adding a puppet that is eating the balls provides a playful way to obtain control over some of the balls. Providers are encouraged to take note of unusual play interests because these can often be highly motivating. Consider the example of an adult and a child playing in the child’s bedroom with a box of figurines. The child may appear interested in the beginning of the interaction but then slowly start to turn away from the adult. Finally, with a figurine in hand, the child runs over to the bed and forcefully sits down on the bed with the figurine before returning to the box to exchange the figurine and repeat the sequence (sit down with figurine, jump up, run to the bed, forcefully sit down, get back up, and bring the figurine back to the box for the exchange). After two rounds, if the adult notices this is a routine and imitates the child, the routine can be turned into a game. After a few repetitions, the adult may then offer a variation (an acquisition task) and model the figurine jumping on the bed while saying, “Wheeee!” The child imitates the model, and the adult and the child repeat the sequence. This unusual routine could likely not have been predicted by the adult, but because the adult paid attention and closely monitored the child’s interest, the adult was able to capitalize on the interest.

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Balancing Maintenance and Acquisition Tasks and the One-Up Rule In every teaching episode, the adult should alternate between new tasks (acquisition) and mastered or maintenance tasks, as well as noncontingent reinforcement and imitation. This alternation ensures motivation remains high and the interaction is balanced (see also Chapter 6). Acquisition tasks should consist of tasks that are just above the difficulty level of the mastered task (i.e., within the child’s zone of proximal development). For example, if the child is engaging in a variety of functional play actions, animated play with a figurine, doll, or puppet could be targeted next. If the child has mastered putting a figurine in the school bus, the next target may be to have the figurine say hello to the figurine bus driver. Not all figurines should be animated when filling the bus because just putting them into the bus would be the maintenance task.

TEACHING PLAY WITH FRIENDS Chapter 5 provides an in-depth review of literature on inclusion and peer-mediated interventions. This section adds practical strategies that promote engagement with peers. It conducts a short review of the literature, followed by practical tips and ideas to promote cooperation and engagement between peers in small-group activities and in playdates. Teaching play can most easily be accomplished in natural contexts (homes, schools, community settings) because play is something that all children do wherever they go. To help children with ASD learn to play with peers, they must have regular access to peers who are potential playmates. Children with ASD ideally should be regularly included alongside their natural peer group of siblings and neighborhood children. Teaching that occurs in these inclusive contexts will be particularly powerful for promoting peer relationship development. It is critical that play interventions focus not just on teaching discrete play skills but also on integrating children into their peer culture in meaningful ways (Wolfberg & Schuler, 2006). Establishing the Play Partner as a Reinforcer Establishing the social partner as a reinforcer is key in NDBI because there is evidence that learning is enhanced when it takes place within emotionally meaningful social interactions (Schreibman et al., 2015; Topál, Gergely, Miklósi, Erdőhegyi, & Csibra, 2008). Making peers reinforcing requires careful planning and ongoing monitoring and may include many steps for some children with ASD. Simply measuring peer proximity in unstructured situations may be one very rough way to quickly gauge how reinforcing peers are (McGee et al., 1999), but generally speaking, careful and in-depth assessment of peer interactions is almost always necessary from a young age. As children become older, their natural environment expands to include peer interaction as an even more critical social context. Although a goal for most children may be to play with same-age and often same-gender peers, it may initially be easier to find matching interests with peers slightly older or younger than the target child or of the opposite gender. School staff can often be helpful and recommend several children who have shown interest in the child with ASD, exhibit frequent unprompted prosocial and empathic behaviors (e.g., helping others, sharing), and may make good play partners. In

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addition, generally speaking, the more inclusive activities in which the child is involved, the easier it will be to find peers for practice. One helpful strategy is to linger before and after activities in order to naturally connect and socialize with parents of peers before and after school or to offer to drive carpool. Bringing extra snacks to share and bringing games for multiple players to the park to entice peers to join the activity while waiting can also foster connections. Children with ASD may initially show a lack of interest in playing with peers. Pairing peers with strong reinforcers such as favorite snacks and toys may increase interest. It is important to prompt the child with ASD primarily to make simple requests from peers to pair direct natural reinforcement with peer initiations and to initially have a high level of reinforcement combined with low task demand. Parallel play near a peer with the occasional exchange of toy material can also be a good starting point, and teaching can build toward longer, reciprocal interactions. Peer-Mediated Interventions Because the use of adult partners to train social skills does not generalize easily to peer social skills, teaching social skills directly through peer-mediated approaches has particular promise. Peer-mediated interventions typically involve training peers to implement an intervention directed toward a child with a disability (Chan et al., 2009), often by teaching persistence in initiating specific play behaviors (sharing, helping, giving affection and praise; Rogers, 2000). Though this approach tends to be underutilized in practice (Rogers, 2000), there are manualized and highly effective approaches for peer-mediated intervention (Wang, Cui, & Parrila, 2011; Zhang & Wheeler, 2011). For instance, school-age peers have been taught to implement PRT in order to increase social-communication behaviors (including both initiations and responses) of children with ASD (Harper, Symon, & Frea, 2008; Kuhn, Bodkin, Devlin, & Doggett, 2008; Pierce & Schreibman, 1995, 1997a, 1997b). The procedures for the peer coaches included instruction and modeling with an adult trainer, role play with an adult and other peer coaches, and intermittent feedback during play sessions with children with ASD. Collateral changes in language and joint attention (and toy play) have been reported (Pierce & Schreibman, 1995, 1997b). Peer tutoring has also been used to teach peers IT techniques (McGee, Almeida, Sulzer-Azaroff, & Feldman, 1992), with improvements in reciprocal social behavior, social initiations, and peer acceptance. Evidence suggests that parents can also teach siblings to use peer-mediation strategies (Strain & Danko, 1995; Strain, Kohler, Storey, & Danko, 1994). One of the first models for peer-mediated intervention was developed by Odom and Strain (1984) and involved behaviorally based training of peers to increase social initiations and responses of the children with ASD. Another such approach comes from the integrated play groups model (Wolfberg & Schuler, 1993), where peers are guided to encourage toy play by children with ASD by directing attention, modeling symbolic play, and embedding the behaviors of children with ASD into their broader play theme (Zercher, Hunt, Schuler, & Webster, 2001). This model involves many components consistent with an NDBI approach, including conducting the intervention within natural integrated and developmentally appropriate play settings, using consistent routines and toys with interactive potential to provide a context that is conducive to interaction, and

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emphasizing child-initiated behaviors through adult scaffolding. These strategies have been shown to result in more functional, symbolic, and social play and decreases in nonfunctional object manipulation and isolated play (Wolfberg & Schuler, 1993). More recently, Kasari and colleagues (2012) demonstrated lasting changes in school social networks following a relatively brief (6-week) peer training intervention. Facilitated Playdates Playdates hosted by parents of children with ASD are a natural context for building peer relationships and enhancing social skills. Research evidence has repeatedly shown that children with ASD are more likely to have reciprocal friendships if their parents actively set up and facilitate opportunities for peer contact outside school, such as playdates and get-togethers (Frankel, Gorospe, Chang, & Sugar, 2011; Frankel & Myatt 2003; Ladd, Hart, Wadsworth, & Golter, 1988). Research has indicated that naturalistic strategies can be used to increase spontaneous social interactions with adults and peers (Kohler et al., 2001). Common features of successful approaches include both motivational strategies (i.e., incorporating the child’s interests, environmental arrangement, contingent reinforcement) and systematic prompting of play targets according to a developmental sequence (Hwang & Hughes, 2000; Jung & Sainato, 2013). For instance, Kohler and colleagues (2001) demonstrated that when teachers received coaching in specific naturalistic strategies (using novel materials, joining play activity, incorporating choice, arranging the environment, expanding language, drawing attention to peers), preschool children increased their unprompted social interaction. Following the Child’s Lead When applied to peer interactions, the NDBI strategies of using child-preferred activities and following the child’s lead mean that the activity selected for the playdate should be of interest to both children involved (i.e., the child with ASD and the peer). Not only are children more likely to engage with each other when they are enjoying a mutually reinforcing activity, but child-preferred activities also provide an optimal context for teaching skills. That way, if one child struggles to interact appropriately at first, the activity will continue to capture his or her interest while the adult facilitator works to support improved interaction. Of course, to ensure the activity is highly preferred for the child with ASD, general activities can be slightly modified to incorporate specific interests. For example, if both children like playing Bingo but the child with ASD loves animals, then animal Bingo may be an excellent choice. Likewise, if both children like basketball but the game is a little hard for the child with ASD, perhaps playing basketball with balloons may be easier and thus more preferred. Cooperative Arrangements For effective social facilitation, activities must be structured to ensure that the children (and especially the child with ASD) receive contingent and natural reinforcement as often as possible for their use of appropriate social skills. Reinforcement for interaction should ideally come directly from the peer. For instance, if the activity involves constructing a puzzle, the child with ASD could be prompted by an adult to request, “Can you pass one of the puzzle pieces?” from the peer, and the adult can then ensure that the peer provides contingent natural reinforcement for that appropriate request. The easiest

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way to do this systematically is to deliberately engineer the activities to include cooperative arrangements, in which interaction is necessary to complete the activity and directly results in reinforcement for one or both children. Cooperative arrangements can be thought of as one type of environmental arrangement, in which the emphasis is on making sure the peer has control of the materials necessary for the child with ASD to complete the desired task. Cooperative arrangements can easily be established by an adult facilitator in school classrooms, on playgrounds, during extracurricular activities, or during playdates and gettogethers at home. Shared Control in Cooperative Arrangements One way to set up initial cooperative arrangements is to start activities with children having shared control of the materials necessary for the activity. For instance, if the chosen activity involved having children make pizzas, the adult could ask each child to bring a favorite topping to share. When the child who brought pepperoni decides that he or she wants pineapple to add to his or her pizza, the child can be prompted (if necessary) to request some from his or her peer. In this way, motivation to interact initially is built into the structure of the activity. The benefit of cooperative arrangements is that once children learn the skill of making appropriate requests, they will no longer need adult prompting to interact as long as cooperative arrangements are in place. Likewise, activities or games can be designed specifically around a child’s strengths so that the child will immediately become a valued member of the game. For instance, a child with ASD who reads well can be put in charge of reading clues to other children on a treasure hunt. A child who swims well can be put in charge of diving for pool toys to distribute to his or her friends. A child who loves numbers can be made the caller in a Bingo game. Finally, cooperative arrangements can be reestablished continually by an adult facilitator so that the children continue to be highly motivated to cooperate and communicate with each other. Other examples of how to use cooperative arrangements to encourage peer interaction during different types of activities include the following: • When it is time for a snack, give all the plates and cups to the child with ASD and all the snacks to the peer. Encourage the child with ASD to ask his or her friend which color plate and cup he or she wants. Once the child has passed out the plates, he or she can request snacks from the peer. In this way, the child will receive direct natural reinforcement for initiating to his or her peer. Children can also be encouraged to prepare snacks for each other so that they get practice asking questions about which, where, and how much food another child would like. • If the children want to play with trains, place the desirable parts of the train set in clear containers or bags and distribute them among the children so that no one child has a sufficient number of items to construct a track and play alone. Remind the children to look at what the other children have and ask to trade if they want an item a friend is holding. This will encourage children to practice initiating requests to peers for toys when highly motivated. To encourage children to practice play acts with peers, the adult can prompt the target child to imitate a peer’s use of toys before taking a turn.

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• When introducing an activity such as an art project, set the expectation that the children will work together to complete a single project. This creates a reason for ongoing interaction and negotiation about what the project should look like. For instance, if the children are making a puppet together (rather than each child making his or her own puppet), the adult can encourage them to talk with each other about what it should look like and to ask and answer questions about the color of the hair, type of clothes, and facial features until they come to a shared decision. Materials for completing the project (scissors, glue, ribbon) can be moved around the table by the adult facilitator to keep creating new reasons for the children to interact by asking for what they need from a friend. Having only one pair of scissors or one container of glue will further ensure that the children have to take turns and ask for the items frequently. • Physical games and sports can also be designed to include cooperative arrangements. This may often involve changing the rules slightly, but if introduced at the start of the game, new rules that also make the game more fun will often be well received. For instance, putting two buddies in charge of calling out “red light, green light” will mean that the two children will have to discuss when to call which instruction. Shooting baskets can be made cooperative by setting a timer and having the children work together to get as many baskets as possible in 2 minutes, perhaps even with balls worth different numbers of points. • During a cooking activity, a child with strong reading skills can be put in charge of the recipe, and other children can be prompted to ask questions about what steps need to be completed next. In a large group, each ingredient can be given to a different child so that the child holding the mixing bowl gets repeated practice requesting the items he or she needs. For children who are ready to practice conversation skills (beyond requesting), the adult can encourage the children to ask questions and share comments about their favorite foods, making sure to time prompts for these challenging tasks right before the target child’s turn to receive the next ingredient (the natural reinforcer for trying conversation). When the food has been prepared, the children can enjoy eating it together. Box 12.5 provides some general tips related to playdates.

CONCLUSION This chapter focused on using NDBI to enhance meaningful social skills, that is, those skills that have potential to make lasting differences in the quality of a child’s relationships over time. The focus also was on teaching strategies that can be used in the natural environment with the child’s natural play partners, whether those are parents of very young children or typically developing peers. These strategies are intended to promote better engagement and also greater independence through self-monitoring. One of the key advantages of the NDBI approach is the emphasis on making the treatment interaction enjoyable for the child. Whether teaching initiations during sensory social routines, teaching functional or symbolic play, or teaching advanced cooperative play skills, the use of motivational strategies such as following a child’s interests can be particularly powerful for teaching social skills because the core purpose of socialization is to have fun.

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Ready, Set, Implement! BOX 12.5: Tips for playdates •

• •

•

•

• • • • • •

Make sure playdates are initially short. A short successful playdate is much more valuable than a longer playdate that ends with the children ignoring each other—or worse, engaging in challenging behaviors. For a quick play encounter, offer to carpool to school or events, and give the children a few minutes to play before or after the car ride. Going out for an ice cream after school can be a playdate; it is short and sweet and can help establish the peer as a reinforcer. Even having a snack with a peer on the playground after school is a social activity. Tell peers in advance about the planned activity so they can come excited to participate and can even bring materials to contribute (e.g., pizza or ice cream toppings, craft supplies), which gives you initial cooperative arrangements. If the kids are sensitive about having an adult around when playing at home, do an activity in the kitchen requiring cutting or cooking, or take them somewhere outside the home where adult supervision is required (e.g., swimming, bowling, rock climbing wall at the local gym). Think about how you position children at a table, making sure the kids face each other but are not close enough to grab materials from each other. Be sure to provide feedback and prompting to both children during the playdate. Intersperse snacks, and set them up using cooperative arrangements. Coordinate with the other family to find out what the peer’s favorite snacks and/or activities are. Intersperse a physical activity to get some of the wiggles out. Pick activities that have a clear beginning and end.

REFERENCES Baker, M. J. (2000). Incorporating the thematic ritualistic behaviors of children with autism into games: Increasing social play interactions with siblings. Journal of Positive Behavior Interventions, 2(2), 66–84. Bellini, S., & Peters, J. K. (2008). Social skills training for youth with autism spectrum disorders. Child and Adolescent Psychiatric Clinics of North America, 17(4), 857–873. Belsky, J., & Most, R. K. (1981). From exploration to play: A cross-sectional study of infant free play behavior. Developmental Psychology, 17(5), 630–639. Berger, N. I., & Ingersoll, B. (2013). An exploration of imitation recognition in young children with autism spectrum disorders. Autism Research, 6(5), 411–416. Berger, N. I., & Ingersoll, B. (2015). An evaluation of imitation recognition abilities in typically developing children and young children with autism spectrum disorder. Autism Research, 8(4), 442–453. Carpenter, M., Pennington, B. E., & Rogers, S. J. (2002). Interrelations among social-cognitive skills in young children with autism. Journal of Autism and Developmental Disorders, 32(2), 91–106.

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Kuhn, L. R., Bodkin, A. E., Devlin, S. D., & Doggett, R. A. (2008). Using pivotal response training with peers in special education to facilitate play in two children with autism. Education and Training in Developmental Disabilities, 43(1), 37–45. Ladd, G. W., Hart, C. H., Wadsworth, E. M., & Golter, B. S. (1988). Preschoolers’ peer networks in nonschool settings: Relationship to family characteristics and school adjustment. In S. Salzinger, J. S. Antrobus, & M. Hammer (Eds.), Social networks of children, adolescents, and college students (pp. 61–92). Hillsdale, NJ: Lawrence Erlbaum Associates. Liber, D. B., Frea, W. D., & Symon, J. B. G. (2008). Using time-delay to improve social play skills with peers for children with autism. Journal of Autism and Developmental Disorders, 38(2), 312–323. Lifter, K., Ellis, J., Cannon, B., & Anderson, S. R. (2005). Developmental specificity in targeting and teaching play activities to children with pervasive developmental disorders. Journal of Early Intervention, 27(4), 247–267. Lifter, K., Sulzer-Azaroff, B., Anderson, S. R., & Cowdery, G. E. (1993). Teaching play activities to preschool children with disabilities: The importance of developmental considerations. Journal of Early Intervention, 17(2), 139–159. Longhi, E., & Karmiloff-Smith, A. (2004). In the beginning was the song: The complex multimodal timing of mother–infant musical interaction. Behavioral and Brain Sciences, 27(4), 516–517. Lydon, H., Healy, O., & Leader, G. (2011). A comparison of video modeling and pivotal response training to teach pretend play skills to children with autism spectrum disorder. Research in Autism Spectrum Disorders, 5(2), 872–884. Martins, M. P., & Harris, S. L. (2006). Teaching children with autism to respond to joint attention initiations. Child & Family Behavior Therapy, 28(1), 51–68. Mason, S. A., McGee, G. G., Farmer-Dougan, V., & Risley, T. R. (1989). A practical strategy for ongoing reinforcer assessment. Journal of Applied Behavior Analysis, 22(2), 171–179. Masur, E. F., & Rodemaker, J. E. (1999). Mothers’ and infants’ spontaneous vocal, verbal, and action imitation during the second year. Merrill-Palmer Quarterly, 45(3), 392–412. McGee, G. G., Almeida, M. C., Sulzer-Azaroff, B., & Feldman, R. S. (1992). Promoting reciprocal interactions via peer incidental teaching. Journal of Applied Behavior Analysis, 25(1), 117–126. McGee, G. G., Morrier, M. J., & Daly, T. (1999). An incidental teaching approach to early intervention for toddlers with autism. Journal of the Association for Persons with Severe Handicaps, 24(3), 133–146. Meek, S. E., Robinson, L. T., & Jahromi, L. B. (2012). Parent–child predictors of social competence with peers in children with and without autism. Research in Autism Spectrum Disorders, 6(2), 815–823. Meltzoff, A. N., & Moore, M. K. (2000). (a) Imitation of facial and manual gestures by human neonates (b) Resolving the debate about early imitation. In D. Muir & A. Slater (Eds.), Infant development: The essential readings (pp. 167–181). Malden, MA: Blackwell Publishing. National Research Council. (2001). Educating children with autism. Washington, DC: National Academies Press. Odom, S. L., & Strain, P. S. (1984). Peer-mediated approaches to promoting children’s social interaction: A review. American Journal Of Orthopsychiatry, 54(4), 544–557. Pierce, K., & Schreibman, L. (1995). Increasing complex social behaviors in children with autism: Effects of peer-implemented pivotal response training. Journal of Applied Behavior Analysis, 28(3), 285–295. Pierce, K., & Schreibman, L. (1997a). Multiple peer use of pivotal response training social behaviors of classmates with autism: Results from trained and untrained peers. Journal of Applied Behavior Analysis, 30(1), 157–160. Pierce, K., & Schreibman, L. (1997b). Using peer trainers to promote social behavior in autism: Are they effective at enhancing multiple social modalities? Focus on Autism and Other Developmental Disabilities, 12(4), 207–218. Rieth, S. R., Stahmer, A. C., Suhrheinrich, J., Schreibman, L., Kennedy, J., & Ross, B. (2014). Identifying critical elements of treatment: Examining the use of turn taking in autism intervention. Focus on Autism and Other Developmental Disabilities, 29, 168–179. Rogers, S. J. (2000). Interventions that facilitate socialization in children with autism. Journal of Autism and Developmental Disorders, 30(5), 399–409.

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Rogers, S. J. (2005). Play interventions for young children with autism spectrum disorders. In L. A. Reddy, T. M. Files-Hall, & C. E. Schaefer (Eds.), Empirically based play interventions for children (pp. 215–239). Washington, DC: American Psychological Association. Rogers, S. J., & Dawson, G. (2010). Early Start Denver Model for young children with autism: Promoting language, learning, and engagement. New York, NY: Guilford Press. Rogers, S. J., Dawson, G., & Vismara, L. A. (2012). An early start for your child with autism: Using everyday activities to help kids connect, communicate, and learn. New York, NY: Guilford Press. Sallows, G. O., & Graupner, T. D. (2005). Intensive behavioral treatment for children with autism: Four-year outcome and predictors. American Journal on Mental Retardation, 110(6), 417–438. Sandbank, M., Woynaroski, T., Watson, L. R., Gardner, E., Keçeli Kaysili, B., & Yoder, P. (2017). Predicting intentional communication in preverbal preschoolers with autism spectrum disorder. Journal of Autism and Developmental Disorders, 47(6), 1581–1594. Schreibman, L., Dawson, G., Stahmer, A. C., Landa, R., Rogers, S. J., McGee, G. G., . . . Halladay, A. (2015). Naturalistic developmental behavioral interventions: Empirically validated treatments for autism spectrum disorder. Journal of Autism and Developmental Disorders, 45(8), 2411–2428. Sigman, M., & Ruskin, E. (1999). Continuity and change in the social competence of children with autism, Down syndrome, and developmental delays. Monographs of the Society for Research in Child Development, 64(1), v–114. Slaughter, V., & Ong, S. S. (2014). Social behaviors increase more when children with ASD are imitated by their mother vs. an unfamiliar adult. Autism Research, 7(5), 582–589. Smith, T., Klorman, R., & Mruzek, D. W. (2015). Predicting outcome of community-based early intensive behavioral intervention for children with autism. Journal of Abnormal Child Psychology, 43(7), 1271–1282. Stahmer, A. C. (1995). Teaching symbolic play skills to children with autism using pivotal response training. Journal of Autism and Developmental Disorders, 25(2), 123–141. Stahmer, A. C., Ingersoll, B., & Carter, C. (2003). Behavioral approaches to promoting play. Autism, 7(4), 401–413. Stone, W. L., Ousley, O. Y., & Littleford, C. D. (1997). Motor imitation in young children with autism: What’s the object? Journal of Abnormal Child Psychology, 25(6), 475–485. Stone, W. L., & Yoder, P. J. (2001). Predicting spoken language level in children with autism spectrum disorders. Autism, 5(4), 341–361. Strain, P. S., & Danko, C. D. (1995). Caregivers’ encouragement of positive interaction between preschoolers with autism and their siblings. Journal of Emotional & Behavioral Disorders, 3, 2–12. Strain, P. S., Kohler, F. W., Storey, K., & Danko, C. D. (1994). Teaching preschoolers with autism to self-monitor their social interactions: An analysis of results in home and school settings. Journal of Emotional and Behavioral Disorders, 2(2), 78–88. Strain, P. S., & Schwartz, I. (2001). ABA and the development of meaningful social relations for young children with autism. Focus on Autism and Other Developmental Disabilities, 16(2), 120–128. Thiemann-Bourque, K., Brady, N. C., & Fleming, K. K. (2012). Symbolic play of preschoolers with severe communication impairments with autism and other developmental delays: More similarities than differences. Journal of Autism and Developmental Disorders, 42(5), 863–873. Thorp, D. M., Stahmer, A. C., & Schreibman, L. (1995). Effects of sociodramatic play training on children with autism. Journal of Autism and Developmental Disorders, 25(3), 265–282. Topál, J., Gergely, G., Miklósi, Á., Erdőhegyi, Á., & Csibra, G. (2008). Infants’ perseverative search errors are induced by pragmatic misinterpretation. Science, 321(5897), 1831–1834. Toth, K., Munson, J., Meltzoff, A. N., & Dawson, G. (2006). Early predictors of communication development in young children with autism spectrum disorder: Joint attention, imitation, and toy play. Journal of Autism and Developmental Disorders, 36(8), 993–1005. Vernon, T. W., Holden, A. N., Barrett, A. C., Bradshaw, J., Ko, J. A., McGarry, E. S., . . . German, T. C. (2019). A pilot randomized clinical trial of an enhanced pivotal response treatment approach for young children with autism: The prism model. Journal of Autism and Developmental Disorders, 1–16. https://doi.org/10.1007/s10803-019-03909-1

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13 Supporting Behavior, Self-Regulation, and Adaptive Skills Mendy B. Minjarez, Yvonne Bruinsma, and Rosy Matos Bucio

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ompared to their typically developing peers, individuals with autism spectrum disorder (ASD) have increased rates of challenging behaviors, including aggression, self-injury, noncompliance, and tantrums. Researchers generally agree that this occurs due to skill deficits (e.g., poor communication skills), sensory sensitivities, rigid behavior patterns, and lack of supports available in many settings where individuals with ASD work, learn, and play. Like their typically developing peers, individuals with ASD must learn to self-regulate their behavior and to engage in positive behaviors, such as staying on task and using skills appropriate to the setting. This chapter focuses on strategies for supporting appropriate and adaptive behaviors and skills, including self-regulation. It discusses both strategies for remediating skill deficits, with a focus on adaptive behavior and self-regulation skills, as well as environmental supports that can be used to reduce challenging behaviors and assist individuals with ASD in participating in a variety of activities. Positive behavior is a broad term and may vary by context; by age; and dependent on an individual’s family system, cultural values, life experiences, and background. In this chapter, positive behaviors are defined as those that are developmentally appropriate for the particular developmental stage the individual is in and that support improvements in functioning and quality of life and movement toward less restrictive settings. In contrast, challenging behaviors pose great risk to long-term well-being and quality of life and are cited as one of the primary reasons individuals with ASD fail to successfully participate in many community settings (Carr, 2011). Challenging behavior also is one of the leading causes of stress for families of individuals with ASD (Bristol, 1984; Koegel, Schreibman, et al., 1992; Lucyshyn, Dunlap, & Albin, 2002) and often leads to living in restrictive environments, potentially limiting quality of life. As such, a portion of the field of Applied Behavior 309

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Analysis (ABA) focuses on developing scientifically validated technological procedures for reducing challenging behavior in individuals with ASD and intellectual disabilities while also teaching functional, adaptive replacement skills. Systematic and direct instruction may be necessary for individuals with ASD to learn skills such as waiting, asking for a break when frustrated, politely taking turns, preparing a healthy meal, or living on a budget. All these skills must be practiced, shaped, and reinforced over time. Consistent with Naturalistic Developmental Behavioral Intervention (NDBI) models, strategies for shaping such skills must be practical, socially valid, and designed for implementation in the natural environment. Tools such as functional behavioral assessments (FBAs) are critical in determining the functions of behavior, identifying functionally equivalent replacement behaviors, and ultimately providing the information needed to construct comprehensive positive behavior support (PBS) plans. When supporting individuals with ASD struggling with challenging behavior, NDBI rely on the science of ABA, including PBS (Carr et al., 2002; Horner, Dunlap, Koegel, & Carr, 1990).

NDBI AND CHALLENGING BEHAVIOR Several NDBI discuss specific frameworks for addressing challenging behavior (e.g., Early Start Denver Model [ESDM], Pivotal Response Treatment [PRT]; however, PRT relies on the principles of ABA and PBS [e.g., Project ImPACT (Improving Parents as Communication Teachers)]). For example, ESDM uses a stepwise approach to addressing challenging behavior that relies on principles of ABA (Rogers & Dawson, 2010). These steps include the following: 1. Describe behavior and gather frequency data. 2. Collaborate with a behavior analyst to conduct an immediate functional assessment if the behaviors are unsafe (e.g., aggression, self-injury). 3. Seek the input of the primary care physician to rule out biological causes if the onset of behavior was sudden. 4. Continue to monitor behavior, including topography, function, and frequency while implementing the ESDM treatment plan if the behavior is not unsafe and it is unclear whether a behavior plan is needed. 5. When needed, develop a behavior plan based on functional assessment data, implement it along with the regular ESDM treatment plan, take data on progress, and monitor closely for 8–12 weeks. 6. After 8–12 weeks, if the behavior plan has not been effective, consult with a behavior analyst. Project ImPACT notes that if the clinician has appropriate skills for assessing and intervening with challenging behavior (i.e., background in ABA), parent training can focus on reducing challenging behavior before moving into more specific training in the Project ImPACT model. Clinicians who do not have this skill set should work with colleagues with ABA expertise (Ingersoll & Dvortcsak, 2010). ESDM also notes that children with challenging behaviors tend to recruit decreasing positive attention from adults over time, making it important to provide noncontingent positive attention to these children during activities in which the

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probability of problem behavior is low. This strategy is consistent with the general notion, shared by many NDBI, that positive affect and interactions are an important component of intervention. In PRT, principles such as functional assessment, antecedent interventions, self-management, and multicomponent treatment packages are used to reduce challenging behaviors (Koegel, Koegel, Boettcher, Harrower, & Openden, 2006; Koegel, Koegel, Hurley & Frea, 1992), and self-management, transfer stimuli, and competing reinforcement are used to reduce interfering behaviors, such as stereotypy and restricted interests (Koegel, Talebi, & Koegel, 2006). ESDM also uses teaching functionally similar replacement behaviors to reduce stereotypy (e.g., teach appropriate object play with objects the child uses repetitively) and use of children’s restricted interests and repetitive behaviors as reinforcement for engaging in periods free of such behavior (Rogers & Dawson, 2010). These strategies are consistent with the broader ABA literature, which has demonstrated that use of stereotyped or repetitive behavior as reinforcement enhances learning and does not lead to increases in this behavior (Charlop, Kurtz, & Casey, 1990; Charlop-Christy & Haymes, 1998). Some NDBI models, such as Joint Attention, Symbolic Play, Engagement, and Regulation (JASPER), also rely on additional strategies for targeting self-regulation, such as adult matching and modeling of appropriate affect. Strategies that are consistent with most NDBI that can be used to target challenging behaviors are outlined next.

RELEVANT APPLIED BEHAVIOR ANALYSIS INTERVENTIONS A number of general ABA principles apply when addressing challenging behaviors using an NDBI framework. Behavior should be addressed systematically using principles of functional assessment with an emphasis on prevention (antecedent interventions) and teaching functional replacement behaviors. Interventions for challenging behavior should also incorporate principles that are emphasized in PBS, including focusing on inclusion, providing environmental supports to decrease challenging behavior, and teaching functional skills to enhance quality of life. That is, sometimes it is as much about the setting’s lack of readiness to meet the needs of an individual with ASD as it is about that individual needing to gain skills to function in the setting. Functional Approach to Challenging Behavior Most NDBI embrace a functional approach to challenging behavior, which relies on the notion that all behavior serves a communicative function. Identification of function then leads to treatment planning, which includes strategies for teaching functionally equivalent replacement behaviors. There are a number of approaches for assessing behavior to determine function, including functional assessment (Durand, 1990; Matson & Minshawi, 2007; Matson & Nebel-Schwalm, 2007) and functional analysis (Hanley, Iwata, & McCord, 2003). Functional assessment, typically done through observation of behavior and data collection on the antecedentbehavior-consequence (A-B-C) sequence or by interviews, such as the Functional Analysis Interview Form (O’Neill, Horner, Albin, Storey, & Sprague, 1990), are more commonly used in NDBI than is functional analysis. Functional assessment procedures rely on observation of behavior in the natural environment or interviews about naturally occurring antecedents and contingencies; this approach is more

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consistent with NDBI principles than functional analysis procedures, which often take place in clinic settings using highly structured procedures. More recently, however, procedures have been developed for conducting functional analyses in the natural environment (e.g., trial-based or classroom-based functional analysis) (Bloom, Iwata, Fritz, Roscoe, & Carreau, 2011; Larkin, Hawkins, & Collins, 2016), which may also be used in conjunction with NDBI procedures. The functional approach is recommended because research supports that intervention plans based on behavioral function are more effective than those that are not. Important information that can be derived from the functional assessment process may include 1) information about antecedents that lead to challenging behavior or increase the probability of occurrence, 2) information about maintaining consequences that may need to be altered, 3) information about skill deficits that may lead to selecting replacement behaviors to be taught, and 4) information about environmental variables that may affect the probability of behavior (e.g., setting, time of day, presence of certain individuals who are preferred or nonpreferred). Because most behavior typically serves either an “obtain” (e.g., to obtain attention or tangible objects) or “avoid” (e.g., to avoid demands or aversive sensory input) function, which are the opposite of one another, understanding function prior to designing interventions is considered key in ABA. Prevention of Challenging Behavior (Antecedent Interventions) It has often been written that the most effective time to address challenging behaviors is when they are not occurring, meaning prevention is key (Bambara & Kern, 2005; Schwartz, Ashmin, McBride, Scott, & Sandall, 2017). Those who work with individuals with ASD (e.g., parents, teachers, therapists) can often prevent challenging behaviors by arranging the environment to support and teach behaviors that increase participation, self-regulation, and successful demonstration of skills and give individuals increased control (Schwartz et al., 2017). Antecedent interventions can be blended with most NDBI interventions (because they are focused on strategies for supporting individuals in the natural environment); are often essentially prompts that can be faded over time; and often incorporate use of choice, sharing control, and following the child’s lead. Antecedent interventions used for optimizing learning opportunities are also discussed in detail in Chapter 7. Universal Antecedent Interventions Antecedent interventions can take many forms, and some could be considered universal best practice for supporting all children’s successful participation in their daily routines and age-appropriate settings (e.g., educational, child care, community). Universal antecedent strategies perhaps lend themselves the best to use in conjunction with NDBI because they can be implemented routinely in the natural environment for all children and do not require specialized supports for one individual. Schwartz and colleagues have published extensively on this topic (e.g., Sandall et al., 2019; Schwartz et al., 2017). Although these resources are geared toward the classroom setting, they can be easily adapted to any natural environment; thus, the reader may find them useful for pairing with NDBI strategies in addressing challenging behavior. Some examples of universal antecedent strategies include 1) following a consistent daily routine, 2) setting clear behavioral expectations and rules, 3) focusing on positive adult–child interactions (e.g., as mentioned with regard to the ESDM approach to challenging behavior),

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4) embedding strategies for consistent contingent reinforcement of appropriate child behaviors (e.g., reinforcement systems as well as incidental reinforcement, such as “catching them being good”), 5) designing the physical setting to support positive behavior and discourage challenging behavior (e.g., avoid long pathways that facilitate elopement or furniture clusters that promote children chasing each other in circles), and 6) providing opportunities for children to make choices (e.g., designing the setting or the schedule so that the child can easily make choices about materials to be used or the order in which to complete tasks). Individualized Antecedent Interventions Even with universal antecedent interventions in place, some children may experience behavioral challenges, in which case individualized prevention strategies are helpful. These strategies can take a number of different forms (see Box 13.1), such as the use of priming, visual cues, environmental and physical strategies, and removal or avoidance of stimuli that increase the probability of challenging behavior (e.g., an activity that leads to repetitive behavior or an object that leads to challenging behavior when access is denied). Many of these can be effectively incorporated with NDBI because they focus on altering the natural environment to better support the child. Because antecedent interventions need to be individualized for the child, the challenging behaviors, and the setting, they can take many different forms and are often combined to increase the probability that behavior is prevented. Antecedent interventions are most useful when based on functional assessment and may include some of the following examples. Priming Used just prior to when a skill is required or when the probability of a challenging behavior is increased, priming is defined as any strategy that is a preview designed to prepare the child for the expectation or help the child understand what is coming next. Priming can take many different forms. For example, it can include reminders about appropriate skills to use (e.g., remember to find a friend to play with at recess) or a verbal review of expectations (e.g., at school you are expected to sit quietly). Priming can also incorporate visual cues, such as reviewing a visual

Ready, Set, Implement! BOX 13.1: Antecedent interventions Antecedent interventions are any strategy designed to prevent challenging behavior, including the following: • Visual cues • Warnings for transitions • Priming for expected behaviors • Placement or removal of objects associated with behavior • Placement of adults in proximity to child • Pairing preferred with nonpreferred activities to increase compliance or participation

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schedule or Social Story for appropriate behavior in the store prior to shopping. Warnings, whether visual or verbal, are also common priming strategies (e.g., for transitions, changes in routine, or removal of preferred objects). “Start” directions, meaning directions that tell the child what to do, as opposed to what the child should stop doing, can be a useful priming strategy to promote expected behaviors (e.g., a teacher might say, “Remember your walking feet,” “Here is the ball,” “Let’s share with our friends,” or “It’s time for lunch; let’s sit while we eat”). Visual Cues Although there are many forms of priming, visual cues are commonly used and can take many forms. Visual schedules can be used to review daily routines (e.g., the steps in the morning routine) and schedules (e.g., the periods in the school day), as well as more extended schedules (e.g., events across the week). Common schedules may include the school day routine, the therapy schedule, when the child will see certain people or family members, Mom’s house or Dad’s house for two-household families, or a calendar countdown to a preferred activity (e.g., trip to the amusement park, vacation). Another form of visual schedule depicts the steps in completing a skill or single routine (e.g., getting dressed, going to the bathroom, steps in an employment task). These schedules are often developed in conjunction with task analysis procedures and are used to support skill development and compliance. Visual cues are also often used to prepare individuals for transitions, such as a cue depicting one more minute, time to clean up, or what activity is coming next. Although extensively detailing types of visual cues is outside the scope of this chapter, there are several resources available about the many ways in which visual cues can be developed and used (e.g., Hodgdon, 2016, 2017). When using visual cues in the capacity described here, consider how they fit with the NDBI strategies being used, how effectively they can be embedded across natural environments, and whether they are being used in conjunction with other strategies (e.g., teaching replacement behaviors) so that they can eventually be faded. Environmental and Physical Strategies It is often useful to consider how characteristics in the physical environment may be associated with increased risk for challenging behavior. For example, are preferred objects in view during times when they cannot be accessed? Are there clear cues for which activities are available versus not available (i.e., choice/not a choice)? Does the child need a visual indication of where to sit or stand in line? Are objects available that lead to repetitive behaviors? Is the space large and open so that it promotes running back and forth and crashing against the walls in a self-injurious manner? Careful consideration of how the physical environment may be contributing to challenging behavior may be useful when developing individualized antecedent interventions. Visual cues may also be combined with environmental and physical strategies, for example, placing preferred objects into a bin that is clearly marked “all done” when they are no longer a choice. Although there may be endless environmental or physical antecedent interventions that are useful, common ones include the following: 1. Cues for where to sit or stand (e.g., a line on the floor at the door where children should line up, dots on the floor for each child during circle time, a special chair at the dinner table to indicate where to sit, a picture of the child in their expected location)

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2. Cues for whether objects are available or not (e.g., bins with clear visual cues that depict whether objects are a “choice” or “not a choice,” “all done” bins or locations, for example, placing the iPad or cell phone on a specific shelf at home when it is not a choice) 3. Removal of objects that are all done, not a choice, or do not promote functional behavior (e.g., objects that promote self-stimulatory behavior) 4. Use of furniture and organization systems that automatically restrict access to preferred objects when they are not available (e.g., shelving that can close when it is time to go to bed or come to the table in a classroom, use of bins with lids) 5. Partitions, furniture arrangements, or assignment of a child to a certain part of the room or area of the house that works well for that child (e.g., arrange shelving to create smaller spaces, limit open spaces for individuals with significant hyperactivity, place the child’s bedroom away from the noisiest part of the house) 6. Strategic placement of reinforcement to encourage desired or expected behaviors (e.g., a rule that snacks must stay at the table to promote eating at the table, preferred items at circle time to promote remaining present) Replacement Behaviors Although antecedent interventions are designed to prevent challenging behavior, the functional approach to behavior necessitates teaching functionally equivalent replacement behaviors that allow the individual with ASD to have his or her needs met in more adaptive ways. Understanding the communicative function of the behavior allows clinicians to select replacement behaviors that serve the same function. Although teaching skills that serve other functions may be useful to the individual, these new skills are unlikely to assist with a reduction in challenging behavior unless they serve the same function. Replacement behaviors can be selected from a range of skills that serve the same function as the challenging behavior. Because social-communication challenges are a core feature in ASD, replacement behaviors will often fall into this category. Skills for requesting objects, gaining attention, initiating and sustaining social interactions, appropriate refusing and protesting, requesting breaks, and gaining access to help are common social-communication replacement behaviors. Chapters 11 and 12 discuss teaching communication and social skills. Additional replacement behaviors, such as self-regulation behaviors and adaptive skills, are addressed next. Selecting Efficient Replacement Behaviors There are several key factors to consider when selecting replacement behaviors, such as response match, efficiency, acceptability, and recognizability (Durand, 2012; see Box 13.2). First, as stated, when considering response match, the new skill must serve the same function as the challenging behavior (e.g., teaching appropriate skills for gaining attention or social initiation if challenging behavior is to gain attention from peers; teaching requesting objects, tolerating delayed access to reinforcement, and tolerating removal of preferred objects if behavior is for access to preferred items). The new skill must also be as or more efficient as the challenging behavior. That is, the new skill

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Ready, Set, Implement! BOX 13.2: Replacement behaviors Replacement behaviors must • Serve the same function as the challenging behavior (response match) • Work as well or better than the disruptive behavior in gaining access to reinforcement (efficiency) • Be recognizable to a range of individuals across settings • Be acceptable and functional for the context or setting • Be generalizable across appropriate individuals, settings, and so forth • Be socially valid for the individual, context, family, setting, and so forth

must result in natural reinforcement and should be associated with low response effort. Because new behaviors are often not associated with low response effort by definition, the child may need to initially be taught the behavior explicitly and reinforced systematically to build mastery. Such behaviors should be taught outside the context in which challenging behavior occurs. Once mastery is achieved, generalization of these behaviors can be systematically reinforced, until, finally, the child can be prompted to use the behavior in the actual context in which the challenging behavior previously occurred. Consider the simple example of a child who does not have a communication skill to request objects and instead uses whining and crying to get something out of reach. Pointing to objects could first be taught during one-on-one interactions with a therapist in which preferred objects are used to enhance motivation to request and physical prompts are used to evoke pointing behavior. At the same time, parents, teachers, and therapists can use prompts to help the child point to the desired item as soon as the child notices he or she wants it (before the crying) and reward that behavior quickly. Once this skill is mastered, more opportunities can be provided throughout naturally occurring routines (e.g., meals, play in the home setting), and prompts can be reduced in all settings. Again, at first the point needs to be rewarded in all environments as quickly as possible; otherwise, the child will go back to crying because it works quicker. Once the pointing is clearly established, the child can learn to wait, be told “not right now,” and so forth. Selecting Functional, Generalizable, Socially Valid Replacement Behaviors The new skill or replacement behavior should also be functional across settings and easy to recognize. All settings in which the child must function should be considered when selecting replacement behaviors. A behavior that is functional in one setting but not another may hinder generalization of reductions in challenging behavior. For example, teaching a child to use a communication device that is only available in the therapy setting but not the home setting has limited utility. Replacement behaviors should also be socially valid from the perspective of the child and relevant stakeholders, meaning it should be functional but also acceptable. For example, if a parent is focused on the child learning a communication skill that

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does not require keeping track of any materials or augmentative and alternative communication (AAC) devices, it may be more useful to teach pointing, reaching, or gesturing than use of picture cards or a device. Finally, replacement behaviors must be as universally recognizable as possible so they are functional no matter who the communication partner is. Teaching skills that are not easy for others to recognize may limit their effectiveness and may limit opportunities for movement toward less restricted environments and inclusion. For example, teaching a child to use a picture communication system may be more effective than teaching signs to communicate because pictures are universally recognizable, whereas signs may not be. If the new skill is too hard, does not result in reinforcement, is difficult to generalize across settings, or is not recognizable to everyone who interacts with the child, it is not likely to take the place of the challenging behavior because the behavior will still be more effective. Using Task Analysis Procedures Some replacement behaviors, particularly adaptive skills, are actually complex chains of behaviors that may need to be broken down for teaching. The field of ABA has developed helpful tools, such as task analysis, for teaching these complex behaviors. A task analysis helps break down complex behaviors or skills into smaller, more manageable steps. The process of the task analysis also provides an opportunity for identifying where chaining and shaping can be used during skill building. The information gathered from the task analysis can then be used to systematically teach each new adaptive skill step by step. When using task analysis, modeling the skill is often the first step before providing the individual with ASD with the opportunity to practice. With each step, assistance (prompting) should be provided when necessary and then faded, instead of allowing the individual to struggle or make mistakes. Consequence Strategies Examination of maintaining consequences is an essential part of any functional assessment procedure. Functional assessment results may indicate that it is necessary to alter consequences to attain reductions in challenging behavior. However, consequence strategies alone are not likely to lead to long-lasting behavior changes and should be used in conjunction with a comprehensive positive support behavior plan, including antecedent strategies and plans for teaching replacement behaviors. Consequence interventions in NDBI are outlined in Chapter 9 and are briefly discussed here in relation to challenging behaviors. Consequences should be examined to determine whether challenging behaviors are being inadvertently reinforced, in which case this contingency will need to be altered. Furthermore, appropriate replacement behaviors may not be present or consistently reinforced, especially if the child’s skill deficits result in productions of appropriate behavior that are impaired or approximations. If these challenges are present, consequences will need to be altered so that challenging behavior is not reinforced and appropriate replacement behaviors are. Several ABA principles apply here. Reinforcement of Replacement Behaviors As discussed previously, replacement behaviors will not be effective unless they are reinforced. Ensuring they are functional, generalizable, and socially valid will increase the likelihood of reinforcement for these behaviors across settings. The NDBI principle of natural

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reinforcement almost always applies when teaching replacement behaviors because these behaviors are selected to be functional and result in reinforcement in the natural environment. Many NDBI also incorporate reinforcement of reasonable behavioral attempts, which is especially relevant when teaching replacement behaviors. Because children may have difficulty producing appropriate behaviors when upset or frustrated, accepting and reinforcing any approximation of the replacement behavior can be a useful strategy for building motivation and skills over time. Extinction Extinction is defined as the removal of previously available reinforcement, resulting in a decrease in probability of the occurrence of the behavior. Extinction is often used when reinforcement was inadvertently being applied to negative behaviors. For example, consider the case of a child who always screams when his or her mother is cooking dinner. The behavior is reinforced when the mother leaves the kitchen to provide the child with attention, snacks, and activities to try and keep him or her busy while she finishes cooking. When this behavior is placed on extinction, the child’s mother will no longer leave the kitchen and will ignore the child while he or she continues screaming. Those who have used this intervention before will be familiar with the concept of the extinction burst, the classic initial and temporary sharp increase in behavior under these circumstances before learning occurs and the behavior decreases (discussed further in Chapter 8). Because some behaviors are difficult to place on extinction (e.g., those that are unsafe) and this intervention may not be suitable in all settings (e.g., public places, such as the grocery store), extinction is frequently used in conjunction with antecedent interventions to prevent the behavior as well as replacement behaviors that can be proactively prompted in an additional effort to prevent the behavior. Self-Management Individuals with ASD may demonstrate skills in a certain set of circumstances but not in another or may struggle to use skills across communicative partners. For instance, a child may struggle with social initiations in the classroom but not on the playground at recess; another child may carry a conversation with adults but struggle to converse with peers. Furthermore, individuals may struggle with skill initiation or fluency, leading to skills that are acquired but not well generalized. Self-management, defined as monitoring one’s own target behavior production, data collection, and recruitment of reinforcement, is a valuable, evidence-based tool that can be useful in addressing these performance issues. Teaching an individual to take charge of his or her own behavior may also lead to empowerment, thus decreasing dependence on adults (Lee, Simpson, & Shogren, 2007). Research supports the use of self-management to increase or decrease a range of skills for students of all ages and most skill levels (National Autism Center, 2015). A comprehensive overview and in-depth discussion of this literature is not provided here but is available in three literature reviews (Aljadeff-Abergel et al., 2015; Lee, Simpson, & Shogren, 2007; Southall & Gast, 2011) and in the National Standards Project, Phase 2 report (National Autism Center, 2015). For children who are accustomed to adult-implemented token reward systems, self-management is often an easy adjustment, with the main difference being teaching the child to independently monitor his or her own behavior. For children who are still learning

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Ready, Set, Implement! BOX 13.3: Self-management steps • • • • • • • •

Identify the behavior Develop a measurement strategy Select reinforcement Implement discrimination training Practice the target behavior Learn to record the target behavior and recruit reinforcement Make the transition from training to self-managing behaviors Generalize self-management

to count or learning how to wait for reinforcement, it is often helpful to start with a simple target behavior (e.g., a behavior the child can already perform). The measurement system can also be simplified to help the child learn how self-management works. For example, the child might earn reinforcement after just two or three successful instances of a simple behavior. Often stickers or small tokens (e.g., balls, marbles, pennies) can be more motivating and concrete for young children just learning self-management. Bingo stampers or dot art markers can be a good substitute for children with minimal writing skills or children who are averse to writing instruments. There are a number of steps in teaching self-management that are briefly reviewed in the sections that follow (see Box 13.3). Correct implementation of self-management procedures is relatively easy if the planning stages have been completed carefully. Identify the Behavior The first step in teaching self-management is to identify what behavior will be targeted for decrease or increase and then describe it in as much detail as possible. The level of detail is important for data collection but even more important to ensure the person with ASD can learn exactly what behavior is being targeted during discrimination training. It is best to target a positive behavior rather than describe the challenging behavior to be decreased (e.g., “safe hands” versus “no hitting”). During initial discrimination training, the adult must explain the target behavior to the child with ASD; it is helpful if the name is child friendly and short (e.g., “taking turns with friends,” “staying on topic,” “being flexible”). No matter what behavior is selected, the adult should collect baseline data to establish the current level of performance. The adult can then set goals just slightly above the baseline level to ensure initial success. Develop a Measurement Strategy Once the behavior has been identified, the adult must develop a plan for measuring it. This plan should address if measurement will be based on the presence or the absence of the target skills (e.g., intervals without hitting, intervals with peer interaction). Counting positive behavior is often more effective. Both frequency and duration data can be appropriate, depending

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on the behavior being measured. For example, is it a frequency count of how many times the child initiated to a peer during recess or an interval recording where the student is marking on-task behavior every 5 minutes? A variety of options are available for behaviors counted as a frequency. The student can simply make a mark on paper with a pencil, a dot art marker, or a marker. Or the student can cross out a picture showing a thumbs-up or a star. However, because frequency counting needs to take place in the natural environment (e.g., in social settings), a number of other unobtrusive solutions may be a better match, including commercially available counters, bracelets and rubber bands that are moved from one wrist to the other, or electronic solutions on tablets and phones. Target behaviors counted in duration can be measured by clocks or timers (e.g., wristwatch, phone, tablet, kitchen). Special gadgets are also available that can be set for a certain interval and carried in a pocket to alert the student that an interval has passed (e.g., MotivAider). For some children, it can be helpful if the measurement system includes visual reminders of the target behavior. For example, the system might include a picture card to represent “brain working” or “safe hands.” Select Reinforcement Once the behavior is defined and the measurement method is selected, the adult should designate what the child will earn for engaging in the identified target behaviors. Although NDBI place high value on the use of natural reinforcement, self-management systems usually require artificial reinforcers in the beginning of the program. Nevertheless, from the beginning, a plan should be in place to transfer reinforcement from artificial to natural as the child gains skills. For example, when increasing social initiations on the playground, having more friends to play with during recess may eventually serve as reinforcement. As with any reinforcer, it must be defined by the individual; however, it is also important to assess feasibility (e.g., it is not feasible to give large reinforcers when first teaching self-management because many trials will be required). Every time reinforcement is delivered, it should be paired with behavior-specific praise (e.g., “Great job being flexible!”). Implement Discrimination Training Once the preparation is completed, discrimination training can begin. In this phase, the main objective is to teach the individual what the target behavior is and what it is not. The quality of the descriptions completed in the behavior definition phase will help to determine how easily the child will understand the nuances of the target behavior. When beginning discrimination training and introducing the target behavior, it may be appropriate to briefly explain the importance of the behavior (e.g., being flexible is important because sometimes other people like to be the ones who get to make decisions). The next step in discrimination training is to model the correct target behavior, which is most often done in person but can also be done through video modeling. Modeling should begin with explicit and obvious models to increase the likelihood of correct responding and can then fade to more subtle models. The child with ASD will then be asked to identify the behavior in the model before learning to identify it in him- or herself. If the child provides the correct response, the adult should immediately provide reinforcement with behavior-specific social praise. If the child incorrectly identifies the behavior, the adult should explain why this is incorrect and try again, but the adult should make sure to reinforce with social praise for trying. If the child has multiple errors in a row, the discrimination training

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may need to be terminated and evaluated. Once the child has responded correctly across several trials, then it is time to introduce the incorrect target behavior using the same discrimination training strategies. Identification of correct and incorrect responses should be practiced until the child is at least 80% accurate or has met other specified mastery criteria. Practice the Target Behavior Once the child reliably identifies the correct and incorrect target behavior in others, it is important for him or her to practice giving correct and incorrect responses. If the child does not want to engage in incorrect responding (e.g., being off task if the target behavior is staying on task) or if this is not appropriate (e.g., in the case of aggression), the adult can just wait until the incorrect response occurs naturally and then ask the child to self-evaluate. After each occurrence of behavior, the child should be prompted to evaluate his or her performance. All correct identifications of the child’s own behavior should be reinforced. When practicing the target behavior, the goal should be set at an attainable level because the child is learning a new skill. For example, if teaching staying on task, the child should be expected to stay on task for a short period (e.g., 30–60 seconds) initially in order to earn immediate reinforcement. The child should also receive reinforcement for all attempts at the target behavior at this stage because he or she is just learning a new skill. The goal at this stage is not to increase the rates of behavior but rather to teach the system, which will sustain long-term performance change. Learn to Record the Target Behavior Once the child can correctly identify the target behavior for at least 80% of all trials, measurement can be introduced as the next step. The child must be taught to use the measurement system. Many children find it exciting to take data for themselves; they may enjoy having a special pencil or a bingo stamper in their favorite color. At first, the child can receive reinforcement for providing the correct response and recording the response correctly. The first few times, the child may need prompting to record the correct response. It is helpful to fade these prompts very quickly to ensure that the individual becomes independent in his or her measurement. Once the child can independently identify and record correctly at least 80% of trials, he or she is generally ready to begin self-management. While the child is learning to discriminate and accurately record behavior, reinforcement should be frequent because the child is learning a new skill. Fading of reinforcement should not begin until after self-management has actually begun and the child is consistently providing correct responses and correctly measuring the target behavior without prompting. Although the adult is likely still controlling access to reinforcement during this phase, the child must be actively evaluating whether he or she has met the goal in order to learn self-recruitment of reinforcement. Make the Transition From Training to Self-Managing Behaviors Once the child has learned to discriminate and accurately record behaviors, he or she can begin to self-manage. First, the child will practice self-management with monitoring from an adult to allow prompting as needed. Prompting initially may be required both for correct production and discrimination of the behavior as well as for correct recording. Once the child is at or above 80% accuracy, prompting

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can be faded. The goal is to fade prompting to the point that an adult can check in with the child at certain points during a specified time period to review the selfmonitoring. If the child will earn reinforcement multiple times per session or day, it may be necessary to teach him or her to notify an adult when reinforcement has been earned, rather than waiting for a designated check-in time. Children can also be taught to access reinforcement independently. The amount of control transitioned will depend greatly on the child’s cognitive abilities, the child’s self-control, and the setting in which the behavior is ultimately going to be self-managed. When increasing independence with self-management, it is important to note that the child’s accuracy of discrimination and recording does not have to be perfect. When children are above 80% accuracy, their behavioral change is typically comparable to those with higher accuracy. As such, those who are teaching self-management to individuals with ASD can be comfortable reinforcing attempts as long as they meet this threshold. Generalize Self-Management Many behaviors taught with self-management will ultimately have to be generalized to other settings or social partners. Other providers and staff should be made aware of the treatment plan so that they can provide initial encouragement to use the skill. Also, the tracking system should be feasible and socially valid across settings. Once the child is able to use the selfmanagement system on his or her own, adult support can be faded. It is often still helpful to have the adult check in periodically to make sure the self-management system is being used appropriately. For instance, an adult can occasionally rate the child’s behavior and compare to the child’s ratings to check for accuracy. The child can even earn extra points for accurate ratings. However, as noted previously, 100% accuracy in recording is not necessary for the child to demonstrate general improvement in the target skill. If the child is able to do the skill without selfmanagement, it may be time to take the self-management system away. Often children forget to use the system but continue to show the target skill, which is a sign that the intervention has worked and the self-management system can be faded.

NDBI STRATEGIES FOR TEACHING SELF-REGULATION AND ADAPTIVE SKILLS Many behaviors may be appropriate to teach as replacement behaviors when intervening on challenging behaviors. Clinicians should consider many of the social and communication strategies discussed elsewhere in this book when developing behavior plans that include replacement behaviors. Although the range of possible replacement behaviors is broad, two other common areas to address include selfregulation and adaptive skills. This section addresses NDBI strategies for teaching these skills, and subsequent sections discuss examples of skills that may be useful to teach in each domain. Provide Clear Cues and Prompts As with any behavior, clear cues and prompts are used when teaching selfregulation and adaptive skills. Because many of these skills can be abstract (e.g., having good hygiene, being flexible), it can be helpful to give them concrete names

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to ensure that cues for the behavior are clear. For example, being flexible could be called “doing things differently” or “staying cool when things change,” and hygiene behaviors could be called “having a clean body.” Because many of the behaviors discussed in this chapter are either complex behaviors or chains of behavior, adults should carefully consider the use of prompts in teaching. It is likely to take time and patience to teach many of these behaviors, and adult prompts may be necessary for quite some time to ensure success. As a result, adults should systematically address the need for prompt fading to ensure these adult prompts do not become habit and to increase independence over time. Provide Modeling Modeling is often helpful when teaching self-regulation and adaptive skills and can take many forms. As discussed previously, modeling is a key step in discrimination training when teaching self-management. In this type of modeling intervention, the skills are modeled purposely and often out of context to teach an individual to identify correct and incorrect behavior. Similar modeling can be used when teaching self-regulation skills, such as waiting calmly or staying on task. Modeling can also be incidental, such as modeling self-talk during unexpected events for a child with flexibility goals (e.g., “I wasn’t expecting the stickers to be gone, but I can make another choice”). Video modeling is also commonly used to teach adaptive and other skills (Bellini & Akullian, 2007; Charlop-Christy, Le, & Freeman, 2000; Keen, Brannagan, & Cuskelly, 2007; Shipley-Benamou, Lutzker, & Taubman, 2002). Incorporate Child-Selected Materials and Choices When possible, it can be useful to incorporate child-preferred materials when teaching self-regulation and adaptive skills. When teaching adaptive skills, adults may find it difficult to incorporate natural reinforcement for some behaviors (e.g., toilet training, brushing teeth), but with a little creativity, they can build in childselected materials and choices. One way to accomplish this is to incorporate a child’s interests even if those interests cannot serve as the natural reinforcer. For example, the child might select a toothbrush that looks or feels a certain way or shampoo that smells a certain way. For toilet training, the child might select stickers with his or her favorite character on them. The adult may place pictures of the child’s favorite characters, books, toys, or shows in the area where the skill will be taught (e.g., on the bathroom door, on the dresser when targeting dressing). Another way to build in child preference is to teach adaptive skills within routines where desired activities naturally follow the skill being targeted. For example, teeth-brushing could be followed by reading the child’s favorite bedtime book, or getting dressed can be followed by going outside to play. The proximity of these events within the child’s routine can lead to a broader form of natural reinforcement. When teaching self-regulation, adults may find it easier to incorporate the child’s preferred activities in a way that is consistent with NDBI practices. For example, when teaching flexibility, adults can create opportunities to practice the associated skills during a preferred activity (e.g., interrupting or blocking the child’s play) and then provide access to the activity as reinforcement. Many target behaviors in the area of flexibility are outlined next, with examples of how to teach each within child-selected activities.

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Use Natural Reinforcement Following from the previous discussion of child-selected materials and choices, reinforcement for self-regulation and adaptive skills should be natural and directly connected to the behavior when possible. Some adaptive skills are easier than others to accomplish this. For example, it is easy to build natural reinforcement into teaching money skills because the individual with ASD can purchase a desired item or activity (even if it’s through role-playing at home). Finding the natural reinforcement for making a bed might be trickier because a tidy room may not be a strong natural reinforcer. In these cases, the strategies discussed for incorporating child-selected materials or embedding the skill in routines in which preferred activities follow may be useful. For example, adults could use visual cues for bed making on an iPad, followed by access to the iPad for a specified period of time. If natural reinforcement is difficult for a specific adaptive skill, self-management (discussed previously) may also be useful. Although natural reinforcement is ideal, reinforcement in some form is essential! Reinforce Attempts Many self-regulation and adaptive skills are complex skills or combinations of skills; therefore, significant time and practice may be required to gain mastery and build fluency of these skills. As such, use of reinforcing attempts and shaping may be useful because reinforcing successive approximations of skills is an excellent strategy for both facilitating skill building and enhancing motivation. This strategy may be particularly important in terms of motivation because the individual with ASD is likely to become frustrated if required to practice a difficult skill for long periods of time without reinforcement. Consider the child who is just learning how to wait. Waiting nicely may need to be shaped over time so that the child initially receives reinforcement for waiting for a brief period, even if he or she is not quiet or is displaying negative affect without engaging in more severe challenging behavior (e.g., aggression). If the expectations are set to high from the beginning, the child may never have a chance to begin learning the contingency. Provide Prompt Fading As with most skills, prompt fading is essential in teaching self-regulation and adaptive skills because these skills are most useful when used flexibly and independently in the natural environment. Self-regulation skills can be challenging to teach because they are often required under frustrating circumstances, and adaptive skills can be challenging because they often require sequences of multiple behaviors (e.g., getting dressed, using the bathroom, taking the bus). Given these challenges, prompt fading many need to be carefully planned to ensure skills are maintained and generalize. In addition to typical prompt-fading strategies, selfmanagement strategies may be helpful in building independence. Furthermore, it may be useful to consider prompts that are not delivered by another person, such as visual cues (e.g., task analysis for making lunch), lists (e.g., a permanent grocery shopping list that is kept on the individual’s phone), and calendars. Some of these prompts may not even need to be faded because they are consistent with strategies that are used by many individuals to organize their lives (e.g., calendars, lists, planners).

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Technology can be another helpful tool in prompt fading. For example, calendars can be set up with daily and weekly reminders or alarms for specific adaptive skills. These strategies can be particularly useful with adolescents and adults who may be resistant to adult prompts. It is also important to consider that adult prompts may set individuals apart from others their age and create stigma, although use of an electronic device is a completely acceptable behavior. There are countless apps for chores, homework organizers, reminders, cooking, and budgeting. Given the popularity of videos, older children, teens, or adults can work with family members and staff to create video models of specific adaptive skills that can be saved onto their smartphones or tablets and used for priming or referencing at any point. Although technology is definitely a motivator and advantageous teaching tool, monitoring its use is also important. Consider Adult Affect Several NDBI have increased focus on the role of adult affect in intervention. For example, ESDM and JASPER focus on both matching the child’s affect, when appropriate, and modeling appropriate affect when trying to help the child regulate. As such, the role of adult affect should be considered when addressing challenging behaviors and teaching skills such as self-regulation and adaptive functioning. Several affective strategies may be useful, including matching, modeling, and use of positive affect to enhance motivation and engagement. Matching affect is most appropriate when the child is demonstrating appropriate affect that the adult wishes to reinforce or sustain. For example, if a child is calmly practicing independent work, verbal praise in a low but positive tone of voice would be more appropriate than using a high-affect energetic voice. Likewise, if a child is attempting to calm down during a tantrum, using a lower and slower voice to provide verbal prompts or direction would be more appropriate than an excited voice or a stern voice. Modeling affect is appropriate when the adult is trying to promote changes in the child’s affect. For example, if a child is becoming frustrated with having to be flexible and is beginning to escalate, it would be most appropriate to model calm affect even when acknowledging the child’s frustration. Finally, the adult may wish to use a high level of positive affect in order to increase motivation and engagement. For example, if a child is low energy and is becoming bored, which might be an antecedent for challenging behavior, the adult may want to use a high level of positive affect to energize and engage the child. Or in a really high-energy game, if a child becomes overly excited, which may be an antecedent for aggression, the adult may want to slow down and become calmer. Use of varied affect to enhance interactions is a general strategy that is incorporated into most NDBI. Embed Practice in Daily Routines As discussed, self-regulation and adaptive behaviors can be complicated to teach and may require direct instruction. When possible, embedding this instruction into daily routines and the natural environment is ideal, although these may need to be taught outside of daily routines before being generalized. When behaviors are taught within daily routines, it is important to remember that they may be time consuming to execute until they can be emitted fluently. For example, when targeting

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self-advocacy behaviors (e.g., saying “that’s mine”), adult coaching may be required for the child to engage in the skill, which may be frustrating because the coaching will cause this interaction to take longer, delaying reinforcement. Likewise, when targeting adaptive skills, behaviors may be emitted quite slowly, especially when they are actually chains of behavior. For example, making a sandwich or counting money will take much longer when these skills are not fluid. As a result, it is important to consider what preteaching might be necessary before moving into the natural environment and/or to proactively plan when skills will be targeted to ensure there is time to do so. Teaching breakfast making may be better targeted on a weekend than a busy weekday morning.

PROMOTING SELF-REGULATION IN INDIVIDUALS WITH ASD In the simplest of terms, self-regulation refers to the ability to direct and manage behavioral as well as emotional responses to the environment (Bronson, 2000). Selfregulation is a skill set that includes a number of different subskills, such as being able to calm down when something upsetting has happened; being flexible; and tolerating disappointment, frustration, and delayed reinforcement (Arain et al., 2013). Children and individuals who struggle with self-regulation are more likely to demonstrate challenging behaviors, such as aggression (Raaijmakers et al., 2008), and tend to experience more anxiety and depression (Martel et al., 2007). Self-regulation is necessary in all contexts, including school, and researchers have found that students who have more advanced self-regulation skills develop better academically (McClelland & Wanless, 2012). Children at all ages and abilities, including children with ASD, may benefit from instruction in this developmental domain (Bronson, 2000). Although difficulties with self-regulation are not reflected in the diagnostic criteria for ASD, they are frequently major areas of challenge for this population and often cause significant family stress as well (Hepburn & Wolff, 2013; OstfeldEtzion, Feldman, Hirschler-Guttenberg, Laor, & Golan, 2016). As such, providing systematic teaching and opportunities to practice self-regulation with support is often part of treatment for individuals with ASD. With intervention, individuals can learn a range of self-regulation skills that will greatly affect their quality of life. The acquisition and use of behavior regulation skills requires instruction, practice, and reinforcement (Bronson, 2000), just like any other skill set. Self-management (discussed previously) is an especially useful intervention when teaching selfregulation skills because of its emphasis on self-evaluation and self-reinforcement (Todd, Reid, & Butler-Kisber, 2010). Skills related to self-regulation are especially relevant in the reduction of challenging behaviors because self-regulation helps prevent challenging behavior, and many skills related to this domain can be taught as replacement behaviors. Several examples of self-regulation behaviors commonly taught in NDBI are discussed next. Selecting Self-Regulation Targets Often self-regulation behaviors are relevant when developing behavior intervention plans because they can become part of antecedent interventions and can be taught as replacement behaviors (e.g., teaching flexibility and then priming for flexibility and related coping skills in relevant contexts). These skills should be

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selected using the general guidelines discussed for selecting appropriate replacement behaviors (e.g., functional, generalizable, socially valid). Skills such as tolerating delayed reinforcement and removal of objects and flexibility may have a significant impact in the reduction of challenging behaviors. Like most skills taught using NDBI, these skills can be taught by either creating opportunities in the natural environment or capitalizing on those that naturally occur. The teaching strategies reviewed throughout this book, such as using prompts and prompt fading, teaching within child-selected activities, sharing control, using balanced turns, using natural reinforcement, and reinforcing attempts, can all be used to teach self-regulation skills. Teaching Self-Regulation Skills Using NDBI It can be tempting to avoid situations that are difficult for individuals with ASD. Doing so prevents triggers to challenging behavior and reduces stress for everyone involved. Although this antecedent strategy can be effective, it may only provide a short-term reprieve because the underlying challenges with self-regulation persist. Providing a safe and supportive framework in which individuals can be coached through their self-regulation challenges is likely to result in more durable long-term improvements in self-regulation skills and decreases in challenging behavior. If a child typically yells and cries during mealtimes at family get-togethers, instead of avoiding these events all together, caregivers can learn to scaffold by teaching the child to calmly ask to be “all done” when relatives start to sit down. As this improves, the caregiver could have the child sit with a timer on his or her chair for a few seconds before asking to be done. The caregiver can then slowly and systematically increase what the child practices, using motivation to avoid as a natural consequence for having the child politely leave the area instead of melting down. Two examples (targeting flexibility and teaching waiting) are outlined in detail next, with additional self-regulation behaviors and examples outlined in Table 13.1. Targeting Flexibility Behavioral flexibility consists of a number of skills, including the ability to adjust to and tolerate changes in routines, activities, and expectations; a willingness to compromise; the ability to remain calm when things do not go one’s way; and the capability to solve problems in new ways. Individuals with ASD have a tendency to adhere to routines and seek sameness in activities (American Psychiatric Association, 2000), which can interfere with daily functioning. Deviation from familiar routines or a disruption in activities can easily lead to challenging behaviors, stress, or anxiety. Research on flexibility has addressed a range of areas, for example, play (Baker, 2000), conversation (Koegel, Park, & Koegel, 2014), and food choices (Dominick, Davis, Lainhart, Tager-Flusberg, & Folstein, 2007; Koegel et al., 2012). NDBI strategies commonly used to address this challenge include arranging the environment, reinforcing attempts, natural reinforcement whenever possible, and practice in everyday routines and activities. Several strategies are commonly used when teaching self-regulation skills, such as flexibility and waiting. These are outlined next and are also integrated into the behavior-specific examples in Table 13.1. 1. Operationally define and label flexibility for the child or individual with ASD (e.g., “trying new foods,” “staying calm when changes happen”).

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Table 13.1. Example self-regulation behaviors categorized by function Behavior

Description

Example target behaviors

Teaching example

Function: Access to tangibles Tolerating removal of preferred objects

Child remains calm Remain calm. Create learning opportunities when preferred Use coping skills, by removing objects, moving objects are such as self-talk from least to most preferred. removed from (e.g., “I can have Begin with short intervals (e.g., possession. it later”). 1–3 seconds), and reinforce Accept alternatives. with access to the object contingent on tolerating delay. Increase length of delay over time until the child can tolerate total removal. Accepting Child remains calm Remain calm. Create learning opportunities by denied access when access to Use coping skills, denying access to objects and to preferred preferred objects such as self-talk. then following the procedures activities or is denied. Accept alternatives. listed previously. objects Function: Escape or avoidance Requesting a break

Protesting

Child uses communication strategy (e.g., verbal, visual, gestural) to indicate a break is needed.

Child uses communication strategy (e.g., verbal, visual, gestural) to indicate he or she does not want something or does not want to do something. Requesting help Child uses communication strategy (e.g., verbal, visual, gestural) to indicate help is needed.

Verbally ask for a break. Use a visual cue to request a break.

Create learning opportunities by instructing the child to engage in adult-directed activities and then prompting behavior to request a break. Provide natural reinforcement in the form of a break. Begin with short intervals of adultdirected activities, and extend the time the child can sustain before requesting a break over time. Verbally say “no” Create opportunities by offering or “I don’t want nonpreferred objects and to.” prompting the child for the Push away objects. target protest skill. Reinforce Shake head “no.” by removing the objects Gesture, such as contingent on use of the hold up hand appropriate protest behavior. with palm facing out to indicate “no.” Verbally say “help” Create opportunities by putting or “help me.” the child in situations in which Give objects to help is required (e.g., place others for help. objects in containers with Point to an object tight lids, present snacks in to indicate help. unopened packages). Prompt the child for the target skill, and reinforce by providing help.

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Table 13.1. (continued) Behavior Self-advocacy

Persisting with difficult tasks

Description

Example target behaviors

Teaching example

Child uses communication strategy (e.g., verbal, visual, gestural) to advocate for needs or wants.

Verbally advocate, Create opportunities by such as saying, interrupting the child, gently “Move please,” removing objects, or blocking “That’s mine,” or the child’s play. Prompt the “I don’t like that.” target skill, and then reinforce Gesture to self to by removing the interruption. indicate “that’s mine.” Child persists with Try for a specified Create opportunities, as done task for specified period of time in requesting help trials (see period of time before or after previous example), and then without giving asking for help prompt the child for the target up or asking for (before actually behavior (e.g., persisting, help. receiving help). trying another way). Gradually Try other strategies increase the amount of before asking for persistence required before help. providing reinforcement. Reinforce by providing help or a break.

Function: Tangible, escape or avoid, or attention due to rigidity (flexibility training) Accepting interruptions and unexpected changes (often tangible function)

Child accepts interruptions and unexpected changes without challenging behaviors and moves on.

Remain calm. Accept interruptions, and move on. May protest, but do not engage in challenging behavior.

Tolerating when things do not go as expected (often tangible or escape or avoid function)

Child accepts unexpected outcome (e.g., losing a game, something breaking) without challenging behaviors and moves on.

Remain calm. Accept the outcome, and move on. May protest verbally, but do not engage in challenging behavior. Use self-talk (e.g., “It’s no big deal. I can try again”) or other coping strategies.

Create opportunities by interrupting activities, moving from least-to-most preferred activities. Begin with brief interruptions, and gradually increase. Reinforce by providing access to the activity contingent on tolerating the interruption. Create opportunities by creating unexpected outcomes (e.g., set up a game where winning or losing can be controlled by the adult), moving from least to most difficult. Reinforce by either providing the outcome the child expected or desired or giving access to other preferred activities if the child moves on.

(continued)

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Table 13.1. (continued) Behavior

Description

Tolerating transitions (often tangible and/ or escape or avoid function)

Child accepts transition without challenging behavior and moves on.

Tolerating others entering play or activities with the child or wanting to direct the play (often tangible or attention function)

Child accepts others’ actions or involvement in play and/or responds to the ideas or actions of others in play (rather than directing it).

Example target behaviors

Teaching example

Make the transition Create opportunities by placing without demands for transitions. Begin displaying with transitions that are set challenging up just for practice and are behavior. not actually part of the daily Accept the routine. Use the following outcome, and hierarchy as a guideline: move on. • Nonpreferred to highMay protest preferred activity verbally. • Low preferred to high Use self-talk (e.g., preferred “I can always • Preferred to preferred finish that later”) (matched) or other coping • Low preferred to strategies. maintenance nonpreferred • Low preferred to acquisition nonpreferred • High preferred to maintenance nonpreferred • High preferred to acquisition nonpreferred Initially require only brief periods with the new activity, and gradually expand the time frame. Reinforce by allowing the child access to the highpreferred activity after making the transition and staying with the new activity for the specified time period. Remain calm. Create opportunities by having Attend to the adults insert themselves into actions or ideas the child’s play, beginning with of others. less-preferred activities and Respond to the brief insertions and gradually actions or ideas increasing to preferred of others. activities and longer insertions. Remain calm if Prompt the child using first, others do not then language (e.g., first the follow one’s dinosaur will eat and then you directions. can make him play). Reinforce by allowing the child to direct the play following compliance with demand.

2. Break down the targeted “flexibility” behavior into hierarchical, teachable steps. The easiest steps should be targeted first, and subsequent steps can work up the hierarchy. For example, when targeting making transitions, begin with making transitions away from less-preferred activities before working up to those that are highly preferred. Likewise, when targeting waiting or tolerating removal of items, begin with brief time intervals and expand to longer intervals. 3. Systematically increase the degree of flexibility before the child or student earns his or her reinforcement. For example, initially the child may only need to demonstrate flexibility with turn taking once before earning his or

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her reinforcement. As the child is successful, the requirement for contingent reinforcement can be increased to two, then three, then four, and so forth. 4. Practice flexibility goals by creating opportunities where skills are required. These opportunities are often contrived at first to allow the child to practice outside of the actual situation and ensure they can be targeted systematically and with enough repetition to lead to learning. Prompt behaviors explicitly, and use errorless instruction when possible to promote initial success. 5. Reinforce attempts across people, settings, and activities to enhance motivation. 6. Try to use natural reinforcement when possible, even if this means going back to the child’s preferred activity or way of doing things. For example, a child can be reinforced by being able to direct the play after allowing someone else to direct it for a brief period. 7. Determine if a self-management program would be beneficial, especially when fading adult prompts. For example, it may be useful to train a child to monitor whether he or she was flexible in play and accepted and responded to the ideas and actions of other people in order to earn reinforcement at the end of a brief (e.g., 5-minute) play session. 8. Begin by teaching these skills during adult–child interactions before targeting them during peer interactions. 9. Be sure it is necessary to teach flexibility for the specific area of concern and that the new skills are functional. Once the target skill has been explicitly taught, it can be practiced incidentally, for example, by changing game rules or routines on a regular basis. For example, during dinner, parents might change where everyone sits once or twice a week. Bath time could be switched from after dinner to before dinner. Varying or modifying rules and routines on a regular basis helps children and adolescents learn that small changes are part of everyday life and are manageable. Teaching Waiting One of the most practical and easiest self-regulation skills parents, clinicians, and teachers can teach children with ASD is waiting (i.e., tolerating delayed reinforcement). Opportunities to teach waiting can be incorporated into natural activities and routines just as any behavior being taught using NDBI. As with any skill, waiting can be effectively taught in situations in which the child wants access to an object or activity and the adult has shared control over available reinforcement. When the child indicates a desire for access to reinforcement, a cue to wait can be given (e.g., “wait,” “1 minute,” a gesture such as raising the index finger), a brief waiting period can be required (e.g., a few seconds for a child who is just learning this skill), and natural reinforcement can then be provided in the form of access to the object or activity. The duration of waiting time can then be gradually and systematically increased until the child can wait for a functional time period such as 1–2 minutes. Several additional simple strategies may be useful when teaching waiting. These are outlined in Table 13.2 Considering Commonly Taught Self-Regulation Behaviors The behaviors listed in Table 13.1 can be taught using similar strategies and may be useful in

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Table 13.2. Strategies to support teaching waiting Strategy Use auditory cues (e.g., counting)

Use visual cues Use natural opportunities, even when waiting is not required

Description Counting is a very practical way of signifying the passage of time. Use a calm, neutral voice, and count out a predetermined set of numbers so the child has a way to understand progress toward the goal. Visual cues can also be helpful, for example, counting on fingers or the use of visual timers once the time intervals become longer. Children make many requests throughout the day. Purposely practice waiting some of the time before providing natural reinforcement to increase the frequency of opportunities to practice this skill.

improving self-regulation and decreasing challenging behaviors. Children often need to learn multiple behaviors in this category at one time. Furthermore, many of these behaviors can go together, and it may be important to consider how one behavior may be a requirement for or support another. For example, it may be helpful to teach waiting prior to teaching removal of objects so that the child has already learned that objects will be returned after waiting.

TEACHING ADAPTIVE SKILLS Adaptive skills include a broad range of behaviors related to daily, functional, and self-care activities, such as hygiene, dressing, cooking, money management, timeliness, and leisure. These types of daily living skills are essential to independent living and quality of life. Adaptive skills for individuals with ASD have been a topic of great interest for decades. In fact, some of the earliest intervention studies for individuals with ASD focused on teaching adaptive skills (Wolf, Risley, Johnston, Harris, & Allen, 1967; Wolf, Risley, & Mess, 1964). More recent studies have found that even individuals with ASD who have average cognitive abilities frequently demonstrate low levels of adaptive functioning, making the transition into adulthood challenging (McGovern & Sigman, 2005). As with other developmental areas, NDBI emphasize teaching adaptive skills in the natural environment. Furthermore, essential to adaptive functioning is generalization of skills across settings, people, and activities. Because generalization is automatically embedded into NDBI instruction, NDBI may be particularly well suited for supporting adaptive skill development. Teaching adaptive skills can also be important in the reduction of challenging behaviors, particularly when challenging behavior emerges in response to difficult daily routines in which skill deficits may be present (e.g., dressing, bathing). Selecting Adaptive Skill Targets Like self-regulation behaviors, adaptive skills are important when developing behavior intervention plans because they can be addressed using antecedent interventions (e.g., visual schedules for compliance daily routines) and can be taught as replacement behaviors (e.g., teaching skills, such as dressing and bathing, that are required in daily routines but may be associated with challenging behaviors). These skills should be selected using the general guidelines discussed previously

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for selecting appropriate replacement behaviors (e.g., functional, generalizable, socially valid). Skills such as dressing, brushing teeth, bathing, self-feeding, and keeping track of belongings may have a significant impact on the reduction of challenging behaviors. Like most skills taught using NDBI, these skills can be taught by creating opportunities in the natural environment. The teaching strategies reviewed throughout this book, such as use of prompts and prompt fading, teaching within child-selected activities, sharing control and using balanced turns, and use of natural reinforcement and reinforcing attempts, can all be effectively used to teach adaptive skills. Many skills fall into the adaptive category, and systematic assessment may be useful. A range of assessment tools may be useful in assessing adaptive skills, such as standardized measures (e.g., Vineland Adaptive Behavior Scales, Third Edition; Sparrow, Cicchetti, & Saulnier, 2016) and developmental checklists (e.g., the DATA Model Skills Checklist; Schwartz et al., 2017). Once adaptive skill deficits have been identified, it may also be useful to conduct a task analysis to further evaluate exactly which parts of a behavior need to be explicitly taught. For example, a child who cannot drink from an open cup may have difficulty picking up the cup but may actually drink from it just fine, or vice versa. Careful assessment of adaptive skills is recommended before developing goals in this domain. Table 13.3 lists examples of adaptive skills across skill domains and developmental levels. Because this table is by no means exhaustive, it should not be used in place of a thorough assessment. Teaching Adaptive Skills Using NDBI Once adaptive functioning targets have been selected, they can be taught using many NDBI strategies. One example (teaching dressing) is outlined in detail next, with additional adaptive skills and examples outlined in Table 13.4. Adaptive skills vary greatly in the number of steps that may be involved and the complexity of the behavior. A skill such as spearing food with a fork and putting it in one’s mouth is much simpler than a skill composed of a number of steps (e.g., dressing) or a skill that requires cognitive ability, background knowledge and experience, or judgment about safety (e.g., cooking items based on the appropriate amount of time required). A number of behavior analytic strategies are useful when targeting adaptive skills goals (e.g., chaining, backward chaining, shaping), yet these skills can nonetheless be taught in the natural environment using NDBI strategies. For example, adaptive skills are easily taught in the natural environment and can be taught in preferred contexts using natural reinforcement. Modeling, prompting, and prompt fading are also commonly used. For example, getting dressed is a complex behavior. First, the developmental level of the child must be considered because the expectations for independence in a 3-year-old may differ from the expectations in a high school student. Once the target behaviors have been identified, it may be useful to use procedures such as task analysis to break them down and develop strategies for teaching such as forward or backward chaining. A prompt hierarchy and prompt fading strategy are also likely to be useful. Appropriate context for teaching and natural reinforcement should then be considered; for example, will the skills be taught during the actual daily routines or during a time of day designated for practice until a specified level of mastery is attained? Once context is determined, natural reinforcement can be identified;

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Table 13.3. Example adaptive behaviors across the life span Behavior

Example target behaviors

Mealtime or feeding Drinking from an open cup Using a spoon or fork

Sitting at the table Clearing dishes Making simple food Making food that requires multiple steps Making a meal

Takes a sip from a cup held by an adult. Picks up the cup and puts it to his or her lips. Picks up cup and takes one sip. Takes food from a fork or spoon held by an adult. Scoops the food with spoon. Spears the food with a fork. Scoops or spears independently and moves food into mouth. Sits in a high chair or booster for a specified time period. Sits in a chair for specified time period (beginning with short intervals and systematically increasing). Puts a dish in a “dirty dishes” bin at the table. Takes the dish to the counter. Clears food from the dish into the trash. Makes toast. Pours cereal and adds milk. Puts cheese and crackers on a plate. Makes a sandwich. Uses the microwave. Makes instant oatmeal. Heats soup. Makes eggs, toast, and coffee. Makes pasta and salad. Makes a sandwich and fruit.

Hygiene or self-care Toilet training Washing hands

Brushing teeth

Bathing

Dressing Managing menstrual cycle

Successfully voids in the toilet on a schedule (habit trained). Initiates using the toilet by telling an adult. Initiates using the toilet by going independently. Turns on water and adjusts temperature. Turns off water. Gets soap. Rinses hands. Dries hands. Throws away paper towels. Allows an adult to brush. Holds brush and puts it in his or her mouth. Brushes teeth for an appropriate time period. Brushes all parts of teeth consistently. Puts own toothpaste on brush. Tolerates being bathed by adult. Helps wash self. Helps dry self. Washes own body. Washes own hair. Dries self. Puts on shirt, pants, underwear, socks, or shoes. Takes off items. Ties shoes. Identifies when period is starting. Changes own pad based on schedule. Changes own pad based on judgment of needing to change.

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Table 13.3. (continued) Behavior

Example target behaviors

School behaviors Keeping track of materials

Keeps appropriate materials in backpack. Keeps appropriate materials where they belong in his or her desk. Takes lunch box to lunch and returns it to the appropriate place. Places jacket in the appropriate place and takes it at the end of the day. Using classroom materials Knows how to use scissors, pencils, pencil sharpeners, markers, glue, and erasers. Walking with peers in line Walks immediately behind the teacher. Walks in any place in line. Keeps hands to self. Attends to the teacher’s verbal instructions. Completing independent work Works for short period of time. Works for period of time using a self-management system. Works independently on preferred, and later a nonpreferred, activity. Requests help. Requests a break. Executive functioning behaviors Staying on task for a specified Stays on task for a short period of time. time period Stays on task for a period of time using a self-management system. Following multiple steps in an Follows two short related steps (e.g., get your pencil, and activity start your work). Follows two short unrelated steps (e.g., finish your work, and choose a book to read). Follows increasing number of steps with longer duration. Finishing an activity, cleaning Completes an activity and puts one item away. up, and moving on Completes an activity and cleans up. Completes an activity, cleans up, and chooses a preferred activity. Persisting with difficult tasks Persists for a specified period of time with difficult activities before requesting help. Tries multiple strategies before asking for help. Asks a peer, rather than an adult, for help when appropriate. Community behaviors Counting money

Counting change

Reading bus schedules

Identifies coins by name. Identifies coins by value. Recognizes dollars by value. Adds dollar amounts from varied bills. Adds change amounts from varied coins. Adds dollars and cents. Counts change in dollars. Counts change in cents in round numbers. Counts change in cents in any increment. Counts change in dollars and cents. Reads the schedule of arrivals and departures, where the correct route is already identified. Finds the correct route on a schedule. Searches the Internet for the correct bus schedule web site. Searches the bus schedule web site for the correct route.

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Table 13.4. Example adaptive behaviors and teaching examples Behavior

Description or example overall goal

Example target behaviors

Teaching example

Mealtime or feeding Sitting at the table

Child can sit at Sit at the table for a Create learning opportunities the table for short time. by prompting the child to an appropriate Sit for an increasing sit for very short periods of amount of time length of time. time, followed by access to based on the meal Say, “All done.” preferred activities that are (e.g., shorter for natural to the setting. Begin snack, longer for this goal by requiring sitting meals). with preferred foods only, and later move to nonpreferred foods. Systematically increase the amount of time. Once the child can sit for a short period, teach “all done” and reinforce it no matter how long the child has been sitting. Combine with the waiting goal to increase the amount of time the child is required to sit before “all done” is reinforced. Making a snack Individual can Make toast. Create learning opportunities by prepare three Pour cereal and add having the individual select simple snacks for milk. preferred snacks to learn self that do not Put presliced to make. Incorporate visual require cooking. cheese and cues, chaining, and other crackers on a Applied Behavior Analysis plate. (ABA) teaching methods as needed. Teach in the natural context with appropriate prompt levels, and fade prompts over time. Provide natural reinforcement in the form of eating the snack once prepared. Hygiene and self-care Bathing

Individual can participate in bathing at developmentally appropriate level (up to independent bathing if appropriate).

Tolerate being bathed by adult. Help wash self. Help dry self. Wash own body. Wash own hair. Dry self. Adjust the water temperature.

Develop a clear and consistent routine using visual cues, adult prompts, and prompt fading as needed. Teach specific skills using ABA methods if needed. Incorporate choice and following the individual’s lead by allowing children to choose bath toys and adolescents or adults to choose bath products if interested. Provide natural reinforcement by providing bath toys contingent on compliance with washing or by following a bath routine with a preferred activity (e.g., preferred snack or meal, toy or game, or story depending on the time of day).

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Table 13.4. (continued) Behavior

Description or example overall goal

Example target behaviors

Teaching example

School behaviors Walking with peers in line

Independent work

Individual can walk in line in front of or behind peers from one place to another.

Walk immediately behind teacher. Walk in any place in line. Keep hands to self. Attend to teacher’s verbal instructions.

Create opportunities to practice this behavior, beginning with very short walks and then increasing duration. Use ABA strategies, such as prompting and prompt fading, to target the skill. Begin by walking to preferred locations and following appropriate walking with natural reinforcement in the form of preferred activities. Then, make the transition to walking to nonpreferred locations, followed by preferred locations as natural reinforcement. Individual can work Work for a short Create opportunities to without adult period of time. practice this behavior, support for a Work for a period beginning with very short specified period of of time using a periods of independent time. self-management work on maintenance system. tasks, followed by access to Work independently preferred activities as natural on a preferred, reinforcement. Increase to and later a longer periods of work on nonpreferred, acquisition tasks or multiple activity. tasks in a row. Incorporate Request help. choice when possible (e.g., Request a break. order of tasks, materials to be used). Once the child can work for a period of time, begin incorporating requests for help or a break, followed by the natural reinforcement of receiving the corresponding outcome.

Executive functioning behaviors Persisting with Individual persists Persist for a Create opportunities to practice difficult tasks with a difficult specified period this behavior in the natural task for a specified of time with environment by presenting period of time difficult activities difficult tasks or those that and then uses before requesting may require help. Incorporate appropriate help. child choice and following problem-solving Try multiple the child’s lead by targeting strategies if the strategies before this skill during preferred task cannot be asking for help. activities (e.g., place marbles completed. Ask a peer, rather for a marble ramp in a tightly than adult, sealed container). Reinforce for help when the child for persistence by appropriate. providing access to materials. Eventually incorporate other skills, such as asking for help or trying two strategies before asking for help. (continued)

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Table 13.4. (continued) Behavior

Description or example overall goal

Example target behaviors

Teaching example

Community behaviors Counting money

Individual can count bills and coins when required to do so to make a purchase.

Reading bus schedules

Individual can correctly use the bus schedule to get from one location to another at a level appropriate for his or her current independence (e.g., some individuals may need more supervision than others in this process for safety reasons).

Identifies coins by Create opportunities to practice name. this skill in the natural Identifies coins by environment by going to value. stores that sell small preferred Recognizes dollars items and are conducive to by value. practicing (e.g., small store, Adds dollar amount not crowded). Incorporate from varied bills. choice by allowing the Adds change individual to select the store amount from and item to purchase. Begin varied coins. with easy amounts of money Adds dollars and to count, and gradually cents. increase the difficulty. Provide access to the item as natural reinforcement. Read the schedule Create opportunities to practice of arrivals and this skill in the natural departures in environment by planning bus which the correct outings to preferred locations. route is already Incorporate choice by having identified. the individual select where Find the correct to go. Plan the trip using the route on a targeted skills (e.g., reading schedule. the bus schedule). Practice Search the Internet additional skills during the for the correct ride (e.g., paying the driver). bus schedule web Provide natural reinforcement site. in the form of access to the Search the bus preferred location upon schedule web site arrival. Incorporate multiple for the correct opportunities to practice by route. going to several destinations before going home if appropriate.

for example, is there a preferred activity that might naturally follow the routine (e.g., choosing favorite breakfast food after completing morning dressing routine)? Consider the case of Abdul, a 5-year-old boy who could not dress himself. He had tantrums most mornings when his mother laid out his clothing, gave him instructions to get dressed, and left the room to make breakfast. His mother reported significant tantrums each morning but did not connect these challenges to his lack of dressing skills until Abdul’s therapist completed a functional assessment interview. She identified the dressing routine and then completed a task analysis. She determined that, for his developmental level, Abdul should be able to put on underwear, sweat pants (no buttons or zippers), and shirts without buttons as long as the clothing was laid out for him to avoid putting it on backward. Because Abdul was highly motivated to choose his breakfast foods and have his favorite Lightning McQueen plate and cup, the therapist made a first-then visual to cue him that he would be reinforced with these choices upon completion of getting dressed. She also gave him the opportunity to select his clothing, thus

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building in choice and shared control. She then taught his mother how to use backward chaining, starting with providing full assistance with all aspects of the routine except the final step of pulling up his sweatpants. Once Abdul was independent with this step and understood the routine of being reinforced following its completion, the therapist developed a visual schedule that included the multiple steps in the routine. This was then used in place of adult prompts as they were faded within the process of backward chaining until Abdul could independently complete all steps in the routine in order to earn reinforcement. When teaching adaptive skills within daily routines, it may be useful to think of natural reinforcement as being “natural” because it involves reinforcement that would naturally occur next within the daily routine (e.g., receiving dessert after dinner, playing a game after homework) rather than in the more concrete sense as discussed elsewhere throughout this book. This definition of natural reinforcement may also include use of the Premack Principle (discussed in Chapter 8), which states that the opportunity to engage in a high-probability behavior contingent on the occurrence of a low-frequency behavior will function as reinforcement for the low-frequency behavior (Cooper, Heron, & Heward, 2013). Although Abdul’s example relies heavily on the use of ABA intervention strategies, the use of shared control, natural reinforcement, and emphasis on teaching in the natural environment are consistent with most NDBI. For additional examples of adaptive behaviors being taught using NDBI, please see Table 13.4.

TIPS FOR TEACHING SELF-REGULATION AND ADAPTIVE SKILLS Like social-communication skills, self-regulation and adaptive skills are complex sets of behavior with many intertwined components. The complex nature of these skill sets and the many components that must be taught may challenge even the best clinicians, especially when disruptive behaviors are also present. Following are a few tips that may increase success when teaching self-regulation and adaptive skills. Be Patient and Provide Time Teaching self-regulation and adaptive skills can be challenging when children are used to having their maladaptive behaviors reinforced or having others do these tasks for them. Remind yourself that these behaviors take time and practice to develop. Some may require more explicit teaching and practice before they are fully generalized than others. Do not introduce opportunities to practice a selfregulation or adaptive skill if you are going to be rushed. For example, if you are working on shoe tying, do not ask the child to practice in the morning when there is less time and more urgency to leave. Rather, wait and provide an opportunity before going outside to play in the afternoon or on the weekend. Maintain the Focus on Motivational Strategies As mentioned previously, the skills discussed in this chapter can be challenging to learn and may take time. As a result, these skills may also be frustrating for the individual with ASD to practice. Furthermore, because the rationale for learning many of these skills relates to social norms that may not motivate the individual with ASD (e.g., others are more likely to interact with someone who is clean), a

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focus on incorporating motivational strategies into teaching these skills is critical. Strategies such as choice, following the child’s lead, prompting, reinforcing attempts, and natural reinforcement are particularly important to incorporate into teaching strategies. Prompts and prompt fading may also be important because many target behaviors discussed in this chapter are actually complex sets of behavior or steps in a sequence. Making sure the appropriate amount of adult support is available to create success (errorless instruction) and then fading over time is one important strategy for enhancing motivation. Reinforcing attempts is also an important strategy to consider when teaching complex chains of behavior because the individual may perform some steps more easily than others but will become frustrated and unmotivated if reinforcement cannot be earned until all steps are performed with the same level of fluency. Consider the Natural Environment As discussed throughout this chapter, many self-regulation and adaptive skills are difficult, complex, and include multiple behaviors rather than just one. As a result, these behaviors are more likely to require careful consideration of prerequisite skills, as well as appropriateness for teaching in the natural environment versus teaching skills out of context first before generalizing to the natural setting. For example, if an individual has never seen money or the bus schedule before, it is probably not appropriate to introduce these skills in the natural environment. Or if a child cannot wait for even 3 seconds, he or she is not likely to be successful waiting in line at the grocery store before purchasing a preferred item. Instruction for self-regulation and adaptive skills should be carefully and systematically planned. When possible, teaching in the natural environment with a high level of prompting is desirable to avoid having to generalize skills later; however, when there are barriers to the success of this approach, skills should first be taught out of context and then generalized. Even when teaching out of context, however, NDBI strategies can be used. For example, when teaching waiting, the child can be taught to wait briefly before being given access to preferred items. Or when teaching money skills, the individual can be taught within the context of role-plays in which they purchase preferred items from the therapist. Incorporate Parent Coaching Teaching adaptive skills and self-regulation may present challenges for parents or caregivers who are less likely to be present when teaching other skills. Self-regulation skills are likely to need targeting during times of frustration or in contexts in which challenging behaviors are or were previously present. Likewise, adaptive skills are likely to be or have been sources of challenge and frustration for parents because they often lead to challenging behaviors that interrupt routines and lead to other issues, such as being late. As such, teaching these behaviors is likely to be associated with frustration or negative emotions for parents and caregivers. When targeting these skills, it may be useful to assess the impact of this negative history on the present teaching interactions and troubleshoot with parents. For example, incorporating strategies for two parents in a family to support each other (e.g., one backing up the other during challenging behavior), teaching self-regulation strategies to parents, and teaching parents how to use noncontingent reinforcement

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to enhance positive parent–child interactions may all be helpful. In some cases, parents may also benefit from additional parent training or mental health treatment to assist them in learning skills for managing their own self-regulation when trying to teach these skills to their children. With plenty of research to support that children with ASD can learn from modeling, it is important to be sure parents are modeling desirable behaviors.

Case Example: Jonas Jonas is a 12-year-old boy with a diagnosis of ASD and attention-deficit/hyperactivity disorder (ADHD). He has average cognitive and language ability and primarily is in general education classes at school, with supports through an individualized education program (IEP). Given his many age-appropriate skills, Jonas has the potential to do well in many areas (e.g., academic achievement); however, he is currently struggling a great deal. Jonas has significant impulsivity and challenges with self-regulation. These difficulties result in daily behavioral and emotional outbursts that include behaviors such as yelling, screaming, cursing, banging his fists, kicking furniture and people, and elopement. Outbursts are more frequent at school and last longer, although they happen in home and community settings as well. Frequency of outbursts is two to three times per day. Duration ranges broadly, from a few minutes to a half hour. Jonas was previously in ongoing ABA therapy but eventually stopped because his parents felt he was doing better in terms of social-communication skills, which had been his primary treatment targets. After a particularly long and intense outburst at school that lasted about 45 minutes and necessitated clearing the other children from the classroom, Jonas’s teacher called a team meeting to discuss next steps in how to support Jonas. The team, including the parents, discussed the current concerns and agreed to start with a functional assessment of behavior at school. Jonas’s parents also decided to contact his previous ABA provider to see if the provider could assist with a functional assessment in the home and community settings, which the provider agreed to do. Once the functional assessment was completed, the team reconvened to discuss next steps. Results were very similar across settings. Both parents and service providers noticed that Jonas was struggling with a significant increase in rigid adherence to routines (e.g., wanting to finish things before moving on), was more easily frustrated by transitions (e.g., when he was not finished yet, when moving away from preferred activities), was avoidant of demands being placed on him (e.g., activities of daily living, homework, school work), and was struggling to stay organized and on task with the increased expectations of sixth grade. Given these challenges, the primary functions of his behavior were task avoidance, tangible (e.g., when required to make the transition from preferred activities), and attention, although the latter was primarily a secondary function that emerged when Jonas was upset in the context of another function (e.g., task avoidance). Given these challenges, the team began to develop a behavior plan for Jonas across settings. First, they introduced a number of antecedent interventions. At school, they first considered universal antecedent interventions because Jonas was in a general education classroom. For example, the teacher agreed that all sixthgrade students could benefit from some improvements in their organization skills and

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implemented a homework tracking system that was tied to the existing classroom behavior goals system. If all students turned in their homework and checked their completion off on the tracking sheet, the class received a point toward its overall behavioral goals. The teacher also began priming all students during periods where Jonas was at risk for behavioral challenges, for example, reminding all students to raise their hands if they needed help. Individualized antecedent interventions were also implemented, such as priming Jonas for transitions at home and at school. Priming was developed for both transition scenarios that were challenging for Jonas, including warnings that a preferred activity was about to end and warnings that he might not have time to finish something but could make a plan for finishing it later. As Jonas gained skills for remaining calm when frustrated, his parents, teachers, and therapists also implemented a priming plan for reminding him to use his coping strategies during times of risk for behavioral outburst. Although Jonas had many strong skills (e.g., verbal and cognitive ability), the team agreed that there were several skills he should be taught as replacement behaviors. Because Jonas often became upset when demands were placed on him, the team taught him asking for help and asking for a break. These were initially taught using naturalistic opportunities during his ABA therapy sessions (e.g., working on homework during ABA, reinforcing requests for a break with 2 minutes of free time) and were eventually generalized to the school setting. When these skills were generalized to school, the teacher also used priming to remind Jonas he could request short breaks and help from teachers or peers to decrease risk of behaviors. The team also taught Jonas coping skills for managing frustration. He learned skills such as coping statements (e.g., “It’s okay. I can finish my work later”), counting exercises, and deep breathing, first during ABA therapy and eventually at school or during parent–child interactions at home and in the community. These skills were taught using modeling, prompting, and natural reinforcement (e.g., access to preferred activities if he could tolerate finishing his work later), which were eventually faded. In conjunction with learning these coping skills, Jonas’s ABA team began working on practicing waiting, making transitions from preferred activities, and having preferred activities removed from him. These skills were initially targeted by setting up many transitions during therapy sessions and providing Jonas with natural reinforcement (e.g., regaining access to his preferred activities) contingent on his ability to remain calm and tolerate the targeted skill (i.e., waiting, coming away, removal of preferred activities). The skills eventually were targeted across settings and reinforcement was faded so that Jonas could tolerate longer delays and denied access before receiving access to reinforcement again. Because Jonas was being taught coping skills in conjunction, he was also encouraged to use these skills to remain calm while practicing these targeted behaviors. Once Jonas learned to tolerate delayed access to reinforcement and transitions, he used self-management to maintain his use of the coping skills he had learned. Jonas learned to track instances where his frustration was triggered and when he used his coping skills. He kept track using a simple application on his phone, so his friends were not aware that he had an individualized behavior plan. He would then show the data to his mother after school to confirm whether his goals had been met and reinforcement had been earned.

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Several consequence interventions were also put in place by the team. The team was in agreement that Jonas’s avoidance behavior was often inadvertently reinforced, especially if his behavior was so escalated that the classroom had to be cleared. With the use of antecedent interventions and teaching replacement behaviors, the frequency of high-intensity outbursts decreased at school, but the team also agreed to bring in adult support during outbursts, rather than clearing the room, which would allow teachers to follow through with demands. At home, his parents and therapists agreed to wait him out and then follow through, as long as access to reinforcement was removed in the meantime. This strategy was feasible because Jonas was not severely aggressive or destructive during outbursts. Upon further discussion, the team also realized that most of the adults who interacted with Jonas during his tantrums were providing attention, especially because Jonas yelled and used a great deal of foul language during these episodes, which adults found to be stressful. Parents and teachers realized that they were being reactive even when they did not intend to. As such, the team defined a clear set of adult behaviors for ignoring outbursts, including turning one’s body away, not speaking, not crossing arms, and not making eye contact. The team also agreed on a time interval of calm behavior that was required before reinforcement (e.g., attention, help, access to tangibles) would be offered to Jonas. Because Jonas was being educated in a general education classroom and had age-appropriate intelligence and verbal skills, the team prioritized implementing his interventions in a developmentally appropriate and naturalistic manner. As much as possible, replacement behaviors were taught during typical daily routines (e.g., homework, schoolwork, getting ready in the morning). When necessary, they were taught first by his ABA therapists, but they still focused on teaching during natural routines and activities. As mentioned, the self-management program was tracked using Jonas’s phone so it could remain private from his peers. Over time, with the combination of universal and individualized antecedent interventions, replacement behaviors, and changes in consequences, the frequency of behavioral challenges decreased. Nonetheless, these behaviors would sometimes emerge again, especially with changes in routines or new stressors (e.g., new school year). To continue addressing these concerns, Jonas’s ABA team continued to consult as needed, and they re-introduced strategies such as self-management and priming in order to maintain previous skills or assist with generalization of new skills.

CONCLUSION The big picture for ASD intervention should include systematic and programmatic opportunities for developing positive behavior, self-regulation, and adaptive skills. Learning to cooperate with less preferred situations, deal with frustration, be flexible, wait, and manage daily living skills is essential to living a well-rounded life. These are also skills that have a high likelihood of contributing to the reduction of challenging behavior, which, in turn, increases opportunities for success in natural environments. The strategies used in NDBI are particularly well suited for teaching these skills, and when used in conjunction with ABA approaches to reducing challenging behavior, the opportunity for enhanced quality of life and participation in the least restrictive environment can be maximized.

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Rogers, S. J., & Dawson, G. (2010). Early Start Denver Model for young children with autism: Promoting language, learning, and engagement. New York, NY: Guilford Press. Sandall, S. R., Schwartz, I. S., Joseph, G. E., Gauvreau, A. N., Horn, E. M., Lieber, J., & Odom, S. L. (2019). Building blocks for teaching preschoolers with special needs (3rd ed.). Baltimore, MD: Paul H. Brookes Publishing Co. Schwartz, I. S., Ashmin, J. A., McBride, B., Scott, C., & Sandall, S. R. (2017). The DATA Model for teaching preschoolers with autism: Blending approaches to meet individual needs. Baltimore, MD: Paul H. Brookes Publishing Co. Shipley-Benamou, R., Lutzker, J. R., & Taubman, M. (2002). Teaching daily living skills to children with autism through instructional video modeling. Journal of Positive Behavior Interventions, 4(3), 166–177. Southall, C. M., & Gast, D. L. (2011). Self-management procedures: A comparison across the autism spectrum. Education and Training in Autism and Developmental Disabilities, 46(2), 155–171. Sparrow, S. S., Cicchetti, D. V., & Saulnier, C. A. (2016). Vineland Adaptive Behavior Scales, Third Edition. San Antonio, TX: Pearson. Todd, T., Reid, G., & Butler-Kisber, L. (2010). Cycling for students with autism: Self-regulation promotes sustained physical activity. Adapted Physical Activity Quarterly, 27(3), 226–241. Wolf, M., Risley, T., Johnston, M., Harris, F., & Allen, E. (1967). Application of operant conditioning procedures to the behavior problems of an autistic child: A follow-up and extension. Behaviour Research and Therapy, 5(2), 103–111. Retrieved from https://search.proquest .com/docview/84454450?accountid=14522 Wolf, M., Risley T., & Mess, H. (1964). Application of operant conditioning procedures to the behaviour problems of an autistic child. Behaviour Research and Therapy, 1, 305–312.

14 Implementing NDBI in Schools Aubyn C. Stahmer, Jessica Suhrheinrich, and Laura J. Hall

O

ne of the primary purposes of the Individuals with Disabilities Education Improvement Act of 2004 (PL 108-446) was to support high-quality in-service preparation and professional development for all personnel to ensure that they have the knowledge and skills to improve the academic achievement and functional performance of children with disabilities. This includes knowledge and skills in the use of scientifically based instructional practices (Yell, 2016). As a result of federal legislation, there has been growing demand for use of evidence-based practices by educators. Research reviews by the National Professional Development Center on Autism Spectrum Disorders and National Standards Project identified specific evidence-based practices and established treatments, such as Naturalistic Developmental Behavioral Interventions (NDBI), that are key for use by special educators (National Autism Center, 2015; Wong et al., 2014, 2015). Although NDBI have been identified as evidence-based, limited information is available about how to use these strategies in group settings or how to use these strategies to teach academic tasks—two challenges teachers face each day. In their review, Wong and colleagues (2014) did not find any research using NDBI (naturalistic interventions [NI]) that targeted “school readiness,” and they found research focused on “academic” outcomes only for children ages birth to 5 years. However, there was research using peer-mediated interventions (PMI) targeting “school readiness” for young children birth to 5 years and targeting “academics” for students ages 6–22 years (Wong et al., 2014, p. 28). Some of the PMI included strategies from NDBI. Educators in the majority of the United States are using standards based on the Common Core State Standards (CCSS; http://www.corestandards.org). CCSS emphasize teaching children problem-solving skills using multiple means to find the best answer rather than focusing on learning the only correct response, which 347

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is compatible with the common instructional strategies used in NDBI. For example, NDBI strategies that are aligned with CCSS include responding to varied cues and opportunities; using multiple materials and examples; rewarding attempts; and using teaching strategies that support generalization, independence, and problem solving. In addition, the emphasis on using real-world contexts when teaching the academic skills that are part of the CCSS is compatible with the focus on arranging the environment as a common element of NDBI. Most NDBI programs have been studied in the context of one-to-one intervention, parent-implemented intervention, or a comprehensive program that incorporates NDBI (see Chapter 5 on inclusion for examples). Many teachers reported that NDBI components fit with their idea of “good teaching” and make sense to them (Stahmer, Suhrheinrich, Reed, & Schreibman, 2012). In addition, they reported that these strategies help children with autism spectrum disorder (ASD) generalize new skills to broader environments. These teacher opinions align with the available scientific literature on NDBI as well (e.g., McGee, Krantz, & McClannahan, 1985). However, specific intervention components and factors related to the instructional environment also influence use. Teachers find some NDBI components—including keeping instructions and opportunities clear, simple, and relevant to the child; gaining the child’s attention; ensuring there is a direct relationship between the reinforcer and behavior; and rewarding goal-directed attempts—to be part of what they would consider good teaching. In contrast, teachers may find the following three areas to be somewhat difficult to implement in classroom settings. These include 1) shared control and turn taking; 2) the use of direct reinforcement, and in some cases, even the use of tangible reinforcement; and 3) the translation of broad learning goals to specific tasks and activities. Often, it can be difficult to determine, for example, a natural reinforcer that links directly to certain academic tasks, such as math or geography. Teachers also say that they do not always have something tangible to provide in a group setting, but instead they use praise to provide feedback to students. Other concerns include how to best incorporate student-specific interests and turns (including modeling) into daily academic lessons and how to take the skills originally designed for one-on-one and use them with groups of multiple children, especially in settings such as circle time, in large-group activities, and without adequate staff support. This chapter provides ideas for overcoming these barriers to using NDBI in academic settings, with a focus on incorporating NDBI in group activies common to most classrooms and addressing academic and individualized education program (IEP) goals.

INCLUDING NDBI COMPONENTS IN GROUP OR ACADEMIC SETTINGS Setting up the teaching environment for NDBI is similar to setting up any good teaching environment for children with ASD. For specific lessons, educators should place teaching materials (including favorite materials if possible) and linked reinforcers in areas that are easily accessible to them but that are out of reach of the students. Having a place to keep extra toys and materials can be useful if students’ motivation changes and the lesson plan needs to shift as a result. Lessons can be

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conducted anywhere, based on the goal of the lesson; however, expectations should be clear for the student within that space. For instance, for a lesson that involves standing in a circle on the playground, it may help to draw a chalk line to indicate where students should stand. Educators can also set up the environment to provide opportunities for students to use their skills naturally throughout the school day (environmental arrangements). For example, a teacher could put art materials and games in a cupboard that may require students to ask for the specific game, label the color of marker they need, use prepositions, or complete sentences to ask for materials, toys, or activities. Giving students specific jobs can encourage peer interaction. For example, one student can be in charge of passing out paper for an assignment or keeping track of who has completed their work. Other students may need to ask him or her for materials or indicate to the leader when they are ready for the next activity. Motivation Is the Key One of the main reasons to use NDBI is to increase student motivation to learn. NDBI offer many ways to do this, so when using NDBI in the classroom, educators should consider their students and what motivators will be most powerful for them or best-suited to the activity. Not all of the strategies need to be used at the same level in each interaction. Table 14.1, the motivational strategies menu, can help teachers decide which strategy may be most effective and when. Shared Control, Choice, or Child-Preferred Activities Shared control occurs when an activity is neither completely teacher led nor completely student led. Rather, teachers and students work together to keep high motivation and engagement in the learning process. Teachers often indicate that this particular strategy is difficult to implement in practice. However, because it also has the potential to improve student motivation, when teachers are successful at incorporating shared control, they often report fewer behavior difficulties and greater engagement from students. Shared control can be used in a variety of ways during academic tasks. Teachers might include student-preferred materials, for example, a math lesson that includes counting pieces of a preferred toy (e.g., legos), which can then be used afterward as reinforcement. They can enhance teaching materials, for example, by adding pictures of animals whose names start with the letter a student is learning to write. Teachers can provide students with a large degree of control in choosing their activities for the day, topics of writing assignments, or leading activities. As an alternative, teachers may offer choices that provide a sense of control to the student with only limited changes to the lesson (see Box 14.1). Examples include a choice of taking a quiz or doing a problem-solving worksheet during a math session, a choice of which center to start with for the day, or a choice of writing in cursive or printing. Teachers often find it helpful to incorporate favorite themes into activities and assignments to motivate students. Shared control can also include turn taking so that appropriate behaviors can be modeled, and students can practice this back-and-forth type of interaction. Depending on the student and the activity, turns can occur with the teacher or with other students.

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Table 14.1. Motivational strategies menu Motivational strategy

It is especially good

It may not be as great

For one-on-one activity For group activities in which most children enjoy the materials For materials that fit the goals When the child is very hard to motivate When there is limited resistance to giving up the materials during the learning interaction When materials can be used to reach goals (e.g., social, language, colors, counting, play) When materials fit the child’s age and developmental level When the child needs a great deal of reward and the play materials are motivating When the child is motivated for play materials and/or use of these materials is a specific goal For children who have difficulty attending to academic tasks For children who need to learn to complete worksheets and other activities for a group environment For homework

For group activities in which children have very different interests For materials that do not fit the goals When the child loves the items so much he or she does not pay attention to the teaching instructions For specific goals that require non–play-based materials

For children who are very difficult to motivate or at times when it is easy to allow greater control (e.g., free play, recess, one-to-one activities) When the child can determine the type and length of the activity When choices need to be limited but more than one activity or set of materials can be used to meet the goals of the activity For group activities When the material or activity is set

For activities where only certain materials, activities, or topics are appropriate or available When the length of the activity is fixed For specific tasks in which only one activity choice is available

Use favorite materials Individual preferred materials

Play-based materials

Enhanced academic materials

When favorite topics, characters, and so forth cannot be incorporated into the task When these topics lead to distraction, rather than engagement and attention

Give choices Between activities: Guided

Between activities: Limited Within activities

When a child has poor motivation for the activity

Choose effective rewards Use real rewards: Timing and value

Reward attempts

When you use rewards the child really Mix with praise or token likes and can see and feel when he when the child is easier or she needs the most motivation to motivate; during When you use real rewards more often motivating tasks; when you when the child is hard to motivate are practicing skills that are During nonpreferred activities pretty easy for the child When a child is learning a new skill When you reward some attempts When you reward fewer during each activity attempts if the child is When you reward more attempts motivated for the activity when the child is difficult to and seems to enjoy the motivate or is frustrated with the challenge of learning new task skills

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Ready, Set, Implement! BOX 14.1: Adding choices A simple way to add choices to most academic lessons is to allow students to choose what they will write with. They can choose to use a pen, pencil, or colored marker to complete a worksheet. This simple choice is easy for teachers and can make students feel more motivated to complete the lesson. Many other similar types of choices can be easily embedded into the classroom.

Examples of how to use shared control to teach academic skills include the following: • If Sarah enjoys numbers, having her label the dates during a calendar activity and place today’s date on the calendar may increase her motivation to attend during circle. Allowing other students to go first and providing Sarah a turn contingent on good attention may further increase her ability to attend to the entire activity. • Perhaps the group is working on forming a paragraph with a topic sentence, supporting sentences, and a concluding sentence. Allow the students to choose the topic either as a group or individually. They may choose to write about a favorite game or activity they often play in the classroom. If students like different games, they can take turns choosing the topics, or the group could write a story that incorporates fun parts of several games. • If students are working on handwriting, they may choose between pictures representing the letters or words they are learning to write. Examples include trains delivering apples, airplanes, and alligators for the letter A or a favorite cartoon character using different objects such as a ball, a car, or a cup for children learning to write simple words. • When working in groups of students, work on social skills and turn taking while incorporating choices. For example, one child can be in charge of scissors; another, glue sticks; and another, colored pencils for an art project. Children can ask for the item they want and trade when they have finished with their turn. • Social skills and math can be a focus during a game in which students have half a circle, square, or triangle placed on their shirt and they have to find their other half in the group. They then tell their peers who has the other half and what shape they make together (e.g., “Dan has the other half, and together we make a rectangle”). • Turns can also be used to model skills between students. For example, students who excel at math or writing can take a turn first to model the skill for other students.

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• Larger group activities may provide opportunities for cooperative action. For example, the entire group may decide on a food to prepare for snack. This activity could focus on literacy by following a recipe to make the snack, as well as group cooperation and social skills, with different students contributing by preparing each of the ingredients. When they are done, they get to eat the snack (reinforcement!). Contingent or Direct Reinforcement Educators often find success using reinforcement appropriately when working with small groups of students. When the student behaves appropriately by responding correctly or making a reasonable attempt, the teacher provides a reward. When the student is incorrect or inappropriate, the teacher ignores the behavior, corrects the behavior, or asks the student to try again. If another student in the group (who is not working directly with the teacher) does something appropriate, such as asking for a new crayon, he or she can also be rewarded for the appropriate behavior. Providing rewards in a larger group environment can be a bit more difficult. Yet, with some creative thinking, the teacher can think of ways for the whole group to earn rewards. If specific students are trying hard or responding appropriately while other students are not listening, the educator can reward those students who are doing a good job. Then, he or she can provide the group as a whole a chance to try again or to earn a new reward. As another group reward, a teacher could use cotton balls to represent snow during circle time. As the class discusses the winter weather, the teacher can hand out snowballs to students who are listening well. Likewise, students can collect small animals, numbers, or letters during lessons on these topics. They can then use the items they collect to make something during free time later on. Direct reinforcement strategies can be more challenging for academic tasks. Throughout the school day, however, educators have the opportunity to require language in naturalistic situations and can provide direct reinforcement. For example, a student may want to use scissors from the cupboard, go to the rest room, or play with a toy from a high shelf. These are all opportunities to provide direct reinforcement for appropriate language use. Incorporating favorite items in the tasks can also be helpful. For example, educators can require language in naturalistic situations through activities such as the following: • Learning to count trains can lead to playing with trains. • Copying letters related to a favorite movie title might be rewarded with being allowed to talk about the movie with a classmate. • Reading the labels for items in containers correctly can lead to using the items (e.g., color of markers, size of Lego pieces, materials needed to put a plant in a pot). • Placing the date on the calendar after naming the number may be rewarding for some students. • Earning game tokens or pieces for writing a paragraph about a game can lead to using them to play the game when the activity is over. • Asking for food items cut in pieces by halves or quarters during snack or breakfast can lead to eating the items.

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Clear Instructions Use of clear instructions involves both providing developmentally appropriate instructions that students can understand and providing uninterrupted instructions. In some classrooms, variability in student skills and language comprehension can make it difficult to provide instructions that everyone can understand. It may be necessary to use multiple methods to give an instruction; for example, a teacher might use verbal instructions and hold up a picture that illustrates what is coming next. Sometimes, providing an instruction in two ways can help. Teachers can also give a group instruction for those who can follow it and then get the attention of students who have more difficulty understanding and present the instruction to them individually. One of the biggest challenges with providing clear instructions in the classroom is the likelihood that the teacher will be interrupted in between the time the instruction is given and when the student responds. When working with a group of students, interruption and distraction are much more likely. Strategies to ensure that instructions to students are clear and not interrupted during group activities include the following: • Teachers can help students anticipate when to pay particular attention to the instructor and when it will be their turn by using a rhythm or pattern when giving instructions. For example, the teacher asks each student to count a certain number of favorite objects using the same rhythm to make it easier for them to anticipate how and when they should respond. • Keeping students busy when it is not their turn is also helpful. For example, the teacher can show students how to label colors and shapes and then trace, draw, or color in a shape (depending the student’s skill level) while the teacher asks the same of the next student. • When giving a group instruction, such as asking students to get their materials out for social studies, the instructor can make sure he or she is ready to give the instructions before getting everyone’s attention. If a disruptive student is interrupting, the teacher can follow through with the group first and then manage that student’s behavior. Of course, interruptions will occur. If that happens, educators should simply provide the instruction or opportunity again when follow through can be completed. The following are examples of how to adapt an instruction for different students. Perhaps the lesson includes doing a science experiment and working on math skills. The teacher can adapt the instructions to include a more challenging task for students with higher math skills and less challenging task for students who have fewer math skills. Some students may be asked to divide in order to get the correct amount of sulfur to add to the mixture (Instruction 1), whereas another student may be asked to measure the sulfur and place it in the bowl (Instruction 2). Likewise, a group of students who are working on writing have decided to write about their favorite movies. The teacher might first provide an instruction verbally for those students with better language skills that requires them to write a paragraph about the film. For example, “Joey, Shana, and Sue, please write a five-sentence paragraph about your favorite movie.” For other students, the teacher might provide pictures of various movie examples known to be popular with the class and a list of specific questions to answer about the movie. For example, “Who is this

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movie about?” Other students may simply need to choose a picture of a favorite movie and copy the title of the film. In this way, students of varying skill levels can work together on the same task. Broad Attentional Focus Lessons should use different materials and methods to teach the same concept in order to give the student a broad understanding of the concept and how to use it in different settings. For example, if only picture flashcards are used when teaching a child to label items, the child may think that “car” is the name of the picture of the blue sedan with four doors; he or she may not understand the broader concept of cars. Therefore, using a variety of materials—photographs and cartoons of cars, remote-controlled cars, real cars, and toy cars—is important to teach the child a more general idea of the concept of car. The same is true when teaching new words, phrases, and play activities. Broadening a child’s attention involves use of varied instructions. Varied instructions mean asking the same thing in slightly different ways. Instructions can vary across seven types of opportunities (see Table 14.2), and the goal is for children to respond to all types of opportunities because that is what they will encounter in the world. For example, if a teacher would like a child to learn to report his or her address, the educator will need the child to respond to the question asked in several ways (e.g., “Where do you live?” “Where is your house?” “What is your address?”) rather than only responding if someone says, “Tell me your address.” The teacher also may put the address on an iPad or place a photo of the child’s house with the address in the student’s backpack so that the student can pull it out if someone asks. Another example would apply in teaching addition; for example, a teacher could use jacks, dice, balls, worksheets, crayons, and flashcards to illustrate the concept of addition. Assuming the most complex of these instructions is at the child’s developmental level, then using all of these opportunities to respond is considered using varied instructions. Educators can also implement differentiated instruction for students with different skill levels by creating a variety of materials. For example, when teaching map reading to a child who is not yet reading, the teacher might provide a small map with stickers of buildings at several points on the map (e.g., a sticker of a house Table 14.2. Example opportunities and cues Opportunity

Description

Gesture/play model Model the action. Verbal model Model exactly what you want your student to say. Instruction Give an instruction telling the student what to do. Question Ask a question. Facial expression Comment Situational

Wait expectantly with eyes open wide. Make a leading comment. Set up situations to elicit a specific behavior.

Teacher behavior Feed a doll with a spoon. Say “spoon” when the student is reaching for the spoon. Say, “Feed the boy.” Say, “Should the boy eat peas or yogurt?” Hold up the doll, and look expectantly at the student. Say, “The boy is hungry.” Put a doll, spoon, and bowl on the table near the student.

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on one end and a school on another, stickers of a farm and a fire station in between). The teacher could then ask the student to move a doll from “home” to “school” on the map and state the directions along the way. The student could then say something such as, “The boy leaves home, goes down this street, past the farm, then turns right at the fire station until he gets to school.” Another child who is reading might be given a list of written instructions about how to get from home to school (e.g., go up two blocks, then right four blocks, then cross the street). He or she could then use those instructions to move the doll along a real map from home to school. Both students are learning the concept of map reading but at their own ability level. Table 14.2 describes a variety of forms that can be used as a cue. Generalization and Maintenance of Skills A focus on maintenance of skills over time and generalization of skills with different people, with different materials, and within different settings and activities is a common instructional strategy of NDBI. Maintenance and generalization are initially targeted through intentional use of varied cues, use of natural reinforcement, and teaching in the natural environment. In fact, the cues that are likely to be used in the natural environment should be identified and embedded at the beginning of any lesson planning (Mayer, Sulzer-Azaroff, & Wallace, 2014). It is important that students have the opportunity to practice any skills across environments and in different contexts to help them master the concept. Instead of assessing fractions using blocks only, for instance, a teacher should assess the use of fractions with food, during time telling, and on math worksheets. Children may also benefit from specific assessment of maintenance and generalization to identify any areas of weakness. This can be done by asking a student to use newly learned skills with new materials or a new person. For example, if the child has learned to follow instructions from the teacher during math, have the speech therapist give similar instruction during language time and see if the student still responds.

SCHOOL-BASED ACTIVITIES MOST SUITED FOR NDBI NBDIs can be used throughout the school day during a wide variety of activities. To identify activities that are a good fit for NBDI use, educators should consider the following questions. • Do I know my student’s preferences or interests and target skills? An important part of using NBDI successfully in the classroom is planning. If an educator does not know what motivates the students, it helps to watch what they do during free play, ask their family members, or conduct a formal preference assessment (see Chapter 6 and Box 14.2). • Do I have the opportunity to share control with my students during this activity? Sharing control means there is some flexibility in how the lesson will run or what materials can be used. Some activities, such as recess or free choice time, may have very little structure. In these situations, the teacher can easily follow the student’s lead for maximal child choices. The teacher still has specific learning goals (e.g., requesting a turn, counting to 10, writing a descriptive paragraph),

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Ready, Set, Implement! BOX 14.2: Incorporating Children’s Interests Into Theme-Based Teaching NDBI strategies can be used during theme-based teaching. For example, if the theme is community helpers, you can talk about the vehicles used by fire fighters, mail carriers, and garbage collectors as a way to incorporate motivating materials for a student interested in cars and use these vehicles as a natural reward for answering questions during the discussion.

but the way in which the goals are taught is flexible. Consider Table 14.3 with examples of how to address the same goals in activities of decreasing structure. • Will I be able to provide regular feedback and natural reinforcement? Students will learn best when given regular and related feedback about their behavior. When teachers are working with only one child, this is no problem. However, providing feedback becomes more difficult as the group size grows. When choosing activities for NDBI, a teacher must consider how to give attention to each student in the group (or the group as a whole) to provide meaningful feedback. Individual students will likely need varied amounts of reinforcement to keep them engaged. See Table 14.4 for examples of ways to provide wholegroup reinforcement and individual reinforcement within a group setting. Table 14.3. Examples of different levels of structure

Goals

Highly structured activity with set goals and procedures

Structured activity with a required sequence of steps or materials

Semi-structured academic or play-based activity

Unstructured activity

Ava will Mrs. Chavez The number While passing At recess, independently prepares several of the week out materials Mrs. Chavez count small cups is 5. During a for an art finds Ava quantities with different group circle activity, playing in up to 10 quantities of small time activity, Mrs. Chavez the sandbox. on 80% of blocks (1–10) Mrs. Chavez asks Ava, Mrs. Chavez opportunities. in each. During places five “How many says, a small-group beanbags in crayons do I “Let’s put math activity, her bucket. She have?” When five scoops Mrs. Chavez asks asks Ava, “How Ava responds in your Ava to “count many beanbags correctly, bucket. You the blocks.” do I have?” Mrs. Chavez count.” She Mrs. Chavez When Ava lets Ava choose blocks the alternates her responds, she the colors bucket until attention between gets to pass out she wants. Ava says the three students beanbags to She repeats each number, in the group, and hear friends to this process then moves each student gets use during the with scissors, her hand to build with the next song. glue sticks, so Ava can blocks between and other dump the turns. materials. sand in the bucket.

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Table 14.4. Examples of reinforcement Activity

Whole-group reinforcement

Individual reinforcement

Multiplication with white The group earns a marker Students who respond correctly boards: Each student for each problem everyone or make a good attempt get writes his or her answer completes correctly (or their choice of extra marker on a personal white attempts). When the group colors to draw on the white board and holds it above earns 10 markers, everyone board between problems, his or her head so the gets to play a Pictionary allowing the teacher to work teacher can review the math game. individually with those who answer. answered incorrectly. Mr. Neilson wants to When Mr. Neilson asks a When Mr. Neilson “catches” a encourage his students question and all students student doing good listening, to raise their hands either raise a hand to answer he praises him or her and before speaking and or sit quietly, the class earns says, “You get to choose a listen while others are 1 minute of song time. song!” talking during circle Likewise, when all students activities. The students’ listen while another student favorite part of circle time answers, the class earns is song time at the end. 1 minute of song time.

EXAMPLES OF ACTIVITIES AND LESSONS Table 14.5 includes examples of how to use one NDBI strategy, Classroom Pivotal Response Teaching (CPRT), to address IEP goals and specific curriculum areas. The table describes three students, Jose, Sara, and Darren, who attend the same K–2 special day class. Their IEP goals and examples of how their teacher uses NDBI strategies to meet their communication and math goals during classroom activities are included. NDBI strategies also have been used to increase motivation and facilitate homework completion. In particular, providing choices (even somewhat superficial choices such as order of task completion), incorporating simple problems with more difficult ones, and rewarding attempts have all been used successfully (Koegel, Tran, Mossman, & Koegel, 2006).

CONCLUSION Research has looked at the use of NDBI strategies in schools, typically in combination with other evidence-based interventions (e.g., Stahmer, Suhrhenrich, & Rieth, 2016; Young, Falco, & Hanita, 2016). Teachers share that these strategies make sense to them and fit well with teaching students with ASD and other students in their classrooms. One teacher learning to use NDBI said, “Once you get used to implementing the choices, shared control, and the rewards for attempts, it makes teaching so much easier for all involved, and we end up with so much more.” Another teacher said, “I found my students did learn the skills presented, and they seemed to have fun while learning (and I did, too!).” We hope these strategies are both fun and useful in the classroom. There are some resources that will provide more information about the use of NDBI in schools. For example, the National Professional Development Center on ASD offers professional development materials, such as the Autism Focused Intervention Resources and Modules (AFIRM) for planning, using, and monitoring 27 evidence-based practices for learners with ASD, including NI, Pivotal Response Treatment (PRT), and PMI.

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Table 14.5. Meeting individual goals using Classroom Pivotal Response Training (CPRT) Kindergarten/first grade Student profile Jose is a 6-year-old boy who attends a K–2 special day class. He has some intelligible phrase speech, which he uses to request and at times to comment, but he does not yet use sentences. He can match uppercase letters but does not name them. Jose is at the beginning level of reading sight words. Jose counts to 20 and can give objects up to 10 from a field of 12–15 with 80% accuracy. He requires visuals to augment learning. Jose has difficulty interacting with other students and is often alone on the playground and at lunch. Sara is a first grader in the same special day class as Jose. She is a 7-year-old girl who uses five- to six-word sentences but does not always express herself well to get her needs met. Sara knows all of the upper- and lowercase letters and the sound each letter makes. She is learning to recognize simple words in print. She prints her first and last names. Sara knows how to do addition for single-digit numbers. She is currently working on subtraction skills. Sara has many friends but still has difficulty sharing materials during class activities. Darren is a first grader. He primarily uses gestures to communicate and makes some inconsistent attempts at single words. He is able to use a Picture Exchange Communication System to make requests with an open-handed prompt. Darren rote sings the ABC song (using approximations) but does not recognize the letters of the alphabet. Darren rote counts to 5 (using approximations) but has not yet developed numeral recognition. Darren parallel plays near peers but has little to no interaction with them. He is often alone and ignores those around him.

Individualized education program goals or curriculum area 1. Jose will name the uppercase letters when they are presented in random order, with 100% accuracy on four of five opportunities. 2. Jose will demonstrate the ability to complete addition sums in single digits with visual support, during four of five opportunities. 3. Within 1 school year, Jose will spontaneously use simple sentences five times in each school day on 6 out of 8 days. 4. Jose will join a group appropriately (e.g., by spontaneously waving, saying hello, asking to play) and will remain in proximity to other students during small group and lunch for 15 minutes over 4 of 5 school days. 1. Sara will decode simple consonant-vowelconsonant words when shown a variety of printed materials, with 8 out of 10 words correct as measured by interim assessment on four out of five occasions. 2. Sara will demonstrate the ability to do single-digit subtraction problems independently with at least 80% correct on 4 of 5 school days. 3. When at an activity with plenty of materials, Sara will be able to share with her peers spontaneously for up to five turns on 4 of 5 school days. 1. Darren will match the letters of the uppercase alphabet when given two sets of letters with 100% accuracy on four of five opportunities. 2. Darren will point to the requested numerals to 10 with 100% accuracy during four of five opportunities. 3. Darren will use words or pictures to communicate at least 20 times without prompting throughout the school day to request objects or activities on 4 of 5 school days. 4. Darren will interact with peers during structured play by turn taking and sharing materials during daily activities with teacher facilitation on 70% of opportunities on 3 days.

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Table 14.5. (continued) Kindergarten/first grade Using CPRT at language arts with Jose, Sara, and Darren Activity: Letter and word recognition Materials: Letter cards, character stickers, writing or matching boards for students, toy animals The students, Jose, Sara, and Darren, are seated at a small round table with the teacher. She reviews the alphabet with the students by showing them letter cards of all the letters and naming them. Jose: The teacher shows Jose a letter card. “What letter is this, Jose?” She holds up an S. Jose looks at it and says, “S” (Goal 1). “Good,” says the teacher and gives him the letter, which has a Superman sticker on it. (He likes superheroes.) Next, the teacher takes a turn and models a more advanced skill. She writes “all” on her white board and places the “B” card in front of it. “B goes with a-l-l to spell ball.” Sara: Sara is working on “at” words (e.g., bat, cat, hat) and has a board with a blank space followed by “at.” The teacher asks Sara if B can be put in front of at to make a word. Sara looks at her board and puts the B in front. “What does it say, Sara?” Sara replies, “B-at. Bat!” (acquisition skill, Goal 1). “That’s great,” the teacher tells her. “It spells bat!” She asks Sara if she would like to take another turn or share her letter with Darren. Sara chooses to give the letter to Darren (Goal 3). Darren: Darren has a matching board for the capital letters. He places the B from Sara on the correct corresponding letter (Goal 1). He is rewarded by being allowed to choose and play with a toy animal that begins with the same letter. The teacher continues the lesson in this manner, allowing Jose to name the letters (being rewarded with the embedded stickers), Sara to test them with the “at” board (being rewarded by allowing her to choose to take a turn or share), and Darren to match them to his board (rewarding him with animal toys that begin with the same letter he is matching). The teacher models as needed and gives praise throughout the session. Using CPRT at math with Jose, Sara, and Darren Activity: Number recognition, addition, and subtraction Materials: Number cards, addition and subtraction folder templates (three squares printed horizontally with + or − and an = between them) The teacher shows and labels each number card and allows the students the choice of whispering or yelling as they repeat each number after her (maintenance skill). She knows that “being the teacher” is motivating for all her students, so she uses this role to reinforce the students’ behavior during a math activity. Darren: Then, the teacher holds up two numbers (3 and 5) and says, “Darren, tell us what numbers these are” (Goal 3). He labels both numbers correctly, and she gives him the corresponding number cards and says, “Okay, Darren is the teacher.” She helps Darren pass out the numbers. He chooses to give the number 3 to Jose and the number 5 to Sara (Goal 4). Next, she holds up two more numbers (1 and 2) for Darren and asks, “Where is number 2?” Darren takes the 2 card and, smiling, gives it to Sara (Goals 2 and 4). The teacher wants to reward his spontaneous sharing. “That was great, Darren!” she says, “You picked the correct number and even gave it to Sara without being asked! You may choose two animals.” Sara: Sara’s folder has a subtraction sign between the first two boxes. The teacher tells Sara, “Put your number 5 here” and points to the first box, “and your number 2 here” and points to the second box. She then asks, “What is the answer?” and points to the third box. Sara says, “Five minus two equals three.” The teacher announces, “Great job! Now Sara is the teacher.” With the teacher’s help, Sara gives Jose the number 2 card and tells him to do his math problem. Jose: Jose makes a nice attempt by reading the numbers on his folder without solving the problem (Goal 2). The teacher praises his effort, and he is allowed to flick the number cards with his fingers. The teacher says, “Now I will take a turn” and solves an addition problem on another folder. The lesson continues in this manner until math time is over. Source: Stahmer, 2011.

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Books that may be useful include the following: Delmolino, L. (2015). Solve common teaching challenges in children with autism: 8 essential strategies for professionals and parents (topics in autism). Bethesda, MD: Woodbine House. Hall, L. J. (2018). Autism spectrum disorders: From theory to practice (3rd ed.). New York, NY: Pearson. Leach, D. (2012). Bringing ABA to home, school and play for young children with autism spectrum disorders and other disabilities. Baltimore, MD: Paul H. Brookes Publishing Co. Stahmer, A., Suhrheinrich, J., Reed, S., Schreibman, L., & Bolduc, C. (2011). Classroom pivotal response teaching for children with autism. New York, NY: Guilford Press.

REFERENCES Individuals with Disabilities Education Improvement Act (IDEA) of 2004, PL 108-446, 20 U.S.C. §§ 1400 et seq. Koegel, R. L., Tran, Q. H., Mossman, A., & Koegel, L. K. (2006). Pivotal response treatments for autism: Communication, social, and academic development. Baltimore, MD: Paul H. Brookes Publishing Co. National Autism Center. (2015). National Standards Project, Phase 2. Randolph, MA: Author. Mayer, G. R., Sulzer-Azaroff, B., & Wallace, M. (2014). Behavior analysis for lasting change. Cornwall-on-Hudson, NY: Sloan. McGee, G. G., Krantz, P. J., & McClannahan, L. E. (1985). The facilitative effects of incidental teaching on preposition use by autistic children. Journal of Applied Behavior Analysis, 18(1), 17–31. Stahmer, A. C., Suhrheinrich, J., Reed, S., & Schreibman, L. (2012). What works for you? Using teacher feedback to inform adaptations of pivotal response training for classroom use. Autism Research and Treatment, 2012, 1–11. (Article ID 709861) Stahmer, A. C., Suhrheinrich, J., & Rieth, S. R. (2016). Classroom pivotal response teaching: A pilot examination of the adapted protocol. Journal of the American Academy of Special Education Professionals, Winter, 119–139. Stahmer, A., Suhrheinrich, J., Reed, S., Schreibman, L., & Bolduc, C. (2011). Classroom pivotal response teaching for children with autism. New York, NY: Guilford Press. Wong, C., Odom, S. L., Hume, K., Cox, A. W., Fettig, A., Kucharczyk, S., . . . Schultz, T. R. (2014). Evidence-based practices for children youth and young adults with autism spectrum disorder. Chapel Hill: The University of North Carolina, Frank Porter Graham Child Development Institute, Autism Evidence-Based Practice Review Group. Wong, C., Odom, S. L., Hume, K. A., Cox, A. W., Fettig, A., Kucharczyk, S., . . . Schultz, T. R. (2015). Evidence-based practices for children, youth, and young adults with autism spectrum disorder: A comprehensive review. Journal of Autism and Developmental Disorders, 45(7), 1951–1966. Yell, M. L. (2016). The law and special education (4th ed.). New York, NY: Pearson. Young, H. E., Falco, R. A., & Hanita, M. (2016). Randomized, controlled trial of a comprehensive program for young students with autism spectrum disorder. Journal of Autism and Developmental Disorders, 46, 544–560.

15 Collecting Data in NDBI Mendy B. Minjarez, Melina Melgarejo, and Yvonne Bruinsma

L

ike all interventions grounded in behavior analysis, data collection is a critical component of Naturalistic Developmental Behavioral Interventions (NDBI). Not only have data supported the efficacy of NDBI in numerous published research studies, but consistent with data-based decision making as a cornerstone of Applied Behavior Analysis (ABA), data guide treatment planning by demonstrating the effects of ongoing treatment programs for individual learners. Data provide the information needed for developing goals and planning intervention programs, ensuring the intervention is implemented accurately, monitoring progress, guiding treatment decisions, facilitating communication across team members, and evaluating the program’s overall effectiveness. Although the details of data collection vary depending on the specific intervention and target skill, all NDBI incorporate a system of data collection. Ongoing collection of skill and behavior data allows for the tracking of progress without judgment based on temporary bias or misinterpretation of singular events. For example, if a parent experiences a tough weekend of challenging behaviors, he or she may get discouraged and think that progress is not being made when the data actually may continue to show an improving trend. Or, if a teacher observes a student engage in a new skill, he or she may determine the goal is met without realizing that the skill is only produced in the teacher’s presence and more work is needed before the student uses that skill with others. In NDBI programs, data help clinicians track whether the skills taught are 1) firmly assimilated into the child’s repertoire or if the child needs additional instruction and practice; 2) used fluently, flexibly, and in meaningful ways or are difficult to produce or rigidly applied; 3) used in situations that have not been directly taught or limited to a particular teaching context (i.e., generalization); and 4) maintained over time. As described in Chapter 16, use of a clear system of data collection to guide the intervention is one of the quality indicators of NDBI programs. Data provide essential feedback on clinical strategies and guide clinical programming and goal development. 361

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GENERAL FRAMEWORK FOR DATA COLLECTION All NDBI emphasize the importance of data collection, but there is great variability in how specifically the models outline strategies for doing so. The data collected must be reliable (precise enough to be replicated) and valid (accurate); otherwise they may be misleading (see Box 15.1 for complete definitions of reliability and validity). Because data are used to drive clinical decision making, their reliability and validity are of utmost importance. Several NDBI programs have outlined important considerations for developing data collection strategies in their manuals (e.g., Classroom Pivotal Response Teaching [CPRT], Project DATA [Developmentally Appropriate Treatment for Autism]). Clinicians may find it helpful to think about the following questions when developing data collection methods (Schwartz, Ashmun, McBride, Scott, & Sandall, 2017; Stahmer, Suhrheinrich, Rieth, Schreibman, & Bolduc, 2011): • What information are you trying to capture? That is, will your data provide you with the information you need to answer the question you have? Will your method be valid, meaning it measures what you intend it to measure? • Will the method be reliable, meaning it is precise enough to achieve interobserver reliability? • What measurement criteria are written into the goal? • What data are required in the setting (e.g., schools, for insurance)? • Will the data collection system be manageable, be practical, and make sense for those who will be collecting the data? • What information do you need to evaluate progress and make program changes? Additional considerations for developing and using data collection methods may include deciding 1) where to collect data (setting), 2) how often to collect data, 3) who will collect the data, and 4) how to measure behavior change. For some behaviors, it may be important to consider whether data from multiple settings is necessary. For example, if a child has tantrums minimally at school but often at home, measurement of tantrums in the school setting may not capture this child’s baseline functioning or progress during treatment at home in a valid manner. Next, clinicians should decide how often data will be collected. For example, will data collection be continuous across treatment sessions or collected in probes?

BOX 15.1: Reliable and valid data collection Reliability: Reliability refers to whether results are precise enough to be consistently replicated. In ABA, the most important kind of reliability is interobserver agreement, defined as more than one person arriving at the same result when data are collected. Validity: Validity refers to the accuracy of data, meaning whether you are measuring what you intend to measure.

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This will depend on how often the behavior occurs and how quickly it is expected to change. It is also important to clearly determine who is monitoring the data. Likely there will be more than one person in each setting, which is why reliability of data recording is important. It is also important to consider what type of data is relevant based on how the goal is written. For example, if the goal states that mastery criteria are based on frequency during a 10-minute probe, the data collection method must match that criterion. Likewise, if the goal states that duration of tantrums will decrease, the data collection method must focus on duration rather than frequency or rate. There are many other considerations for selecting what type of data is appropriate, depending on what behaviors are being measured. These are discussed in more detail later in the chapter but are also well-elaborated in the ABA literature (e.g., Cooper, Heron, & Heward, 2013). Once these decisions have been made, clinicians can design a data sheet. There are many data sheets available in ABA and NDBI books, manuals, and texts, as well as online. Clinicians may find some of these easier to adapt than others, and they often may also wish to develop their own data sheets for specific areas. Many programs routinely follow established treatment procedures or guidelines and often have a core set of data sheets so that a new data sheet is not developed every time a goal is written. Nonetheless, to gather reliable and valid data, clinicians should ensure their data sheets capture what they are trying to measure. Once a data collection method is determined, clinicians must also decide on data summary and analysis methods. Many NDBI programs use straightforward ABA graphing methods, but some use other methods such as summary face sheets and matrices. Treatment teams must decide on methods that are feasible, efficient for the setting, and effective in progress monitoring and data-based decision making. When determining these methods, it is also important to determine who will be overseeing data analysis and using this information to make program changes (e.g., teacher, lead Board Certified Behavior Analyst [BCBA], therapist) and how and when this person will review the data. Data are only helpful if summarized, analyzed, and used effectively to monitor treatment.

DATA COLLECTION ACROSS NDBI MODELS NDBI target a wide variety of skills across the various domains of development (e.g., communication, social, play, behavior, motor, self-help, cognitive). Although some programs may be more focused and others more comprehensive, each one targets socially significant skills that help children actively and meaningfully participate in the world around them. With an understanding of developmental and behavioral perspectives, and considering social- and age-appropriateness, clinicians prioritize the most critical skills for intervention and track them via data collection. All NDBI models focus on data collection in order to evaluate treatment progress and guide treatment planning; however, there is considerable variability across models. The next section provides a review of data collection methods across a sample of NDBI models. NDBI models with more explicit and detailed data collection systems are reviewed first, followed by those that rely on broader strategies available in the ABA and developmental literature. The data collection methods reviewed here pertain primarily to skills acquisition because most NDBI use standard ABA data collection methods for taking data on challenging behavior.

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Early Start Denver Model In the Early Start Denver Model (ESDM), specific data sheets include fields for data collection on targets that are most commonly generated from the ESDM curriculum checklist. Although the targets themselves can be flexible, the general data collection method is set. Daily data are collected on the Daily Data Sheet, typically on acquisition skills as well as maintenance skills. Data are then used to modify teaching within sessions and track progress across sessions. Within sessions, data are used to track which skills have been targeted so clinicians can monitor whether teaching needs to be adjusted over the course of a session to ensure they have worked on all goals. These data can also provide information about how to adjust teaching based on performance. For example, if a child does not perform well on a maintenance skill, teaching an acquisition skill may need to be temporarily put on hold until the maintenance skill can be confirmed. Across sessions, data are summarized and transferred to a Data Summary Sheet so overall progress can be effectively monitored. The ESDM manual does not specify any other data summary methods, such as graphing; however, many sites graph data over time for ease of review. Once data are summarized, the information is used to make decisions regarding treatment format and structure based on decision trees available in the manual. ESDM specifies an interval recording procedure in which the clinician stops briefly every 15 minutes and documents presence or absence of correct responding on skills that were targeted. In this way, targeted skills are recorded four times during a 1-hour session, yielding a uniform data set that can be evaluated across sessions. Detailed information is provided in the ESDM manual about how to code behaviors based on child performance (e.g., nonresponse, incorrect response, correct response; Rogers & Dawson, 2010). As with all NDBI, ESDM’s naturalistic approach means that data collection must be feasible in the natural environment. This data collection method is used because it only requires brief pauses in treatment every 15 minutes, and otherwise, the clinician can focus solely on intervention. Such an approach may be particularly useful when working with very young children whose high energy level and rapidly shifting attention can make the pacing of intervention quite fast. There are several advantages to the data collection method used in ESDM. Because it was developed specifically for use in the natural environment, it is very user friendly. It uses premade data sheets, and it can be used across developmental domains (i.e., it is not just focused on one developmental area, such as language). It also includes a simple way to track both maintenance and acquisition tasks. Challenges with this data collection method may include concerns about areas where it lacks specificity. For example, this method does not include detailed information about any error correction methods used. Its lack of trialby-trial information makes it challenging to evaluate learning, error patterns, and trajectories. For example, a child may demonstrate a skill once within a 15-minute time interval over multiple days, thus getting credit for the skill but not actually increasing the frequency or duration with which that skill is used. However, because all data collection methods have pros and cons, it may be useful to consider the ESDM method as being very feasible and user friendly while also remaining open to adding other more specific data collection methods when needed.

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Classroom Pivotal Response Teaching CPRT has a comprehensive data collection system in its manual, both with methods for daily use and methods for tracking progress over time in accordance with individualized education program (IEP) standards (Stahmer et al., 2011). Although this model is adapted for the school setting, much can be learned from how these procedures are modified for use in the natural environment, as well as the varied types of data they can be used to collect. As discussed previously, the CPRT manual encourages clinicians to think about the following questions when developing data collection methods: 1) What information are you trying to capture? 2) What measurement criteria are written into the goal? 3) What data are required in your setting (e.g., school, insurance)? 4) What is manageable for those who will have to collect data? and 5) What information do you need to evaluate progress and make program changes? (Stahmer et al., 2011). These general tenets of data collection are similar to those put forth in the Project DATA manual, discussed later. As with ESDM, the CPRT manual contains both data sheets for summarizing progress, as well as those for daily data collection methods. Progress can be summarized at any interval that is relevant for the treatment setting, the broadest of which is quarterly, in keeping with how often IEP goals are typically reviewed. The CPRT manual is an excellent resource for a number of types of data sheets, including those that can be used to summarize progress over various periods of time, those that range from structured (i.e., forced choice format) to unstructured (i.e., with fields to fill in), those that document presence or absence of a skill versus trial by trial, and those that can be used to take data on multiple children at one time in group settings (Stahmer et al., 2011). Again, although these methods have been developed for the school setting, they can also be adapted for use in other settings and represent one of the more comprehensive sets of data collection examples that is available across NDBI models. Advantages of the data collection methods reviewed in the CPRT manual include the multiple choices of data sheets that can be reproduced and used based on the needs of the activity and goals. Because they were developed for use in naturalistic intervention, they are also fairly easy to complete, although some do require becoming familiar with measurement systems that clinicians may not be accustomed to using. However, with some practice, these resources can prove useful in a number of settings for different goals and skill sets. Developmentally Appropriate Treatment for Autism in Toddlers (Project DATA) Although Project DATA is not reviewed as an NDBI program in Chapter 2, it is mentioned in multiple places as an intervention that is consistent with most tenets of NDBI models. Indeed, review of the Project DATA manual quickly reveals that it has merit in terms of its data collection methods, which have broad applicability in any NDBI (Schwartz et al., 2017). The Project DATA manual first highlights the reasons data are collected, including to monitor progress, evaluate programming, communicate with others about the child’s performance, identify phases of learning (mastery, generalization, maintenance), and maintain compliance or practice standards. Certainly, these are uses that would apply to all NDBI models.

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Much like CPRT, Project DATA emphasizes that any data collection must be intentionally selected with the earlier discussed questions in mind. Project DATA notes that regular and reliable data collection is important and that data should be analyzed soon after they are collected through effective summarization methods. Although this program has a focus on visual inspection of graphs, the summarization method must be feasible; therefore, tables, matrixes, and other forms of summarizing data may also be acceptable as long as the data are displayed in such a way that they can be used for regular data-based decision making. In Project DATA, at least five data points are required before making programming changes, and 5–10 data points are recommended before making the subsequent set of changes. The Project DATA manual includes a number of data sheets that can be used for a variety of purposes, including trial-based daily data sheets with and without graphing, a daily data sheet (not trial-based), a task analysis data sheet, and a weekly data sheet (Schwartz et al., 2017). Each of these forms of data collection may serve different purposes; the manual encourages clinicians to think about the following questions when developing a data sheet: • Where will the data sheet be used? • What is the best way to organize the data sheet to meet the data collection need (e.g., by day, by activity, by behavior or goal)? • What will the data sheet look like? • Does the data sheet make sense to those who will use it? Like CPRT, an advantage of the data collection systems reviewed in the Project DATA manual includes the large number of reproducible data sheets that can be used across settings to track a broad range of behaviors. The format of these data sheets would likely be familiar to most clinicians with an ABA background and is also easy to learn. The data sheets that track a number of behaviors on one page lend themselves particularly well to the natural environment because no flipping between data sheets is required. Disadvantages of the data methods proposed in Project DATA include that most of the methods are trial by trial, which can be laborious in the natural environment, and that graphing appears to be the best summarization method, which can pose challenges in some settings. Project ImPACT Project ImPACT (Improving Parents as Communication Teachers) does not include as much detail regarding data collection methods as other NDBI, such as ESDM. The manual states that a range of data collection methods can be relied on, and it includes an example data sheet for recording child performance on specified learning targets within a treatment session (Ingersoll & Dvortcsak, 2010a, 2010b). The primary data collected on this sheet are goals targeted, child performance, and type of prompt used. How child performance should be evaluated (e.g., trial by trial, probe) is not specified, leaving the details up to individual clinicians or parents. As such, similar to Enhanced Milieu Teaching (EMT) and Pivotal Response Treatment (PRT), this model relies more heavily on clinician experience with data collection and analysis procedures.

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Because Project ImPACT is heavily focused on parent training, there are two parent treatment fidelity data sheets in the manual that provide significantly more detail than the child-focused data sheet (Ingersoll & Dvortcsak, 2010a, 2010b). These data sheets require clinicians to make ratings of parent performance on a 5-point Likert scale, ranging from low to high treatment fidelity, across a large number of specific skills that are associated with treatment techniques. For example, within the area of following the child’s lead, parents are rated on specific skills, including 1) lets the child choose the activity, 2) is face to face with the child, and 3) joins in the child’s play. Two treatment fidelity data sheets are provided: one that is used when parent training is conducted individually and one for group-based parent training. Other NDBI, such as CPRT, also include data sheets to assess treatment fidelity. The manual for Project ImPACT also notes that although live data collection is important, it can also be challenging when working in the natural environment. In this NDBI model, periodic videos of treatment should be made, and treatment time should be spent reviewing these videos with parents for training purposes. When this more detailed review is taking place without the child present, treatment fidelity data can be collected more easily in addition to any child target behaviors the clinician may wish to score during this video review session. Because a broad range of data collection methods are used to track child target behaviors in Project ImPACT, pros and cons can only be discussed in terms of the treatment fidelity measures used in this model. Much like ESDM and CPRT, a significant advantage of the treatment fidelity measures in this model is that they are premade, user friendly, easy to understand, and generally efficient because they do not require trial-by-trial scoring. Parent treatment fidelity measures are also relatively rare in both NDBI and the broader field of ABA, making these tools unique and useful in a modified form for scoring treatment fidelity of similar NDBI models. The primary disadvantage of this treatment fidelity scoring system is the lack of trial-by-trial data, which can yield more specific information that is helpful; however, in our experience, these data are so challenging to obtain during parent training that the advantages of this checklist make it a very efficient tool. Enhanced Milieu Teaching In the literature on EMT, data collection methods used in research are the primary focus, although some methods that are more clinician friendly are also discussed (Hancock & Kaiser, 2012). Given the focus on communication targets, most data collection in EMT is focused on these goals. In research, EMT uses comprehensive assessment methods (e.g., standardized measures, parent report measures) as well as complicated language analyses methods, such as the Systematic Analysis of Language Transcripts (SALT), which relies on transcription of language samples and then calculation of variables such as mean length of utterance (MLU; Hancock & Kaiser, 2012). Although these methods are too labor intensive and complex for clinical practice, EMT clinicians have adapted certain portions of them to be more user friendly and efficient. For example, data are routinely collected during treatment sessions on spontaneous, imitated, and prompted communication using operational definitions. Functional use of language is sometimes evaluated by asking parents to

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identify rote or stereotyped speech so it can be eliminated from the analysis, especially when calculating MLU. Data are collected by listing communication targets and then either recording examples of each target or tallying frequency. The combination of both types of data has advantages because it provides information on both frequency and variety in speech. Depending on individual child goals, data may also be collected on variables such as communication function (e.g., comment vs. request) and other characteristics of language (e.g., scripted vs. spontaneous speech). Because most data are collected using frequency recording, graphing is then used to summarize the data and make programming decisions. In EMT, data are often collected on both parent use of treatment strategies (treatment fidelity) and child communication targets. Although EMT data collection is not as clearly spelled out as some of the data collection methods discussed previously, it is nonetheless an intuitive and straightforward approach to data collection that is consistent with ABA intervention overall. It is also very similar to the strategies used in PRT, which are discussed next. Pivotal Response Treatment PRT uses data collection methods that are very similar to those outlined for EMT (Koegel & Koegel, 2006). PRT data are most commonly taken on operationally defined target behaviors, such as spontaneous, imitated, prompted, and stereotyped speech. Representative samples of behavior or probes are more commonly gathered in PRT than trial-by-trial data across a treatment session. For example, a common method used in PRT is to transcribe a 10-minute language sample and code the language in vivo by function (e.g., behavior regulation vs. joint attention), including prompt levels (e.g., independent vs. [model] prompted), variation (e.g., number of different words used vs. frequency of functional utterances), and frequency (e.g., number of words or number of utterances). As in EMT, these procedures are also readily adapted depending on child goals. Because PRT sometimes consists of weekly parent training sessions, data collection methods may be adapted to this session frequency. For example, a language sample such as the one described previously may provide broader data that are more useful than trial-by-trial data from week to week. Parent-collected data are also commonly used in PRT because clinic sessions may only occur weekly. Data collection procedures may need to be modified to make them user friendly for parents. For example, it may be more feasible for a parent to take data on one target behavior for a short time period (e.g., 10 minutes) than to have him or her monitor a behavior throughout the day. In PRT, data are typically graphed or visually represented in some way, similar to EMT. PRT also incorporates measures of parent treatment fidelity, which can be scored during sessions or later by video review. There are several parent treatment fidelity measurement strategies outlined in the literature, including procedures for coding videos for the PRT intervention strategies and checklists such as the one described in the Project ImPACT manual. Parents may also be able to take data on treatment fidelity using checklists or treatment logs. For example, checklists that ask parents to rate their use of the PRT strategies have been used, as have logs where parents give a broad estimate of how many trials they provided during each major routine of the day (e.g., getting ready in the morning, after school, bedtime routine). Parents have also been asked to take data on 10 minutes of PRT practice per day as one way to get a representative sample of their PRT treatment fidelity.

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Like EMT, PRT data collection is straightforward and primarily relies on use of ABA procedures in the natural environment. PRT does not have any published or widely used data collection methods, and clinicians will need to develop their own data sheets and data analysis methods when using these treatment models.

Joint Attention, Symbolic Play, Engagement, and Regulation (JASPER) Data collection methods for JASPER (Joint Attention, Symbolic Play, Engagement, and Regulation) are not as clearly spelled out in the literature as other models (Kasari, Paparella, Freeman, & Jahromi, 2008). There are some general guidelines available; however, at this time, clinicians targeting the joint attention and play skills addressed in this model need to rely on data collection methods from other models or from the field of ABA. JASPER specifies that the mastery criteria for treatment goals are typically uniform across joint attention targets and are set at independent performance of the behavior three times across two sessions. Skills with less frequency or that require more prompting are considered emerging. Data are collected as a frequency count during sessions, and prompt levels are also recorded. One data collection procedure unique to JASPER is that it suggests that clinicians take data on targeted and emerging skills simultaneously (Kasari et al., 2008). That is, if a skill that is not yet part of the treatment plan is observed, it should be recorded. In this way, a broad inventory of the child’s existing and emerging skills is maintained over the course of treatment. This method may be useful across NDBI and could be applied in a more targeted way when appropriate. For example, when teaching skills that may rapidly generalize to other areas, data collection on untargeted areas may be useful (e.g., when teaching pointing for joint attention, it may be useful to take data on any pointing that occurs for the function of requesting). JASPER suggests that generalization should be evaluated by having an independent observer, such as a parent or teacher, evaluate carryover of skills to other settings. Alternatively, if this is not feasible, a clinician can visit other settings to collect these data.

WHEN AND WHY DATA ARE COLLECTED Across NDBI and the field of ABA there are many types of data that may be relevant and many methods for collecting those data. In NBDI, the focus is on practical data collection strategies that can inform treatment in the natural environment and demonstrate the effectiveness of intervention strategies in both skill acquisition and behavioral reduction. Over the course of intervention, data are collected at different times and for different purposes (see Box 15.2). Data collection begins before treatment starts in order to gather baseline data that allow providers to evaluate treatment progress. It continues during treatment, both to evaluate treatment effects and to take baseline on new skills as goals are added to programming. It is also common for new reasons for data collection to emerge, such as the emergence of challenging behavior that requires functional assessment and ongoing data collection to monitor effects of subsequent treatments. Data on maintenance and generalization are considered key. The following section provides a number of considerations that may be helpful when writing treatment plans and thinking about data collection.

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Ready, Set, Implement! BOX 15.2: Key contexts for data collection Data should be taken for the following phases or situations: • Initial assessment and/or baseline • Acquisition skills • Emergence of challenging behaviors • Maintenance skills • Generalization • Treatment fidelity

Initial Assessment Most treatment programs begin with some sort of initial assessment. Described in Chapter 10, many tools are commonly used during initial assessments (e.g., behavioral observation methods, standardized assessments, checklists, curricular materials), and these can be used effectively for treatment planning and goal setting. Because these tools may not yield the kind of data behavior analysts use to evaluate treatment effects, clinicians should also collect baseline data on target behaviors being addressed in treatment. For example, using a standardized intelligence or achievement test may provide useful information, but it will not yield information that will facilitate evaluation of treatment effects during the first weeks of treatment. Initial assessment tools can provide rich information across a broad range of developmental domains, and once clinicians set treatment goals, they should collect baseline data before implementing specific interventions. Baseline Although part of treatment planning may involve taking baseline data on individual target behaviors, baseline data are not necessarily only collected at the beginning of treatment. Any time a new skill is introduced or a new behavior emerges that is the focus of behavioral reduction procedures, clinicians must first collect baseline data. There are many strategies for taking baseline data and for deciding on criteria before moving into the treatment phase for a given goal. For example, for some skills, baseline can be assessed once (e.g., across one treatment session), and if it does not meet criteria (e.g., 80%), treatment is initiated. In contrast, it may be more useful to take baseline data across multiple sessions for some behaviors to demonstrate stability of data before moving on to treatment. The nuances of how to select baseline data collection measures are well covered in the ABA literature. Most important, baseline data must not be overlooked in order to evaluate the effects of NDBI treatments as they are introduced. Once the intervention is underway, data are systematically collected on an ongoing basis throughout the duration of the program. These progress data, capturing the child’s performance on specific target skills, are used to monitor learning and make any necessary adjustments to the intervention.

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Data on Skill Acquisition Target Behaviors Once a program has started, data should be collected during ongoing treatment in order to monitor progress on skill acquisition and evaluate the response to treatment. As a recap, skills that are new or continue to be difficult for the child are called acquisition skills. Data collection methods for skill acquisition may include trial-by-trial recording of a child’s response to each opportunity, interval recording of child progress during a session, or probes of specific behaviors to examine progress at specific time periods. The method of data collection should be linked to the child’s goals and then used to adapt the intervention to the specific needs of the child and family. Several methods for collecting data during treatment are outlined later in the chapter. For other considerations and uses of data collection, see Box 15.3. Data Collection for Use Within Versus Across Sessions As described previously, data collection can serve several functions and, therefore, can be used both during sessions and across sessions. One prominent way data are used during a session is to assess what level of prompting should be used or if prompting should be adjusted depending on the child’s response pattern. In ESDM, data are used during sessions to track which skills have been targeted so clinicians can monitor whether teaching needs to be adjusted over the course of a session to ensure all goals are worked on. Data are also used to track progress on target behaviors across sessions. Across sessions, data collection informs about the overall effectiveness of the treatment and allows for the determination of when goals are met or not met and when treatment should be adapted or ended. Data on Prompt Type and Level Data on prompt type and level are often collected to track progress toward independence. For example, when utilizing most-to-least prompting procedures where assistance is systematically reduced from session to session (or trial to trial) until the antecedent stimuli reliably evoke the target behavior, data on prompts are essential to guide the intervention. Many of the NDBI models, including ESDM, Project IMPACT, EMT, and CPRT, include prompt type in their data sheets. In addition to the type of prompt used, the prompt level is often also recorded. The level of prompting is usually differentiated as a full or partial prompt, which

BOX 15.3: Data collection during ongoing treatment Data collection during ongoing treatment is used for the following: • Evaluating response to intervention • Troubleshooting when treatment is not working • Monitoring skill acquisition versus generalization • Deciding when a goal is met • Adjusting treatment sessions (planning the session, as in ESDM, or modifying the prompt level according to progress)

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Prompt level: F, full; P, partial

primarily applies to physical prompting. A partial physical prompt indicates guidance is provided to help the child complete a portion of a step, whereas in a full physical prompt, guidance is provided to complete the entire step. Recording prompt level allows for additional detail, which is especially useful when focused on prompt fading. Figures 15.1 and 15.2 illustrate how prompt level and type can be recorded as part of data collection.

Prompts

Prompt type: Ph, physical; V, verbal Vs: visual; G, gestural I, independent (no prompt)

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Figure 15.1. Sample Data Sheet for recording of prompt level and type.

Data on Maintenance of Skills Once the student meets initial mastery criteria, clinicians should collect data on maintenance of target behaviors. Tasks that the student has mastered and can produce consistently and easily are called maintenance tasks, and maintenance refers to the lasting change in behavior after intervention ends. Maintenance of target behaviors can be monitored through probes. Probes are used occasionally but systematically to assess the maintenance and generalization of skills or target behaviors. Probes can occur during intervention or after intervention has ended. Probing during instruction can assist the practitioner or parent in assessing the generalization or maintenance of a skill and adjusting instruction if needed. Probes after intervention ends help to determine the maintenance of target behaviors. When deciding when to conduct probes, several factors may influence the timing and frequency, including the severity of the behavior and the maintenance of the behavior to date. Most data sheets used in ABA allow for the collection of both skill acquisition data and maintenance data, making it easy to collect acquisition data on one skill and maintenance data on a separate skill on the same data sheet. An example of a trial-by-trial data sheet that allows for the selection of maintenance or acquisition skill is illustrated in Figure 15.3, and an example of a less structured data sheet is shown in Figure 15.4.

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+ − NR

+ − NR

+ − NR

+ − NR

+ − NR

+ − NR

Prompt Level/ Type

PP

FP

G

FV

PV

Prompt Level/ Type

F = Full P = Partial

V Verbal

Vs Visual

G Gestural

P Physical

NR = No Response Figure 15.2. Sample Data Sheet for recording prompt level and type by trial.

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Acquisition skill: Maintenance skill: Trial

1

2

3

4

5

6

7

8

9

10

Target

M A

M A

M A

M A

M A

M A

M A

M A

M A

M A

Response

+ _

+ _

+ _

+ _

+ _

+ _

+ _

+ _

+ _

+ _

NR

NR

NR

NR

NR

NR

NR

NR

NR

NR

Prompt

KEY: M, Maintenance Skill; A, Acquisition Skill; NR, No Response. Figure 15.3. Sample Data Sheet to record one Acquisition Skill and one Maintenance Skill simultaneously.

Data on Generalization of Skills Generalization refers to whether the target behavior is exhibited in settings other than where the instruction or intervention occurred. This means that a child who can use certain skills under one set of circumstances is able to use the same skills under different conditions. Data must ultimately reflect Data Sheet that the child can produce the same response independently across contexts in varied ways. Data collection on generalization can be obtained through generalization probes or by collecting data as treatment is implemented by various individuals (e.g., teachers, parents, staff) and in various settings (e.g., school, home, community). Some NDBI, such as CPRT, include a specific data sheet to collect data on generalization of skills. The CPRT generalization probe allows for the observer to select three materials or activities, three settings, and three partners as important for the generalization of the skill. The observer selects the Figure 15.4. Sample Data Sheet with record for multiple acquisition material, the setting, and the and maintenance skills. +

Date

Acquisition skills

−

+

Most frequent prompt level/type (If any)

Maintenance skills

KEY: + = Responds independently to all or almost all (at least 80%) opportunities √ = Responds independently to most opportunities (50%) but requires support for some opportunities − = Requires support to respond to all or almost all opportunities. Prompt level: F, full; P, partial.

Prompt type: Ph, physical; V, verbal; Vs, visual; G, gestural.

Naturalistic Developmental Behavioral Interventions in the Treatment of Children with Autism Spectrum Disorder edited by Yvonne Bruinsma, Mendy B. Minjarez, Laura Schreibman, and Aubyn C. Stahmer. Copyright © 2020 by Paul H. Brookes Publishing Co., Inc. All rights reserved.

−

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Applications of NDBI Strategies

Generalization Data Sheet Indicate the date, setting, and communicative partner, which you will probe the skill. Circle the child’s response as C, correct ; I, incorrect ; NR, no response.

Skill:

Date

Setting

Communicative Partner

Child response C

I

NR

C

I

NR

C

I

NR

C

I

NR

C

I

NR

partner and collects data on 1) whether the skill is correct, 2) whether the skill is incorrect, or 3) whether no response occurred. Generalization data collection can be obtained with data sheets used for skills acquisition or with specific data sheets such as the one in Figure 15.5. Data on Challenging Behaviors

Data collection is usually ongoing for challenging behaviors and may include frequency, duration, intensity, and rate of challenging behaviors. In addition, more detailed information is collected by taking A-B-C data (antecedent-behaviorconsequence). A common Figure 15.5. Sample Generalization Data Sheet across settings and communicative partners. way of collecting A-B-C data is to note the start and end time of the behavior, along with detailed notes from which antecedents and consequences can be extracted later (see Figure 15.6). Alternatively, data sheets can be prepopulated with common antecedents and consequences to allow for easy checking off (Figure 15.7). Many other data collection methods for challenging behavior exist in the ABA literature and may include strategies that are specific to frequency, duration, and/or intensity data, depending on the behavior being targeted. C

I

NR

C

I

NR

C

I

NR

C

I

NR

C

I

NR

Naturalistic Developmental Behavioral Interventions in the Treatment of Children with Autism Spectrum Disorder edited by Yvonne Bruinsma, Mendy B. Minjarez, Laura Schreibman, and Aubyn C. Stahmer. Copyright © 2020 by Paul H. Brookes Publishing Co., Inc. All rights reserved.

Data on Treatment fidelity It is imperative that data are collected on intervention fidelity, or the extent to which the treatment is implemented as designed. This means no changes or omissions to the planned intervention occur during treatment. Data on treatment fidelity are often measured with checklists in which all components or steps of an intervention are listed. The observer then checks off all the components used or steps taken, and a percentage can be calculated by dividing that by the total number of components or steps in the intervention. A more sophisticated way of measuring treatment fidelity is by rating each treatment component or strategy on a Likert scale and setting criterion for achieving treatment fidelity, as illustrated in Figure 15.8. It is important to collect treatment fidelity data for anyone implementing treatment, including professionals, parents, teachers, and staff. As previously mentioned, some of the NDBI models, such as Project ImPACT and PRT, include data sheets specifically designed to obtain parent treatment fidelity data, and these

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sheets can easily be modiAntecedent-Behavior-Consequence Data Sheet fied to take treatment fidelity data on other implementers. Taking treatment fidelity data helps identify whether the parents, teachers, or staff have sufficient training to implement the intervention independently or if more training and support are required. In addition to checklists and Likert scales, treatment fidelity has also been scored using trial-by-trial scoring in models such as PRT (e.g., Hardan et al., 2015). In trial-by-trial scoring, each trial is scored for each treatment component, and then a percentage of correct implementation for each component is calculated, as well as a percentage for the overall correct implementa- Figure 15.6. Sample A-B-C Data Sheet with fill in the blanks. tion. Although this method has been successful in research, in practice it is time consuming and challenging unless very clear operational definitions of each behavior are available. A recent study found that more general rating scales, such as those described previously, have very high agreement with trial-by-trial coding and therefore may be sufficient for clinical settings (Suhrheinrich et al., 2019). As such, it may be more practical to use trial-by-trial scoring in special circumstances only. For example, if a child was struggling to gain a skill and the clinician felt there were inconsistencies in parent treatment adherence but could not pinpoint them, trial-by-trial scoring could be useful as a clinical tool to further assess these challenges. Date/Time

Activity/ Setting Event

Antecedents

What happened right before the behavior

Behavior

What the behavior looked like

Consequences What happened after the behavior

Date:

Start: Stop: Date:

Start: Stop: Date:

Start: Stop: Date:

Start: Stop: Date:

Start: Stop: Date:

Start: Stop: Date:

Start: Stop:

Naturalistic Developmental Behavioral Interventions in the Treatment of Children with Autism Spectrum Disorder edited by Yvonne Bruinsma, Mendy B. Minjarez, Laura Schreibman, and Aubyn C. Stahmer. Copyright © 2020 by Paul H. Brookes Publishing Co., Inc. All rights reserved.

TYPES OF DATA AND MEASUREMENT SYSTEMS Measurement systems for data collection are extensively described in the ABA literature (e.g., Cooper et al., 2013), and this chapter can only provide a brief overview of types of data and measurement decisions. Table 15.1 contains common types of data that are collected when using behavior analytic interventions that may lend themselves well to use with NDBI. Frequency It is important to calculate both correct and incorrect response rates in order to assess skill development. Increasing rates of correct responding may indicate a child is improving, but only if the rate of incorrect responses is decreasing.

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Applications of NDBI Strategies

Antecedent-Behavior-Consequence Data Sheet Child Code

Operational Definition:

Behavior

Date: Start Time Date:

Start time:

Antecedent What happened before

Behavior Observable, specific description

Consequence What happened after

qq Given instruction or prompt

qq Yelling

qq Additional prompts

qq Whining

qq Asked to wait

qq Throwing

qq Blocked physical aggression

qq Redirected

qq Spitting

qq Told no

qq Walked away

qq Given praise

qq Eloped

qq Physical touch (hug/high five)

qq Aggression:

qq Given preferred item

qq Self-injurious behavior:

qq Given non-preferred item qq Unintentional ignoring

End time End time:

qq Blocked self-injurious behavior qq Ignored qq Moved away qq Given item or activity qq Removed item or activity qq Other:

qq Property Destruction:

qq Intentional ignoring qq Other:

Date:

Start time:

qq Given instruction or prompt

qq Yelling

qq Additional prompts

qq Whining

qq Asked to wait

qq Throwing

qq Blocked physical aggression

qq Redirected

qq Spitting

qq Told no

qq Walked away

qq Given praise

qq Eloped

qq Physical touch (hug/high five)

qq Aggression:

qq Given preferred item

qq Self-injurious behavior:

qq Given non-preferred item qq Unintentional ignoring

qq Blocked self-injurious behavior qq Ignored qq Moved away qq Given item or activity qq Removed item or activity qq Other:

qq Property Destruction:

qq Intentional ignoring qq Other:

Naturalistic Developmental Behavioral Interventions in the Treatment of Children with Autism Spectrum Disorder edited by Yvonne Bruinsma, Mendy B. Minjarez, Laura Schreibman, and Aubyn C. Stahmer. Copyright © 2020 by Paul H. Brookes Publishing Co., Inc. All rights reserved.

Figure 15.7. Sample A-B-C Data Sheet with prepopulated checkboxes.

End time:

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377

Fidelity Data Sheet To achieve fidelity, the adult (therapist, parent) must receive a score of 4 or 5 on each of the technique summary scores that are being measured. Low fidelity 1

2

Not implemented throughout session

Implemented occasionally but misses majority of opportunities

3 Implemented up to half of the time but misses many opportunities

Implemented a majority of the time but misses some opportunities

Intervention technique

Summary

High fidelity 5

4

Implemented throughout the session

Fidelity

1 2 3

4 5

1 2 3

4 5

1 2 3

4 5

1 2 3

4 5

1 2 3

4 5

1 2 3

4 5

1 2 3

4 5

1 2 3

4 5

1 2 3

4 5

1 2 3

4 5

Naturalistic Developmental Behavioral Interventions in the Treatment of Children with Autism Spectrum Disorder edited by Yvonne Bruinsma, Mendy B. Minjarez, Laura Schreibman, and Aubyn C. Stahmer. Copyright © 2020 by Paul H. Brookes Publishing Co., Inc. All rights reserved.

Figure 15.8. Sample Treatment Fidelity Data Sheet for multiple NDBI techniques.

Notes

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Applications of NDBI Strategies

Table 15.1. Types of data Type of data Frequency Rate

Duration

Latency

Intensity

Definition

Uses

The number of Used for behaviors with occurrences of a discrete beginnings and behavior endpoints The number of Used for behaviors with occurrences of a discrete beginnings and behavior identified endpoints when the in a ratio of time length of sessions varies The amount of Used for behaviors with time in which a discrete beginnings behavior occurs and endpoints and the primary concern is the length of time a child engages in a behavior The measure of the Used for behaviors with time between the discrete beginnings and presentation of endpoints when the a stimulus and clinician is interested in the start of the how long a child takes response to begin performing a particular behavior once the opportunity has been presented The force with which Most often used to a response is measure the intensity or emitted severity of behaviors

Example The number of times a child initiated during a 10-minute probe The number of words read per minute across probes of varying lengths How much time passes between the beginning and the end of a tantrum

The time elapsed between the onset of the question “Hi, what is your name?” and the response “My name is Emily”

Measuring severity of aggressive behaviors: caused no injury, caused minor injury but did not break the skin, caused minor injury but drew blood, caused major injury that required medical attention

For example, when toilet training, increased voiding in the toilet in the presence of increasing accidents as well does not represent the same type of progress as increasing voids without accidents. Rate Rate is a commonly used measurement in ABA and is calculated by taking the frequency of a behavior and dividing that by the length of time of an observation, resulting in a ratio. A general guideline is that the unit of time stays consistent across observations so that rates can be compared; however, length of observation periods can vary. For example, if a student initiates conversations with peers three times during a 20-minute recess period and five times during a 45-minute recess period, the rates of initiation would be 0.15 per minute and 0.11 per minute, respectively. When lengths of observation periods vary, clinicians should annotate the duration of the observation period as well in order to have a complete understanding of performance. For example, two children can both perform jumping jacks at a rate of 0.25 per minute. However, one student is performing at this rate over the course of 10 minutes, whereas the other student is performing at this rate for 2 minutes.

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Duration There are two common ways to measure duration: duration per session and duration per occurrence. For duration per session, the total amount of time a child engages in behavior is recorded. For example, if in an hour session, a child engages in tantrums for 6 minutes, 8 minutes, and 4 minutes, the total duration of the tantrum behavior would be 18 minutes. Another way to use duration measures is to measure per occurrence of behavior. For example, a child might have a goal to stay seated for dinnertime but frequently gets up. The amount of time the child stays seated before getting up could be recorded. This may better inform whether staying seated is increasing over time. Latency Latency is used to measure how long it takes for a child to respond once an opportunity has been presented. Latency is often reported as the average of the latency measure per observation period. For example, if a child responds within 1 second, 2 seconds, and 3 seconds to a question from a peer within the observation period, the average latency would be 2 seconds. Intensity Intensity is sometimes referred to as severity, or the magnitude or force of a behavior. Intensity can be helpful in measuring various behaviors, including selfinjurious behaviors. For example, clinicians might measure the frequency of biting occurrences, but measuring intensity can provide valuable information about the severity of the biting. Did the biting leave a red mark or did it break skin? Intensity may also be used to measure the voice volume of responding. Was the child barely audible? If so, does that count as an occurrence of responding? Another way to think about intensity is to ask, “To what degree is the behavior present?” When measuring intensity, it is important that guidelines are put in place that clarify levels of intensity so that measurement is consistent across observers. To the extent possible, these guidelines should consist of clear operational definitions. For example, clinicians might define biting severity, as mentioned previously, by defining amount or type of tissue damage associated with the behavior (e.g., red mark that is gone within a minute is low intensity, whereas broken skin is high intensity). Methods of Measurement Once the type of data to be collected is selected, it is time to choose a measurement system. Careful selection is less of an issue when using rate and frequency because these can simply be tallied without any additional tools. For measurements such as duration and latency, instruments such as stopwatches or phone applications are generally used. Technology continues to advance, and collecting and graphing data on tablets, phones, and laptops is becoming more common. Once the data collection method has been selected, clinicians must address additional questions, such as whether data will be measured on each trial (trial by trial), on a sample of trials, or a number of other ways, outlined in Table 15.2.

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Applications of NDBI Strategies

Table 15.2. Method of measurement Method of measurement Permanent product

Time sampling

Interval recording

Definition

Uses

This method involves It is used when the selecting a product or observer cannot result that indicates always be present the occurrence of the when the behavior target behavior, and a occurs. response is recorded if the product is or is not produced. This is a variation of It is used because the interval recording in observer does not have which the behavior is to observe the behavior recorded if it occurs for the entire interval, at any time during the just a portion of the interval. interval or at a specific time in the interval. This method documents It is used for behaviors whether a behavior with no clear occurred during a beginning or end particular period. (continuous) and/or There are two types that occur at a high of interval recording: frequency. whole and partial interval.

Task analysis

The process of breaking a skill down into smaller, more manageable components.

Rating scale

This method estimates the degree to which a symptom or characteristic is present. It is typically presented with a Likert scale.

It is used to break complex tasks into a sequence of smaller steps or actions. It is used for many skills, including daily living skills and desensitization. It is used for rating the severity of the behavior.

Example Clinician calculates words read per minute from an audio recording of a child reading aloud.

If a child is out of his or her seat at any time during an interval, it is counted as one occurrence of out-ofseat behavior. Whole interval: A child independently played during an entire 30-second interval. Partial interval: A child independently played during 15 seconds of a 30-second interval. Clinician breaks down each step involved in tying the child’s shoes or brushing his or her teeth.

Motivational rating scales are used to measure symptoms.

Continuous Versus Discontinuous Methods of collecting data are generally either continuous or discontinuous measurement. Collecting data on every trial (trial by trial) is a form of continuous measurement, which provides the most complete description of an individual’s performance. However, collecting data on every trial might not be feasible across professionals, teachers, and parents. In addition, collecting data on every trial can have other setbacks, such as increasing the duration of sessions and decreasing a child’s overall exposure to teaching (i.e., time spent in data collection is not spent teaching) and interrupting reciprocity of interactions during treatment. Continuous data collection can also be challenging in the natural environment. Discontinuous measurement, on the other hand, involves recording data on only a subset of trials. For example, instead of recording every response during a 10-trial session, clinicians may record data on only the first 3 trials or on only a portion of an interval. Although discontinuous measurement might be more feasible, it can produce an incomplete record of performance.

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Permanent Product Permanent product measurement refers to the measurement of real or concrete objects or outcomes resulting from a behavior after the behavior has occurred. All of the types of measurement described in this chapter can be used in permanent product measurement. In a classroom, a permanent product might be the number of worksheets completed in a week or an audio recording of the student reading. At home, this may be the number of dishes washed or the number of puzzles completed. This type of measurement might be especially helpful for teachers who have to attend to all students during instruction but can judge a student’s performance by how much work the student completed. There are several advantages to this type of measurement, including that it provides a more complete picture of the observation, and data for several behaviors can be collected by reviewing the permanent product multiple times. However, there are some factors to consider before using permanent product measurement. If treatment decisions occur during a session (e.g., level of prompting), then realtime measurement is necessary. Clinicians must also consider how the permanent product might affect the behavior, for example, if a video recording affects how a child interacts with the therapist. Time Sampling (Interval Recording) Time sampling is used when it is not feasible to continuously observe a child. There are three types of time sampling: whole-interval recording, partial-interval recording, and momentary time sampling. Whole-interval recording is used to measure continuous behaviors, such as on-task behavior. An observation period is divided into small intervals, and then the observer records whether the behavior was present for the entirety of each interval. For example, if an interval lasted 10 seconds and the student was on-task for 8 seconds, that interval would not be recorded for on-task behavior. The clinician reports the percentage of intervals in which the target behavior was present for the entire duration. For example, if a student was on-task for 7 out of 10 intervals, his or her percentage would be 70%. Because any deviation from the target behavior during an interval results in the entire interval being scored as negative, whole-interval recording often underestimates the actual percentage of time spent engaged in the target behavior. Partial-interval recording is used when the observer is interested in measuring if the target behavior occurs during any point of the interval. For example, if a student exhibits social engagement behaviors for 2 seconds of a 10-second interval, the observer would record that interval as correct. Partial-interval recording is useful for behaviors that may be challenging to count but where pauses in the behavior are appropriate (e.g., remaining engaged in conversation). Because credit for the entire interval is given if the behavior is present at all, partial-interval recording may overestimate the actual percentage of time spent engaged in the target behavior. Momentary time sampling is used to measure if the target behavior occurs at the end of each interval. The difference between this type of sampling and wholeor partial-interval recording is that the observer must continuously pay attention in whole- and partial-interval recordings, whereas in momentary time sampling, the observer only records if the behavior occurs at the end of the interval. Momentary time sampling is a useful tool in NDBI because continuous observation can be challenging while also trying to watch the time interval and record data accurately.

382

Applications of NDBI Strategies

Interval Recording Data Sheet Behavior Whole interval: + = Behavior is continuous during the interval Partial interval: + = Behavior occurs even once during the interval Momentary: + = Behavior occurs at the end of the interval

Date Interval Length Intervals: 1 2 3 4 5 6 7 8 9 10 % Activity

Figure 15.9. Sample Interval Recording Data Sheet.

For example, when collecting data on sitting during circle time, data could be collected by rating the behavior every 5–10 seconds, which allows the rater to observe the child, watch the stopwatch, and code data simultaneously. Figure 15.9 illustrates how the different methods of time sampling can be used with the same data sheet. Naturalistic Developmental Behavioral Interventions in the Treatment of Children with Autism Spectrum Disorder edited by Yvonne Bruinsma, Mendy B. Minjarez, Laura Schreibman, and Aubyn C. Stahmer.

Copyright © 2020 by Paulis H. Brookes Co., Inc. All reserved. Task Analysis Task analysis the Publishing process ofrightsbreaking a skill down into smaller, ordered components, which can then be taught to an individual (see Chapter 13 for a detailed description). Task analysis is frequently used to teach self-help skills (e.g., brushing teeth, washing hands), to teach adaptive skills (e.g., counting money, buying groceries), and for desensitization (e.g., going to the dentist). When developing a task analysis, the clinician should remember the skill level of the person so the number of steps and wording match the individual’s developmental level. Once a task analysis is developed, there are a number of chaining procedures that can be used to teach the skill that are beyond the scope of this chapter but are readily available elsewhere (e.g., Cooper et al., 2013). Task analysis data

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collection and measurement provides ongoing determination of components of the chain that have reached mastery level. In the single-opportunity method, the clinician assesses the individual’s ability to perform each step in the chain in the correct order; if only the first 3 steps of a 10-step task analysis are performed correctly, the teacher stops the assessment, and the rest of the steps are marked as incorrect. In the multiple-opportunity method, the teacher assists the student in completing the step if it is performed incorrectly and allows for the student to continue with the chain; subsequent steps that are performed correctly would be marked as correct. Example data sheets for task analysis are shown in Figures 15.10 and 15.11. Rating Scales Rating scales are considered indirect assessments of behavior and can be used for several purposes, including as part of a functional assessment. Rating scales are often used in school settings to obtain information from several informants, including teachers and parents. Rating scales typically assess a wide range of behaviors and should have strong psychometric properties. In addition to rating behaviors, rating scales usually include items that assess the extent to which certain behaviors impede the quality of life of the individual or family. A disadvantage of rating scales is that there is no direct measurement of behavior, potentially limiting the usefulness and applicability. Box 15.4 summarizes some of the general reminders to think about when thinking about data collection.

DATA COLLECTION IN THE NATURAL ENVIRONMENT Though NDBI can be provided in a clinic setting, they are designed for the individual’s natural environments, and as such, data collection also takes place in natural environments. Over the course of intervention, data are collected in a variety of contexts to ensure the child is learning the necessary skills when and where those skills are needed. In other words, it is important to collect data on the child’s performance in different settings (e.g., home, school, clinic, community), with different individuals (e.g., parent, siblings, teacher, therapists), across various activities (e.g., free play time, bath time, mealtime, structured tasks) and situations within the same environment (e.g., one-on-one with an adult vs. in a group, when the room is noisy vs. when it is quiet), and during transitions (e.g., from mealtime to bath time, from the classroom to the playground, from one play activity to the next). This helps the team assess whether discrepancies exist between the skills the child is (and is not) using and the skills needed for successful functioning in varied, everyday environments. There are a number of challenges to data collection in naturalistic programs. The very nature of NDBI is that they are provided in natural settings. Living rooms, kitchens, backyards, local parks, school, playdates, and the grocery store are all therapeutic settings to teach skills. In addition, in NDBI, activities are fluid and shift to accommodate ongoing routines. Trying to collect sufficient data on a single skill can be difficult when the parent is playing with trains in the living room, then kicking a soccer ball in the backyard, followed by making a snack in the kitchen, before going on a shopping trip to the local store. Ensuring the adult has collected sufficient opportunities or trials to measure progress on a skill in a specific context can require careful thought about data collection methods and creativity in how treatment is implemented. Following are some considerations that may be helpful when collecting data in the natural environment.

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Applications of NDBI Strategies

Task Analysis Data Sheet Target Skill:

Dates:

% Independent

Prompting Hierarchy: I, Independent VP, Verbal Prompt IVP, Indirect Verbal Prompt GP, Gestural Prompt

M, Modeling PP, Physical Prompt NR, No Response/Refused

Naturalistic Developmental Behavioral Interventions in the Treatment of Children with Autism Spectrum Disorder edited by Yvonne Bruinsma, Mendy B. Minjarez, Laura Schreibman, and Aubyn C. Stahmer. Copyright © 2020 by Paul H. Brookes Publishing Co., Inc. All rights reserved.

Figure 15.10. Blank Sample Task Analysis Data Sheet.

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Task Analysis Data Sheet Target Skill: Shirt on

Dates: 2/12

2/15

2/18

Find tag in neck

VP

VP

I

Put shirt down with neck up and tag on top

GP

VP

VP

I

GP

I

Pull head through hole

PP

PP

M

Bring right arm through

I

I

I

Bring left arm through

I

I

I

Pull shirt down

I

I

I

57%

43%

71%

Put head in shirt

% Independent

Prompting Hierarchy: I, Independent VP, Verbal Prompt IVP, Indirect Verbal Prompt GP, Gestural Prompt

M, Modeling PP, Physical Prompt NR, No Response/Refused

Naturalistic Developmental Behavioral Interventions in the Treatment of Children with Autism Spectrum Disorder edited by Yvonne Bruinsma, Mendy B. Minjarez, Laura Schreibman, and Aubyn C. Stahmer. Copyright © 2020 by Paul H. Brookes Publishing Co., Inc. All rights reserved.

Figure 15.11. Sample Task Analysis Data Sheet with example of “shirt on”.

2/21

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Applications of NDBI Strategies

Ready, Set, Implement! BOX 15.4: Data collection strategies • • • • •

Use probing and sampling when appropriate. Use video data collection when time is available to score the videos. Develop clear and concise data sheets that appropriately measure the target behaviors. Keep data sheets simple, and collect data on multiple goals on one sheet of paper to reduce flipping through data sheets. Ensure data are summarized and analyzed frequently to help guide the intervention.

Goodness of Fit Acceptability of assessments and data collection methods is key to their success. Acceptability can be considered from several viewpoints. First, it is important that the methods being used are acceptable to those who will be collecting the data. Clinicians must consider and balance variables such as effort required, understanding of the method, and compatibility with other responsibilities. For example, if a method is easy to understand, but is too time consuming to allow the clinician to collect data simultaneously while conducting intervention, it is likely to have low acceptability. Likewise, if a method uses a relatively simple data sheet but requires complex judgements about behaviors in the moment, it may also have low acceptability. When developing data collection methods, these variables should be discussed with those who will be collecting the data to ensure goodness of fit. Acceptability must also be considered from a social validity perspective. That is, because NDBI are implemented in the natural environment, the data collection method must not be stigmatizing or interfere with the intervention. One way to assess social validity of data collection methods is to ask the family or involved individuals about the acceptability of the procedures. Clinicians can also compare the child with peers in the treatment context and evaluate how much the data collection methods will stand out from the activities of the peers and the adults who are interacting with them. How obvious data collection methods are should also be considered from a confidentiality perspective. A child at the park who is being shadowed by a clinician with a clipboard is very likely to be labeled as receiving support, which may allow others to be privy to the child’s special needs status. In these instances, discreet data collection methods are often useful, as well as data collection methods that can be conducted on common devices such as smart phones. Feasibility As mentioned throughout this chapter, the feasibility of data collection needs to be assessed before and throughout treatment because it will also influence acceptability. Feasibility and acceptability are closely related, but feasibility may require

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some additional assessment. For example, clinicians must consider the skills of the individual collecting data. Minimally trained classroom aides will have far fewer skills for handling complex data collection methods than experienced behavior technicians. Session length may also affect feasibility. For example, it may not be feasible to take trial-by-trial data across a 3-hour session, but this level of attention to detail may be easier to maintain across a 1-hour session. Likewise, frequency of behavior may influence feasibility so that high-frequency behaviors are more challenging to document than those that are low frequency. The setting in which data must be collected is also an important factor to consider. For example, data collection in the living room may be easier than data collection at the park. Furthermore, even within a setting, the activity may affect the data collection. Data collection on waiting in line for the slide may be much easier than data collection during a game of Frisbee in which the clinician is the social play partner. Parent Data Collection in Naturalistic Programs Caregiver involvement and empowerment are integral components of NDBI. After parents or other caregivers learn strategies they can use within their daily routines, it is important that they understand how they can measure their child’s progress. Parents can begin to identify skills or behaviors to change and may be able to target those skills independently. Data collected by parents provide the treatment team with information about how the child is performing without the support of a clinician; it allows the team to assess generalization and maintenance without the need for clinician presence. When using parent-mediated interventions, it can also be useful for parents to take intervention fidelity data. For example, in PRT, parents are sometimes asked to estimate the number of trials implemented within daily routines as a way of obtaining an estimate of treatment dose. For some parents, data collection comes easily, and they quickly hang data sheets on the refrigerator, carry a notebook to record data, or start making notes on their smartphone. For other parents, however, the task of data collection can be daunting and may actually seem aversive. It takes months or years to become adept at implementing NDBI while simultaneously collecting accurate data; expecting parents to master this skill set while also tending to their child’s needs and other daily responsibilities may be unreasonable. As such, special considerations may be helpful when assessing feasibility and goodness-of-fit of data collection procedures to be used by parents. A first step in engaging caregivers in the data collection process is having them actively participate in development of their child’s goals. Stakeholder buy-in is also discussed in Chapter 10. The clinician may review the intervention plan and ensure the caregiver understands each goal, why it is included in the program, and how data will be collected. It may be useful to have the parent prioritize those skills or behaviors that are most important to the family’s quality of life and select priority goals for parent-collected data, especially because it may only be feasible for a parent to track one or a small number of behaviors at a time. It may also be helpful to select behaviors that will show rapid progress, especially initially, so the parent can see the value in the data he or she is collecting. Skills or behaviors that are likely to take a long time to change or are severe in nature may be less motivating for parents to track.

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Feasibility and goodness-of-fit considerations should be evaluated with parents just as with clinicians and may include questions such as where the data sheets will be kept, whether data will be collected on paper or electronically (e.g., in a smartphone), what type of data a parent feels will be easiest or make the most sense (e.g., tallies in categories of behavior vs. writing a narrative), how often a parent feels he or she can take data, and how many goals the parent feels he or she can track at one time. When thinking about how the data will be collected, clinicians should first determine with parents if it will be on paper or electronic. Many parents prefer smartphone use because they tend to have their phones available most of the time. Once the format is decided, the clinician and parent can collaboratively determine the type of data (e.g., tallies, checkboxes, or coding on a predetermined data sheet vs. written narrative that a clinician can derive the data from). Although certain behaviors may lend themselves best to a certain data collection method, flexibility may be required in order to accommodate parent needs and increase parent adherence to the selected data collection method. For example, using a functional assessment data sheet with predetermined antecedents and consequences may be an easier way to immediately see the patterns in behavior; however, parents may have a hard time knowing how to categorize the behaviors they are seeing. In this case, a written narrative of A-B-Cs may be more accurate, and a clinician can then derive the A-B-Cs and transfer them to another functional assessment data sheet to summarize the data. How much data a parent will collect is another important consideration. Unlike clinicians, who are solely focused on the child they are working with, parents have many competing demands in the natural environment. Depending on the behavior, continuous data collection may be more desirable than probe data collection from the clinician perspective; however, parents may not be able to take data continuously unless the behavior is low frequency or only occurs in a narrow context. As such, it may be more feasible to have parents take probe data, which can then either be analyzed as frequency within a set time frame (e.g., 10 minutes) or rate if the time frame varies. When asking parents to collect probe data, clinicians should work with the parents to define when the data will be collected. For example, some parents may easily make independent decisions from day to day to take data during an appropriate period, whereas other parents may be more successful with a clearly defined time or routine for taking data (e.g., every day after dinner for 10 minutes of play, daily during the bath routine). When considering the burden on parents of data collection, clinicians should also consider the number of goals being tracked. Some parents may be able to track several behaviors at once, whereas others may need to focus on one behavior at a time. How often the behavior occurs may affect how many goals a parent can take data on at once; for example, collecting data across one behavior that occurs 30 times versus three behaviors that each occur 10 times provides data on 30 behaviors either way. The most important part when helping parents to learn data collection methods is a focus on setting them up for success. Unlike direct teaching methods that result in immediate successful responses for the child and thus reinforcement of parent behavior, data collection may yield more delayed reinforcement for parents. As discussed, feasibility and goodness of fit are of utmost importance, as is

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BOX 15.5: Examples of practical questions for parents Use the following questions to create a feasible data collection method that will be a good fit for a parent, caregiver, or family. • Do you prefer to take data on paper or on a smartphone or device? • If paper, where will you keep your data sheets? For example, on the fridge, in a notebook, or on the counter? Will a pen or pencil be accessible? • Do you prefer a data sheet with checkboxes or coding procedures that might require some training during treatment sessions first or would you rather write down what happened in narrative form? • What is your estimate of how often this behavior will occur? Do you think it is feasible or makes sense to record every instance of the behavior? If we only recorded it for a short period of time (e.g., 5–15 minutes), would it occur? (Note: Depending on the behavior, clinicians may already know the answers to these questions.) • Depending on how often each behavior may be happening, do you think we can/should take data on more than one behavior at a time?

setting reasonable expectations. Starting with an “anything is better than nothing” mentality can be helpful so parents can feel successful and eventually build up to more consistent data collection. Working collaboratively to determine the best methods can also build buy-in and success. Box 15.5 provides a practical list of questions clinicians can ask parents in order to develop successful data collection methods for home and community settings.

CONCLUSION All NDBI place emphasis on the importance of data collection, although data collection methods may differ. The goal of this chapter was to review data collection methods and types of data commonly used and collected in ABA but also to provide a number of variables to consider when developing data collection methods for use in NDBI. Although clinical expertise is required to develop data collection methods from scratch, the content in this chapter should be useful in helping clinicians to build this skill set, especially as applied to interventions in the natural environment.

REFERENCES Bruinsma, Y., & McNerney, E. K. (2012). Pivotal Response Treatment. In P. A. Prelock & R. J. McCauley (Eds.), Treatment of autism spectrum disorders: Evidence-based intervention strategies for communication and social interactions (pp. 281–312). Baltimore, MD: Paul H. Brookes Publishing Co. Cooper, J. O., Heron, T. E., & Heward, W. L. (2013). Applied behavior analysis (2nd ed.). Upper Saddle River, NJ: Pearson/Merrill-Prentice Hall. Hancock, T. B., & Kaiser, A. P. (2012). Implementing enhanced milieu teaching with children who have autism spectrum disorders. In M. E. Fey & A. G. Kamhi (Series Eds.) & P. A.

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Prelock & R. J. McCauley (Vol. Eds.), Communication and language intervention series. Treatment of autism spectrum disorders: Evidence-based intervention strategies for communication and social interactions (pp. 163–188). Baltimore, MD: Paul H. Brookes Publishing Co. Hardan, A. Y., Gengoux, G. W., Berquist, K. L., Libove, R. A., Ardel, C. M., Phillips, J., . . . Minjarez, M. B. (2015). A randomized controlled trial of pivotal response treatment group for parents of children with autism. Journal of Child Psychology and Psychiatry, 56(8), 884–892. Ingersoll, B., & Dvortcsak, A. (2010a). Teaching social communication to children with autism: A manual for parents. New York, NY: Guilford Press. Ingersoll, B., & Dvortcsak, A. (2010b). Teaching social communication to children with autism: A practitioner’s guide to parent training. New York, NY: Guilford Press. Kaiser, A. P., & Hampton, L. H. (2016). Enhanced milieu teaching. In R. McCauley, M. Fey, & R. Gilliam (Eds.), Treatment of language disorders in children (2nd ed., pp. 87–120). Baltimore, MD: Paul H. Brookes Publishing Co. Kasari, C., Fannin, D. K., & Goods, K. S. (2012). Joint attention intervention for children with autism. In P. A. Prelock & R. J. McCauley (Eds.), Treatment of autism spectrum disorders: Evidence-based intervention strategies for communication and social interactions (pp. 139–162). Baltimore, MD: Paul H. Brookes Publishing Co. Kasari, C., Paparella, T., Freeman, S., & Jahromi, L. B. (2008). Language outcome in autism: Randomized comparison of joint attention and play interventions. Journal of Consulting and Clinical Psychology, 76(1), 125–137. Koegel, R. L., & Koegel, L. K. (2006). Pivotal response treatments for autism. Baltimore, MD: Paul H. Brookes Publishing Co. Rogers, S. J., & Dawson, G. (2010). Early Start Denver Model for young children with autism: Promoting language, learning, and engagement. New York, NY: Guilford Press. Schwartz, I. S., Ashmun, J., McBride, B., Scott, C., & Sandall, S. R. (2017). The DATA Model for teaching preschoolers with autism: Blending approaches to meet individual needs. Baltimore, MD: Paul H. Brookes Publishing Co. Stahmer, A. C., Suhrheinrich, J., Rieth, S., Schreibman, L., & Bolduc, C. (2011). Classroom pivotal response teaching for children with autism. New York, NY: Guilford Press. Suhrheinrich, J., Dickson, K., Chan, N., Chan, J. C., Wang, T., & Stahmer, A. C. (2019). Fidelity assessment in community programs: An approach to validating simplified methodology. Behavior Analysis in Practice, online First, 1–11. https://doi.org/10.1007/s40617-019-00337-6

16 Identifying Quality Indicators of NDBI Programs Aubyn C. Stahmer, Sarah R. Rieth, Brooke Ingersoll, Yvonne Bruinsma, and Aritz Aranbarri

T

he quality of community programs serving children with autism spectrum disorder (ASD) can be quite variable. Some programs are using evidencebased strategies and have mastered using them with fidelity in their programs, and others may not have the training and experience needed to use Naturalistic Developmental Behavioral Intervention (NDBI) strategies effectively. This chapter provides information about how to decide if an NDBI program is high quality. The intention is to help programs ensure that they have in place the pieces of a highquality program that are known to be most effective for children and families.

QUALITY INDICATORS VERSUS COMMON FEATURES This book describes the common features necessary for a program to be considered an NDBI program (see Chapter 2 for a review). Having those common features is necessary, but not sufficient, to ensure a program is effective for children and families. Each feature or strategy must be completed competently and consistently. This chapter provides simple ways to ensure that NDBI features are implemented with high quality by identifying specific quality indicators (see Box 16.1). Quality indicators are defined, evidence-based measures of program quality that can be used to measure and track clinical performance and outcomes. For a more thorough description of a specific procedure, refer to the relevant chapter.

SPECIFIC PROGRAM ELEMENTS TO LOOK FOR IN A QUALITY NDBI PROGRAM A quality NDBI program must have defined procedures, treatment fidelity measurement procedures, individualized programs for the child and family, clearly defined treatment goals, progress tracking, and quality staff training. 391

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BOX 16.1: Elements of a quality NDBI program 1. Defined procedures: Does the program have an intervention manual available? 2. Treatment fidelity measurement procedures: Does the program have a way to measure how well providers use NDBI? 3. Individualized programs for the child and family: Are families included as partners in developing the NDBI program and treatment goals? 4. Clearly defined treatment goals: Are goals developed based on an assessment of the child’s developmental level? 5. Progress tracking: Are data collected regularly and used to make changes to goals and programs? 6. Quality staff training: Does the program have a clear training plan that includes active learning, coaching, and ongoing supervision?

Defined Procedures For an intervention to be considered an NDBI, its procedures must be clearly described and written down so that everyone using the intervention is doing roughly the same thing. This process, called manualization, is a key aspect of evidencebased practice and is important for accurate training and implementation of an NDBI (Durlak & DuPre, 2008; Fixsen, Naoom, Blase, & Friedman, 2005). Having clearly described NDBI procedures ensures that everyone is using the intervention the same way and has the same ideas about the essential features of the intervention. Although referencing the manual by itself can increase a clinician’s skill in using an intervention, additional training and feedback are typically necessary to achieve treatment fidelity (Herschell et al., 2009). Treatment fidelity means the intervention is being used as it was designed (see next section). Thus, the existence of a manual and clearly specified procedures is necessary, but not sufficient, for appropriate and effective implementation of NDBI (Durlak & DuPre, 2008; Fixsen et al., 2005). In line with evidence-based practice, all NDBI have clearly defined procedures and associated methods for measuring and ensuring treatment fidelity for the intervention strategies used with the child. In addition, some parent-mediated NDBI also include clearly defined procedures for conducting parent coaching (e.g., Project ImPACT). Some NDBI also include additional support materials, such as checklists, video examples, visual reminders, and self-monitoring tools designed to help community clinicians and families use the program more successfully. As of the writing of this chapter, the Early Start Denver Model (ESDM), Pivotal Response Treatment (PRT), Classroom Pivotal Response Training (CPRT), and Project ImPACT (Improving Parents as Communication Teachers) manuals have each been published and can be purchased directly by clinicians or parents. Other NDBI manuals are forthcoming or may currently only be available through participation in a training program or directly from the intervention developer. Key quality indicator: When determining the quality of a community program, one simple item to look for is whether the teacher, clinician, or supervisor has a copy of the intervention manual available. Does it seem as if the program is using

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the manual when training staff, tracking use of the intervention, and making adaptations for individual children? If a program says it is using a specific NDBI program but does not have a manual available, this might be cause to question the program’s use of the strategies it reports are being used. Treatment Fidelity Measurement Procedures One of the main measures of quality is whether the NDBI procedures are being used correctly during treatment sessions. This is called treatment fidelity, or the degree to which the intervention is implemented as it was intended by the developers (Gresham, MacMillan, Beebe-Frankenberger, & Bocian, 2000). When an intervention is studied in a research setting, the individuals using the intervention are required to maintain high levels of treatment fidelity. That is, as part of the research procedures, they make sure they are doing each step as planned. These procedures are used in the studies that showed the intervention to be effective. In community care, however, treatment fidelity is not often measured, so it is hard to know if the intervention is being used as planned. Oftentimes, treatment fidelity in the community is not measured because there is not a feasible way to do it. Researchers traditionally have used complicated and time-consuming methods of checking how well their procedures are being implemented, which is not practical in the real world. However, researchers have begun to develop new, simpler ways of checking how well intervention procedures are being used. For example, the National Professional Development Center for Autism’s (NPDC) Autism Focused Intervention Resources and Modules (AFIRM) include implementation checklists for each evidence-based practice (https://afirm .fpg.unc.edu). Even though it may take extra time, measuring treatment fidelity is important for several reasons (Hume et al., 2011). First, treatment fidelity affects child outcomes (Durlak & DuPre, 2008; Gresham et al., 2000; Stahmer & Gist, 2001; Strain & Bovey, 2011). Educators, practitioners, clinicians, and other professionals want to make a difference for children. Without accurate measurement of how intervention components are being used (or not used), they cannot draw clear conclusions about how the pieces of the intervention affect children. If a child is not making progress, providers do not know if it is because the child is not responding well to the intervention, because the intervention is not being done correctly, or because important pieces of the intervention are being left out. The use of a treatment fidelity checklist can tell providers which components are being used well and where providers might need to improve. By checking the treatment fidelity of their intervention, providers can safely say that good child outcomes are likely because of the intervention they are using. If children are not making good progress, providers may need to try something new. Second, without some type of measurement of treatment fidelity, providers have no way to know if the procedures are being used with high quality. In fact, providers do not know if most of the steps of an intervention are being used at all. When providers are looking for quality indicators of a program, treatment fidelity to whatever practice they are using is essential. Third, treatment fidelity measurement is very important for training. Just as they develop measureable goals for children, adults learning new skills also need a way to measure and track their progress. Treatment fidelity measurement can help supervisors know where support is needed, and it can help providers know when to ask for help or where to put their practice efforts. Tracking treatment fidelity can

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also let a program manager know when it is okay to have a new provider work independently with a child in a successful way. It may also be important to have clear treatment fidelity measures to document that therapists have received appropriate training. Many more insurance companies are beginning to require clear documentation of therapist training and many states are beginning to have state licenses or credentials that therapists must obtain. As the onus is often on agencies and providers to take responsibility for the appropriate training and credentialing of their therapists, clear treatment fidelity procedures, measures, and documentation are important in this context. Fourth, treatment fidelity is important for making sure the intervention practices are used well over the long term. Oftentimes there will be drift in practices as individuals go back to old habits or begin to adapt strategies. Periodically measuring treatment fidelity can keep everyone on track and make sure everyone uses strategies consistently over time. Finally, measuring treatment fidelity can help users effectively individualize intervention, which is discussed later in this chapter. Most NDBI programs have some measure of treatment fidelity, at least for research purposes. These usually measure procedural treatment fidelity (or the use of key ingredients of the intervention) and therapist competence (the level of skill and judgment used in executing the treatment; Schoenwald et al., 20l1) and give a guideline for a minimum level of treatment fidelity needed to be considered competent. The specific level that is “good enough” to see clinical improvement in children is often arbitrary. There have been limited studies determining the level needed to ensure positive outcomes. In research, 80% correct use of strategies is often the benchmark. This may not be necessary for good outcomes, but research does not yet have this information. The other piece that is important is intensity. A provider can be great at using NDBI strategies, but if he or she never actually uses a strategy, that does not help much! Although researchers do not know how much is enough for most interventions, they do know that using NDBI consistently leads to better outcomes (Pellecchia et al., 2015). So, how can providers track these things in practice? As mentioned previously, the NPDC (http://autismpdc.fpg.unc.edu/) developed treatment fidelity measures for many of the evidence-based practices, including some NDBI. These use a rating scale format so that each step of the intervention is rated on a 3-point scale, indicating that a step was not implemented, partially implemented, or implemented. Items on the NDBI treatment fidelity list include “choosing motivating materials/activities to engage learners and promote the use of target skills,” “following the learner’s lead,” and “expanding the response and providing the requested material (if the learner gives the target response).” In this way, providers see which components they are implementing well and which are more challenging. This can be done both as a self-assessment and as part of a supervisor or peer feedback session. Few of these brief treatment fidelity formats have been validated, but there is some new research in NDBI looking at how to simplify this process for community providers. In a project looking at PRT, teams compared a research-based treatment fidelity tool to a rating scale format and found good agreement for determining pass-fail for each component strategy (Suhrheinrich et al., 2019). The authors are currently working with providers to simplify this process even further into a checklist format that includes simple ways to provide feedback during training (see Figure 16.1).

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CPRT Checklist Name:

Date:

Activity: Easy tasks:

Learning goals:

Use the scale below to score your use of each component of CPRT. Then, fill in the narrative boxes with your coach. √

− Did not use this component (Oops!)

Used this component sometimes There were some ways it could have been used better.

+ Rocked it; used this component often.

Teacher selfassessment −/ /+

Antecedent components (CREATE) 1. Ensures student is paying attention before providing a cue 2. Provides clear and developmentally appropriate cues 3. Varies instructions 4. Intersperses learning goals with easy tasks 5. Uses preferred materials

q Individual

q Play-based q Enhanced academic

6. Varies materials 7. Gives choices

q Between activity

q Within activity

8. Follows the student’s lead 9. Takes turns when appropriate

q Modeling

q Social interactions q Turns with peer(s)

Waits 5–10 seconds for child to respond (PAUSE) Consequence components (RESPOND) 10. When rewards are provided, they are direct 11. Provides contingent rewards for appropriate responses 12. Provides reinforcement for good trying (attempts) Preparation and general session management 1. Identifies effective rewards 2. Amount of reinforcement maintains student motivation 3. Manages distractions from the teaching environment Eliminates distractions from the teaching environment 4. Maintains control of instructional materials 5. Varies prompt level appropriately Naturalistic Developmental Behavioral Interventions in the Treatment of Children with Autism Spectrum Disorder edited by Yvonne Bruinsma, Mendy B. Minjarez, Laura Schreibman, and Aubyn C. Stahmer. Copyright © 2020 by Paul H. Brookes Publishing Co., Inc. All rights reserved.

Figure 16.1. Classroom Pivotal Response Teaching checklist.

Notes

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Projects such as these may simplify this process for providers. In the meantime, when considering whether a program is measuring treatment fidelity, ask how the program or school decides if a provider is using the NDBI correctly. Key quality indicator: Does the program have a systematic way to measure how well the providers are using the NDBI program? Do providers regularly measure treatment fidelity procedures during provider training and periodically over time? Individualized Programs for the Child and Family All children with ASD and their families are different, and even though programs may have operationalized procedures and high-quality interventions, experienced clinicians need to understand how to use the strategies in ways that are individualized to each child and family’s needs. Providers should not confuse individualization with a decrease in treatment fidelity. A clinician should first learn to use all the strategies well so that individualization can be thoughtful and systematic. Then, assessment of child and family needs, coupled with collaborative goal development, should be used to adapt the NDBI program to meet the needs of individual children as well as to ensure fit of the program within the family system, culture, values, and routine. There are many ways that programs can be individualized to fit the needs of the family system, culture, values, and routines. For example, active parent involvement in intervention is a recommended component of NDBI. If goals and strategies that are targeted with the NDBI meet the needs of the family, parents will be more motivated to participate, and children will make better progress (BrookmanFrazee & Koegel, 2004; Schreibman & Koegel, 1996). Does the provider collaborate with families on choosing goals that are important to them? In addition, any use of NDBI strategies needs to fit into the family context. For example, in some cultures, praising children by saying things such as, “Great job!” and “Way to go!” does not feel natural. Does the provider work with the parents to understand what social rewards might be more in keeping with the family culture? In some cultures, mealtime is a sit-down time with family, whereas for others, children choose when and where they would like to eat or eat separately from adults. Does the provider tailor ideas and recommendations about using NDBI strategies during mealtimes and other routines in a way that matches the family’s day-to-day reality? Quality treatment plans respect these differences when determining natural rewards and strategies. When using NDBI, it is also important to understand family routines because one of the hallmarks of these programs is using the strategies in natural contexts. Generalization of strategies to daily routines can be challenging for families because most practitioners have caregivers learn in the context of play or other structured activities. Effective providers will talk with families about how to integrate strategies into usual family routines and activities, which vary by family, and help problem-solve challenges in different contexts. In this way, families and providers work together to make the NDBI strategies fit the family, not the other way around. In addition, there is some research to indicate that parent-implemented intervention may not be as effective for families who are under very high levels of stress. This may mean clinician-implemented treatment is a better place to start. Highquality programs may also consider creative ways to include multiple caregivers

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through offering flexible times for training, video recording sessions, and conducting phone meetings with caregivers who cannot attend sessions. Experienced clinicians also understand that different caregivers have different interaction styles and will adapt the intervention based on that style. For example, some parents may wish to focus on interaction with toys, whereas others may wish to focus on large motor or self-help activities. A good program will adapt to these needs and consider the family context in developing an intervention program. When considering individualization for a specific child, clinicians should use the data about a child’s current skill level and goal progress to decide which strategies to start with and when to change strategies. For example, a child may be making progress on production of nouns but may not be making progress in following directions using typical NDBI strategies within daily routines and play. A provider might add more structure, such as visual supports or practicing the specific behavior in a more structured way, to try to help the child learn to follow directions. This does not mean that more structure should also be added to noun production. Once the skill is learned in the structured setting, supports might be faded to ensure independence and generalization. ESDM, for example, has a decision tree that can be used to help understand when to add more structure when a child needs it (Rogers & Dawson, 2010). Data on progress should guide these types of changes. High-quality programs will vary their use of NDBI strategies for individual goals to maximize child progress and will base any changes on data. Key quality indicator: Does the program or provider include the family as a partner in the development of goals and choice of strategies? Are parents and caregivers (and the person with ASD, if appropriate) integrated into the program in a meaningful way as an equal part of the intervention team? Does the provider respect the culture and context of the family as treatment goals and programs are developed? Clearly Defined Treatment Goals One way to determine whether a program is of high quality is to ask about the process of goal development. Based on research indicating that teaching within a developmental framework has both long- and short-term benefits, NDBI use this framework to guide the selection of intervention targets based on child-specific development, with a particular focus on social-communication. For example, typically developing infants begin using gestures and other nonverbal communicative behaviors prior to using words. Thus, when working with a child who is nonverbal or preverbal, the adult will encourage gesture use prior to language. This is one way programs can be individualized to the needs of the child. The types of goals chosen may depend on the specific NDBI program being used. Although all NDBI target early social-communication development, they vary on the specific social-communication skills that they emphasize, as well as whether they include instruction in a broader range of skills. For example, some NDBI (e.g., reciprocal imitation training [RIT]; Joint Attention, Symbolic Play, Engagement, and Regulation [JASPER]) focus primarily on nonverbal behaviors (imitation, joint attention, symbolic play), whereas others, such as enhanced milieu teaching (EMT), focus more explicitly on language. NDBI also differ in the extent to which they focus on social-communication development or whether they target a broader range of developmental skills. For example, Project ImPACT focuses on

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social-communication development in the areas of social engagement, communication, imitation, and play. ESDM uses a comprehensive developmental curriculum that also targets self-regulation, self-care and independence skills, and preacademic concepts. A high-quality program will specify developmentally appropriate goals that fit with the intervention. An assessment is needed to determine which goals are appropriate. NDBI use various assessment methods for identifying goals. Some NDBI, such as ESDM, have a formal assessment process that is directly tied to their curriculum. For example, ESDM uses a clinician-administered curriculum checklist that is completed within the context of a 1- to 1.5-hour play-based interaction with the therapist and the child. The therapist uses specific play-based materials and activities designed to evoke a defined set of skills across developmental areas, including social, communication, cognitive, and motor skills. The therapist then develops individualized goals based on the child’s performance on the curriculum checklist and input from the parent and other professionals, if relevant. Parent-mediated NDBI are often more focused on the assessment of child skill use with the parent. For example, Project ImPACT uses a developmental skills checklist and naturalistic observation as part of a collaborative goal setting process between the parent and clinician. Both the parent and clinician complete the checklist based on their knowledge of the child’s skills and the observation of a parent–child and clinician–child interaction. The parent and the clinician then work together to identify appropriate goals in the areas of social engagement, communication, imitation, and play. Other NDBI use less formalized approaches for setting goals that may include a combination of naturalistic observation, standardized assessment, and parent report of skills. Some, such as PRT, recommend using existing curricula to determine the child’s current skill level and form developmentally appropriate goals. If goals are chosen without an assessment or standard process of some kind, teaching may not be happening within a developmental framework. A high-quality goal-setting assessment process should include opportunities to identify what the child can do not only during a standardized assessment but also in daily routines. As discussed previously, the assessment and goal development should occur in collaboration with parents and caregivers to ensure that any goals selected match the values and beliefs of the family. Research demonstrates benefits for both parents and children when clinicians and parents collaborate to set goals and implement treatment (Brookman-Frazee & Koegel, 2004). Of course, in using NDBI, the aim is for children to meet their initial goals and move toward more complex ones, meaning goal setting should be an ongoing and continual process in any good treatment program. Key quality indicator: Does the program use an assessment or curriculum to help determine the child’s current skill level? Are goals grounded in a developmental framework and based on the assessment of the child’s skills? Are goals developed in collaboration with the family? Progress Tracking All NDBI emphasize the importance of ongoing measurement of child skill use to determine progress toward goals and to guide treatment methods. Although standardized assessments of language and developmental skills are important for

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evaluating long-term outcomes, they are not as useful for measuring regular progress toward goals within the time frame needed to monitor and modify treatment goals and procedures. Progress should typically be monitored about monthly to quarterly, and standardized assessments often are not recommended to be administered that frequently. In addition, standardized assessments are usually focused on broad domains (e.g., receptive language, expressive language) rather than the type of specific, measureable goals that are part of high-quality treatment. Thus, NDBI use a variety of behavioral methods for tracking child progress toward goals. The ongoing interaction between the child and adult inherent in NDBI can make session-by-session data collection more challenging than more structured Applied Behavior Analysis approaches (see Chapter 15 for a detailed description of data collection strategies for NDBI). However, some programs, such as ESDM, have developed methods for tracking skill use within the session. Other programs collect session data from video so as not to interrupt the ongoing interaction. Although possibly more accurate and less challenging than collection within the session, video-based data collection is time consuming and thus tends to be less practical for community settings. Other approaches involve periodic tracking of child skill uses (rather than session by session) using naturalistic observation or the re-administration of curriculum checklists, usually no less frequently than every 3 months. Multiple data collection methods may be appropriate, and the AFIRM modules developed by the NPDC offer data sheets for various NDBI (https://afirm .fpg.unc.edu). Data collection is essential for knowing when a set of strategies is not working to help a child meet his or her goals and requires summarization methods (e.g., graphing or summary face sheets) to be effective, as discussed in Chapter 15. The data collection procedures should clearly link to the child’s goals so the provider can use the data over time to change strategies, add new goals, and improve individualization of the program (Simpson, 2005). Key quality indicator: How are goals developed and tracked? How are data being summarized and reviewed? Is there a way to measure goal progress over time and make changes to the program and strategies based on goal progress? Programs should have an assessment protocol and progress-monitoring system that can be reviewed to know what skills the program is designed to address, whether goals are developmentally appropriate, and what progress is being made. Quality Staff Training The quality of the training that clinicians receive has a significant impact on their ability to use NDBI effectively. Although some training likely occurs in the process of formal schooling and licensure (where applicable), the majority of service providers report that most of their training takes place on the job, once they have begun working clinically. Many clinicians providing the actual service to children with ASD are paraprofessionals, often not licensed, who are under the supervision of a licensed, experienced, or specialized clinician. In this service model, the direct services providers ideally receive training and supervision from experienced and specialized clinicians within their program to ensure service quality. As mentioned above, this training is also increasingly required for insurance billing or state licensing and credentialing. The presence of formal training for direct services roles within agencies is crucial because there is significant variety in the amount and content of training

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received before service. Providers come to their job with varying backgrounds and levels of experience. Similar clinical roles (e.g., behavioral therapist) may serve different populations depending on the organization or setting. To address the full range of learning needs related to using NDBI, training may be needed on ASD specifically, on the age or developmental level of children served, on the actual strategies that compose the approach, or on broader contextual factors of a job, such as how to work collaboratively with parents and other service providers. For example, a provider who previously worked with middle school children with ASD who is moving into an early intervention program may be familiar with the behavioral principles and practices that partially compose NDBI, but he or she may need more instruction on developmentally appropriate strategies for working with young children or including extended family members in the intervention sessions. Giving providers background knowledge of the reasoning behind specific practices and the foundational theories of NDBI (i.e., principles from developmental science and Applied Behavior Analysis) may facilitate providers’ learning of how to implement individual strategies and thus may be an important content area for training (Rieth et al., 2018). The range of training content for learning to use NDBI is wide. However, clinicians typically come to the job with some ability and knowledge on which they can build. A modularized approach to training, which includes assessment of what clinicians already know and can use and then provides needed training accordingly, may be a useful and optimally efficient approach for preparing direct services staff. The skills necessary to use an NDBI strategy can be broken down into several smaller pieces, and therapists can only be taught those pieces they do not know. Prior knowledge ideally would be determined by a combination of self-report from the trainee as well as observation of current clinical skills in practice by a knowledgeable supervisor. The method in which training is delivered is equally as important as the content covered. Literature from adult learning theory and health care provider behavior change has identified several effective practices for supporting the learning and implementation of new strategies by clinical practitioners. Based on this literature, high-quality training in NDBI should include 1) a manualized procedure with clear criteria for implementing the intervention; 2) initial training that includes didactic presentation, model demonstrations of target skills, and opportunities to practice with coaching; 3) mastery criteria that are related to the provider implementing the new skills in routine practice and are assessed on a routine basis; and 4) regular and ongoing supervision that includes structured assessment of treatment fidelity. Taken together, these elements compose adequate preparation and ongoing support to providers delivering services to individuals with ASD and their families. Behavioral skills training, a set of training procedures clearly described in the Applied Behavior Analysis literature, is a useful framework when developing plans for training staff. A formal, initial intensive training period is a common approach across organizations providing behavioral services (LaVigna, Christian, & Willis, 2005). Research indicates that delivery of the initial content should occur in both verbal and written form in order to have a maximal impact on knowledge and performance (Macurik, O’Kane, Malanga, & Reid, 2008). Advancements in technology have allowed for initial didactic instruction to occur either in-person or online, thus potentially decreasing training costs and time commitments for agencies as

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well as potentially expanding the audience who receives training. Comparisons of training methods indicate that technology-based (e.g., web-based, video presentations) initial training is equally as effective as or more effective than in-person information delivery for acquiring knowledge of the content (Macurik et al., 2008). Regardless of format, several important features of initial training should be present in high-quality programs. These include opportunities for active learning (Birman, Desimone, Porter, & Garet, 1995; Garet, Porter, Desimone, Birman, & Yoon, 2001), reflection and collaboration (Joyce & Showers, 1995; Lieberman & Pointer Mace, 2008; McLaughlin & Darling-Hammond, 1995), and alignment with provider needs (Desimone, 2009; Garet et al., 2001). Active learning means that trainees are not simply passive recipients of information (e.g., watching a presentation, slide show, or video) but also contribute, act, and respond throughout the initial training process (Banilower & Shimkus, 2004; Bonwell & Eison, 1991; Borko, 2004; Darling-Hammond, 1998). Likewise, opportunities for collaboration and reflection should be present that give trainees a chance to connect the training content to their own personal experiences and prior background. Last, alignment with provider needs ensures that the training offered to providers matches the skills they need to acquire and fits the individuals and families that they will serve (Desimone, 2009; Garet et al., 2001). These features (active learning, opportunities for reflection or collaboration, and alignment with provider needs) all serve as strong quality indicators for the initial training that interventionists receive to prepare them for work with individuals and families. Even the best initial training in NDBI strategies, however, is unlikely to be sufficient to fully support clinicians’ use of an intervention in practice. Research demonstrates that coaching is crucial in order to promote active and correct use of the material learned (Beidas & Kendall, 2010; Miller, Yahne, Moyers, Martinez, & Pirritano, 2004; Odom, 2009; Scheuermann, Webber, Boutot, & Goodwin, 2003; Sholomskas et al., 2005; Stahmer, Suhrheinrich, & Rieth, 2016; Suhrheinrich, 2011). In education, support from a coach has been shown to make it 13 times more likely that a teacher will use an intervention (Driscoll, Mcardle, Plumlee, & Proctor, 2010). Coaching typically involves an expert, supervisor, or mentor observing a clinician using an intervention and then providing specific feedback on the strengths and weaknesses of what the clinician is doing (Lee, Frey, Herman, & Reinke, 2014). The most important part of coaching appears to be receiving performance feedback because this is the piece that is consistently related to the clinician using the intervention as it was intended (Reinke et al., 2014). This may take the form of formal, structured feedback (e.g., a treatment fidelity checklist on NDBI components or a structured observation), or it may be informal and semi-structured (e.g., pointing out what went well and what to improve for next time). The presence of coaching in a program’s training plan for new providers is a quality marker that increases the likelihood that providers are receiving training and information that they will actually be able to use in practice. After high-quality initial training, it is important to ensure ongoing quality and sustained use of specific practices over time. Drift inevitably occurs in how providers use strategies, and direct services providers will undoubtedly encounter difficult cases or unfamiliar territory in how to apply interventions. Receiving ongoing feedback is important for improving and maintaining treatment integrity and providers’ confidence in their ability to use the intervention (Bush, 1984; Cornett

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& Knight, 2009). This type of ongoing feedback is useful from a supervisor, but it can also be from peers or colleagues because the process of watching another person use strategies and providing semi-structured feedback (e.g., via a treatment fidelity checklist) is likely to improve practice for the observer as well as the recipient of the feedback. The presence of ongoing coaching can also address the need for training to span a sufficient duration of time, meaning it is spread out over multiple months or contacts with supervisors or trainers, rather than occurring in a single-shot intensive workshop or presentation (Desimone, 2009; Guskey, 1994; Supovitz & Figure 16.2. Quality Indicator Checklist for NDBI. Turner, 2000) because this is known to be best practice. Programs should have training that focuses broadly on the multiple skills necessary to deliver NDBI (e.g., intervention strategies, developmental appropriateness, ASD, behavioral principles, working with families, parent training) and involves ongoing monitoring and support. Training should not be a one-time bar to clear but rather an evolving and continual process of improvement. Regular and (at least) semi-structured feedback on their use of intervention strategies and their work with children and families should be consistently available to therapists, either from a supervisor or a peer. Key quality indicator: Does the program have a clear training plan for new staff with didactic training that features active learning, opportunities for reflection or collaboration, and alignment with provider needs? Is coaching with feedback until a provider meets mastery criteria part of the program’s training plan? Does the program have ongoing supervision practices in place to ensure continued quality after initial training? Figure 16.2 provides a reproducible checklist that can be used when evaluating NDBI programs. Quality Indicator Checklist Quality elements

Quality questions

Defined procedures

1.1. Does the program have an intervention manual available?

Fidelity measurement

2.1. Does the program have a way to measure how well providers use NDBI during training and over time?

Staff training

3.1. Does the program have a clear training plan for teaching new staff the intervention?

Indicators

3.2. Does the training include active learning, coaching, and collaboration? 3.3. Does the program provide ongoing supervision?

Individualized treatment

4.1. Are families included as partners in developing the treatment goals?

4.2. Are caregivers taught to integrate intervention strategies into natural routines? 4.3. Are intervention strategies adapted to fit the family context and culture?

Treatment goals

5.1. Are goals developed based on an assessment of the child’s developmental level?

5.2. Are goals clearly defined and measurable?

5.3. Are goals functional for the child and family?

Progress tracking

6.1. Are data collected regularly to track progress?

6.2. Are these data summarized and reviewed regularly by a lead therapist (e.g., Board Certified Behavior Analyst)?

6.3. Are these data used to make changes to goals and programs?

Naturalistic Developmental Behavioral Interventions in the Treatment of Children with Autism Spectrum Disorder edited by Yvonne Bruinsma, Mendy B. Minjarez, Laura Schreibman, and Aubyn C. Stahmer. Copyright © 2020 by Paul H. Brookes Publishing Co., Inc. All rights reserved.

CONCLUSION The goal of this book is to provide practical information about how to use NDBI to support individuals with ASD from diverse backgrounds, across a variety of community settings, and to teach a range of skills. The use of high-quality NDBI

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strategies, regardless of the brand name of the intervention, is motivating for learners with ASD, improves social relationships and engagement, and increases the generalization and natural use of new skills. Involving parents and other caregivers can extend intervention intensity and increase learning opportunities as well as support family functioning and parental well-being. NDBI strategies were designed specifically for families to use during daily activities and highlight integration of family input into all aspects of goal development, intervention delivery, and progress monitoring. Social-communication, as a key challenge for individuals with ASD, is often the focus of NDBI. Incorporating peers into NDBI programs further helps individuals with ASD by supporting both their own social development and peers’ understanding of how to interact with diverse learners. NDBI strategies are best used in coordination and with high treatment fidelity to ensure effective outcomes in individuals with ASD. By understanding the theory behind the strategies; using the examples provided across settings, ages, goals, and skills; and monitoring quality indicators, practitioners can use NDBI to enhance the developmental potential of the individuals with ASD they serve.

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17 Considering Future Directions in NDBI Laura Schreibman, Mendy B. Minjarez, and Yvonne Bruinsma

A

s demonstrated throughout this book, Naturalistic Developmental Behavioral Interventions (NDBI) were developed with both behavior analytic and developmental conceptual and theoretical foundations. NDBI enjoy strong empirical support, demonstrated by a substantial and broad body of research. This research has shown that NDBI are highly effective with children with autism spectrum disorder (ASD) and that they can be implemented with treatment fidelity by a variety of individuals (e.g., clinicians, parents, teachers) and in a variety of settings, including the clinic, home, community, and school. The early studies in the area were primarily single subject design studies (e.g., Koegel, Camarata, Koegel, Ben-Tall, & Smith, 1998; Koegel, Dyer, & Bell, 1987; Laski, Charlop, & Schreibman, 1988; Pierce & Schreibman, 1995, Stahmer, 1999), and this methodology is still employed regularly. In addition, more recent studies of NDBI have tested their effects via larger randomized controlled trials utilizing group research designs (e.g., Dawson et al., 2010; Hardan et al., 2015; Kasari, Kaiser, et al., 2014; Kasari, Lawson, et al., 2014; Landa, Holman, O’Neill, & Stuart, 2011). In essence, NDBI owe their existence to sound single subject design research that teased out some of the effective components and underlying mechanisms. Research then systematically advanced these interventions to allow increased refining of strategies so that NDBI became increasingly effective, efficient, and tailored to the specific needs of the children with whom they are applied. It is the nature of all intervention science to continue this improvement and refinement process. Therefore, we have identified the following research directions as important for future investigation of NDBI (see Schreibman et al., 2015, for a more comprehensive discussion) as well as future directions for dissemination of NDBI interventions.

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RESEARCH FUTURE DIRECTIONS Although researchers know a lot about NDBI and the effectiveness of NDBI strategies, they can still learn more. This section offers an inventory of six broad areas that need further exploration and scrutiny. We propose the following future research directions. • Increased focus on larger scale and more contemporary pragmatic randomized controlled trials (RCTs) to allow for the study of moderators and mediators of treatment effectiveness and efficiency in community settings. The first RCTs addressing NDBI focused on young children with ASD with the goal of preventing or ameliorating the early social and communication indicators of the disorder (i.e., early intervention) and/or testing the efficacy of a particular intervention. The effectiveness of NDBI with older children with ASD or with children who fail to respond to other types of early intervention has yet to be sufficiently addressed by research (e.g., Kasari, Kaiser, et al., 2014). In addition, larger RCTs will help identify important mediators and moderators of treatment, which will help to further tailor treatments to individual children. For example, Sherer and Schreibman (2005) identified a specific behavioral profile that predicted the effectiveness of Pivotal Response Treatment (PRT). This study focused on observable behaviors exhibited by the children. Further research must also specify the characteristics of participants in terms of ASD diagnostic status, particularly communication and social abilities. Another important focus is on treatment dosage. Future RCTs should focus on the dosage (hours of treatment) applied and assess child response over time as a means of investigating outcome effects associated with specific dosages and time in intervention. Dosage is particularly important in terms of dissemination of NDBI because many geographic areas experience a shortage of treatment providers, and information about the lower limits of effective dosing is relevant for developing service models that can serve a larger number of individuals effectively. • Measurement of intervention outcomes to evaluate change that is truly meaningful Earlier studies of the effectiveness of intervention strategies demonstrated improvements in IQ score but more limited changes in core symptoms of ASD and limited assessment of long-term social functioning. For instance, in Lovaas’s (1987) early intervention study, determination of “normal” functioning was defined as an IQ score in the average range and successful placement in first grade. However, IQ score and classroom placement are only two limited measures of a child’s response to treatment because it is possible to meet both of these criteria and still have ASD and/or experience ongoing functional impairments. Thus, it is important to extend outcome assessments to include both proximal and distal estimates of truly functional changes in the child’s behavior in a variety of natural social contexts (e.g., interactions with parents and others, behavior in the classroom, peer interactions). Such studies should include generalization and maintenance of acquired behavior across settings, people, and time. Common, standardized measures of social functioning examining changes in ASD core deficits would also be beneficial.

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• Empirical analysis of the active components within multicomponent interventions All NDBI are composed of multiple components, or elements, as part of an intervention package. Although empirical validation of the packages has been obtained, the contribution of each embedded element frequently has not been determined. Also, one or more of the embedded elements may not be required in order for positive outcomes to be achieved. In order to sort out these types of questions, dismantling studies, in which individual components are separately evaluated, are required. Clinicians need to know under what circumstances, for whom, at what level, and if a particular element is important to include in the package. Given the renowned heterogeneity of expression of ASD, child characteristics likely will have a substantial impact on such findings. The ability to tailor treatments to individual children in a wider variety of contexts will be enhanced with such studies and a clearer understanding of the role of treatment package components. Researchers have only begun to explore these issues in NDBI (e.g., Gulsrud, Hellemann, Shire, & Kasari, 2015). This will be even more important as treatments are transferred into community settings because community adoption is more likely if interventions are easier to implement and methods for adoption in different settings with individual children are clearly specified. Last, the field would greatly benefit from studies that establish both conceptual and empirical links between active ingredients and outcomes, both at the behavioral level and the level of underlying functional brain activity (Dawson, 2008; Sullivan, Stone, & Dawson, 2014). • Understanding the necessary procedural treatment fidelity of both treatment packages and their individual components The next stage of research in NDBI must involve independent replication of intervention effects by researchers who were not involved in the treatment’s development. In addition, procedures often need to be altered and adapted for cultural and community contexts. Clinicians need to know how NDBI can be altered for individual children or contexts while retaining their effectiveness. Means for assessing treatment fidelity for packages as well as components must be clearly described and available for researchers and providers. Although treatment fidelity measures exist for most NDBI models, these are primarily focused on treatment fidelity within research studies rather than treatment fidelity of clinical implementation. Furthermore, for those models that do use treatment fidelity measurement as part of clinical implementation, the proposed treatment fidelity methods have not been studied for their reliability or validity, nor have they been compared to alternative ways of measuring treatment fidelity. Given the pressures on community-based intervention providers to be efficient with time and justify how it is spent to insurance or other payers, user-friendly treatment fidelity measures for use in clinical settings are warranted. • Developing new methodological approaches for testing intervention strategies for improving outcomes of NDBI for all children, including children who show slower response to a specific intervention. A substantial advantage of a systematic approach to developing and evaluating the effectiveness of NDBI is continued research aimed at refining strategies

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and understanding how specific NDBI, and their components, interact with different children. Researchers need to more fully understand how existing, and future, NDBI might be altered or combined to increase the overall positive outcome rate for all children with ASD. This includes finding strategies to improve outcomes for children who prove to be the most challenging in terms of treatment response. Researchers studying ASD have begun to explore new research designs that allow better understanding of how to combine and individualize interventions (Almiral, Kasari, McCaffrey, & Nahum-Shani, 2018). • Employing innovative methods to implement and sustain research-based NDBI in community programs serving children with ASD As noted previously, research into expanding the use of NDBI in community settings in which children are more likely to have access to them is an important priority. Researchers can develop the most effective treatments possible, but if these treatments are not accessible to the children and families who would most benefit, then they have achieved little. Although researchers have demonstrated the effectiveness of NDBI in laboratory studies, the fact remains that NDBI are not yet widely delivered in community settings (Hess, Morrier, Heflin, & Ivey, 2008; Stahmer et al., 2005). We suggest innovative models of intervention implementation that shift from the more traditional “uni-directional” model of transferring researchbased intervention into community settings to a more “bi-directional” or reciprocal model involving researchers and community providers working together to establish effective community implementation (Bondy & Brownell, 2004; Meline & Paradiso, 2003; Weisz, Chu, & Polo, 2004). NDBI may be particularly well suited for public intervention systems because of their focus on early child development and the naturalistic strategies required by early intervention legislation. Future research must address the challenges posed by the complexity of interventions, the cost of high-intensity treatment implementation, and the demands of training and ongoing support and monitoring (especially in areas where resources are limited).

DISSEMINATION AND IMPLEMENTATION: FUTURE DIRECTIONS The need for research regarding community implementation of NDBI also raises some pressing questions regarding dissemination of NDBI models. NDBI were developed at universities across the country, and like many other areas of science, the gap between discovery of knowledge and practical implementation can be many years. Given the increase in prevalence of ASD and the tremendous lack of available service providers, a focus on strategies to improve dissemination is warranted. The following strategies may be helpful to accelerate community implementation. • Incorporating NDBI training into existing undergraduate and graduate programs Undergraduate and graduate degrees and areas of academic focus could be appropriate places to focus efforts in training future clinicians and educators in NDBI models. Board Certified Behavior Analysts and behavior technicians are often thought of as the primary agents of intervention for core symptoms for

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children with ASD. Training programs in behavior analysis are variable in the extent to which they provide training in naturalistic forms of behavior analysis. In addition, many programs are quite brief (e.g., 1 year), resulting in a primary focus on education in core behavioral principles without ample time to cover NDBI models and strategies in depth. To expand NDBI use into the schools more effectively, special education programs could also begin to incorporate coursework regarding the delivery of such interventions in classroom settings. Psychology and counseling programs could do the same, especially in light of the focus on the parent training components of these interventions. Improvements in the research base, as discussed previously, are one important step, but educators and community intervention providers must then carry the findings over into academic training programs. • Working with community-based providers and educators to implement treatment An alternative to inclusion into existing undergraduate and graduate programs may be to offer NDBI training through continuing education programs on a wider scale for professionals already licensed or certified. This would provide an opportunity for more in-depth training and allow for training to meet quality measures such as treatment fidelity. Although postgraduate certification is now available through some of the NDBI models, this type of certification is often research oriented and very expensive. Community providers are often unable to reimburse these training programs, especially in light of the high turnover in the industry as a whole. Clinicians and researchers with NDBI background may also consider how to develop partnerships with their local service systems, such as early intervention Birth to Three programs, state organizations that support individuals with developmental disabilities, and school districts. Some NDBI models (e.g., Joint Attention, Symbolic Play, Engagement, and Regulation [JASPER]; Enhanced Milieu Teaching [EMT]; PRT) have done research in settings such as schools and have developed models for school-based dissemination (e.g., Classroom Pivotal Response Teaching [CPRT]). Continuing both the research and dissemination efforts focused on public service systems will aid in much wider access to services for children with ASD, especially those who live in areas where access to private treatment agencies is limited. • Exploring novel service-delivery models that maximize effective implementation Research and implementation through novel service-delivery models is also warranted. Although many NDBI rely on clinician expertise, others are partially or completely parent-mediated. Novel service-delivery methods may include parent training groups, web-based training, applications that use artificial intelligence and smart bots to guide parents through coursework, and telehealth. Technology can be leveraged to expand access to services, particularly those that are parent-mediated. Several NDBI have been studied using novel methods, such as group PRT and Internet-based training in the Early Start Denver Model (ESDM) and Project ImPACT (Improving Parents as Communication Teachers). Further work in this area will also enhance access to services.

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Applications of NDBI Strategies

• Increasing access to published documentation Although most NDBI have published manuals, dissemination may be accelerated by access to more published documentation, including, but not limited to, curricula (especially for older children and adults), guides to parent training (especially for older children and adults), workbooks, data sheets, and checklists. These types of intervention supports, guidelines, and instructions will ensure knowledge is not lost when intervention is disseminated into the community. Furthermore, considering more bi-directional research that brings together communities and universities, research institutions may want to engage with community providers to test the materials they have developed to aid their implementation.

CONCLUSION In conclusion, we feel the concept of NDBI provides for parsimony of distinct intervention models (e.g., PRT, ESDM, JASPER) and allows for a clearer appreciation and understanding by families, professionals, insurance carriers, and other consumers. Researchers and clinicians must self-identify their intervention as an NDBI strategy. To be identified as such, however, requires that the intervention has strong empirical support and incorporates the requirements described in this book. Various ASD treatment consumers can then have confidence that an intervention has met the qualifications and requirements of NDBI. We are hopeful that our field will continue to advance and collaborate. This book is likely only the beginning of a movement to bring research and practice together and into the communities where these interventions are needed most. We hope this book is one positive way to help practitioners and others understand and use NDBI.

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Kasari, C., Lawton, K., Shih, W., Landa, R., Lord, C., Orlich, F., . . . Senturk, D. (2014). Caregiver-mediated intervention for low-resourced preschoolers with autism: An RCT. Pediatrics, 134, e72–e79. Koegel, R. L., Camarata, S., Koegel, L. K., Ben-Tall, A., & Smith, A. E. (1998). Increasing speech intelligibility in children with autism. Journal of Autism and Developmental Disorders, 28, 241–251. Koegel, R. L., Dyer, K., & Bell, L. K. (1987). The influence of child preferred activities on autistic children’s social behavior. Journal of Applied Behavior Analysis, 20, 243–252. Landa, R. J., Holman, K. C., O’Neill, A. H., & Stuart, E. A. (2011). Intervention targeting development of socially synchronous engagement in toddlers with autism spectrum disorder: A randomized controlled trial. Journal of Child Psychology and Psychiatry, 52(1), 13–21. Laski, K., Charlop, M. H., & Schreibman, L. (1988). Training parents to use the natural language paradigm to increase their autistic children’s speech. Journal of Applied Behavior Analysis, 21, 391–400. Lovaas, O. I. (1987). Behavioral treatment and normal educational and intellectual functioning in young autistic children. Journal of Consulting and Clinical Psychology, 55, 3–9. Meline, T., & Paradiso, T. (2003). Evidence-based practices in schools: Evaluating research and reducing barriers. Language, Speech, and Hearing Services in Schools, 34, 273–283. Pierce, K., & Schreibman, L. (1995). Increasing complex social behaviors in children with autism: Effects of peer-implemented pivotal response training. Journal of Applied Behavior Analysis, 283, 285–295. Schreibman, L., Dawson, G., Stahmer, A. C., Landa, R., Rogers, S. J., McGee, G. G., & Halladay, A. (2015). Naturalistic Developmental Behavioral Interventions: Empirically validated treatments for autism spectrum disorder. Journal of Autism and Developmental Disorders, 45, 2411–2428. Sherer, M. R., & Schreibman, L. (2005). Individual behavioral profiles and predictors of treatment effectiveness for children with autism. Journal of Consulting and Clinical Psychology, 73, 525–538. Stahmer, A. C. (1999). Using pivotal response training to facilitate appropriate play in children with autism spectrum disorders. Child Language Teaching and Therapy, 15, 29–40. Stahmer, A. C., Leslie, L. K., Hurlburt, M., Barth, R. P., Webb, M. B., Landsverk, J., & Zhang, J. (2005). Developmental and behavioral needs and service use for young children in child welfare. Pediatrics, 116, 891–900. Sullivan, K., Stone, W. L., & Dawson, G. (2014). Potential neural mechanisms underlying the effectiveness of early intervention for children with autism spectrum disorder. Research in Developmental Disabilities, 35, 2921–2932. Weisz, J. R., Chu, B. C., & Polo, A. J. (2004). Treatment dissemination and evidence-based practice: Strengthening intervention through clinician-researcher collaboration. Clinical Psychology: Science & Practice, 11, 300–307.

Glossary AAC Augmentative and alternative communication. All systems and ways individuals communicate without speaking. AAC may include picture systems, tablet systems, and speech-generating devices. A-B-C sequence Antecedent-behavior-consequence sequence. See also threeterm contingency. abolishing operations Reduction in value of a reinforcer due to satiation. acquisition tasks Tasks that are new. active listening Technique in which the listener fully hears what the other person says and conveys interest by using nonverbal and verbal messaging. affective engagement The interactive relationship with positive emotions between caregiver and child. affective reciprocity The emotional experience in back-and-forth interactions, usually between a parent and a child. affective sharing Automatic mirroring of the other person’s emotional state. antecedent Preceding event or stimulus that sets the occasion for and influences the actions or behaviors that follow. antecedent interventions Strategies that focus on the events or stimuli that precede a behavior in order to reduce the likelihood of challenging behavior. backward chaining Instruction begins with the last step of the sequence. balanced turns Back-and-forth exchanges in activities or with objects in which both people have more or less the same number of turns. behavior regulation communicative intents Behaviors that regulate the behavior of another person. behavioral momentum Increasing the likelihood of responding by presenting easier or already acquired tasks to establish a pattern of responding before presenting the more difficult or newer task. cascading effect A cumulative effect on development whereby acquisition of lower level skills propels spreading effects toward other skills. 415

416

Glossary

chaining Breaking a target behavior down into component steps and teaching the steps individually in sequence; when these steps are performed in sequence, the target behavior is achieved. contingent/contingency Dependent and/or temporal relations between operant behavior and its controlling variables. continuous reinforcer schedule Every correct response is reinforced. cooperative arrangements Arrangements of materials so that peers need each other to complete the activity. differential reinforcement Reinforcing a specific class of behavior while withholding reinforcement for other classes of behavior. directive coaching Telling the parent what to do. discrete trial training A method of teaching based on Applied Behavior Analysis principles, where skills are broken into smaller subsets and taught one at a time. discriminative stimulus A stimulus in the presence of which a particular response will be reinforced. dyadic synchrony A regulated, reciprocal, and harmonious interaction between two people. echolalia Repetition of noises, words, or phrases. ecological validity The extent to which research findings can be generalized to everyday real life. Intervention studies with strong ecological validity are conducted in a fashion that mimics real life as much as possible. This term clinically refers to whether interventions are feasible in the natural environment and whether context-specific barriers have been taken into account, such as parental involvement and cultural factors. emotional attunement Being aware and responsive to the other person’s emotions and non verbal cues. enticing strategies Animation, narration, imitation, or humor used to increase the likelihood of child engagement. environmental arrangement Purposeful planning of a learning environment and the materials in order to increase the likelihood of appropriate behaviors and decrease the likelihood of challenging behaviors. errorless learning Using prompting from most to least intrusive to ensure the child’s successful responding and high levels of reinforcement. establishing operations (EO) Environmental event that increases the value of a stimulus due to deprivation, in this case a consequence. evidence-based interventions Treatments supported by empirical evidence as effective. expansions Response to a child utterance in which something is added to the child’s language.

Glossary

417

extinction Removing previously provided reinforcement, decreasing the likelihood of subsequent behavior. Also called planned ignoring. extinction burst Temporary increase in the strength of a behavior after extinction is first employed. fixed interval schedule of reinforcement The time interval after which reinforcement is provided is consistent. fixed ratio schedule of reinforcement The number of responses between reinforcements is consistent. forward chaining Instruction begins at the beginning of the complete response. free operant preference assessment Allowing a child free access to all types of materials (but typically not food) to identify potential positive reinforcers. function of the behavior The reason a behavior occurs. functional behavior assessment (FBA) Assessment that identifies and operationalizes target behaviors—identifies their function or purpose and what maintains them. functional communication Practical and meaningful communication skills that the child can use to be more independent. functional skills Practical skills that allow individuals to be more independent. functionally equivalent replacement behaviors New behavior that serves the same purpose (function) as the previous behavior. generalization Use of skills across various people, places, and materials. goodness of fit Contextual fit; the treatment plan works well for stakeholders in the natural environment (home, school, community), which improves the likelihood of its long-term use. IEP Individualized education program. A written education plan designed to meet a child’s learning needs. imitation A behavior controlled by any physical movement that serves as a novel model, has formal similarity with the model, and immediately follows the occurrence of the model. The model must serve as a controlling variable for the imitative behavior. inclusion Including individuals with disabilities in everyday activities and encouraging them to have roles similar to their peers who do not have disabilities. instructional cue Providing an action to assist or encourage the desired response from the individual. Also see discriminative stimulus. interval schedule of reinforcement The reinforcer is delivered after a specified amount of time. Reinforcement is delivered after the first correct response upon the interval ending.

418

Glossary

joint activity routines Play activities in which both partners have key roles and build on each other’s contributions. Parents build on child behavior in a predictable manner and add variation to increase learning opportunities. joint attention Ability to coordinate attention between objects and people. Sometimes called triadic attention. Is typically divided into response to joint attention bids by others and initiations of joint attention bids by the individual. joint attention initiation Directing another’s attention to an object or event of interest using eye gaze to share interest and/or pointing and/or giving and/or showing. learned helplessness Lack of understanding of the contingency relationship between responses and reinforcement; this occurs when an individual no longer responds because he or she no longer associates a response with a consequence. learning opportunities Teaching trials consisting of antecedents, behaviors, and consequences. maintenance tasks Tasks that have been mastered. mastery criteria The specified standard used to determine whether a new skill is considered acquired. modeling Adult demonstration of appropriate responses or behaviors, typically demonstrating the target skill the child is to perform. morphology Small units of meaning within words. motivating operations Environmental variables that strengthen or weaken the effect of a consequence. natural environment The context in which the individual lives, goes to school, works, and/or engages in social or extracurricular activities. natural reinforcement Reinforcer that has a direct relationship to the behavior and task; in other words, the consequence is logically related to the response. negative punishment Positive stimulus is avoided or removed, decreasing the likelihood of this behavior subsequently. negative reinforcement Undesirable stimulus or event is removed, stopped, or avoided after a behavior, which strengthens the behavior, making it more likely to occur again. noncontingent reinforcement Reinforcement that is provided independent of the target behavior. nonverbal mirroring Term used in enhanced milieu teaching (EMT) to describe an adult imitating his or her child’s actions. one-up rule When speaking to children, using one more word than the number of words the child is using. operant conditioning Method of learning in which associations are made between behavior and consequences.

Glossary

419

operant learning Method of learning that occurs through rewards and punishments for behavior. Through operant conditioning, an association is made between a behavior and a consequence for that behavior. Also called operant conditioning. operational definitions Clear and specific definitions of behavior that are written to ensure individuals can reproduce treatment procedures and/or code the same thing when measuring behavior. overgeneralization Error as the result of a behavior being under the control of a stimulus class that is too broad. paired choice preference assessment Assessment that provides a hierarchy of a child’s preferences by providing choices. parent empowerment Providing parents with the resources, tools, and supports needed to be successful. PECS Picture Exchange Communication System. A systematic comprehensive way to teach communication through the use of small cards with simple icons or photos in six consecutive phases. peer-mediated intervention Therapy that uses the person’s peers to deliver treatment. person-centered planning An ongoing collaborative process in which stakeholders (e.g., treatment providers, parents, caregivers, school personnel) partner with the individual with autism spectrum disorder (or any developmental or medical condition) to develop and actualize that person’s vision for his or her life and future. phonology Rules about speech sounds. pivotal areas Areas that, when targeted, result in widespread gains in untargeted areas of behavior. positive behavior support Set of evidence-based strategies used to increase quality of life and decrease challenging behavior by teaching new skills and making changes in a person’s environment. positive punishment An aversive stimulus follows a response and decreases the likelihood of this behavior subsequently. Also called punishment by application. positive reinforcement Desirable stimulus or event that occurs after a behavior and strengthens the behavior, making it more likely to reoccur. pragmatics Rules for communication through language. Premack Principle Positioning a higher probability behavior after (or contingent on) the occurrence of a lower probability behavior in order to increase the likelihood of the lower probability behavior’s occurrence. Also called first, then. priming Behavioral intervention involving the presentation of upcoming activities in a low-demand context with high levels of reinforcement prior to when the appropriate behavior is expected to be performed.

420

Glossary

prompt Type of antecedent; an additional cue that can be delivered with or after the initial instructional cue; provides extra support to elicit a correct response. prompt dependence Pattern in which the child does not engage in the behavior without prompts or assistance. In other words, the child may become reliant on prompts to complete a skill rather than gaining the ability to perform the skill independently. prompt fading Systematic reduction to less-intrusive prompting with the goal of independence. prompting Systematic way of providing and removing assistance to help an individual learn a skill. randomized controlled trials Research designs in which individuals are randomly allocated to groups and compared to each other after implementation of an independent variable (e.g., a specific treatment). ratio schedules of reinforcement Every response is not followed by a reinforcer, but rather reinforcement delivery is determined by the number of responses that have occurred since the last reinforcement. recasting Repeating the child’s response. Can be used to expand the child’s response by adding on to what the child did or said, often along with providing reinforcement. reinforcement When an event occurs (is perceived, received, or removed) that follows and strengthens a behavior, making it more likely to reoccur. reinforcing attempts Providing reinforcement not only for correct responses but also for a goal-directed attempt in the right direction. reliability Whether results are precise enough to be consistently replicated. replacement behaviors Skills taught to take the place of the challenging behavior. To be successful, the selected skills must be a response match, be efficient, be acceptable, and be recognizable. responsive interaction Ability of the parent or therapist to connect with the child emotionally. Following the child’s lead, mirroring nonverbal actions (sometimes referred to as synchronization), and turn taking are examples of responsive interactions that provide the context and the interaction in which teaching is optimized. self-management Monitoring and rewarding of one’s own behavior. semantics The meaning of words (vocabulary). sensory social routines Social game made up of a sequence of back-and-forth actions by parent and child in which repeated actions and affect sharing combine to enhance social interaction and joint attention. setting event Prior events or conditions, internal or external to the individual, that increase the likelihood that an antecedent will evoke a response.

Glossary

421

shaping Reinforcing successive approximations to the target response. single subject design studies Research design in which the subject serves as his or her own control. social motivation hypothesis of autism spectrum disorder Suggests that the social reward system in the brain is compromised, resulting in children with autism spectrum disorder receiving limited reinforcement from social engagement, which leads to less learning from the environment. social orienting Develops before joint attention and consists of a child directing attention to another person: turning to and responding to naturally occurring social stimuli. social validity Social importance and acceptability of treatment goals or target behaviors, intervention procedures, and treatment outcomes. A well-rounded view of social validity takes into account the acceptability from the perspective of the client, the treatment provider, and society; however, the client and family view is often most emphasized. stimulus discrimination Extent to which a stimulus evokes a specific response to the exclusion of others. stimulus generalization When related or similar stimuli evoke the same response. stimulus overselectivity Attentional deficit in some children with autism spectrum disorder wherein a child’s behavior might only be affected by a small portion of a compound stimulus. strength of the behavior Behavior’s frequency (how often it occurs, e.g., how many tantrums in a day), latency (how soon after the antecedent the behavior occurs, e.g., how quickly the child says “daddy” when his or her father appears), and magnitude (with how much force the behavior occurs, e.g., decibel level of screaming). synchronization Mirroring nonverbal actions. syntax Rules that govern sentence structure, including word order. task analysis Process that breaks a complex multistep behavior down into a sequence of smaller steps or actions. task variation Providing a mix of targets within a sequence (as opposed to the same task repeatedly). three-term contingency Each behavior can be understood and broken down into what happened before (antecedent or discriminative stimulus), the behavior (operant response), and the consequence (reinforcer or punisher). time delays Prompts used to transfer stimulus control from adult prompts to naturally occurring stimuli by increasing the time between the discriminative stimulus and the prompt. topography Description of a behavior without values or expectation.

422

Glossary

treatment fidelity Sometimes called fidelity of implementation or treatment adherence: the degree of accuracy with which a procedure or a set of strategies is implemented or used. validity Represents something accurately and completely. variable interval schedule of reinforcement Time interval after which reinforcement is provided varies. variable ratio schedule of reinforcement Number of responses varies between reinforcements.

Index References to tables, figures, and boxes are indicated with a t, f, and b, respectively. Abolishing operation (AO), 125b in consequence strategy, 197, 197b Academic setting, see School setting Acceptability, see Goodness of fit Acquisition tasks, 14, 23, 32 data collection and, 371, 371b social skills and, 248, 266t, 282t, 297 Activities child-selected, 133–134, 134b, 135t Classroom Pivotal Response Teaching (CPRT) examples, 357, 358t–359t group-based, 61 planning of, 156–160, 157b, 158t–159t school setting and, 355–357, 356b, 356t–359t self-regulation behavior and, 323, 327, 333 Adaptive behavior bathing and, 332–333, 334t, 336t cooking and, 318, 325, 332–333, 336t dinnertime meal and, 314, 318, 331, 339 maladaptive behavior and, 10, 339 selecting targets of, 332–333 self-regulation and, 322–326 teaching of, 333–341, 334t–338t Vineland Adaptive Behavior Scales and, 52 see also Challenging behavior; Naturalistic Developmental Behavioral Interventions Adaptive Behavior Assessment System (ABAS), 52, 106 Adult affect, 325 Adult imitation, 11b, 15, 78, 131–132, 284 Affective engagement, 7–8 Affective reciprocity, 7 Affective sharing, 7–8 Affect-laden interactions, 123–124 Age appropriateness, 312 case example of, 114–115, 341, 343 data collection and, 363 of goals, 54, 228, 231

of peers, 109 play development and, 286–288, 287t–288t of toys, 155 Aggression, 195 in antecedent-behavior-consequence (A-B-C) data sheet, 376f self-regulating behavior and, 309–310, 324–326 Aikido, martial art, 68 Alexa’s Playful Learning Academy for Young Children (PLAYC), 62–63 inclusion and, 102, 112–113 Alternative communication, see Augmentative and alternative communication Americans with Disabilities Act (ADA) of 1990 (PL 101-336), 100 Antecedent, behavior, and consequence (A-B-C) framework, 6, 23 antecedent-based intervention and, 151–152, 152b in communication development, 241–242 consequence strategies and, 193, 210 data sheet for, 374, 375f–376f learning opportunities and, 175–177 sharing control and, 140 Antecedent-based intervention behavioral momentum in, 166–167 case example of, 171–172 child’s attention in, 166 conclusion on, 172 Early Start Denver Model (ESDM) and, 154–155, 160, 165 engaging and enticing in, 164–165 Joint Attention, Symbolic Play, Engagement, and Regulation (JASPER) and, 154–155, 165 routines in, 164–167, 168t–170t in self-regulation, 311–315, 313b, 318, 341–343 setting events and, 151–152, 152b, 156 423

424

Index

Antecedent-based intervention—continued shared control in, 167, 168t–170t task variation in, 166–167 teaching and see also Naturalistic Developmental Behavioral Interventions Antecedents, 31 Applied Behavior Analysis (ABA) challenging behavior and, 309–322, 313b, 316b, 319b consequence strategies and, 193, 197, 208, 210 curriculum checklists and, 220–221 data collection and, 361–363, 362b, 366–375, 389 empowering parents and, 85, 91 learning opportunities and, 177, 191 Naturalistic Developmental Behavioral Interventions (NDBI) and, 3–17, 11b progress tracking and, 399–400 in social initiations, 278 Assertiveness, 26 Assessment curriculum-based, 13, 54 free operant preference, 160 functional behavioral assessment (FBA), 310 in goal development, 218–224, 221t, 223t initial assessment and, 66, 221, 370, 370b paired choice preference, 160 published curricula and, 53–54 standardized assessments, 219–220 Verbal Behavior Milestones Assessment and Placement Program (VB-MAPP), 54, 222 Assessment Evaluation and Programming System for Infants and Children (AEPS®), 54, 222 Assessment of Basic Language and Learning Skills (ABLLS), 54, 222 Attentional focus, 11b, 15–16, 30, 35t case example of, 229 inclusion and, 109 in school settings, 354–355, 354t Attention-deficit/hyperactivity disorder (ADHD), 341–343 Auditory cues, 332t Augmentative and alternative communication (AAC) device, 188–189 nonverbal individuals and, 253–254 prompting and, 183, 188–189 replacement behavior and, 317 teaching strategies in, 253–254 Autism education associates (AEA), 112 Autism Focused Intervention Resources and Modules (AFIRM), 357, 393, 399–400

Autism Research Foundation, 100 Autism Society of America, 100 Autism Speaks, 5 Autism spectrum disorder (ASD), 3 communication development and, 237–338 defined, 4–5 developmental science and, 7–10 earliest symptoms of, 7 history of intervention, 5–7 National Professional Development Center on, 347, 357 social motivation hypothesis of, 22 see also Applied Behavior Analysis; Naturalistic Developmental Behavioral Interventions Autistic Self-Advocacy Network (ASAN), 100 Autoimmune disease, 80 Autosymbolic play, 287t Aversive sensory input, 61 Backward chaining, 201 Baer, D.M., 11–12, 58 Balanced turns, 78, 91, 92t, 109 motivation and, 141–144, 143t in social skills, 285, 295–296 Balloons, 135t, 159t, 259t–260t, 282t, 293t Baseline data, 370 Bathing, 50, 169t, 204t, 291 adaptive behavior and, 332–333, 334t, 336t Bayley Scales of Infant and Toddler Development (BSID), 52, 219–220 Behavior, see Adaptive behavior; Challenging behaviors Behavior regulation communicative intents, 251 Behavioral momentum, 137t, 144, 166–167 Behavioral observation, 53 in goal selection, 222–224, 223t Behavioral Skills Training, 85 Bingo game, 299–300, 319, 321 Board Certified Behavior Analyst (BCBA), 10, 23, 33, 363, 402f, 410–411 Board games, 64, 227, 292, 292b, 296 Body movements, imitation of, 132 Brainstorming, with parents, 84–86, 84t Brown’s Stages of Language Development, 239 Brushing teeth, 334t Bubbles bath time and, 169t communication behavior and, 250, 260t, 264t expanding interest and, 135t goal development and, 227–228 instructional cues and, 181, 184t

Index

recasting and, 243 time delay strategies and, 283 word vocalization of, 131t, 145–146, 202 Bus schedule, 335t, 338t, 340 Camp settings, 61 Caregiver buy-in, 225–226, 226b Carolina Curriculum for Infants and Toddlers with Special Needs, 54 Cascading effect, 8, 230–231 Celebrity advocacy, 4 Centers for Disease Control and Prevention (CDC), 99 in consequence strategy, 201–202 in self-regulation behavior, 317, 333, 336t, 382 Challenging behaviors adaptive skills teaching and, 339–341 antecedent interventions, 311–315, 313b, 318, 341–343 Applied Behavior Analysis (ABA), 309–322, 313b, 316b, 319b behavioral flexibility and, 327–331, 327t–330t case example on, 341–343 conclusion on, 343 consequence interventions, 317, 343 data collection on, 374, 375f–376f discrimination training and, 319–321, 319b, 323 extinction in, 318 functional approach to, 311–312 individualized antecedent interventions, 313–314, 313b, 342–343 measurement strategy in, 319–320 Naturalistic Developmental Behavioral Interventions (NDBI) and, 310–311, 322–326 priming and, 313–314, 313b prompt fading in, 324–325 reinforcement in, 318–324, 319b, 330–343 replacement behavior and, 314–318, 316b, 322, 326–327 selecting targets of, 332–333 self-management and, 318–319, 319b self-regulation in, 327t–330t, 332–333 target behavior in, 318–323, 328t–330t, 334t–338t, 340 task analysis, 317, 333 teaching self-regulation in, 339–341 universal antecedent interventions, 312–313, 341 waiting and, 331, 332t Child-initiated teaching, 11b, 16, 27, 62, 125 Child-parent dyadic play, 31, 33, 52, 141, 165, 279

425

Child-preferred activities, 16 motivation and, 124, 135–136, 141 in school settings, 349–352, 351b social skills and, 296 Child’s attention, 13, 16, 89t, 135t in antecedent strategies, 156, 164, 166 consequence strategies in, 205–206, 207t joint attention behaviors and, 237–240, 240t, 249–252, 252t, 265 see also Joint Attention, Symbolic Play, Engagement, and Regulation Child’s lead, 16, 23–25, 29–34 antecedent-based strategies and, 167, 168t–170t empowering parents and, 78, 81, 89t motivation and, 124, 134–136, 137t–138t in peer interactions, 299 social skills and, 289, 290t–291t, 299 Child-selected activities, 23 free play, 134b motivation and, 133–134, 134b, 135t self-regulation and, 323, 327, 333 see also Child-preferred activities Choices, providing of, 136–139, 139t in school settings, 349–352, 351b Circle of Friends, 105 Classroom Pivotal Response Teaching (CPRT), 31 checklist, 392, 395f data collection and, 365 example activities, 357, 358t–359t individual goals and, 357, 358t–359t Cleaning, 137t, 155, 205 adaptive behavior and, 335t case example of, 114, 116 symbolic play and, 287t Clear cues, 180, 314, 322–323 Clear instruction clear rules and, 164, 172 in group settings, 353–354 Clinic settings, 64–65 Clinician, 12, 16, 31, 36 delivered intervention, 78 staff training and, 399–402 see also Data collection Cognitive subscale, of Bayley Scales of Infant and Toddler Development (BSID), 219–220 Common Core State Standards (CCSS), 104, 347–348 Communication and Symbolic Behavior Scales (CSBS), 52, 219 Communication development augmentative and alternative communication in, 253–254 Autism spectrum disorder (ASD) profile in, 237–338

426

Index

Communication development—continued Early Start Denver Model (ESDM) in, 240–241, 244, 250–251, 253 goal targeting in, 243–244, 245t–247t joint attention behaviors in, 237–240, 240t, 249–252, 252t, 265 modeling in, 242–243 narrating in, 242–243 noncontingent reinforcement and, 243–244, 248b, 262, 262t one-up rule in, 243 Picture Exchange Communication System (PECS), 242, 245t, 253–254 recasting in, 243 receptive language and, 243, 251, 270t reinforcing attempts, 244–248 shared control strategies, 243–244, 245t–247t teaching and typical children in, 238–240, 240t visual cues and, 252, 271 Community programs, inclusion and, 106–109 Community settings, 60–62 Compound stimulus, 15 Comprehensive Assessment of Spoken Language (CASL), 52 Comprehensive treatment model (CTM), 36 Consequence strategies, 317, 343 Applied Behavior Analysis (ABA) and, 193, 197, 208, 210 behavior change and, 199–200, 200t child’s response in, 205–206, 207t conclusion on, 210 effectiveness and, 196–199, 197b, 198t extinction, 194t, 195, 199–201 free play and, 203, 208 natural consequences and, 202–205, 204f negative punishment and, 194t, 195 negative reinforcement and, 194t, 195, 197–198 positive punishment and, 194t, 195 positive reinforcement and, 193–194, 194t, 203–204 Premack Principle and, 196, 196f punishment and, 193–195, 194t, 197, 199 reinforcing attempts, 205 shaping and chaining, 201–202 strength of behavior and, 194–195, 194t troubleshooting, 206–210, 207t Contextual fit, see Goodness of fit Contingency, 32 Contingent consequence, 196–199, 197b, 198t Contingent reinforcement in communication development, 243–244, 248b, 262, 262t motivation and, 137t, 140 in school settings, 352

Continuous data collection, 380 Continuous reinforcer schedule (CRS), 200, 200t Cooking, 50, 111, 160 adaptive behavior and, 318, 325, 332–333, 336t symbolic play and, 287t, 291t, 301 teaching moments and, 261t, 270t Cooperative arrangement, 299–301, 302b Corrective feedback, 88, 89t Counting money, 326, 335t, 338t Culture, 47–49 in goal selection, 224–225 Curriculum checklists, 220–221 Curriculum-based assessments, 13, 54 Daily living skills prompting and, 190 routine in, 9 see also Routines Data collection acquisition tasks and, 371, 371b Antecedent, behavior, and consequence (A-B-C) data and, 374, 375f–376f Applied Behavior Analysis (ABA) and, 361–363, 362b, 366–375, 389 Autism Focused Intervention Resources and Modules (AFIRM) and, 399–400 baseline and, 370 on challenging behaviors, 374, 375f–376f Classroom Pivotal Response Teaching (CPRT) and, 365 conclusion on, 389 contexts for, 369–375, 371b, 372f–377f embedded trials and, 177–179, 178b, 178t general framework for, 362–363, 362b on generalization, 373–374, 374f initial assessment and, 370 Likert scale in, 367, 374–375, 380t on maintenance of skills, 372, 372f–373f measurement systems, 379–383, 380t, 382f, 384f–385f, 386b models of in natural environments, 383 permanent product, 380t, 381 probes in, 362, 368–373, 378t prompt type and level, 371–372, 372f reliability and, 262–263, 262b across sessions, 371 task analysis in, 382–383, 384f–385f time sampling, 380t, 381–382, 382f treatment fidelity and, 374–375, 377f trial-by-trial types of data validity and, 362, 362b, 386 see also Naturalistic Developmental Behavioral Interventions

Index

Data sheets, 363, 399, 412 for Antecedent, behavior, and consequence (A-B-C) framework, 374, 375f–376f in Classroom Pivotal Response Teaching (CPRT), 365 in Developmentally Appropriate Treatment for Autism in Toddlers (Project DATA), 365–366 in Early Start Denver Model (ESDM), 364 on fidelity, 367, 377f on generalization, 373–374, 374f in Project Improving Parents as Communication Teachers (ImPACT), 366–367 trial-by-trial, 371–372, 373f Data Summary Sheet, 364 DeMyer, Marian, 5 Denver model, original, 22–23 see also Early Start Denver Model Depression, 80, 326 Depth, of skills, 231 see also Goal development Developmental cascades, 230–231 Developmental pragmatic communication approach, 24 Developmentally Appropriate Treatment for Autism (Project DATA), 21 data collection and, 362, 365–366 goal development and, 214, 222 inclusion and, 102 manual, 54 Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5), Autism Spectrum Disorder (ASD) criteria for, 5 Differential Ability Scales (DAS), 219 Differential reinforcement, 10 Dining behavior, 64, 107, 115 Dinnertime meal, 9, 47, 68 adaptive skills and, 314, 318, 331, 339 consequence behavior and, 194, 196f data collection and, 379, 388 motivational behavior and, 136, 138t, 141 shared control and, 247t Direct reinforcement, 104, 210, 245t in group settings, 348, 352 Directive coaching, 82 Discontinuous data collection, 380 Discrete trial training (DTT), 6–7, 16, 240 Discrimination training, 319–321, 319b, 323 Discriminative stimulus (SD), 14, 176 Dressing skills, 332–333, 334t, 338 DSM-5, see Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition Duration data, 378t, 379 Dvortcsak, Anna, 32, 82, 250, 285b Dyadic play, 31, 33, 52, 141, 165, 279 Dyadic synchrony, 279

427

Early cooperative play, 10 Early infantile autism, 4 Early intervention, 3, 7–8 Early learning, 9, 15 Early Social Communication Scales (ESCS), 53, 222 Early Start Denver Model (ESDM), 4, 10 antecedent strategies and, 154–155, 160, 165 case example and, 112 in communication development, 240–241, 244, 250–251, 253 core components of, 23 data collection an, 364 empirical support for, 22 4-day workshop in, 22 functional skills and, 51–52 introduction to, 21–22 relationship to other models, 23, 35t in social skills, 283, 285–286, 289 Echolalia, 25, 130 Ecological validity, 9, 46, 47b see also Natural environments Effective feedback, in parent coaching, 87–88, 89t Electroencephalogram (EEG), 22 Embedded trials, 177–179, 178b, 178t Emory Autism Center, 114–115 Emotional attunement, 279 Emotional cues, 7, 130 Empirical validation for Early Start Denver Model (ESDM), 22 for Enhanced Milieu Teaching (EMT), 24 future directions and, 409 of incidental teaching (IT), 26 of Joint Attention, Symbolic Play, Engagement, and Regulation (JASPER), 27–28 of Naturalistic Developmental Behavioral Interventions (NDBI), 10, 11b of Pivotal Response Treatment (PRT), 31–32 of Project Improving Parents as Communication Teachers (ImPACT), 33–34 Empowerment, of parents, 80–82, 81b Engagement, 164–165 Joint Attention, Symbolic Play, Engagement, and Regulation (JASPER) and, 28–29 motivation and, 126–130, 127t–129t, 129b Engaging and enticing, see Antecedentbased intervention Enhanced Milieu Teaching (EMT), 10, 248 in antecedent-based treatment, 165 core components of, 24–25, 35t data collection and, 367–368 empirical support for, 24

428

Index

Enhanced Milieu Teaching (EMT)— continued goal selection and, 223 introduction to, 23–24 Naturalistic Developmental Behavioral Interventions (NDBI) and, 25, 35t social skills and, 282–283, 285 Enticing strategies, 164–166 Environmental arrangement, 13–14, 153–155 in social skills, 282–283 strategies of, 314–315 Establishing operations (EO), 125b European-American culture, 48, 225 Evidence-based interventions, 357 Executive functioning behaviors, 335t, 337t Expressive communication, 10, 26, 188, 220, 221t prompting and, 188 see also Communication development External variables, in behavioral observation, 222–224, 223t Extinction, 31, 194t, 195, 199–201 in challenging behavior, 318 Extinction burst, 195 Facilitated playdates, 299 Families routines of, 47–48, 59–60, 78, 396 stress and, 309, 326–327, 343, 396 values in goal development, 224–225, 226b, 232 see also Social skills Feasibility, of data collection, 386–387 Ferster, Charles, 5 Fidelity, see Treatment fidelity First grade, 408 using Classroom Pivotal Response Training (CPRT), 357, 358t–359t First words, 55, 209, 227 communication skills and, 254–262, 256t–261t goal development and, 227, 237, 239, 242 Fixed interval (FI) schedule of reinforcement, 200, 200t Fixed ratio (FR) schedule of reinforcement, 200, 200t Flexibility, of behavior, 327–331, 327t–330t Forward chaining, 201 Free operant preference assessment, 160 Free play child-selected activity, 134b consequence and, 203, 208 inclusion and, 110t, 113 natural environments and, 383 school and, 350t, 355 Frequency data, 375–378, 378t Function, of behavior, 315

Functional behavioral assessment (FBA), 310 Functional communication, 8 Functional magnetic resonance imaging (fMRI), 56 Functional skills, 36 assessment for goal setting in goal selection, 226 individualization and, 54–56 across intervention models, 51–52 see also Adaptive behavior Functionally equivalent replacement behaviors, 310 Game play, 293t–294t Bingo and, 299–300, 319, 321 board games, 64, 227, 292, 292b, 296 free play, 110t, 113, 134b Hide and Seek, 163, 269t kinetic sand and, 135t, 261t Lego blocks, 105–106, 142t memory matching, 292, 295 video games, 114, 134, 167, 227 see also Social skills Generalization, 24 data sheet on, 373–374, 374f in group settings, 355 of skill, 57–58, 57b, 59b Gestures, 9 imitation of, 131t, 132 prompting and, 188 Goal development age appropriateness in, 231 assessment in, 218–224, 221t, 223t behavioral observation in, 222–224, 223t caregiver buy-in, 225–226, 226b cascading effect and, 230–231 case examples and, 221, 221t, 226–227, 229–230 conclusion on, 231–232 considerations for, 224–227, 226b developmental considerations in, 228–231 family values in, 224–225, 226b, 232 formulating goals, 214–216, 217t–218t, 218b individualization and, 54–56 mastery criteria in, 214–215 Naturalistic Developmental Behavioral Interventions (NDBI) and, 213–216 parent training goals, 216, 218b published curricula in, 53–54 receptive language and, 219–220 standardized assessments, 219–220 standardized testing and, 52–53 Goodness of fit data collection and, 386 of intervention approaches, 46–49, 47b

Index

Graduate education, 114 Naturalistic Developmental Behavioral Interventions (NDBI) training, 410–411 Grandma’s Rule, see Premack Principle Grandparents, 48 Gross motor play, 64 Group parent education, 79 Group settings, 61 research design, 407 shared control in, 349–352, 351b see also School settings Handwriting, 351 Hart, Betty, 25 Heart disease, 80 Hide and Seek game, 163, 269t, 293t Home settings, 59–60 Humor, 165–166 Hygiene, 334t Imitation, 7, 9, 22, 46 of adult, 15 of body movements, 143 of child, 248, 249b of child’s actions, 131, 131t in consequence strategy, 206, 207t of gestures, 131t, 132 with novel actions, 131t, 132 objects and, 131t, 132 parent coaching and, 78, 84, 84t, 91, 92t, 94 of vocalizations, 132–133 see also Social skills Incidental teaching (IT), 10 core components of, 26–27, 35t empirical support for, 26 introduction to, 25–26 Naturalistic Developmental Behavioral Interventions (NDBI) and, 27, 35t Inclusion Alexa’s Playful Learning Academy for Young Children (PLAYC), 102, 112–113 case example of, 112–116 challenges to, 110t–111t, 111 community programs and, 106–109 conclusion on, 116 free play and, 110t, 113, 134b importance of, 99–100, 100b Learning Experiences: An Alternative Program for Preschoolers and Parents (LEAP), 102–103 Naturalistic Developmental Behavioral Interventions (NDBI) and, 102–106 in practice, 100–101, 101b Independence, 153 encouragement of, 86, 104, 107–108, 112–113

429

functional skills and, 45, 49–50, 63 quality indicators and, 397–398 Individual parent education, 79 Individual preference, see Child-selected activities Individualized antecedent interventions, 313–314, 313b, 342–343 Individualized education program (IEP), 63, 99–100 case example on, 341–343 goals and, 348, 357 quality indicators of, 386–397 standards in data collection, 365 team, 171 Individuals with Disabilities Education Improvement Act of 2004 (PL 108-446), 62, 99 Ingersoll, Brooke, 32, 82, 250, 285b In-home child care providers, 31 In-home intervention, 26 Initial assessment, 66, 221, 370, 370b Initiation behaviors, 30 Instructional cues, 30 antecedents and, 176 bubbles and, 181, 184t definitions and, 175–176 learning opportunities and, 177–182, 178b, 178t, 180f, 182t natural and varied, 181, 182t receptive language and, 182t, 189–190 in school settings, 353–354 see also Communication development; Prompting Instructional strategies, 9–10 Intensity data, 378t, 379 Internet use, 50 Internet-based training, 79 Interspersing maintenance tasks, 144 Interval recording, see Time sampling Interval schedules of reinforcement, 200 Intervention outcomes, measurement of, 408 IPad, 208, 253, 324, 354 IQ score, 6, 22, 284, 408 Joint activity routines, 23 Joint Attention, Symbolic Play, Engagement, and Regulation (JASPER), 10, 24 in antecedent strategies, 154–155, 165 in challenging behavior, 311, 325 in communication development, 241–242, 251–252 core components of, 28–29, 35t data collection and, 369 empirical support for, 27–28 functional skills and, 51–52 introduction to, 27

430

Index

Joint Attention, Symbolic Play, Engagement, and Regulation (JASPER)—continued motivation and, 128, 130–131, 133, 145 Naturalistic Developmental Behavioral Interventions (NDBI) and, 29–30, 35t teaching play and, 289 Joint attention behaviors, 8–10, 46 in communication development, 237–240, 240t, 249–252, 252t, 265 initiation of, 27, 229 Joint engagement, 29, 56, 178, 281t Kanner, Leo, 4 Key stakeholders, 58, 77 parents as, 36 Kindergarten, 105, 112, 114, 358t–359t Kinetic sand, 135t, 261t Kitchen, 8–9, 59, 64, 179, 318, 320 antecedent behavior and, 151, 168t cleaning of, 116 natural environments and, 383 Language Assessment of Basic Language and Learning Skills (ABLLS), 54, 222 Comprehensive Assessment of Spoken Language (CASL), 52 natural language paradigm, 23–24 receptive language, 10, 52, 112, 138, 399 speech-language pathologist (SLP), 253–255 Systematic Analysis of Language Transcripts (SALT), 223, 367 see also Communication development; Social skills; Verbal skills Latency data, 378t, 379 Learned helplessness, 124 Learning Experiences: An Alternative Program for Preschoolers and Parents (LEAP), 21, 63 inclusion and, 102–103 Learning opportunities, 9, 13 case examples of, 190–191 conclusions on, 191 definitions of, 175–176 embedded trials and, 177–179, 178b, 178t instruction pace and, 179–180, 180f Naturalistic Developmental Behavioral Interventions (NDBI) and, 177–182, 178b, 178t, 180f, 182t prompting and, 182–186, 184t–185t Lego blocks, 105–106, 142t natural consequences and, 203–204, 204f question asking and, 270t in reinforcement activities, 349, 352 teaching first words and, 259t

Likert scale, 367, 374–375, 380t Lovaas, Ivar, 6, 240, 408 Maintenance of skills, 57–58, 57b data collection on, 372, 372f–373f in group settings, 355 Maintenance tasks, 14, 181–182 acquisition tasks in, 282t, 297 task variation and, 248 Maladaptive behaviors, 10, 339 Manualization, 12, 392 Manualized content, 35t, 36, 85, 103, 298, 400 Martial arts, 61 Mastery criteria, 13, 214–215 Math centers, 156 Math skills, 17 in school setting, 348–349, 351–353, 355, 356t, 359t McGee, Gail, 25–27 Mealtime, 47, 78 adaptive behavior and, 327, 334t, 336t data collection and, 383 joint engagement and, 281t pizza and, 55, 68, 257t, 291t, 300, 302b quality indicators and, 396 routines and, 156, 168t see also Dinnertime meal Mean length of utterance (MLU), 367–368 Measurement systems in challenging behavior, 319–320 continuous data collection, 380 discontinuous data collection, 380 methods of, 379, 380t see also Data collection Memory matching game, 292, 295 Menstrual cycle, 334t Milieu teaching, see Enhanced Milieu Teaching Modeling, 10, 15 in communication development, 242–243 in consequence strategy, 205–206 in imitation, 285 inclusion and, 109 Morphology, 239 Motivating operations (MO), 125b in consequence strategy, 197, 197b Motivation behavioral momentum and, 137t, 144 child’s lead in, 124, 134–136, 137t–138t child-selected activities and, 133–134, 134b, 135t choices and, 136–139, 139t engagement and, 126–130, 127t–129t, 129b imitation and, 131–133, 131t Joint Attention, Symbolic Play, Engagement, and Regulation (JASPER) and, 128, 130–131, 133, 145

Index

maintenance tasks and, 144 measurement of, 125–126 natural reinforcement and, 145 Naturalistic Developmental Behavioral Interventions (NDBI) and, 124–125, 125b noncontingent reinforcement, 137t, 140 operational definitions of, 125–126, 127t–128t Pivotal Response Treatment (PRT) and, 125, 133, 135, 141, 144–146 Project Improving Parents as Communication Teachers (ImPACT) and, 125, 130–133, 135, 143, 146 reinforcing attempts, 125, 145–146 in school settings, 349, 350t shaping procedures, 125, 145–146 shared control and, 139–141, 142t–143t taking turns and, 141–144, 143t task variation and, 144 Motivational behavior, dinnertime meal and, 136, 138t, 141 Motivation-based interaction, 9 Movies, 47, 116, 171, 353 Mullen Scales of Early Learning (MSEL), 52, 219 Music, 64, 199 instruments of, 132, 135t, 259t, 267 lessons, 61, 171, 230 social games and, 293t time delay and, 283 toys, 91, 155 MyLIFE program, 114–116 Narration, 165, 242–243 National Professional Development Center on Autism Spectrum Disorder, 347, 357, 393–394, 399 National Research Council, 45, 77 National Standards Project, 318, 347 inclusion and, 101 Natural environments, 9 conclusion on, 69 data collection in, 383–389, 386b, 389b examples of, 66–68, 66t free play and, 383 goodness of treatment fit and, 46–49, 47b selecting meaningful skills for, 45–46 self-regulating behavior and, 340 skill maintenance and, 57–58, 57b social validity and, 47–49, 47b, 49b, 60, 65 types of Natural language paradigm, 23–24 Natural reinforcement, 14, 202–205, 204f inclusion and, 108 Naturalistic Developmental Behavioral Interventions (NDBI)

431

in academic settings, 347– 350t, 351b, 354t adaptive skills and, 333–339, 334t–338t antecedent strategies and, 151–152, 152b challenging behavior and, 310–311 common procedural elements and, 12–13 communication goals communication targeting, 240–248, 245t–247t, 248b–249b in community programs, 106–109 consequence strategy troubleshooting, 206–210, 207t core components of, 8, 11–12, 35t data collection and, 13 Developmentally Appropriate Treatment for Autism (Project DATA) and, 362, 365–366 empirical validation of, 10–16, 11b, 22–34 future directions in, 407–412 goal development, 213–216 goodness of fit of, 46–49, 47b incidental teaching (IT), 26–27, 35t inclusive setting and, 102–106 instructional strategies and, 9–10, 13–16 introduction to, 3–4, 8–10 learning opportunities and, 177–182, 178b, 178t, 180f, 182t models of motivation and, 124–125, 125b parent-mediated intervention and, 77–79 quality indicators of in school settings self-regulation skills and, 327, 328t–330t teaching play and, 288–289 teaching targets and, 8–9 treatment delivery contexts, 9 see also Social skills Negative cascading effects, 230 Negative punishment, 194t, 195 Negative reinforcement, 194t, 195, 197–198 No Child Left Behind Act of 2001 (PL 107110), 99 Noncontingent reinforcement, 161, 161b in communication development, 243–244, 248b, 262, 262t, 290b, 297 motivation and, 137t, 140 Nonverbal individuals, 237–238 Augmentative and alternative communication (AAC), 253–254 Nonverbal mirroring, 143 Nonverbal Reasoning Ability, of Differential Ability Scales (DAS), 219 Nonverbal self-stimulatory behavior, 56 Nonverbal skills, prompts for, 183, 184t–185t Novel actions, 131t, 132 Obesity, 80 Object play routines, 280–282, 281t–282t

432

Index

One-on-one activity, 316, 350t playdates, 278 setting, 163 teaching, 26, 383 One-up rule, 243, 265, 297 Operant conditioning, 175 see also Instructional cues; Prompting Operant methodology, 6 Operational definitions, 367, 375, 379 of motivation, 125–126, 127t–128t Overdependence on prompts, 6 Overselectivity, to stimulus, 15–16 Paired choice preference assessment, 160 Parallel play, 26, 298 Paraprofessionals, 31 Parent and Caregiver Active Participation Toolkit (PACT), 82–83, 83t, 85 Parent coaching effective feedback in, 87–88, 89t imitation and, 78, 84, 84t, 91, 92t, 94 Project Improving Parents as Communication Teachers (ImPACT) and, 82–83, 83t, 85 reflective discussion in, 90, 90b in self-regulation behaviors, 340–341 written content of, 85 Parent education program, 33 Parent psychological functioning, 79–82, 81b Parent stress, 31, 35, 56, 78–82, 81b, 225 Parent training goals, 216, 218b Parent-child interactions, 81–82, 91, 341–342 dyadic play and, 31, 33, 52, 141, 165, 279 see also Families Parent-mediated intervention brainstorming and, 84–86, 84t coaching practices, 82–83, 83t group parent education and, 79 individual parent education and, 79 Naturalistic Developmental Behavioral Interventions (NDBI) and, 77–79 parent empowerment and, 80–82, 81b parent stress and, 80 Project Improving Parents as Communication Teachers (ImPACT) and, 82–83, 83t, 85 psychological functioning in, 79–82, 81b treatment fidelity and, 77, 79, 82, 94 see also Project Improving Parents as Communication Teachers Parent-professional collaboration, 48–49 Patience, 323, 339 see also Waiting Peekaboo, 251, 271 Peer imitation, 26 Peer-mediated interventions (PMI), 31, 272, 347, 357

child’s lead in, 298–299 inclusion and, 104–105 see also Inclusion Permanent product, 380t, 381 Person-centered planning, 55 Person-engaged play, 29 Phonology, 239 Photographic activity schedules, 162 Phrase speech, 263–265, 264t–266t Physical education (PE), 162 Physical prompting, see Gestures Picture Exchange Communication System (PECS), 56, 230 book, 188–189 in communication development, 242, 245t, 253–254 Pivotal areas, 30, 125 Pivotal Response Treatment (PRT), 4, 10, 22, 125, 133, 135, 141, 144–146 in antecedent strategies, 155, 160 in challenging behavior, 310–311 core components of, 32, 35t data collection and, 368–369 empirical support for, 31–32 functional skills and, 50–51 goal development and, 216, 223, 229 introduction to, 30–31 learning opportunities and, 179, 183, 186 Naturalistic Developmental Behavioral Interventions (NDBI) and, 32, 35t teaching play and, 286, 289, 298 Pizza, 55, 68, 257t, 291t, 300, 302b PL 101-336, see Americans with Disabilities Act (ADA) of 1990 (PL 101-336) PL 107-110, see No Child Left Behind Act of 2001 (PL 107-110) PL 108-446, see Individuals with Disabilities Education Improvement Act of 2004 (PL 108-446) Planning, of routines, 156–160, 157b, 158t–159t Play routines, see Routines Play skills, 46 cooking and, 287t, 291t, 301 development of, 286–288, 287t–288t object play routines, 280–282, 281t–282t Pivotal Response Treatment (PRT) and, 286, 289, 298 prompting and, 189 routines in, 280–282, 281t–282t teaching of, 288–289, 290b see also Free play; Social skills Playpartner, as reinforcer, 297–298 Positive behavior, 309, 313, 319, 343 Positive behavior support (PBS), 310–311 Positive punishment, 194t, 195 Positive reinforcement, 5–6, 193–194, 194t, 203–204

Index

Pragmatics, 52 Prelinguistic behaviors, 51 see also Imitation; Joint attention Premack Principle, 196, 196f, 339 Preschool programs case example, 112–114 Enhanced Milieu Teaching (EMT) in, 24 inclusion and, 102–103 Joint Attention, Symbolic Play, Engagement, and Regulation (JASPER) in, 28 Project Improving Parents as Communication Teachers (ImPACT) in, 33 Presymbolic play, 287t Preverbal communication, targets and strategies, 249–252, 252t Priming antecedent strategies and, 163–164, 313–314, 313b case example of, 172 inclusive settings and, 105 Probes, in data collection, 362, 368–373, 378t Progress tracking, 398–399 Project DATA, see Developmentally Appropriate Treatment for Autism Project Improving Parents as Communication Teachers (ImPACT), 4, 10 antecedent strategies and, 154, 165 challenging behavior and, 310 in communication development, 241, 244, 250 core components of, 34, 35t data collection and, 366–367 empirical support for, 33–34 functional skills and, 51–52 goal development and, 216, 221 introduction to, 32–33 Joint Attention, Symbolic Play, Engagement, and Regulation (JASPER) and, 30 learning opportunities and, 179, 186–187 motivation and, 125, 130–133, 135, 143, 146 Naturalistic Developmental Behavioral Interventions (NDBI) and, 34, 35t parent coaching and, 82–83, 83t, 85 quality indicators and, 392, 397–398 social skills and, 282–283 Prompt fading, 11b, 187, 187b community programs and, 108–109 in self-regulating behavior, 324–325 Prompting, 10, 14 daily living skills and, 190 data collection and level, 371–372, 372f hierarchy and, 183–186 imitation and, 285 least-to-most supportive, 186

433

most-to-least supportive, 186 play skills and, 189 receptive language and, 182t, 189–190 social skills and, 190 for specific skills, 187–190 types of, 183, 184t–185t Prompting strategies definitions in, 175–176 for self-regulation, 322–323 in social skills, 294–295 Published documentation in goal development, 53–54 increasing access to, 412 Punishment, 193–195, 194t, 197, 199 Quality indicators, of treatment programs, 391–403, 392b, 395f, 402f Question-asking, 267–271, 267t–270t Rady Children’s Hospital, 112 Randomized controlled trial (RCT), 27–28, 289 in communication development, 240–241 future directions and, 408 Rapport, 160–161, 161b Rate data, 378, 378t Ratio schedules of reinforcement, 200, 200t Recasting, 243 Receptive labeling, 26, 189 Receptive language, 10, 52, 112, 138, 399 Bayley Scales of Infant and Toddler Development (BSID) and, 219–220 communication development and, 243, 251, 270t goal development and, 219–220 prompting and, 182t, 189–190 Reciprocal conversation, 271–272 Reciprocal imitation training (RIT), 132, 284–285, 285b Reciprocity, 127t Reflective discussion, in parent coaching, 90, 90b Reinforcement, 13 in challenging behavior, 318–324, 319b, 330–343 natural reinforcers, 202–205, 204f playpartner in, 297–298 in school settings, 348–349, 352, 355–356, 357t see also Consequence strategies Reinforcer value, 180, 180f Reinforcing attempts, 14, 125, 145–146 communication goals and, 244–248 in consequence strategy, 205 Relationship building, 160–161, 161b see also Social skills

434

Index

Reliability, in data collection, 262–263, 262b see also Empirical validation Replacement behaviors, 23, 314–318, 316b, 322, 326–327 Response latency, 126, 127t Response-reinforcer contingency, 124 Responsive interaction, 23 Responsivity, 15, 127t, 206, 271 Restrictive environments, 36, 62, 99–100, 309 Risley, Todd, 25 Routines, 9 family, 47–48, 59–60, 78, 396 mealtime and, 156, 168t object play and, 280–282, 281t–282t opportunity set up, 165–166 optimizing of, 164–167, 168t–170t planning and, 156–160, 157b, 158t–159t quality indicators and, 396–398, 402f self-regulation and, 325–326, 330t, 332–333, 339 sensory social, 279–280, 281t, 285–286 violation of, 13 Sameness, 166, 327 Schedules, 161–162 School settings, 62–64 activities and, 355–357, 356b, 356t–359t behavior in, 335t, 337t child-preferred activities, 349–352, 351b Classroom Pivotal Response Teaching (CPRT) in, 357, 358t–359t clear instruction in, 353–354 Common Core State Standards (CCSS) and, 347–348 contingent reinforcement and, 352 first grade and, 357, 358t–359t, 408 free play and, 350t, 355 generalization in, 355 individual goals and, 357, 358t–359t kindergarten, 105, 112, 114, 358t–359t maintenance of skills in, 355 math skills in, 348–349, 351–353, 355, 356t, 359t Naturalistic Developmental Behavioral Interventions (NDBI) in, 348–349 peer-mediated interventions (PMI) and, 347, 357 reinforcement in, 348–349, 352, 355–356, 357t shared control in, 349–352, 351b Self-advocacy behaviors, 325–326, 329t Self-management skills, 30, 105, 272 challenging behavior and, 318–319, 319b generalized, 322 transition to training and, 321–322 Self-monitoring, 102–103, 105, 272, 322, 392

Self-regulation behavior aggression and, 309–310, 324–326 behavioral flexibility and, 327–331, 327t–330t chaining in, 317, 333, 336t, 382 child-selected activities and, 323, 327, 333 commonly taught behaviors in, 327t–330t, 332–333 daily routine in, 325–326, 330t, 332–333, 339 natural environments and, 340 Naturalistic Developmental Behavioral Interventions (NDBI) skills and, 322–326, 327, 328t–330t parent coaching in, 340–341 promoting of, 326 prompt fading in, 324–325 selecting targets in, 326–327 teaching of, 339–341 Self-stimulatory behavior, 288 Semantics, 239 Sensory social routines, 22, 279–280, 281t, 285–286 Service-delivery models, 411 Setting events, 151–152, 152b, 156 Shaping procedures, 10 chaining and, 23, 201–202 motivation and, 125, 145–146 Shared control antecedent-based strategies, 167, 168t–170t communication goals and, 243–244, 245t–247t in community programs, 107–108 in cooperative arrangements, 300–301, 302b in group settings, 349–352, 351b motivation and, 139–141, 142t–143t in social skills, 296 Shared engagement, 9, 10 Siblings, 48, 271–272, 273t Single subject design studies, 407 Skill acquisition, 371, 371b see also Acquisition tasks Skill generalization, 57–58, 57b, 59b Skinner, B.F., 11 Sleep disturbances, 80 Smartphones, 325 Social Communication, Emotional Regulation, and Transactional Support (SCERTS) Model, 21 Social emotion, 8 Social initiations, 31 Social motivation hypothesis, 22 Social orienting, 7 Social reciprocity, 15

Index

Social skills acquisition tasks and, 248, 266t, 279, 282t balanced turns, 285, 295–296 child’s lead in, 289, 290t–291t, 299 conclusion on, 301 cooperative arrangement, 299–301, 302b Early Start Denver Model (ESDM) in, 283, 285–286, 289 environmental arrangement in, 282–283 facilitated playdates, 299 imitation and, 131t, 132–133, 285 music and, 293t peer-mediated interventions, 298–299 play and playdates and, 278, 297, 299–301, 302b playpartner in, 297–298 prompting and, 190 Reciprocal Imitation Training (RIT), 284–285, 285b sensory social routines, 279–280, 281t, 285–286 teaching strategies for, 284–286, 285b turn taking in, 285, 295–296 vocal imitation, 132–133, 285–286 Social Skills Improvement System (SSIS), 106 Social Story, 314 Social validity, 47–49, 47b, 49b, 60, 65 Special education programs, 29, 54, 101, 114 future directions and, 411 teacher of, 193 Speech-generating devices, 28, 56, 253 Speech-language pathologist (SLP), 253–255 Spontaneous speech, 26 Staff training, quality of, 399–402 Standardized assessments functional testing and, 52–53 in goal development, 219–220 Stimulus discrimination, 176 Stimulus generalization, 176, 181 Stimulus overselectivity, 15–16 Stokes, T.F., 11–12, 58 Strategies for Teaching Based on Autism Research, 63 Strength of behavior, 194–195, 194t Stress family, 309, 326–327, 343, 396 of parents, 31, 35, 56, 78–82, 81b, 225 Structured Laboratory Observations (SLO), 53 Structured playgroups, 102–103, 105–106 Superman, 291b, 359t Swimming, 61, 302 Symbolic play, 28–29, 202, 228 autosymbolic play and, 287t cooking and, 287t, 291t, 301 across models, 51–52

435

presymbolic play and, 287t in social skills, 287t, 289–290, 291b see also Joint Attention, Symbolic Play, Engagement, and Regulation Synchronization, 25 Synchronizing, adult behavior, 136 Syntax, 52 Systematic Analysis of Language Transcripts (SALT), 223, 367 Target behavior, 318–323, 328t–330t, 334t–338t, 340 see also Challenging behaviors Task analysis, 106 in challenging behavior, 317, 333 in data collection, 382–383, 384f–385f Task variation, 32, 144, 166–167, 248 reinforcer value and, 180, 180f Teaching adaptive behavior, 333–341, 334t–338t antecedent-based intervention and, 153–164, 158t–159t, 161b, 175b Augmentative and alternative communication (AAC) and, 253–254 child-initiated, 11b, 16, 27, 62, 125 Classroom Pivotal Response Teaching (CPRT) and, 357, 358t–359t, 365, 392, 395f incidental teaching (IT) and, 10, 25–27, 35t one-on-one activity, 26, 383 Pivotal Response Treatment (PRT) and, 286, 289, 298 of play skills, 288–289, 290b question-asking, 267, 267t–270t, 271 routines, 11b, 15, 156 self-regulation, 339–341 Strategies for Teaching Based on Autism Research and, 63 targets of, 8–9, 187–188, 222 see also Communication development; Enhanced Milieu Teaching (EMT) Teaching environment, 12, 51, 62 antecedent-based strategies and, 151–152, 155, 164 playdates and, 297–301, 302b see also Natural environments Team activities, 61 “Technical eclectic” approach, 36 Technology-based parent-mediated intervention, 79 Telehealth, 33 Telemedicine, 79 Three-term contingency, 6, 151–152, 210, 241 see also Antecedent, behavior, and consequence Time delays, 24, 187, 283

436

Index

Time sampling, 380t, 381–382, 382f Toilet training, 302, 323, 334t, 378 Topography, 310 Toys, 91, 155 see also Play skills Treatment fidelity, 11b, 12–13 data collection and, 374–375, 377f data sheets, 367, 377f future directions of, 409 inclusive settings and, 106–107 parent-mediated intervention, 77, 79, 82, 94 quality indicators of, 393–398, 395f Triadic attention, 251 Trial-by-trial recording, 13, 364–368, 379–380, 387 data sheet of, 371–372, 373f Turn taking, 248 balanced turns and, 78, 91, 92t, 109 motivation and, 141–144, 143t in social skills, 285, 295–296 Two-word utterances, 263, 265t Undergraduate education, 114 Naturalistic Developmental Behavioral Interventions (NDBI) training, 410–411 Uni-directional model, 410 United Nations, 99 Universal antecedent interventions, 312–313, 341 Validity data collection and, 362, 362b, 386 ecological validity, 46, 47b social validity, 47–49, 47b, 49b, 60, 65 Variable interval (VI) schedule of reinforcement, 200, 200t Variable ratio (VR) schedule of reinforcement, 200, 200t Varied turns, 248 see also Balanced turns Verbal Behavior Milestones Assessment and Placement Program (VB-MAPP), 54, 222 Verbal cues, 180, 183, 185t

Verbal requesting, 84, 84t Verbal skills imitation and, 132–133, 285–286 prompting and, 188 prompts for, 183, 184t–185t Video, 53, 325 games, 114, 134, 167, 227 in priming, 163 Video modeling (VM), 272, 289, 320, 323 strategies of, 104 Vineland Adaptive Behavior Scales, 52 Violation, of routine, 13 Visual cues, 109, 138–139, 282 communication development and, 252, 271 prompting and, 184t–185t self-regulation and, 313b, 314, 324, 328t Visual schedules, 314, 332, 339 Visual Spatial scale, of Wechsler Intelligence Scale for Children (WISC), 219 Vocal imitation, 132–133, 285–286 Vocalization, see Verbal skills Vygotsky’s theory, 228 “Wait-ask-say-show-do,” 27 Waiting, 331, 332t Walden Early Childhood Program, 102 Walden Toddler Model, 27, 62 Walden Toddler Program, 25–27 Water balloons, 159t, 259t–260t, 282t, 293t Wechsler Intelligence Scale for Children (WISC), 219 Wechsler Preschool and Primary Scale of Intelligence (WPPSI), 219 Whole-group reinforcement, 356, 357t Words, 55, 209, 227 first words, 254–262, 256t–263t goal development and, 227, 237, 239, 242 imitation of, 132–133, 285–286 two-word utterances, 263, 265t vocalization of, 131t, 145–146, 202 See also Communication development Written content, of parent coaching, 85 Zone of proximal development, 228, 297